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This is Brent of the Brookbush
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Institute in this video we're bringing
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you another manual technique. Now if
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you're watching this video I'm assuming
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you're watching it for educational
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purposes and that you are a licensed
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manual therapists following the laws
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regarding scope of practice in your
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state or region. That means athletic
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trainers, chiropractors, physical
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therapists, osteopaths, licensed massage
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therapists you are likely in the clear
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to do these techniques. Personal trainers
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this probably does not fall within your
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scope of practice, although you might be
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able to use the palpation portion of
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this video to aid in learning your
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functional anatomy in an educational
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setting, supervised by a licensed manual
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therapist. Now before we place our hands
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on a patient or client it is important
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that we assess and have a good rationale
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for doing so, and of course if we're
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going to assess then we should be
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reassessing to ensure that the manual
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technique we're using is effective and
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we have a good rationale for continuing
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to use that technique. In this video
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we're going to do static manual release
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of the sternocleidomastoid. I'm going to
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have my friend Melissa come out, she's
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going to help me demonstrate. We're going
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to use the same four step process we've
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been using for all of our manual release
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techniques. We're going to talk about how
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to differentiate this structure from the
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other structures around it, and it's
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actually fairly simple. I think this is a
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structure that most of you would be very
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visually familiar with. If i just take
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Melissa's head and turn it away, you can
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see this line right here is her
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sternocleidomastoid. There's actually two
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heads which if I follow just behind this
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head, I can feel the other one going into
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the clavicle. This head that you can see
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goes right into the sternocostal joint.
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So second step is do we have
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any structures around the
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sternocleidomastoid that could be
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offended, insulted or injured by
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compression, and the answer to that one
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is yeah we definitely do in this
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case. So a lot of people are really
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scared of this technique and it's
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because of things like the carotid
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artery is right behind the
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sternocleidomastoid. There's a lot of
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nerves obviously in the neck, and since
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we're on the front of the neck we have
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things like your trachea that like
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people don't really like getting pressed
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on. So we're probably not going to use
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to posterior pressure to release the
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sternocleidomastoid, but there is an
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answer, there is a different way to
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release this. So let's skip to step
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number three, where are the common
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trigger points. Well it ends up the
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common trigger points are kind of
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throughout the sternocleidomastoid,
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ranging all the way from the mastoid
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process up here, so I can go just
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inferior the mastoid process and I can
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start feeling some increase in tissue
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density all the way down, and depending
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on who you're working with and what
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dysfunction they have, and what history
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they have, you'll find varied trigger
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points throughout. So it's going to be
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important to kind of search the entire
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muscle rather than finding a trigger
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point, landing on the first trigger point
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or increased tissue density nodule that
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you feel and calling it a day. You
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need to make sure you search the whole
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thing, and then of course step number
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four is how do i get myself and my
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patient comfortable so that i can hold
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the technique long enough, and my patient
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can relax. Since we're talking about the
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sternocleidomastoid you can
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probably guess that sitting up is not a
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great idea, the only way I'm going to get
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the sternocleidomastoid to relax is with
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her head supported; and I haven't
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even had that much luck with that
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forehead headlock position that we've
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done another techniques. I've tried
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because I have somebody in sitting and
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I'm trying to do a bunch of techniques
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all in a row, it just never really seems
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to work out. My suggestion is going to be
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to put them in supine, so go ahead and lay
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move the table up here a little bit. Now once
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she lays down her sternocleidomastoid is
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going to relax, which is a good thing. Now
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we just have to solve the problem of I
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can't put an anterior to posterior
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force of this muscle, that would
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look a little something like this, that's
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probably going to get me fired. I don't
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know about you, but I'd like to keep
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doing what I'm doing so let's not use
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anterior to posterior force. Now Travell
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and Simons describes a very simple way
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around this, which is a pincer grip. Now a
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pincer grip is just taking your your 2nd
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finger here, your index finger and
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curling up like this and then having
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your thumb and kind of pinching it in
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between, and if you have the other hand
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to kind of put behind the occiput and
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you kind of mess with contralateral
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rotation here and put her in a little
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flexion, her sternocleidomastoid becomes
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really laxed, I can start up at the
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mastoid process where I might be able to
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use a little bit more of like a lateral to
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medial pressure with my fingertips. But
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then as I can get a hold of the whole
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muscle I'm just going to put the muscle
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inside of that pincer grip, and I'm going
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to kind of search the tissue by
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strumming, I'm kind of strumming this
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way so I need to go from like, since this muscle
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is long this way, I would strum the
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muscle medial to lateral and i'm
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just kind of taking segments down at a
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time in my little pincer grip. These
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little short strokes, looking for
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anything that seems to have an increase
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in tissue density or something that
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feels like a nodule. Now notice guys
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I'm not pushing down far into her neck. I
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started by palpating the muscle up here
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really finding it, really knowing what
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i'm going for which i just fell off
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inferior and slightly anterior to the
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mastoid process here, and then I went
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into my pincer grip this way. I know
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some of you guys are thinking oh man
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he's going to kill her, he's just going to
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pinch off her carotid artery and game
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over. Well it's not
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that easy, to have somebody pass out like
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that she would probably had some
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symptoms first like nystagmus, or
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lightheadedness, or her speech would
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start to slur or something weird.
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More than that as long as I'm not going
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in and pinching down real hard,
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real fast, if I'm being gentle with these
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tissues and I'm just slowly increasing
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my pressure, I'll feel a pulse from her
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carotid artery before I cut off
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circulation. If it pulses I have the
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chance to move and chances are if you
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could do this technique and you're
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working on this technique you will feel
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a pulse at some point of time, and you
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will have to move over a little bit and
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that's okay, no damage done. I can
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actually feel her pulse against my thumb
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on this side, right at the tip
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of my finger which means i'm not
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actually squeezing her carotid
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artery, i'm actually squeezing her SCM
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more at my second knuckle and
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my IP of my thumb. So i know where her
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carotid artery is. I found my densest
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fascicles here. I'm finding a little bit
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of a nodule of increased density right
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here about a centimetre, two centimeters
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below her mastoid process there, and
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I'm just going to hold it until it
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releases, that's it. How bad is this? Not
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bad at all. It's a little less
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comfortable if somebody has a trigger
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point down here, be warned but like I
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said if you start up here at the mastoid
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process, you fall off, you get a good idea
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of where that muscle is and you slowly
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take out little parts, not take out
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but slowly strum little sections of that
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muscle with your thumb and be careful
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when you feel a pulse, I think you guys
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will find this technique is not that
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uncomfortable.
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If you want you can even add a little
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stretch to the tissue by going back into
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contralateral flexion, or back into
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ipsilateral lateral rotation.
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This muscle is definitely very related to arthrokinematic
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inhibition, and you will see an increase
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in tonicity if somebody's sternal
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clavicular joint it is really locked up
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or really hypermobile, so be aware of
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that as you get down here. It's always
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worth kind of checking on the how
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stiff that joint is, kind of in
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conjunction with this technique. Stay
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tuned for the close up recap. All right
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so here we go with our close-up recap of
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the sternocleidomastoid static manual
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release. I'll show you guys a real easy way to
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find the sternocleidomastoid, if I
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contralaterally rotate Melissa's head
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here and then have her try to lift her
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head off the table, you can see that
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sternocleidomastoid just pops right
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out and then I can place my pincer grip
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right over the top of her
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sternocleidomastoid at her mastoid
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process, tilt her head back and now
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we're in a nice relaxed position. I'll
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keep her in a little contralateral
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rotation just to keep some slack off
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this muscle, and then I'm just going to
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do my little medial to lateral strokes,
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looking for those densest fascicles,
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and then once I find an area of
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increased activity I can move a little bit
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proximal or a little superior and
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inferior. Keep in mind you want to
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be pretty close to where you
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think that nodule is before you start
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just kind of rubbing up and down the
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muscle, because you don't want to take a
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bunch of skin with you that's going to
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be really uncomfortable. if I go right
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here and then I just moved a little superior
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there and I found a little point of
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hyperactivity, and I'm just going to keep
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my pincer grip right where it is until I
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feel a release. Note I am not laying my hand
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on top of Melissa's neck, there's no weight
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from anterior to posterior on her
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neck that would make her feel like she's
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being choked, or like I'm putting
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pressure on her trachea. I can feel the
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pulse of her carotid artery a little bit
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on just medial to my thumb,
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and so for the most part the carotid
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artery is medial to the
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sternocleidomastoid. That doesn't mean
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I'm compressing the carotid artery, it
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doesn't mean that she's going to pass
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out. It doesn't mean I'm doing any damage,
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like I said I can just kind of feel the
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pulse which is probably a good sign that
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i shouldn't press any further
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medialy, I shouldn't press any
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further anterior to posterior but I'm
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okay. I can just check the rest of
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the muscle here, you're
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sternocleidomastoid does get trigger
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points throughout its entire length. It's
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a little hard to identify where the most
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common point would be, I do find that
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near the mastoid process some trigger
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points often get hidden and they are a
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little easier to get to up here, you
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have less chance of compressing the
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carotid artery and the muscles a little
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easier to grab up here so that helps. If
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I wanted to I could add a little bit of
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tension by going back into
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ipsilateral rotation and contralateral
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flexion just like so if I thought that
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would help pin down tissues, or add
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enough tension to to maybe stimulate a
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stretch, an autogenic inhibition. So
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there you have it knowing your
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functional Anatomy will definitely help
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your manual technique. It'll help you
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differentiate structures so that you can
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place your hands where they need to be,
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as well as make you aware of these
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sensitive structures around the tissue
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that you're trying to target; things like
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nerves and lymph nodes, and arteries. Make
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sure that if you're going to place your
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hands on a patient that you have done an
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assessment and have a good rationale for
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placing your hands on that patient, and
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if you're going to assess make sure you
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reassess to ensure that your technique
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was effective and you have a good
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rationale for using that technique again.
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Now with manual therapy one-on-one live
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education is incredibly important, please
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be looking for opportunities like
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workshops and mentorships and maybe even
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classes at your local university that
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can get you some one on one individual
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instruction, or at least some live
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classroom instruction so you've had a
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chance to be critiqued and mentored by
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somebody senior to you with some
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experience in manual
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therapy techniques; and before you bring
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this stuff back to your rehab, fitness or
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performance setting please practice on
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colleagues. There is no substitute for
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practice and it is going to take a while
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to get accustomed to some of the
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techniques that we show in these manual
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technique videos. Don't expect to learn
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them in two or three or even five
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minutes, you want to have hours of
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experience under your belt working on
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various different body sizes and shapes,
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so that when you do get that first
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paying client, first paying customer and
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you're really trying to make a good
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positive impact, really trying to promote
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better outcomes, you feel comfortable
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with that technique. I look forward to
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hearing about your outcomes and hearing
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your questions in the comments section