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This is Brent of the Brookbush Institute and
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in this video we're going to go over
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manipulations, or high-velocity thrust techniques. I assume that if you're
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watching this video you're watching it for educational purposes and that you
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are a licensed professional with high velocity thrust or manipulation
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techniques in your scope of practice. If you are not sure check with your state
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board, most physical therapists, chiropractors and osteopaths you're in
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the clear, I believe that ATC's you can't do manipulations in the United States,
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although other countries again check your scope. Of course massage therapists
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and personal trainers these are generally not within your scope. Of
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course you could continue to watch these videos just for educational purposes,
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learn a little Anatomy learn a little biomechanics. If you're going to do these
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techniques please make sure that you have a good rationale for putting your
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hands on a patient, this should be based on assessment, and if you're going to
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assess I'm hoping that you'll assess use these interventions and reassess to
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ensure that you're getting the result that you're looking for, and have good
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reason to continue using this technique. In this video we're going to go over thoracic
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manipulations, these are the thoracic manipulations that are P to A high
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velocity thrust, also sometimes referred to as the screw manipulation. I'm going to
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have my friend a Yvette come out, she's going to help me demonstrate. Now remember
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if we're doing manipulations we're doing manipulations because we need to
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increase mobility in a segment that we think is stiff, and that's going to be based
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on not just subjective information but objective information as well. For
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example, maybe we've seen some signs of upper-body dysfunction during like a
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postural exam,maybe arms fall forward or shoulders elevate during one of our
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movement patterns, and then maybe since we don't have great goniometric
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assessments for our thoracic spine we could use something like a rotation test
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for thoracic mobility, that we could at least use as an assessment and
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reassessment as we're going through our interventions.
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Now the screw technique is probably the one that everybody is most familiar with
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and tends to be the most detailed as far as its explanation, and that's the one
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where we find transverse processes right and we go the transverse process
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above and below on opposite sides, and then this is called the screw
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manipulation because we press down on both sides which is supposed to do this
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with our thoracic spine which causes the manipulation. That's great and I think
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it's a good technique to start with to get some detail in, but I've also seen
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people just come and press, I've seen people come and press this way. I think
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all of these techniques generally work, and the reason being is it's very hard
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to be specific to a particular joint in the thoracic spine especially when you
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consider not only the number of facets but the number of costovertebral facets. So you have
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two costovertebral joints on every transverse process, plus your facet
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joints. I think when people do these manipulations a lot of times we're
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getting multiple cavitations because we're manipulating a lot of joints
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in it's segmented area. So with that being said let's
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start with the detailed screw P-A thrust. So the first thing I need to
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do is maybe start with some palpation, in this position I'd probably do my P-A's
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using my pisiform hamate grip this way. So we'll say I've already done
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cervical, I've already done my upper thoracic spine as part of my cervical
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exam and now I'm kind of in through here. I'm just going to feel for some stiffness
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here, maybe I asked Yvette, hey Yvette is any of this painful, or just a lot of
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pressure? Just a lot of pressure right, and you do have to put quite a bit of
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pressure just to get to the end of arhrokinematic motion in the
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thoracic spine, there is definitely some movement this way that can happen,
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and I think what we're finding here is I feel Yvette's a little stiff right here.
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This is kind of common actually with women, you'll find that right about where
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the bra strap would end up they'd either end up really stiff or hypermobile, it
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seems like they either end up stiff because
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of all of the, maybe pressure and maybe that's a compensatory pattern. Or they
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end up hinging over that point and then of course we wouldn't want to do a
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manipulation there, but she is definitely stiff a little bit right here. All right so I can
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keep doing my P-A's, you just saw me cheat there with a little bit of like
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general spring testing. You will see like P-A's would be specific, sometimes you'll
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see people just do this thing right this is just kind of a spring test
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to see if they can feel any of resistance. Another thing that you might
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be able to feel is like tissue density, so maybe some overactivity around the
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segments, and we definitely have some stuff going on here. So what I'm
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going to do is I'm going to find my transverse process, now if I go out
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just a about an inch from either spinous process I can feel the transverse
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process, and then I can actually feel a bump right here about two inches from
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the spinous process, that's where the ribs start, alright there's that little
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bump there at the the beginning of the ribs. But let's say I find these two
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transverse process and I'm going to switch my fingers this way a couple
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times so that I rotate in both directions, figure out which one's
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stiffest. Alright so she tends to be more stiff this way so what I'm
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going to do is get my pisiform hamate on either of those transverse process. I'm
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going to take up all the tissue slack so that my hands don't move around
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and there's a couple ways to do that, you guys can twist your hands, you
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can move up into position so you take up tissue slack this way, but you
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definitely want to do something to take up a little tissue slack because
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otherwise you'll go on press and your your hands will move off those
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transverse process. Then I'm going to ask a Yvette to take a nice deep breath,
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and when she breathes out at the bottom I'm just going to do a little quick, and
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that's it. I think you have seen Yvette in some earlier videos, Yvette's not
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used to getting manipulations which I actually like for these videos
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because I feel like she's very similar to a new patient which I think you
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need to be aware of, that not everybody loves to get manipulated. Some of you
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might like to get manipulated, other people hate to get manipulated, but it's what they
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need. Manipulations are are very effective for increasing mobility,
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they're very effective for decreasing pain for a lot of different pathologies.
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So again going through that, all I did was find two of these
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transverse process where she was tight and I just kind of set my body up right
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over the top, and then just gave a quick P-A down. Now since my hands are set up on
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on the caddy corner transverse
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processes here, when I press down it did this to the two vertebrae. Now could I
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have just laid my hands down like this? The chances are yes. I think people get a
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little too caught up in the details, if I have somebody who's coming in for
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general thoracic stiffness, and I'm not dealing with somebody who's like has a
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very specific pain. For example if Yvette had come in with very specific pain
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right underneath where her bra strap was, I thought there was a chance that there
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was a hypermobile segment surrounded by stiff segments, that's a good reason for
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me to be very specific on where I'm going to apply these techniques. But if
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Yvette's coming in because she's been suffering from thoracic spine tightness,
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maybe you know we started hearing about things like she's got desk work followed
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by these group classes that she teaches, and we think she's probably sitting in
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really bad posture and then reinforcing it with workouts because she doesn't
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really get a chance to do any sort of movement prep before she goes into this
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group class, like I just want to loosen this up. I probably can just put my hands
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down, I take up my tissue slack, big deep breath for me,
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breathe all the way out for me, there you go,
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relax and there you go. Alright you saw I just set my hands down and
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I got multiple cavitations. Do I know whether it was thoracic facets or
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costovertebral facets? No, and honestly it might not matter in a case of general
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stiffness. In the case of general stiffness all we want to do is see
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improvement on a reassessment, and if that was for example upper-body for
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example, maybe she didn't get her arms all the way back during an overhead
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squat assessment, or she was performing poorly on a thoracic spine assessment
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now I would just reassess and see if that got better. If it did good, then
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that was the right technique to use. I've seen people do this thing as well and
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sometimes that works really well, that's not a technique I'm particularly
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comfortable with, but you could just do hand over hand and push down, and now
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you're doing a central P-A high-velocity thrust. I think with all
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these techniques you need to practice, the ability to feel where the stiffness
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is probably is the most important thing because the techniques themselves aren't
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hard. The only part that you as a practitioner you need to get real
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comfortable with, is setting your body up in a way that you're using your
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biomechanics and not your arm strength, because if we were to flip places and
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Yvette was to try to do this on me, granted I probably outweigh Yvette by about
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a hundred pounds, I'm almost twice her size. She's
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going to have to have really good mechanics to be able to move my thoracic spine in
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a way that's going to get a good manipulation, and the way to do that of
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course is to get the table low enough to get your arms straight so that you can
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then use the weight of your torso in a quick fashion. You're almost
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thinking about I'm just going to drop my weight in and try to straighten my arms
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out at the same time, and kind of like a a little bit of a, I don't want to say
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like punching motion, but like you're just kind of doing one of,
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alright I'm all set up and then I'm just going to drop in. So I'm going to
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straighten my arms, let my bodyweight all fall at the same time very quickly. You
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are going to have to move a little more than you expect. If you have
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ever done like the CPR training think about how far a sternum is willing to
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move, you know you have to push the thoracic spine a good couple of
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centimeters before you're going to get any of these cavitations to happen. Last,
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you could potentially, I wouldn't suggest this for everybody, but you might be able
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to get some of the upper thoracic spine by doing a technique up here. Notice that
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if I'm going to do this I'm going to tilt her head down a little bit into flexion, that
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seems to help. I might go cross hand,or this way. I'm
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pushing in this direction. Alright nice deep breaths, and then I
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would push down hard here. The one problem with that particular technique,
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where you want to be careful is you do have to use quite a bit of force, and
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it does tend to push people's clavicle very hard into a tablem and for some
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people that's enough to be uncomfortable enough that they don't want to do it
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again. For individuals like that I would go back to my mobilization techniques
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remembering that most of the research points to manipulations being a little
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more effective than mobilizations, but mobilizations being generally very
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effective unto themselves. Stay tuned for the close-up recap. All right
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for your close-up recap I wanted to give you a little different view here. Of
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course we would go through and do our palpation, take up all that
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arthrokinematic range, ask Yvette here, hey does that cause you any pain? No, so we might
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get a little extra information on top of palpating stiffness on whether that
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particular segment seemed to be the one that was causing some of her symptoms,
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especially if that pain is related to our concordance sign. Now other things we
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might be able to tell is do we have increases in tissue density,
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overactivity and any of the muscles
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around a particular segment, and I mentioned sometimes
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it's coming through and just doing a general spring test, you'll feel where
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the spine is generally tighter. We found with Yvette this seemed to be your
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tighter area. Now if we wanted to get real specific with our screw technique
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and we had found a couple of spinous process that we're really stiff,
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remember that your spinous process actually are quite long in the
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thoracic spine. So the transverse process that is related to it, a little
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trickier, if you fall off that spinous process to the side and start
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rotating. I'm probably going to have to go about two spinous process up, but you can
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lay a thumb down and feel where that transverse process related to that
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spinous process is. So right here would be that particular segment I could
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put one hand here, I could then go one below it or one above it with
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the other hand, and then have Yvette take a nice deep breath, breathe all the way out,
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follow her down and then of course my chest is right over my hand so I can
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just drop in and give a quick thrust, and just like that we got a nice little
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cavitation via our screw technique which is called screw technique because it
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basically does this with the two vertebrae that we're pressing. Now I did
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mention that just general hand placement like as long as you're on either side of
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the spine, chances are a PA thrusts will get you some good manipulations. The
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problem with that technique is it's not specific, the advantage of that technique
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is it's not specific. You're probably getting a lot of stiff joints involved,
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maybe some costovertebral joints as well as facet joints. Of course I've even
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seen this work where the spinous process is put in between the thenar eminence. Essentially that's just
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a central P-A thrust. I don't tend to use that one very often. I think it;s
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a little bit more uncomfortable for the patient and not as effective as the
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other techniques I just showed you for the thoracic spine. Give these a try,
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really start doing some palpation before you try the thoracic
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manipulation if you haven't been successful. I think just determining
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where on the spine is stiff will be the biggest to jump in your ability to make
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this technique successful, as as opposed to continuing to just work on smashing
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the thoracic spine which I think with a little practice anybody can get pretty
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good at by itself. A couple of points to recap, knowing your Anatomy and knowing
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your biomechanics will certainly help you choose the right technique for the
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right patient. If you're unsure whether manipulations are appropriate due to
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their higher intensity, it's okay to do mobilizations. Most research points to
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manipulations being slightly more effective, but mobilizations being very
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effective and of course we have those videos for you if you want to start with
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those less intense techniques. Make sure that if you are doing any technique that
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is based on assessment, and of course that you're reassessing ensuring that
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the technique is effective for the patient that you're working on, and when
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it comes to all manual techniques, manipulations maybe more than any other,
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look for opportunities to get live education. Although I know videos are
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convenient and I'm happy to have these up for you to watch, it would be so
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much more helpful to use those videos as a recap of one-on-one attention with
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somebody who's experienced with manipulation techniques. At the very
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least grab a colleague and grab a friend and start practising these before you
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bring them into clinic and start using them on patients and clients. I hope you
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enjoyed this video, if you have any questions please leave them in the