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Thoracic Spine Mobilization: Posterior-to-Anterior and Transverse

Thoracic Spine Mobilization Posterior-to-Anterior and Transverse is a manual therapy technique used to improve mobility and flexibility of the thoracic spine. During the mobilization, the practitioner applies varying degrees of pressure in the posterior-to-anterior and transverse directions while gently moving the joints of the thoracic spine. The mobilization helps to reduce pain, stiffness and tightness and can assist in restoring normal range of motion of the spine. Each session is tailored

Transcript

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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 a
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joint based manual therapy technique. If you're watching this video I'm assuming
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you're watching it for educational purposes and that you are a licensed
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professional with joint based techniques within your scope. That means osteopaths,
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chiropractors, physical therapists you're probably all in the clear. Physical
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therapy assistants, athletic trainers, massage therapist you need this check
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with your governing body in your state or region to see whether this is within
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your scope of practice. Personal trainers this is definitely not within your scope
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of practice. Of course all professions could use this video for purely
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educational purposes to help with learning biomechanics, anatomy and of
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course palpation. This is Brent of the Brookbush Institute in this video
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we're going over thoracic spine mobilizations, that's posterior to
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anterior mobilizations also known as PAs, and transverse mobilizations. I'm going
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have my friend Melissa step out she's going to help me demonstrate. Now the first
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thing you'll notice is that she's going to lie prone and that I have the table
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fairly low. The table is low for these posterior to anterior mobilizations. I
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want to be able to get my chest over her thoracic spine with my arms straight, so
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that I can use the weight of my torso and not my hand strength to try to do
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these mobilizations which would wear out my hands pretty quickly I think. Now before
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we get into the techniques themselves it is important that we cover anatomy and
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palpation, and of course your knowledge of anatomy is going to determine how
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good you are at your palpations. For those of you just starting out
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I would have you start on bare skin, remember that clothing is just one more
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layer of stuff to feel through. For those of you who've done mobilizations
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before you have a good idea of your palpations, you've been doing some
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release work, I don't think a gym shirt like this is much of an issue. So I would
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actually do therapy right through this fairly thin shirt I wouldn't want to do
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it through a sweater, but a thin workout shirt like this should not be a problem.
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Going back to our Anatomy now, remember that your thoracic spine by definition
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is all of the vertebrae that your ribs attach to. So you can think this
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huge stable rib cage, that alone is going to add a lot of stability to the
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thoracic spine which to us as manual therapists is going to feel
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like stiffness, right the thoracic spine tends to feel fairly stiff even when
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compared to like unilateral PAs of the lumbar spine and of course when compared
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to the more flexible cervical spine. Now finding the thoracic vertebrae if we
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wanted to create our borders we could find the spinous prominence of C7 that
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big bump right at the bottom of the neck, so I know if that's C7 and T1 is
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right here. Then of course we could find rib number 12 and hopefully Melissa
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isn't too ticklish here, but if I follow
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rib 12 on up to T12 I can find my last thoracic vertebrae, so there we go
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there's my thoracic spine. Now I would recommend looking at an anatomy book
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maybe one of these plaster cast models, and start trying to think about how the
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thoracic vertebrae differ from the other vertebrae that I've put my hands on. So
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maybe you've already watched our lumbar spine and cervical spine posterior to
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anterior mobilization videos, you'll notice that the cervical spine and the
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lumbar spine for that matter the spinous process goes fairly straight out. It's
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almost in line with the facet joint. And then you look here to the thoracic
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spine and you notice they all look bent down, aright so they're very very angled.
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So some things that that does its a little different.
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Whereas this feels very pointy up here when you go through the spinous process, and we
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talked about the lumbar spinous process they feel like flat and then divot, flat
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and then divot, flat and then divot. The thoracic spine feels much more like this
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under your fingers if you like just palpate down. Alright it just kind of
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feels like this curve like this like you've seen pictures of sine
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sinusoidal curves or like sound waves, alright so you got those type of bumps.
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The other thing you're going to notice real quick is if you feel the end of a
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spinous process it doesn't match up to the facet of the same segment right.
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So if I wanted to let's say do a transverse mobilization
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and a unilateral posterior-anterior mobilization on the same segment, I'd
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have to go from here to here right, So it's going to feel like one and a half
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almost two segments away from the end of that spinous process, and I'm going to show
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you a way to feel that out so you don't necessarily have to
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remember that it's two away. That's a good thing to
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remember I guess, but the the better thing to do would be able to be tested
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with your fingers so that whether it's one and a half, two, or one away it
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doesn't really matter because you can palpate it. Now the other thing
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to think about and although it's not really clear on this particular model is
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that the transverse process of the thoracic spine feel much shorter this
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way. It's probably partly because they're angled up a little bit, right the ribs
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kind of come up underneath them, alright so that might be part of why their angle
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is a little different. But the ends of those definitely
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feel closer to the spinous process. So already we're starting to see our
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palpations are going to be a little different, this is going to be smoother
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bumps, these bumps aren't going to match up to the facets. The end of our
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transverse processes are going to feel much closer to our spinous process,
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and our facets actually are going to be between those two points, so you're
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literally going to fall right off the spinous process and then look for your
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bumps to do your mobilizations to get over those facets. Alright of course your
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rib cage you can actually feel this, comes this way and you have your
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transverse costal joints and you have your costovertebral joints here right
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they come in this way, you can actually feel the ribs dive underneath the
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transverse processes. So that might be a good place for you to start your
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palpation, there for us to start your palpation. So what we just looked through
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on that let's let's go through real quick and I'll show you guys that again
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on the close-up recap. If I just feel Melissa's rib cage right, I'm
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just using broad hands here right and feel all those
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bumps, and I just I just feel one of the ribs and I just slowly palpate up, and I
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make sure that I'm palpating through the soft tissue I'm keeping on those bones
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all right, I can actually feel right here I run into bone and I know you guys
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can't see this yet but will again see this on the close-up recap, I run
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right into her transverse process. So I can actually even take this hand now and
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put it over the rib and press down and feel like a ledge like this that's the
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transverse process, and the rib kind of do this underneath it. Alright so now I
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got rib, I got transverse process, I got a little bit of a valley and then I got a
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spinous process right in the middle. So that gives me some good
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landmarks; I got rib, transverse process, valley, spinous process and I can feel
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that if I go down them it's smooth bumps like this. So now we get into what am I
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going to mobilize? Well I want to be able to feel stiff segments, and sometimes the
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easiest way to feel through what segments are stiff is using something
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called a central PA. Now for a central PA we want to push down on the spinous
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process posterior to anterior. What I'm going to use generally is I'm going to use my
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pisiform hamate grip, so I'm going to put her spinous process right here, right
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in this meaty portion here right around my pisiform. I'm then going to saddle my
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fingers around the top of them, and I can press down until I run out of
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motion and I can ask Melissa is that pain or pressure, lots of pressure no
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pain. And as well as I'm going down the various spinous process here and notice
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I'm kind of going a little bit in this direction too, we got to think about
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how those facet joints are shaped right they kind of do this thing and they're
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pretty flat this way, and how does that feel? That feels okay. I
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can also take mental note of does part of her thoracic spine feel stiffer, so
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the thoracic spine as a whole is going to feel stiffer than maybe our lumbar or
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cervical spine, but is there a segment or segments in her thoracic spine that
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feels stiffer than others, like maybe she's really stiff up in here and the
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only way you're going to get a good idea of what that feels like, is one comparing it
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to other parts of the spine, and two you're going to have to palpate a lot of
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people. You're going to have to do this on a lot of people and start creating your
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internal frame of reference of what normal is, based on your techniques that
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you use consistently. So Melissa to me feels a little stiff up in here, so now
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what can I do, well I could use my central PA as a technique. So I could
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drop right back into this position, arms straight use this grip, notice
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that my chest is over my hands and now I'm going to find my first resistance
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barrier, I'm going to find my end range, now that's arthrokinematic end range you
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got to push them all the way to the end of their joint it's not going to be
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necessarily very comfortable for them, and I'm going to back off to 50%, and then
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from there I can start with my first end range to just around 50% of resistance
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grade three mobilizations. One to two oscillations per second if you're using
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a Maitland-Cyriax approach like I do, and of course I'm going to keep
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doing this until I feel a change in the amount of stiffness. Usually that's
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around thirty seconds, so make sure you follow through and do as many
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mobilizations as it takes. It could take up to two minutes, you know one minute to
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two minutes of mobilizations like this to really get some significant change
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depending on how stiff they are. If you feel like they might be irritable of
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course you could start with a few seconds like let's say five seconds
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of mobilization, let off and go hey how do you feel, and if they're still feeling
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pain then you know this might be a person that you have to start off
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gently with, just do a little bit of mobilizing and go ahead and let them sit
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up and retest. So that's central PAs and all I'm doing is finding the end of
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the spinous process hooking my pisiform portion of my hand in there right this
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nice meaty part right here. I'm going to hook it in and then do my mobilizations.
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I could do the entire thoracic spine if I thought the whole
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thoracic spine was stiff, I'm just going to go ahead palpate, move down one put my
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pisiform over it. Palpate again and all I'm doing is
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taking these two fingers and putting the spinous process right between it moving
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down one, and boom do it again. What other options do I have? Well I could try to
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get down to the facet joints, realizing that the facet joint if I'm trying to do
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the same segment I have to move up, all right so the spinous process this
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spinous process is actually attached to this facet. I don't know if you can
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see how far my fingers are apart but that's that's a fair distance, that's
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that's for me a good two fingers width. There's actually almost two spinous
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process between, so I can go, if that's one spinous process I can
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go here's my next one, here's my next one. If I drop off laterally and inferiorly,
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so I drop down just a little bit like that, that's where the facet connected
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to this spinous process is. Alright so what could I do there, well I can do a
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bilateral PA. So a bilateral PA you're going to put two fingers over those facets
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like this, these become dummy fingers. They don't do anything but hold your
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place and feel. You're going to use this hand and go over the top and that's
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going to create your pressure, same thing first resistance barrier, last resistance
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barrier, back off and you maybe this time I want to do
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grade four, so I'm going to do small oscillations at 50% plus of resistance.
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Okay so that's one way to do bilateral PAs. The other way I could do bilateral
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PAs is the crossed thumb technique, right so I could do this. Now I've mentioned
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this in other videos, for me if I can get away with not using my thumbs
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I don't use my thumbs because there's way too many techniques that are
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completely dependent on your thumbs like there's just no other ways to do it. So
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you want to save your fingers as much as you can. If you were in a difficult
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situation though and you felt like you were having a hard time just palpating
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what you were supposed to feel, maybe you're having a hard time sticking to
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the facet that you know is stiff, alright maybe somebody has some weird
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anatomy like you don't feel like things are matching up and you feel like your
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thumbs are your best tool alright. So you can do something like this, we could we
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could go this way if we had to. We can go this way, or you saw what I was just
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doing was this, this is a little bit more difficult but could be done.
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What else could I do well we could go back to our workhorse
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of spine mobilizations which is UPA's, and i've talked about this a lot. These
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are the unilateral posterior to anterior mobilizations where you're focusing on
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one facet joint at a time, and again all I'm going to do is find that stiff segment
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alright think about okay well if I want to affect that facet maybe I have to
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find the right facet. So I was just on that spinous process, if I keep
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pushing on that spinous process and then move my thumb around until I feel that
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facet move under my other thumb, so that's right about there. I can then
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use my thumb over thumb technique just like so, I could use kind of
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a dummy thumb pisiform grip, so here's something that I see a lot of people do
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although I don't see it textbooks as often is I'll use my thumb
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as my dummy thumb, and then put my thumb in this pisiform point like I was doing
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with the spinous process and go right over the top just like so. I use
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that really commonly in the thoracic spine because there's so much muscle to
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get through, and Melissa is so jacked because of all the weight training she
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does. So I can go right in there and could I use other fingers?
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Potentially, like I could use maybe you know if my thumb was getting beaten up,
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maybe I go back and look like I'm setting up for that bilateral PA but
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only putting my hand over one finger. That's not very comfortable for me but
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it is a possibility. Alright thumb over thumb, and then the
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question is what else, what else could you do? Well you could do
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transverse mobilizations so hopefully you guys are following me here, we went
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from CPAs which is on the spinous process to bilateral PAs which was this
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like so, or double thumb technique which I'm not actually necessarily
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recommending because we don't want to wear out the thumbs. You could then do
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UPA's which are probably the workhorse and the thing I go back to most often.
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But another thing that's helpful in the thoracic spine and I almost use it
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exclusively in the thoracic spine, it's actually very rare that I would even try
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this in the lumbar spine because of how stiff the lumbar spine is, it's very rare
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that I tried it the cervical spine because I just don't need it, but these
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transverse mobilizations come in real handy for the thoracic spine and
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especially the upper thoracic spine for whatever reason. So if you're going to do a
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transverse mobilization let's think about this for a second, you'll notice
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I'm raising the table way up, because what I'm going to try to do is I'm going to
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try to push the spinous process this way. By pushing the spinous process this way
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I rotate the whole segment, and hopefully you guys can kind of see how that would
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work. Now the problem with transverse mobilizations is they also can be very
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hard on your hands, it's very hard to get a grip on one of these vertebrae. I'm
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actually going to drop Melissa's head down a little bit so I have access to these
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upper thoracic segments, but I'm going to find my
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spinous process and then I need to do a couple things that are kind of
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interesting here. I'm going to use my dummy thumb and I'm going to grab a little bit of
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skin, all right I'm going to actually pull, pull just like this all right like I'm
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going to gather up some of her skin and press it into her spinous process like
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so. So if this was her, the bone that I'm feeling like I want to gather up
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some skin and then push it up against like this, because if you don't and you start
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pressing into a transverse mobilization you're going to stretch the skin on one
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side and it's going to feel really uncomfortable. So let's let's say we're
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doing C7 and T1 which is right there. So I'm going to go on T1 here grab a
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little bit extra, and then I'm going to take this hand I'm going to go like this. Now my
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force needs to go that way so I actually might have to drop down a little bit
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like so, and then you can see I actually have my my hand on Melissa's head so I
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don't push her head to, alright I can kind of stabilize her head put the rest
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of my hand down here on her back and then I'm just going to go this way
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feeling for where's my first resistance barrier, where's my end range and I'm
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telling you guys right now this is not an easy thing to feel, this is going to take
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some practice. But once I find it, back off to my 50% mark and again I can do my
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grade fours or my larger oscillation grade threes just like so, until I get
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some good increase in mobility and I can keep going right on down the spine again,
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feel my next spinous process and like so. Just remember you don't want to do
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this, so this isn't a transverse mobilization, this is like an oblique PA.
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You got to be very careful what your intention is, like if you're trying to do
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transverse mobilizations and you want more motion out of your facets, but then
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all the sudden you're doing an oblique PA you might actually just be closing
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down on facets. You might be doing like some sort of smashing,
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and so we got to kind of keep these angles in mind, and I don't want to go
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too far down the the biomechanic thing because I know research has shown that
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our biomechanics aren't as consistent as we might hope they were as physical
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therapists, but do be aware of the angles that you're using if for no other reason
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than reliability. Alright if I did it this way this time and then I had the
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table lower next time, so it was way up pushing down like this and calling it a
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transverse and then the next time the table was high and I was doing this as a
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transverse, those three things are not the same. So let's let's run through
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those techniques one more time because I just I just threw a bunch of stuff at
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you. So remember your thoracic anatomy, try to keep this stuff
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in mind as you're doing all of these various techniques, your thoracic spine
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is attached to your ribcage that's going to make it a little stiffer. One thing you
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might also want to think about with the thoracic spine it being attached to the
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ribs, is you probably want to keep somebody's hands down because if they
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put their hands up, can you put your hands up real quick, they put their hands
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up like this it's going to posteriorly tilt their scapula which is then going
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to press down into the rib cage which then could extend their spine further,
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and none of this is going to feel the same anymore.
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So from a reliability standpoint you need to be thinking about that, like you
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might be able to get used to somebody's hands being up all the time but that
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means every patient that walks in is going to have to start with their hands up.
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Whereas if you start with their hands down then you don't have the posterior
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tipping of their scapula, you don't have that change to their rib cage, you don't
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have the change to their thoracic spine, and this becomes your norm. So be aware
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of little things like that, right know where your thoracic spine starts so
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right under spinous prominence C7, and know where to find T1 and then of
00:21:5600:22:01
course where's the spinous process? Right down the middle, make sure you can feel
00:22:0100:22:06
all those, make sure you're very aware that the facet and the end of the
00:22:0600:22:11
spinous process don't match. So you're facet is almost 2 spinous,
00:22:1100:22:15
tip of 2 spinous process away. All right we talked about this was one
00:22:1500:22:19
spinous process, and you had this one, this one and then I actually fell off this way
00:22:1900:22:24
and found her facet for this spinous process. And then your transverse process
00:22:2400:22:30
are actually a little shorter this way, so if you are palpating and you feel
00:22:3000:22:34
like you're going to feel a canyon and then a big bump, you know you don't want to go
00:22:3400:22:38
beyond that bump because if you go beyond that bump you're just mobilizing
00:22:3800:22:41
your ribs, which is fine if your intention is to mobilize the ribs but if
00:22:4100:22:45
your intention is to mobilize her thoracic spine then that's not going to
00:22:4500:22:50
work very well. Now I showed you a bunch of techniques we did central PAs which I
00:22:5000:22:55
used this grip, could you use a two thumb technique? Of course, you could do this
00:22:5500:23:00
thing. Again you know that personally my feeling is if you can get
00:23:0000:23:06
away with not using your thumbs for any technique don't use your thumbs
00:23:0600:23:10
because there are techniques like I said where you pretty much are stuck only
00:23:1000:23:15
with being able to use your thumbs, for example unilateral PAs you are kind
00:23:1500:23:20
of stuck on this technique. You could try to do the unilateral over a different
00:23:2000:23:24
finger but it doesn't feel very comfortable. Alright so we tried central
00:23:2400:23:31
PAs with the pisiform hamate grip right which i said was like this, and that
00:23:3100:23:34
worked out pretty well, Then we did bilateral PAs which would have a very
00:23:3400:23:40
similar effect to a central PA but we did that with two fingers, those two
00:23:4000:23:43
fingers of course would end up higher if we were trying to do the same
00:23:4300:23:48
segment, and then I used this hand over those two fingers and that can come in
00:23:4800:23:53
handy, that can definitely come in handy. You feel like you're just not getting it,
00:23:5300:23:57
maybe the the angle of the spinous process on this person is just messing
00:23:5700:24:01
you up, or they're really really thick or maybe they're really really tiny and
00:24:0100:24:06
this just isn't comfortable, okay let's try this technique. Then we talked about
00:24:0600:24:12
unilateral PAs all right and then we just did our thumb over thumb oh that's
00:24:1200:24:17
a that's a nice stiff facet right there. Okay and then of course with all
00:24:1700:24:22
these techniques we found our resistance barriers 50% all the way down at end
00:24:2200:24:27
range, our first resistance barrier I should say end range
00:24:2700:24:30
of arthrokinematic motion, I can't press this joint any further and then
00:24:3000:24:37
back off the 50%. Then I can either go zero to 50/50 plus, or I can stay at
00:24:3700:24:43
50/50 plus for a grade four, so that's my unilateral PA. We did talk
00:24:4300:24:48
about doing like a dummy thumb and pisiform for that, you could do that. Just
00:24:4800:24:50
be careful not to beat up on your thumbs too much
00:24:5000:24:53
all right this can be a little uncomfortable too. Then the last
00:24:5300:24:57
technique we talked about was transverse mobilizations which do tend to come in
00:24:5700:25:03
handy for the thoracic spine, especially the upper thoracic spine, right and with
00:25:0300:25:07
that you'll notice I'll get the table as high as I can because I really want to
00:25:0700:25:11
be consistent and try to create or a horizontal force this way. So that
00:25:1100:25:17
hopefully all I'm doing is tipping essentially the vertebral body there. We
00:25:1700:25:21
don't want to be inconsistent and start creating oblique angles that are going to
00:25:2100:25:29
be this quasi turn, quasi PA, quasi frontal plane smash into the other facet
00:25:2900:25:34
joint. Although that can be a great technique right, there are things
00:25:3400:25:39
called super close techniques right for facet joint mobilizations. The big thing
00:25:3900:25:42
is whatever you're going to do you got to be consistent. So if we're going to do
00:25:4200:25:47
transverse mobilizations let's truly be transverse. You're going to pick up all the
00:25:4700:25:52
slack on the skin around it you're going to use that dummy thumb, and then with your
00:25:5200:25:56
other thumb you're going to push straight this way. Like I said guys you can see
00:25:5600:26:00
that I'm up in her upper thoracic spine or cervical thoracic junction, this is
00:26:0000:26:05
where I find I use these particular techniques most. Part of that might
00:26:0500:26:10
just be because I can then come around this way, and what I'll do is I'll go
00:26:1000:26:15
here's one spinous process let's say C7, here's another spinous process T1, and I
00:26:1500:26:22
can do this thing to them, and I can actually check how mobile they are.
00:26:2200:26:26
So let's see, I feel stiff, that feels a little stiff. Alright let me get set up,
00:26:2600:26:32
do my mobilizations and then I can retest.
00:26:3200:26:37
I know palpation may be my least reliable assessment, but while I'm doing
00:26:3700:26:41
my manual work here for a few minutes I can kind of keep retesting and working
00:26:4100:26:46
different facets, and then I can have her sit up and do whatever my more
00:26:4600:26:51
reliable assessment, in this case maybe goniometry for lateral flexion,
00:26:5100:26:56
or whatever I found to be her concordance sign, whatever test provoked
00:26:5600:27:00
her symptoms I could go back to that. Alright guys so there you have it,
00:27:0000:27:04
work on your palpations, know your thoracic anatomy and then start slowly
00:27:0400:27:11
working through central PA, bilateral PA, unilateral PA, and transverse
00:27:1100:27:15
mobilizations. Stay tuned for the close-up recap. Now close-up recap guys
00:27:1500:27:20
here I have Melissa's thoracic spine down this way. We talked about finding
00:27:2000:27:25
the first thoracic vertebrae by finding spinous prominence at C7 which is right
00:27:2500:27:31
here, and then this is T1. So you can tell if move this way
00:27:3100:27:36
hopefully you guys can see my finger kind of bump up and down, and you can see
00:27:3600:27:40
that if I depress my fingers I can go right around a spinous process just like
00:27:4000:27:45
so. So that's how I'm going to identify these spinous process. I can
00:27:4500:27:49
move out a little bit and I find another big bump right here this would be the
00:27:4900:27:53
edge of a transverse process, and if I fall off that I would get into the
00:27:5300:28:00
ribcage. So spinous process, transverse process, ribcage. Between my
00:28:0000:28:04
spinous process and transverse process are those facet joints I'm going to want
00:28:0400:28:09
to be able to get into. Now let's talk about our hand positions here again. So
00:28:0900:28:15
we did central PAs, and what I did there is I found a spinous process I put my
00:28:1500:28:21
pisiform hamate part of my hand over that spinous process, I saddled with the
00:28:2100:28:26
other hand, got my arms straight, my chest over and then of course found first
00:28:2600:28:32
resistance barrier and range backed off to 50%, and I could do my grade 3s which
00:28:3200:28:37
are my larger amplitude, or I can go a little more intense and do my grade
00:28:3700:28:43
fours which are small amplitude. And we talked about bilateral PAs which is
00:28:4300:28:48
where I'm going to get my fingers over two facets. Now if I wanted to mobilize
00:28:4800:28:53
the same segment I have to realize that the facet for this spinous process is
00:28:5300:28:57
actually probably closer to like up here, and the way I'm going to find that is
00:28:5700:29:04
I can go up two spinous process and then fall lateral and inferior, or I can do a
00:29:0400:29:07
little transverse mobilization with this hand
00:29:0700:29:13
alright you guys see that, and I can wait to see, move my thumb around, until I feel
00:29:1300:29:17
the facet joint under that thumb move a little bit. I got right there
00:29:1700:29:24
right there I feel if I push on this spinous process this moves. So
00:29:2400:29:29
that's a little check for you guys. Now I can do my bilateral PAs first and we
00:29:2900:29:32
talked about this hand position right like this and then putting this hand
00:29:3200:29:35
over like this, once again straightening out my arms,
00:29:3500:29:41
torso over the place I'm trying to, or chest over the segment I'm trying to
00:29:4100:29:47
mobilize, and then I can do my oscillations. We did unilateral PAs which
00:29:4700:29:55
is thumb over thumb all right same thing, and then of course we did transverse
00:29:5500:29:59
mobilizations here and these are the special ones right, so this one is where
00:29:5900:30:03
I would normally raise up the table and then I would try to get my arms
00:30:0300:30:10
horizontal, and I'm actually pushing that way. So I have to take up a little
00:30:1000:30:13
tissue slack, you see how I did that I took a little tissue slack I just
00:30:1300:30:18
kind of ran my finger over the top of the spinous process and then
00:30:1800:30:24
this becomes my dummy thumb. I'm going to push with the other hand transverse just
00:30:2400:30:28
like so. Alright guys have fun practicing. So there you have it
00:30:2800:30:33
assess, address, reassess. Make sure that every time you choose a joint based
00:30:3300:30:38
manual therapy technique it is based on an assessment, and that you return to
00:30:3800:30:41
that assessment after you've finished the intervention to see if it was
00:30:4100:30:46
effective for the individual, the patient, or client that you have in front of you.
00:30:4600:30:51
Ensure that you continue to learn your Anatomy because your Anatomy is going to
00:30:5100:30:56
help you with your hand placement, with understanding what a joint can do, with
00:30:5600:31:02
understanding what you may gain from this particular technique, and of course
00:31:0200:31:07
practice. You have to practice these techniques hopefully not for the first
00:31:0700:31:11
time on a patient, client who just walked in the door. If
00:31:1100:31:15
you can find a more senior instructor or a mentor to give you some really good
00:31:1500:31:22
hands-on instruction, use your peers for some good feedback, and of course always
00:31:2200:31:29
look for live education to help with your manual therapy techniques. I know
00:31:2900:31:34
these videos make education very convenient but there is no substitute
00:31:3400:31:39
for learning manual therapy in a live setting. I look forward to talking to you