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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
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course where's the spinous process? Right down the middle, make sure you can feel
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all those, make sure you're very aware that the facet and the end of the
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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