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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 the upper
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cervical spine manipulations. I'm going to have my friend a Yvette come out, she's
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going to help me demonstrate. Now keep in mind if I'm doing a manipulation I'm
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doing it as part of an integrated intervention routine that's going to
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include things like soft tissue techniques and exercise, and of course
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follow up with a whole exercise program and I'm basing this on more than just
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subjective assessment. Although upper cervical spine manipulation we might be
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able to think symptoms would be cervical spine or maybe cervicogenic related, we
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still want to have movement assessment to be able to reassess if we had any
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effectiveness. We're still going after stiffness in these joints so don't
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forget about your visual range of motion exams with like rotation, flexion-
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extension, lateral-flexion, maybe lateral-flexion goniometry.
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I know your upper cervical segments don't laterally flex much, that doesn't mean that
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stiffness in the upper cervical spine won't change muscle activity enough to
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affect lateral flexion goniometry, and then two ranges of motion to think about
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a little bit are jut, or forward head, and nod or chin tuck. If
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somebody can't get to the ends of range of motion for these right,
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the very extreme end range of motion, they're restricted, that's a good sign
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that some upper cervical stuff is going on, because it's your upper cervical
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spine that allows you to extend your head as your lower cervical spine is
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flexing, and then as your lower cervical spine is extending it's also your upper
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cervical spine that allows you to tuck your chin. So these two ranges of
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motion can be very indicative of upper cervical spine restriction outside of
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just like maybe rotation. Now before we go into this technique, a teaching tip if
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you're new to manipulations, don't start here. Go ahead and go back to our
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cervical manipulation video, in that video I go over mid and lower cervical
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manipulations. Those techniques are much easier for several reasons, including
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blocking out the lower segments is easier because you have more to grab on
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to, finding the lock out position is easier because there's more motion to
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work with, and then actually getting the manipulation is a little easier because what
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your palpating during that is not so small. I think if you started here you're
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going to have a hard time palpitating what you need to palpate, moving in the tiny
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ranges of motion that you need to move, and feeling that walkout position is not
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the easiest thing in the world on this particular technique. Now to get into
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this particular technique I can tell you that if you're familiar with the
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cervical manipulation video we're still using this basic motion. So that's
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lateral flexion away, rotation toward with a little extension. Some differences
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we're going to do a little bit more of a forward head jut, we're also going to do
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a little bit more of a side glide than just pure lateral flexion. So
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before we get into the extension thing we need to come
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into this forward head position. Before we just laterally flex we want to side
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glide as much as we can. Now other weirdnesses, rather than being
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able to use, yeah I made up a word weirdnesses, all right
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second MCP, rather than being able to use my second MCP to lock out the spinous
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process and then bend over it to find locked position. I could only do that if
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I'm C2 and up, right because C2 has a spinous process but C1 doesn't. So
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maybe you want to try second MCP, find the highest spinous process, you can try
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to get your MCP there, jut, side bend and then you know I use cradle grip on
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my cervical manipulations. You could use open hand if you want to, but since I use
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cradle grip on my other manipulations I tend to like to use it here. Once I get
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side glide, jut, blocked out for C2 then I could side-bend then rotate a little
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bit, maybe a little traction I find helps, get her all locked up and then I can do
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my manipulation. But here's the tricky part what if I need to do C1, what if I want
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to do C1 on the occiput, right the atlanto-occipital joint, the a/o joint. I
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don't have a spinous process to use my second MCP on. I need something else, and
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the way to go is to block the transverse process of C1. Now if you've never
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palpated the transverse process of C1 it is just underneath the mastoid process.
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So here's what I'm going to recommend you do, find your earlobe, find your mastoid
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process, go just underneath your mastoid process if you don't feel a bump like a
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peg coming at you into your finger side bend away, and that transverse process
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should pop right into your finger. Once you do that on yourself try
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that little trick on hopefully your friend or colleague
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when you start, not a flared up patient I do not recommend practising these on
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flared up patients. So there's her transverse process of C1 right there,
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transverse process of C1 right there, right underneath each mastoid process.
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Great, so now I know what they are what do I do with them? Well what I'm going to
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do is if I'm trying to do a manipulation on this side, I'm actually going to wrap my hand around
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so i can use a comfortable hand position, because I'm usually using that second
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MCP. But this time I'm going to use my middle finger, and I'm going to push it into
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the back of the transverse process of C1, and push up this way to block out that
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vertebra. So that when I go to do my manipulation, this is blocked and I'm twisting
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on this blocked out vertebra. So the way that would look is here,
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find my transverse process, I can use both hands
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you got it locked in. Now I can use this palm to help control her head a
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little bit. Alright I can get into my quasi-cradle grip here, jut, side-bend,
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good. Now I can laterally flex, rotate, extend or flex, and I find a little
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traction helps a lot, and once I get her all locked up right if I feel like she's
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tense I'll have her do the breath thing.
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Breathe in, breathe out and then rotation is my primary movement, just like that.
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You notice I just tip. Alright so I tipped here, I did keep pressure with my
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forearm against her head right so that I got a little bit of lateral flexion too.
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At the very least when I rotated I don't want her coming out of lateral flexion.
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I'll show you what that looks like on the other side. All right so I'm going to
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find her transverse process, and remember you can use both hands. It's okay, take
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your time. Setup is 99% of this. I keep saying 90 in
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the other videos, I think 99% is where it's at, because even when I'm watching the
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videos I'm like I spent 15 minutes talking about setup, and the actual manipulation
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was nothing. So there's her transverse process, I'm
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going to make sure my fingers there right I can use this palm still to help control
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her head a little bit. I'm going to use this kind of quasi-cradle grip here. I'm
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going to jut a little bit, side glide this way, all right so I'm kind of, you
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can think of like kind of opening up the joint that you're trying to manipulate, side
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glide, rotate this way, lateral-flexion some extension on this side, I'm just
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kidding we're going to save that one for the close-up recap. So there you
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have it C1, fingertip via transverse process, C2 you can use your second
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MCP just like you did on the mid-cervical techniques. The only difference
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is it's harder to get on that spinous process because it's so close to the
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occiput, and you have to jut and side glide first to really make this technique
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work for you. Stay tuned for our close-up recap. For the close-up recap
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I'm going to show you the atlanto-occipital joint manipulation. I think you
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have the blocking of C2 with your second MCP down pretty good, but
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this ability to block out the C1 transverse process with the middle
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finger is a little complicated. So my suggestion is use both hands to find
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first the mastoid process and then the transverse process of C1, and you
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can use a little lateral flexion away to have that poke you right in the
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finger, and then I'm going to use this finger to get underneath that transverse
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process so that I can really get underneath it and like block it. Like
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right now I can, not that this would be great technique for a mobilization, but I
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can literally mobilize C1 on her occiput. Alright so if I feel like I got
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that type of purchase, that's when I'm ready to do this manipulation. So now I would
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jut, alright so pull her into a little bit of this forward head position, and
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I've removed the pillow this time just to make it a little easier for you
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to see. I'm now going to side glide towards the camera,
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alright so towards you and I'm going to try to use open hand technique
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here so you can the motions that I'm doing, because if I
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do cradle grip this close to the camera I'm going to block everything. But I'm going to
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keep my finger there, forward, side-glide, lateral flexion, rotation, get
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her all locked up; and then once I know I have her locked up maybe a little
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traction, and I can just rotate, and that's the manipulation. All right so I'm not
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quite as good as that open hand technique, for me and be a little bit
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more comfortable to get in here. Remember you're only going to go ahead and do your
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high-velocity thrust when you feel lock, and deep breath, and just like so. All
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right so a little scary for Yvette there, but no pain right. All right
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so practice that, remember you have your fingertips here, that you have to
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block the joint out with. A little bit of forward, a little bit of side glide, and a
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little bit of traction really helps with this technique, which then you can do
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your normal cervical manipulation motions; and then I would
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say the other big difference with this manipulation is it's almost totally a
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rotation for the actual manipulation. If you have any questions leave them in the
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comments box below. 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. Nost 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 it
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is based on assessment, and then of course that you're
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reassessing, ensuring that the technique is effective for the patient that you're
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working on; and when it comes to all manual techniques, manipulations
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maybe more than any other, look for opportunities to get live education.
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Although I know videos are convenient and I'm happy to have these up for you
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to watch, it would be so much more helpful to use those videos as a recap
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of one-on-one attention with somebody who's experienced with manipulation
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techniques. At the very least grab a colleague and grab a friend, and start
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practising these before you bring them into clinic and start using them on
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patients and clients. I hope you enjoyed this video, if you have any questions