This is Brent of the Brookbush Institute, in this video we're going to go over
manipulations or high-velocity thrust techniques. I assume that if you're
watching this video you're watching it for educational purposes, and that you
are a licensed professional with high- velocity thrust or manipulation
techniques in your scope of practice. If you are not sure check with your state
board. Most physical therapists, chiropractors and osteopaths you're in
the clear. I believe that ATC's you can't do manipulations in the United States,
although other countries again check your scope. Of course massage therapists
and personal trainers these are generally not within your scope. Of
course you could continue to watch these videos just for educational purposes,
learn a little Anatomy, learn a little biomechanics. If you're going to do these
techniques please make sure that you have a good rationale for putting your
hands on a patient, this should be based on assessment, and if you're going to
assess I'm hoping that you'll assess, use these interventions and reassess to
ensure that you're getting the result that you're looking for and have good
reason to continue using this technique. In this video we're going to go over the
thoracic pistol manipulation, I'm going to have my friend Yvette come out she's
going to help me demonstrate. Now keep in mind if I'm doing a thoracic
manipulation I'm basing it on more than passive accessory motion. I have
subjective complaints, maybe a Yvette has shoulder pain, I've followed that up with
some sort of movement exam like the overhead squat assessment. Maybe on the
overhead squat assessment I saw arms fall and scapular elevation. I like to
have a continuous interval measure so that I can measure progress,
unfortunately with the thoracic spine goniometery doesn't work very well,
it's not very reliable. So maybe you could look into some of those rotation
tests and at least have some sort of visual indicator of pre and post
intervention, and then the last thing we're going to rely on is actually our
palpation skills. So the things that might want to palpate for here, of course
I could do my PA's with my pisiform hamate grip, like a central PA on the
spinous process and look for any stiff segments or painful segments. Painful
segments might be a reason not to do manipulation, keep that in mind. But if I
find some stiff segments that might be a reason to do
manipulation, and as I'm doing these all I'm doing is I'm taking
PA, and you can look up these mobilization videos this is just a
thoracic PA, taking it all the way to end- range. Does it feel stiff to me, I can
talk to Yvette, hey how does that feel Yvette? Pressure right, a lot of pressure.
Generally the thoracic spine you have to push pretty hard, there's probably a lot
of inherent stiffness in the thoracic spine just because of all the rib joints
too. So there's a lot of connective tissue and a lot of joints throughout
this segment of the torso. Any pain there? What I start to notice as I'm going
through the spine here, I won't waste your time going through
the whole thing, but as I go through this I notice that she is real real stiff in
this area. So I'm going to want to take a mental note of this is where I feel
increased stiffness. I could also check for increased tissue density,
that might be an indication of over activity, and of course I could do some
like general spring type testing rather than like a PA, just to see if I feel
like anything and the ribs, do I feel like, once again this segment definitely
feels different than like when I press down here. You okay? (Yeah). Now the
pistol manipulation itself is face up, so we're going to go ahead and have Yvet roll
over, and then I'm going to show you how to set this up the best way I can.
This is definitely one of those techniques where people get caught up in
the minutiae and then they get all freaked out and then they stop thinking
about just doing the technique alright so scoot down a little bit more one
thing you guys want to watch out for for your own hands alright because what
we're gonna do is make a fist underneath the vets back is you don't
want to be on seams right or or creases in your table so I want to make sure
that the portion I'm gonna manipulate is on a nice flat seamless surface the next
thing I'm gonna ask a vet to do is I'm gonna have her interlock her fingers
like this and then put them at the base of her neck because what I'm gonna use
her arms for is controlling her torso now I guarantee this is gonna happen
everybody is gonna do this so go ahead and show them and then they're gonna
you're gonna go put it on your neck and they're gonna go like this but at the
bottom of their head and then they're gonna lay down and you're gonna try to
put their all those together and squish their face we don't want to squish faces
besides this is just not as easy to control but I see it all the time so
again right here right so you guys all I'm doing is interlocking like my
fingers go down to the edge of my other fingers not crossing like this and then
go all the way down to the base of your neck and now when I bring your elbows
together you miss your face and of course I have good control over your
torso notice her head comes with us I can rotate away which when I do this
technique I tend to do this way I will show you guys the other method as well
now from here what I want to do is I'm gonna wrap one hand around forearm like
this and then you notice my wrist and my other form kind of keep her elbows
together pull away I'm then gonna take my fist and place it right over that
stiff part of her spine now the goal is to put the segment that I want to
manipulate just above my last knuckle the reason this is called the pistil
manip is you can do it this way all right like you're making a pistol with
your hand right I like to do it this way and it doesn't matter all that matters
is is this is the last segment that you're bracing and this segment right
here is the one that gets manip we're in essence shearing one vertebrae over
another so yeah go ahead she's stiff up in this area
I can feel for her her spinous process I'm gonna put the spinous process right
here right between my feet our eminence and my ip's I'm then gonna
just bring her over the top of my hand now I have had many a patient with a
nice setup like this who as soon as I drop them back I get a cavitation right
again setup is everything so be comfortable
make sure you have spinous process right here stiff segments of the spine here
make sure you're both comfortable what you're gonna do is as you're laying your
hand down it helps to push a little in this direction I'm gonna lay my chest
kind of over my forearm here sorry I'm gonna lay my my my chest over and then
all I'm gonna do is have a vet take a nice deep breath I'm gonna and as she
breathes out all the way to the end I'm gonna give a nice quick push and that
was it in that particular case I actually felt the vertebrae move but
there was no cavitation big thing to remember guys that is a successful
manipulation cavitation does not mean success increase range of motion on
assessment is success and whether you get a cavitation or not it doesn't
really seem to matter so now let me give you guys a couple tips going back
through that I have no problem with my hands creating this type of fist putting
her spine like this or spinous process like this and pushing down some people
don't like how that feels on their knuckles so they do this thing they
either grab a pencil or a vet here was nice enough to lend me her lip stick
something I don't particularly carry on a regular basis but I've seen people use
chapstick I'm only gonna give you one bit of advice once you find something
that works for you keep it on you because if you get used to this and
switch to this I guarantee you're gonna have a problem with your setup if you
get used to this and switch this same thing if you get used to
adding something in your hands going without anything in your hand is gonna
feel a little weird the setup would be the same let's go ahead and have you
okay the setup would be the same it still put her spinous process between
but now I can feel like I can't crush my own knuckles I do think in general this
over complicates things I don't think it's necessary for most
individuals I think people just get hooked on it in the beginning when
they're learning this technique because they're not real comfortable with their
setup so they tend to spend a lot of time over the top of their knuckles and
then since they're spending a lot of time with us hock of their knuckles it
gets really uncomfortable now if you're not larger than the person that you
happen to be working on there is another way to do this which is hand from the
same side under now every all of the same stuff would still apply so let's go
here she comes here and then all I would do is turn her this way right so turn
her away from me I would take this hand put it under her spine and then flip her
back and the same technique applies right now for me this is a little
uncomfortable because this is not the way I actually do this technique
personally but once you get set up you can see how my fist visit is still in
the same position and now all I'm gonna do is push down this way kind of in that
direction again it's a nice little clinical gem guys it's not straight down
it's go that way with your force right it'll work the same way last variation
you guys might want to try is I have seen this done this way okay I find it a
little harder to control the torso this way but if I was gonna do this I could
still grab her elbow set myself up and now I'm kind of like trying to figure
out how to position my torso and it with a little bit more of like her this part
kind of like here on my ribcage but again the setups the same this
just not as intense on the client shoulders I think all of this once again
guys is really dependent on whatever setup you get good at do I think it's
great to experiment in the beginning but then once you have a technique that you
go to I would just keep going to it because I think a lot of the little
again minutiae of this hurts my knuckles I can't reach my arm around this hurts
the patient's shoulders what that's really a complaint of is it takes you a
really long time to set up because you're not as well practiced as you
should like if I do the pistil minutes go ahead and do the pistol one up one
more time to review here here my clients get used to it
great I'm here I know I want to be ready nice deep breath good and that was it
right so that took took a few seconds I'm not suggesting you do things in a
hurry what I'm suggesting is you practice enough that you can kind of go
into a flow with this particular technique guys stay tuned for your
close-up recap all right guys for the close-up recap I'm gonna go ahead and
have a vet change from this arm position although this arm position for some
people is very comfortable when I have you go ahead and do the little
interlaced fingers at the back of the neck right and remember we go to the
base of the neck so that I'm not squishing her face and then from here I
can use my hand over one forearm and then I actually use my wrist on the
other side of the other forearm so that I have control and I'm gonna pull of
that a little further away than I normally would now you could go the
other way don't forget guys like whatever is your comfort zone like
whether you're gonna wrap around you're gonna come from the same side you're
gonna do this arm position or the other arm position just make sure you get
comfortable the technique is still the same we're still gonna use our fists to
go on either side of the spinous process and then shear the top
Debray over the vertebra we have stabilized all right so what I'm gonna
try to do is I'm gonna feel her spinous process and try to put them right there
you know this IP is gonna be on one side my thinner eminence on the other I'm
gonna try to set this up if you guys prefer this technique then it would be
to set this up as just below the segment that I want on the nip and then I'm
gonna pull her into as much flexion as I can lock her out by going into flexion
with cranial force at that segment so you get this kind of combination of
flexion with extension against your hand just gonna pull up this way feel those
spinous process there they are
check alright maybe there's a little farther be careful it's real easy when
you're not looking I just I caught the end of the ribs there thought it was on
the spinous process double checked and now I'm on the spinous process so I'm
gonna get my hand wrapped around now my hand is there now keep in mind the
direction of my force is more or less gonna be in the direction that her
forearms are currently in alright so if I just kind of follow the direction of
her forearms so anybody set all the direction of our forearms big deep
breath
and that's it guys take your time to get set up make sure you practice this often
and then whichever elbow setup you want hand setup you want whether you want to
put a pencil or or chapstick in there whether you're gonna wrap around or same
side just get used to it practice it if you have any questions leave them below
a couple of points to recap knowing your anatomy and knowing your biomechanics
will certainly help you choose the right technique for the right patient if
you're unsure whether manipulations are appropriate due to their higher
intensity it's okay to do mobilizations most research points to manipulations
being slightly more effective but mobilizations being very effective and
of course we have those videos for you if you want to start with those less
intense techniques make sure that if you are doing any technique that is based on
assessment and of course that you're reassessing ensuring that the technique
is effective for the patient that you're working on and when it comes to all
manual techniques guys manipulations maybe more than any other look for
opportunities to get live education although I know videos are convenient
and I'm happy to have these up for you guys to watch it would be so much more
helpful to use those videos as a recap of one-on-one attention with somebody
who's experienced with manipulation techniques at the very least grab a
colleague grab a friend and start practicing these before you bring them
into clinic and start using them on patients and clients I hope you enjoyed
this video if you have any questions please leave them in the comments box
below
you