This is Brent of the Brookbush Institute, and 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
cervical manipulation, or at least mid to lower cervical manipulation. I'm going to
have my friend Yvette come out, she's going to help me demonstrate. Now if I'm
doing a cervical manipulation we do have to keep in mind that I'm basing this on
more than just subjective complaints of neck pain. We can have neck pain for
hypermobility of cervical segments, if we're doing manipulations it should be
for hypomobility, or some sort of restriction. So I'm going to base this on
some sort of assessment for range of motion, for example we could do our
visual exam of rotation, lateral-flexion, flexion and extension. I might try to add
goniometry, keep in mind the only reliable goniometric assessment for the
cervical spine is actually lateral flexion, and you can look that video
up. Now you might want to continue with some special tests, if you're going to do
this, the VBI and ligament tests are often brought up as necessary before
doing a cervical manipulation, that's probably more dependent on what your
liability insurance states or what insurance companies you're working with
state have to be done; and the reason why I say that is
there is very little evidence to suggest that those tests themselves are
particularly reliable, or that they would give us any indication of somebody who
could be hurt by a cervical manipulation. So I think cervical manipulation
injuries are rare, and that's possibly the most important thing to keep in mind.
If somebody does look like they need this technique due to a mobility
restriction you should probably move ahead and do so with care, and obviously
with practice, and we're going to try to show you some pretty conservative
techniques here. Now after I've gone through my assessments, whether that's
subjective, objective and special tests including VBI, or it's subjective and
objective alone, I'm going to go ahead and have Yvette back off the table here so
our heads hanging, so that now I have control of her head and cervical spine;
and the next thing I'm going to do is I'm going to use what's called a piano
finger grip, I like the Maitland school where I'm going to put my fingertips
between her spinous process. So you can think of her spinous process are
lined up this way and I'm trying to put my fingers just in between, and what I'm
going to try to feel for is, do the spinous process move sequentially, right almost
like dominoes falling they should go tic tic tic tic tic; rather than what
you'll feel with somebody who has restriction, is you'll get one that moves
and then maybe two or three that move together. Or you pulling the
lateral flexion and it's the same thing, where you get one that moves and then a
bunch that move together. Well you know those segments that are stuck together
are potentially something that could be helped by a cervical manipulation. So I
can do this with Yvette here a little lateral flexion, a little rotation and I
can do both ways, and I do feel a little restriction over what's probably between
C3 and C5, so those two segments. Now how am I going to manipulate those
segments, well this was a little confusing when I first got
taught it, but I think part of the reason why it was confusing is nobody really
helped me understand that the most important thing about a cervical
manipulation is finding the lock out position. Finding that position where you
have all of the joints locked, so that when you do the actual manipulation
motion the only thing that can move is the segment you're trying to move and
that comes down to two big things, well maybe more than two big things, but
two major things are going to be that you block out the lower segments and that
you get in locked position with the top segments. So what we're going to do is we're
going to use our second MCP on the spinous process just below the segment we feel
restriction. You don't even have to necessarily know which segment that is
to be quite honest. Some people get very detail-oriented about while I'm
manipulating C4 on C5, or you could just feel for the stiff segments and go after
that, your accuracy is probably pretty similar either way. So I'm going to put this
MCP on the spinous process of the lower segment and press it into the articular
pillar. So you can see I
start to take up some tissue slack by pushing my MCP in this direction,
I'm already stabilizing making sure that those lower segments when I rotate this,
side-bend or extend, I'm resisting all of those motions at anything lower than
this MCP. Once I have that stabilized I'm now going to use this hand, and you can
either use an open hand technique which I'm a little less comfortable with quite
honestly, or you can do head cradle position. So now I have her head
cradled in my elbow crease there, most of what she's feeling is like my bicep on
the top of her head. I can almost control all of it just by doing this. I'm
literally just cradling her head so she feels nice and comfortable and
stable, and then we're going to wrap our hand around her chin, but keep in mind
I'm not like yanking on her face. So I have just got her all wrapped
up so her heads nice and stable, and then once she's nice and relaxed. Now
I can move around a little bit, ninety percent of this is set up. So I
know some of you are waiting for me to do the manipulation, just show me the manipulation,
we got to get it to crack. That's literally the last 10%, and
potentially the least important point because if you lock somebody up perfect,
a lot of times they'll move on you, you'll get a cavitation without even
having to do a high-velocity thrust. So I'm blocking out those lower segments
here up this way. I'm then going to rotate away, I'm going to side-bend
towards me. I'm going to extend and flex and you can see now once
I rotate, side-bend and extend and flex then I search; and what I'm
searching for is if I push up here, or push sideways here or rotate sideways
here, I'm moving her head in this general direction. Get used to that
general direction, you don't even have to think joint actions. So I know you might
be like, well you've got a contralaterally rotate and ipsilaterally
flex and extend. That's all great, but if you just think about this
general motion, and this general motion here, and get all locked up which I am
right now. Now all I have to do is a little lateral flexion and rotation and
I guarantee she's going go. So nice deep breath Yvette,
and that's it. Sometimes it is a surprise to patients. Not everybody is used to
getting their cervical spine manipulated and I appreciate that Yvette is
letting me do this for the first time, because she is not somebody who gets
cervical manipulations done very often. But
that wasn't that bad, no pain. You can see I didn't
move that much, it was more of a startle response than it was any sort of like
pain response. We're definitely not doing big whips this way, or trying to
press in really hard, it's just getting that lock and then just a quick
twist; and I think you have seen chiropractors doing it with the open
hand technique which looks a little bit more impressive. but they just wrap,
it's a very quick little technique. So let's try that one more
time, I'll show you from the other side. I'm going to use this knuckle, I'm
going to get on the spinous process of the segment just below where I think she's
stuck. Now I could use an open hand technique, and I'll show you the
open hand technique this time. So I'm still blocking this way and I'm
still thinking about pushing up in this direction, because I want to
oppose the lateral flexion this way and I want to oppose the rotation I'm going
to do. So I'm trying to keep the spinous process below in position, which
means I kind of have to push up and in this way towards the articular pillar,
kind of in the direction of my thumb right now. Now I can use this hand kind
of wrapped around, you can see like I got my thumb up to her maxilla here and I'm
just wrapped around her head, and I have some some big hands. So it kind of
depends on your hand size too where you're going to end up
as far as your fingertips. So don't look at my hands and be like oh that's
how it's got to be look, you get your hands where they're comfortable. But
if I think about the same direction of motion, yes we can think about
it's the lateral flexion and contralateral rotation and all that
stuff, or you can think of, you're doing this with her head. You're doing
this general motion with her head and you can add a little bit of this to get
locked out. Once I'm locked out I'm here, and
then she takes a nice deep breath for me and all I'm going to do with my hands is
this sort of thing, because I'm going to push her into lateral flexion and
rotation this way, which means I'm going to slide my
hand this way to get that motion. How you feeling Yvette? Okay good, and that's it.
Sometimes you get a cavitation, sometimes you don't. Never forget
cavitation does not mean success. Success is performed better on reassessment, the
manipulation is the manipulation regardless of whether you got a
cavitation. It could be that I didn't get her locked up enough on that particular
try, or it could be that I got it. I would still reassess first before I gave this
one more try, be careful not trying to get a cavitation too many times because
you think you failed, because what you will do is you'll start to flare people
up. We do have to keep in mind that high- velocity also means high-intensity, and
if we keep doing a high-intensity technique to a tissue over and over
again that maybe is already a little irritable,
we could start increasing pain rather than reducing pain. How do you feel Yvette?
Why don't you sit up and take a minute and we'll go to the close-up recap.
Alright for a close-up recap I brought out the spine model, I wanted to
show you some of the stuff we were talking about so you have a little bit
better visualization. So if this is the back of the cervical spine that you
would be feeling, the first thing you're going to feel is those spinous process and
when I talked about that piano grip I was talking about putting my fingertips
between the spinous process, so I could feel them move sequentially like
one, two, three, four. They should just each move like little
dominoes falling, and when two spinous process move together that might be an
indication that I have a little bit of restriction between those segments, so I
use that piano grip for that. All right that's what it would look like from
the other side, and of course then I'm rotating and side-bending. When I talked
about putting my second MCP against the spinous process, realise
I'm trying to fit it in this laminar trough, almost trying to put it on these
articular pillars; and you can see here the articular pillar is called that
because when all these facets come together they kind of make this like
pillar shape. But somewhere between the articular pillar and what this would be
called would be the laminar trough, is kind of where I'm trying to fit my first
or my second MCP so that I stabilize the lower segments. Now if I have Yvette go
ahead and come back here, I'll try to demonstrate for you guys one more time
in a close-up here. So piano grip, what that would look like on her neck is
I would feel my spinous process, and then I would just slide my fingers over so I
was on the side of my spinous process, and then I can laterally flex and rotate
and see if any of those segments seem to want to move together rather than
sequentially; and then once I find some segments realize that I'm going to then
try to place my second MCP right up against that spinous process, or the
spinous process that's lower than the stuck segment. Once I have that set up
then I'm going to rotate away, laterally flex towards, but we're talking
about kind of bending her head or bending her neck over that second MCP;
and then once she's there and I'm nice and locked up, take a deep breath, I can
give her a quick little rotation and lateral flexion thrust. So this, and if
she's locked up properly and we hadn't just done a manipulation on the previous
take of this video which you just saw,
she probably would have got a cavitation on that one. But keep
in mind that cavitations don't mean success, changes on reassessment mean
success. I hope you found this video very helpful. Grab some friends in
practice, and if you have any questions leave them in the comments box 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, manipulations may be 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 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 practising 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.