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 assessmen,t 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. This video we're going to go over the
cervical thoracic junction manipulation or upper thoracic manipulation, that area
between C6 and we'll say T4. I'm going to have my friend a Yvette come out, she's
going to help me demonstrate. Now keep in mind if you're doing manipulation
techniques you're doing them to increase mobility, not just based on subjective
symptoms but also based on objective signs. So in this case I would probably
use something like cervical lateral flexion. Cervical lateral flexion
goniometry is reliable although some of our other cervical goniometery
assessments are not so reliable, and then i might try to find a thoracic rotation
test that works well for reassessment. The last thing i would rely on is
palpation, now i generally do two types of palpation with this particular area.
I'll do my P-A's like I do when I'm doing mobilizations, and then I'll do this
rotation palpation that I learned from the
the Maitland workshops. So the P-A's here, you're going to go thumb over
thumb or you can go your pisiform hamate grip, whichever you find more comfortable.
Generally I find that I'm in this position when I'm working with neck and
and upper back patients like this. So to go thumb over thumb is a little bit more
convenient, and I'm just going to press all the way down to arthrokinematic
end range and feel how these segments feel compared to one another,
and compared to that internal model that I've built up over time with experience
pressing on a lot of necks and upper-thoracic spines. I'm going to try to give
myself a little bit of an indication of how stiff this area feels. Of course we
could add another layer of this and go, hey Yvette how does that feel? Okay so
that feels fine, that feels fine. We might get a little additional information like
what if one of these segments is not only stiff it's actually part of the
dysfunction that's causing her symptoms or complaints, and I can kind of go on
through and do these P-A's. Now what I'm feeling with a Yvette is she definitely
feels pretty good in her cervical spine as as far as motion goes, but then as I
start moving down C6-C7, C7-T1 and then like C7 to T3, it's like really
stif, it's actually really hard to get arthrokinematic motion. I don't think
that's normal, I think that's an abnormal level of
stiffness that maybe indicates I should do this manipulation technique. Now
before I do this manipulation technique I've found that this rotation assessment
that I learn from these workshops works really good and helping me determine
which direction I should go, and all I'm going to do is I'm going to take my thumbs
like so and put them each on a spinous process and rotate the spinous process
in the opposite direction. So we'll go this way and then this way
right. So I went this way and then this way. I rotated the upper segment
to her right and then to her left, and then the same thing going on down, and
what you'll start to notice a lot of times is people get stiff in one
direction. So in a Yvette's case she actually moves better rotating to her
left. Now I cannot explain what I'm about to tell you biomechanically, but it
seems that this manipulation works better if rather than going into the
resistance trying to manipulate to get more range of motion or decreased
stiffness in the direction you're feeling in, it actually works better to
go with the motion they already have. We could make an excuse and say well
technically speaking if we're rotating in either direction the facets on
both sides have to move. So at the very least we know if we get a good
manipulation, everything's moving regardless. I really can't explain to you
though why moving with the direction they already have motion tends
to work better than moving them into the direction they have stiffness like every
other manipulation. Experiment with this yourself, I think you will find the
same thing. One thing about this technique is it's better to be right the
first time because this is one of those techniques that if somebody is a little
irritable, somebody is a little inflamed, flared up, you keep reaching back and
trying to do the technique over and over again and you'll flare them up more. This
is one of those techniques that you might get one, two, maybe three attempts
at the most before you need to back off for the day and wait for them to come
back in. So in Yvette's case I'm going go ahead and I'm going to rotate her this way,
she moves better in this direction and like I said that tends to work better
for this manipulation. Now I said she's stiff in all these
segments going down here. There's two ways to block segments, and there's an
easy way to set up the joint actions that we
need to lock up the upper part of her cervical spine or the upper part of her
thoracic spine as well. So what we're going to do is we can either use that
thumb on a specific segment, or we can use our thenar eminence to block off
several segments. This obviously is probably a little less specific and a
little bit more aggressive. In Yvette's case I'd probably start here, being that
she's not somebody who's accustomed to getting a lot of manipulations, she
hasn't come in to see me before I probably want to start off a little bit
more gentle and see how she responds. Now in order to get her all locked up I want
to rotate her this way, side bend her towards me, so it's still that
contralateral rotation, it's still the ipsilateral flexion and we're still
needing a little bit of extension to get in the lock position just like we did
with the cervical spine. The nice thing about this particular technique is if
you just lift their head out of the head cradle and then rock their head
on their chin just by turning their head, they do it automatically. So you
can see if I just push her out of the head cradle, I'm there. Now I can
tell in this case Yvette's guarding on me a little bit. One other thing I should
probably bring up, that this table does naturally but some of you don't
have tables with these arm thingies, is their arms need to be up, and the reason
why is you want to take slack out of these muscles. If I was to try to rotate
her this way with this arm down you can see I'm adding a lot of tension into her
upper trap, and that's not going to be helpful for getting a manipulation, so
you can bring both arms up. If we didn't have these arms cut out she could
actually put her hands underneath her forehead like this, and we could just
turn her forehead on her hands, it would still work the same way. All right so you
can put your arms down, we're going to try not to guard. In the case of
Yvette, if she is guarding and I feel like I keep getting pushed out of her spinous
process and I can't hold it down with just my thumb, I might go back to my
thenar eminence like this. So now I can really make sure
I stabilize, I just have to try to be a little bit more careful to line up the
end of my thenar eminence with whatever segment I'm trying to lock out from the
bottom down. So in this case I want her about there, I can then bring
her this way. You okay, no pain? Just relax, nice deep breath, try to just
pretend like you're laying on your pillow on your belly. All right so I do
find that that cue helps as I try to get them into like thinking about
relaxing on a pillow. Okay now all we're going to do for the manipulation is
add a little pressure this way. So I'm moving this hand this way to
block out whether it's my thumb or my thenar eminence, and then I'm going to go
this way with this hand because if I do that, I automatically push her into
lateral flexion and rotation. So it ends up being a very easy for technique for
us as long as you spend plenty of time getting your setup right, you make sure
you get a really good lock out, get a nice deep breath, you okay? Deep
breath, breathe out, and that's it. We actually got a pretty good cavitation on
that one, I know Yvette felt it. You're seeing these manipulations
done on somebody who does not get manipulations done. So I think
that is important, that's a lot more realistic than some of the videos I see
out there with people doing manipulations on people who get
manipulations all the time. You do have to be careful, you do have to set
somebody up well, you do have to help them with their expectations and be like
hey this is this is not a big deal it's going to be over really quick, and you know
take a nice deep breath and before you know it, click and then you just let them
go, and a lot of times after I do manipulations like this I'll actually
have somebody sit up take a second before I go ahead and do my next
technique, so they don't feel like they're getting rapid-fire
high-intensity manipulation one over the other.
So I'm going to show you from this side, if I was going to manipulate
her other side I would just block this way, I would put her head on this side
and Yvette I'm not going to manipulate you this way okay. So I would go
ahead and put either her chin up on the table or maybe like in this case on this
head cradle, her maxilla is actually resting at the end of that headrest, and
then I'd get her right here and then I make sure I'm locked. If I need to change
her head position I can, and I want to make sure everything's right. Again
I have said this in every one of our manipulation videos, setup is 90% of this.
If you get somebody locked up right, if you've done your assessment and you're
on the right segment, the manipulation, the high velocity thrust is like the
icing on the cake. In fact I think you will find that if you really get
good at the locked position, you'll get people to like move, manipulate, cavitate
before you even get the thrust to happened a fair percentage of the time.
It's kind of interesting, like you'll just be like okay and you'll get them
here, and they'll be click, click, and you're like oh okay I didn't even need to do the thrust.
So again I could do my little rotation stuff, find the segment in this
case I'm going to go with the easier motion, block out that bottom segment,
make sure that I apply a little pressure this way and then I'm going to rotate
the head this way which is going to push her into rotation a lateral flexion,
while I block out this way. Last thing, and I don't want to
come across the sounding arrogant on this but I think it's something that
needs to be said for whatever reason because I own this education company and
I'm available online, and I get a lot of individuals who come and find me after
other practitioners didn't work for them, and I would say nine times out of ten
I'm able to help somebody because something was missed. That shouldn't
happen, I think this is one of those things that is very often missed. I can't
tell you how many cervical spine patients I've had that were manipulated up here in their cervical spine,
nobody ever looked at their CT Junction and they were never given any sort of
like activation or stabilization exercise. With these type of patients a
lot of times I can come in and I manipulate their cervical thoracic junction using
this technique. I give them some deep cervical flexor activation, maybe some
serratus anterior activation, maybe we'll work on some other stuff for scapular
mechanics, all that stuff that gets left behind because their last
practitioner only looked at their cervical spine and sure enough within a
couple sessions they're on a home exercise program and they're good to
self-manage. Keep this technique, although it's a little difficult,
although it does have a little higher tendency to flare people up than some of
the other techniques I've shown you. Get good at it, because like I said
it will make you a lot of money and it's making me more money than it should. Stay
tuned for the close-up recap. All right for the close-up recap remember
we're going to start with our subjective assessment and objective assessments, and
of course the last assessment we're going to do is our palpation to try to
give us an indication of where and which way we should manipulate, and what you're
seeing me do here is that thumb to thumb on spinous process P-A, and I'm just going
all the way to the end of arthrokinematic range, trying to feel the
relative stiffness joint to joint and then of course my own internal model
of stiffness at these joints based on my experience. To add another layer we could
of course ask Yvette hey how does this feel? Sometimes what you'll get is the
patient will complain about pain when you press on a particular segment which
might help us get a little bit more dialed in with our manipulation
techniques or soft tissue techniques. Then the other thing I'm going to do of
course is that rotation, all right so you can see I'm on either side of spinous
process and then I'm just zip zip, alright and then I'm going to
switch my thumbs so that I rotate the other way. You
see how that works, I think with a little bit of practice you will
get pretty good at going all the way down the spine and starting to determine
the direction here, and then we found that she
moves, she gets stiffer as she goes down here so we might want to block like so,
or we can block with a thumb like so on that spinous process just below the
segment that we think is stuck, and then we're moving with the direction that she
moved better. I know that's very odd and doesn't make a lot of sense but it does
tend to work better based on assessment and outcomes, and then of course we're
going to turn her head off the face hole here, or the face cut out of
on this table which is immediately going to put us into extension, rotation and
lateral flexion, and I'll spend a couple extra seconds trying to get a good
lockout position, maybe a little bit more extension, maybe try a little bit more
flexion, maybe try position a different part of her face, see if that helps. Try
my thumb try my thenar eminence see which one gets the better lock. You do
want to be quick in the sense that nobody likes to be in lockout position
for long, but don't be in a hurry. Everything is set up 90-percent of this
is finding that lockout position, and then once you find it all you have to do
is one quick thrust and be done with it. So it's all set up, the thrust
is just the icing on the top of the cake. If you have any questions on this
whatsoever please feel free to 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
techniques 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 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.