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 a
lumbar spine manipulation. I'm going to have my friend a Yvette come out, she's going to
help me demonstrate. Now of course if I'm doing lumbar spine manipulation I've
done not only passive accessory motion, I've probably done something like a
subjective exam as well as a movement exam like the overhead squat assessment,
and I have some reason to believe that there's lumbo-pelvic hip complex
dysfunction issues, and then I'd like to use continuous interval measures to
measure progress, something like goniometry. Unfortunately in the lumbar
spine goniometry isn't very reliable, so maybe you could work on some of
those rotation tests to at least get some sort of visual indicator to see if
you are actually making progress with this particular technique. Now once we
get through that and we're doing our passive accessory motion exam to try to
figure out which segment is stiff, you can go back to the lumbar mobilizations
video because one of the first things I'm going to do is just a central PA;
where I'm going to go ahead and press all the way down to end range, see
if it feels normal to me which of course is where the reliability of passive
accessory motion exams comes into play. Obviously you have to feel a lot of
different lower-backs to get a good idea of what a lower-
back should feel like, but I also want to take into account what a Yvette feels. So
does that feel like pressure or pain? Obviously pressure is normal and as long
as I don't feel stiffness then fine. How about there? All right and I'm just
pushing all the way down to end range arthrokinematics, and I do feel a
little bit of stiffness in her mid-lumbar spine. So we even have some
research to back this up, L5-S1 tends to get a little hypermobile,
L4-L5 might get a little hypermobile, L2-L4 we tend to get quite a bit of
stiffness. So for this particular technique I'm actually going to have a Yvette
rolling or side facing me. Now some of you have probably seen this technique
before, this of course is the rotational manipulation, and I think a lot of people have a
very hard time with this technique; and it's because they get bound up in the
details of what the legs are supposed to be doing and what the arms are supposed
to be doing, and what the hands are supposed to be doing, and they forget one
simple thing, you have to find the lockout position. So if we're going
for L2-L4 I'm going to get my hands set up with that piano grip, where
I have my fingertips on those spinous process or in between those spinous
process, and once I find that stiff segment I'm going to now lock up from the
bottom using ligamentous lock. The way I do that is by posteriorly pelvic tilt,
right I'm creating a posterior pelvic tilt and creating some lumbar flexion
which will pull all of those posterior spine ligament's tight, that's why we
move this leg. So what I'm going to do is I'm actually just putting my knee right
in the crease of my hip there, so I don't even have to hold her entire weight of
her leg, and I'm going to move up until I feel that segment that I'm trying to
manipulate, move on me. Now I know that's locked I'm going to go ahead and set this
leg down, double-check now that I have it down to make sure it stayed locked. One
thing you will find is it's real easy for people to get
them locked up and then you move, and they unwind on you. So make sure
that once you find your ligament lock from the bottom you tell your patient,
hey don't move your lower-body once they get you there. You can see
you can move this bottom leg, the reason the bottom leg is straight is
to give you something to rotate over. It really doesn't have much to do with the
manipulation itself. I mean I guess technically we could probably bring both
legs up and still make this manipulation happen, but with this bottom leg here I
have something to pivot on, and then I can actually bend it a little bit and
get her foot hooked up so that once I find that lockout position,
Yvette has some pretty good hip mobility here so I had to go up a little further
to get that locked out position. Now I get her set, cool I'm now going to switch
hands. Now I have to figure out how to lock out from the top, and the way
to do that is to rotate and extend a little bit this way, not huge amounts of
extension just a little bit of extension, and what I'm going to do is I'm going to
grab a Yvette's whole arm and I'm going to pull up and back, sliding her arm to
the point that I feel that joint lock out. So I'm rotating all the way up
to where my fingers are, so you can even try to get a little bit more, good
there we go. Now she's wound nice and tight. Now what
I like to do is come back here I have my thigh where her knee
is at, that's going to help me keep her nice and stable, I'm then going to take
this hand, and this hand is going to go between her greater trochanter and
her ilium, and this hand I'm going to slide right between her arm.
Now the reason I'm going to do that is because I'm going to use this forearm
on as much surface area as I can, like over her PEC. So not over her
chest but over her PEC, try to stay off the shoulder you don't want to give like
a really hard anterior to posterior force
to the shoulder that's not going to feel very good either, and once I get
set-up, get my hands back in place; now just like I did with like the cervical
spine or like I was doing with some of the joints of the foot, you want to
kind of mess around just a little bit, a little bit more flexion from the bottom,
a little bit more extension from the top. Get really nice and tight so you
can feel that all it's going to move is those two segments. I'm not saying take all
the time in the world, but make sure that your setup is just like any other
manipulation -setup is everything. All right then I'm going to have a Yvette take a
nice deep breath and my manipulation is going to be pulling down this way, well
going down this way with this side and that's it.
How did that feel? Yeah not too bad right. This is one of those ones
where I told you to take all the time you need for setup, except don't take all the
time you need for setup because your patients hate it; with that being said
how do we how do we bridge those two contradictory statements is
yes take all the time you need to set-up, but you need to practice this.
I would grab some friends, grab some colleagues and make sure that before you
do this on a patient you've had a couple times, to go okay wait how am i adjusting
the leg like what am i doing, where are my hands supposed to be. Okay this is locked
up now how do I get this to stay, okay good adjust this leg, alright good now
that's like that. You know you're going through all this stuff well before
you see your first patient, you don't want this to be a 10-minute setup for
your patient. But if you can get it down to - all right let's let's start all the
way over, right and we'll show them what like a normal setup would look like, so
let's start on your back. Alright so if I'm doing this let's say I have my
patient, all right Yvette we're going to try a little
manipulation, all right so it's going to be one of those quick thrust techniques
that I know you love so much. As you know from some of our other videos
Yvette's not somebody who gets manipulation, she volunteered to model
for these videos and we thank her for that but she's very much a new kind of
patient to this stuff. All right so you did know the cervical spine one though,
right like you've you've seen a couple of them, let's have you lay on your side.
Okay you're going to face me, now sometimes you end up like this with your
patients, just make sure you straighten out their leg, all right and then what I
do is I go ahead and set my left hand up and I get my piano grip to figure
out where I'm at, all right there's our sacrum, L5, L4, L3. Okay I'm going to
try to go L4-L3. Now am I necessarily specific or
surgical in my approach enough to ensure that it's L4-L3 no, but you
know I'm pretty sure I'm going to be able to get a manipulation from a hypomobile
segment. I'm going to go ahead and pull up from the bottom.
All right that's locked out there, good and I want to make sure I follow that
down so you notice here like her foot isn't really hooked in, so this is where
I'll usually pull this leg so I can get their foot hooked in,
because when their foot isn't hooked in that's where they tend to like start
sliding and then you lose your ligamentous lock from the
bottom. So we're all nice there, now I'm going to switch my hand put it
right where my other fingers were. I'm going to grab your arm, thank you, pull up a
little bit this way. If I feel like I need a little bit more extension and rotation I
can come up this way a little bit, go ahead and no no don't help, let
your shoulder roll back, and your patients will try to help, don't let them
help you. All right good, go ahead and one hand like that, so
your hands are kind of one hand over your other wrist. So I'm now going to
put my forearm in this slot, boom, boom. Alright once I get her locked
up, I feel like I got good position here, I'm just going to adjust a little bit more,
there we go, there we g,o that feels nice locked up.
Remember it's down this way, like I'm trying to put my elbow on my back pocket,
or going down this way.
Nice and locked up, big deep breath, alright and that's it. I just wanted to show you
one more view, I'm going to quickly go through this technique but give you a
little bit more of a view of what I see from my side. So Yvette go ahead and roll
towards me, alright you can back up a little bit towards the middle of the
table, and I'm going to have her back up or move forward so that when she gets
locked up I can still set this knee down, but it'll still pass the table if I need
it. Alright so you have to feel
for that adjustment, but if you remember I feel for the segment that I
want to move, I'm going to pull her into a posterior pelvic tilt until I feel the
bottom segment move just a little bit so I know that all of the segments below
are locked up. Alright we have pretty good hip mobility here from Yvette so it
takes a little bit more hip flexion than you will see on some other people,
and then of course I kind of mentioned to you I've been moving the bottom
leg to get that foot hooked up. I mean you noticed I
used my thigh to move her leg, I don't use all my upper-body strength to try to do
that, it's just a little energy saver there. Now I switched my hand
over I'm going to use my other hand to rotate and extend from the top. Alright
so I can go this way if I have to, I can pull up a little bit this way, good get
her all nice and locked up there. Alright and then this hand goes on this wrist,
and then you are going to snake this hand through this way, push down this way.
Now this is where adjustment time comes in, right so I'm going to use this
forearm in between her iliac crest and her greater trochanter to rotate
towards me. I can even laterally flex a little bit, I can move her into flexion
with my thigh a little bit using that knee that's on my thigh,
and once they get her all locked up, nice deep breath and then down this way, push
down this way, I'm just going to drop in all at once. Sorry one more deep
breath Yvette, and just like so. Alright so there you have it, hopefully with
these few times through you can rewatch this video and get this
technique down. I think you'll find it's very helpful for individuals with a hypo-
mobile lumbar spine. 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 it
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 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 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.