This is Brent of the Brookbush Institute, and in this video we're going to go over a joint
based manual therapy technique. If you're watching this video I'm assuming you're
watching it for educational purposes, and that you are a licensed professional
with joint based techniques within your scope. That means osteopath's. chiropractors,
physical therapists, you're probably all in the clear. Physical therapy assistants,
athletic trainers, massage therapist's you need to check with your governing body
in your state or region, to see whether this is within your scope of practice.
Personal trainers this is definitely not within your scope of practice. Of course
all professions could use this video for purely educational purposes to help with
learning biomechanics, anatomy, and of course palpation. In this video we're
going to go over anterior to posterior humerus on glenoid fossa mobilization,
commonly known as a shoulder AP. I'm going to have my friend Melissa come out,
she's going to help me demonstrate. Now if I'm doing this mobilization, chances
are I've already done some sort of functional movement assessment like the
overhead squat assessment, or I've seen that wall shoulder mobility test that
kind of looks like our serratus anterior activation, that is also a great
functional exam. We'll probably follow that up with
goniometery, something like internal and external rotation of the humerus, and
then last I'm going to want to check passive accessory motion to see if there
is arthrokinematic stiffness. Now we do have to be careful using this technique
with the shoulder, the shoulder has a propensity to become both hypermobile
that is too flexible, and hypomobile that's stiff. Now we only want to mobilize those
individuals who have stiffness, somebody who is too flexible who gets this
mobilization done, we might actually exacerbate their symptoms or actually
make them worse. The last thing we want to do is take somebody who's too
flexible, and make them even more flexible.. So now you've done your
assessment, you determined that there is arthrokinematic stiffness and you're
ready to do this mobilization, how do I place my hands? Well that all requires a
little bit of knowledge of anatomy and palpation. Alright so the first thing I
would recommend finding is just the acromion shelf, so the acromion shelf is
that big bony shelf that kind of sits right between
all of the muscle of the deltoid. So if you make a little muscle for me there
Melissa good job, alright you guys see this like dent right here, this dent
between her anterior middle and posterior right, that makes like a little
'U' this way, that dent that is the acromion shelf. So you can have somebody
kind of do this, get your fingers down on that bone, now go ahead and explore the
edges of that bone, explore the edges of the acromion shelf. You need the person
to stay nice and relaxed, good there we go nice and relaxed, so make sure their
arm is supported by the table. Once you've felt through the acromion shelf
you can actually start to feel like a divot underneath it, you can almost get
your fingers underneath it, and then if you keep going down the arm this way a
little bit you'll start to be able to sink your fingers around the humeral
head. Now the humeral head obviously is the most proximal portion of our humerus
bone, and that's going to be where we want to get our hands so we can do this
mobilization. Although we're going to place our hand on the interior portion
of the humerus I do recommend having a good idea of
where all of the humeral head lies, like being able to get your hands on the
posterior humeral head, kind of feeling how it goes down into the the neck of
the humerus as you sink past the deltoids, and keep moving distally. What
you'll notice about the anterior portion of the humerus is it's a lot more bumpy,
so you have the greater and lesser tubercle there, and then you also have
this ropey thing, this really thick rope and what that is is the biceps tendon.
The reason I bring this up is that it's something that we don't really want to
press on. If you really gear into somebody's bicep tendon while you're
doing this mobilization it's going to hurt, if they have impingement syndrome
it might be because it's inflamed, even if they don't have shoulder problems
you're just doing this on your your partner or your practice partner, or one
of your colleagues, or perhaps a mentor or teacher that you're practicing on,
you start gearing down on their their biceps tendon, it's going to hurt no
matter what, so we want to kind of know where that is so we can stay away from
it; and once you have the whole kind of idea of where the humerus is I'm going
to ask you to try to put, or at least imagine putting the humeral head right
in the palm of your hand like so. Now you can use these fingers to kind of wrap
yourself around the rest of the humerus and the acromion shelf, which might come
in handy when we start trying to find the beginning of arthrokinematic
motion, and the end of arthrokinematic motion. Now what I usually do
with this hand is I'm going to have Melissa who'll be inside of my bicep, I'm
going to hold her elbow like this, and now I have good control of abduction
adduction, and a little control over flexion and extension. I could probably
even internally rotate and externally rotate a little bit, like I have good
control over arm. I'm going to use this hand again, put my palm down right over
the anterior portion of her humerus, and then notice that once I'm in position
guys my trunk -my chest is over my hands. So again I'm not going to manhandle this
right, this is not how we do a mobilization that would actually get really tiring if
let's say Melissa was twice my size which would make her absolutely huge, but
if she was a very large person or had a very large arm, let's say I'm working on
like a professional football player or something, that would, this would be
almost impossible. You need to get used to using your body mechanics and save
your own body, perhaps even before you think about saving the body of your
patient because you got to do this all day. Alright because if you're seeing eight, nine, ten,
twelve, twenty patients a day, you need to have good mechanics and and save your
joints. So again I just have my client or patient reach in grab the inside of my
bicep, I grab underneath their elbow, I have to control this hand over the
anterior portion of the humerus, I'm just thinking about putting the humeral head
right in the palm of my hand. Since I'm using such a broad surface area I don't
usually have that problem with the biceps tendon,
if I do I try to put the biceps tendon between my thenar eminence, all right so most
of my pressure is coming here and the biceps tendon is falling in this groove
here. I'm now just going to use the weight of my trunk to kind of find okay
there's the first resistance barrier, and that's going to come on real quick with
the shoulder and then I'm going to find the end, alright you got to be careful
with the shoulder. Shoulder like I said is a very mobile joint, so if you press
too hard you're going to push right out of the glenoid fossa; not that you're
just locating the shoulder, but you will push the humeral head onto the posterior
lip of the glenoid fossa, and if you can do that really easily then this is probably
not somebody who needs this mobilization. The people who need this mobilization are
the ones you press into and you feel like you have something to press into,
there seems to be a certain amount of stiffness almost like you're pushing
into the back of a leather strap, like a like a leather belt.
Alright so beginning, feel like if I go any further than this all right like I'm
going to start pushing through. Now I'm going to back off to 50% and we've
talked about there's a lot of different protocols out there guys, and I just
asked you to follow through with whatever protocol that you learned. I use
generally the Maitland protocols for grade three and grade four mobilizations,
If we're talking about getting mobility here and this isn't like a pain dominant
patient. So we'll go to 50%, and then I can either do back off to where was my
first resistance barrier, to 50% and do my grade threes which is that higher
amplitude mobilization, or I can find my 50% and do my small amplitude
mobilizations right at that resistance barrier, making this a little higher
intensity. Now I'm going to do this until I feel a reduction in joint stiffness,
and then the most important thing as I've said throughout all these videos is
I'm going to reassess. Alright so to go through that just one more time guys.
Hand on inside of bicep, I got her elbow, I'm going to take her to where I need
herin abduction, adduction, more flexion, more extension, wherever
you guys feel like you need to be to work through that stiffness. The palm of
my hand goes over the humeral head, the anterior surface of the humeral head, trying to put the biceps tendon
between my thenar groove there, find the first resistance barrier, the end,
back off to 50%, and then do whatever grade I think is appropriate. I have my
hand around Melissa's elbow, and her hand is up around my arm, although I know you
can't see that you saw that in the previous shot. You guys can see Melissa's
acromion shelf here, and then you guys should be able to palpate around the
acromion shelf to define the subacromial space which is going to feel like a
depression, then as I mentioned before you should take some time to try to
palpate through the relaxed deltoid, to kind of outline the humeral head as it
goes down into the the neck of the humerus here, but once you find the
humeral head now we can place our palm on top of the anterior face of the
humeral head, and I kind of mentioned before if you kind of strum across this
way you'll feel a big rope like tendon there, that's the biceps tendon. I would
put that in your inner thenar groove so that you don't place undue pressure,
and now I can kind of feel like there you go there's your first first little
bit of motion of the humeral head, and I can push down until the end of her
glenohumeral motion there, and then back off to 50%, and then I can either go
from initial resistance to 50% for some grade threes or maybe I can stay at 50%
for grade 4's, but notice I'm using a nice wide palm
getting a lot of surface area, and trying to keep any direct pressure off that
biceps tendon for this joint mobilization. I'm doing my one to two
oscillations per second for 30 seconds plus until I feel a reduction in arthro-
kinematic stiffness, and of course i'm going to reassess. If i did one set and
got a little reduction, I could maybe pull further into flexion see if I run
into more stiffness. I could pull further out into abduction do another set and
see if I run into more stiffness, as I have a lot of control over Melissa's arm
here. So guys make sure you take the time to palpate the humeral head through the
deltoid, palm over anterior face, biceps tendon in thenar groove. Make sure you
feel for initial movement or first resistance barrier, and end of arthro-
kinematic range, and follow through with your protocols. So there you have it
assess, address, reassess. Make sure that every time you choose a joint based
manual therapy technique it is based on an assessment, and that you return to
that assessment after you've finished the intervention, to see if it was
effective for the individual, the patient or client that you had in front of you.
Ensure that you continue to learn your Anatomy because your Anatomy is going to
help you with your hand placement, with understanding what a joint can do, with
understanding what you may gain from this particular technique. And of course
practice, you have to practice these techniques, hopefully not for the first
time on a patient or client who just walked in the door. If you can, find a
more senior instructor or mentor to give you some really good hands-on
instruction, use your peers for some good feedback, and of course always look for
live education to help with your manual therapy techniques. I know these videos
make education very convenient, but there is no substitute
for learning manual therapy in a live setting. I look forward to talking to you
guys again soon,