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 osteopaths,
chiropractors, physical therapists you're probably all in the clear. Physical
therapy assistants, athletic trainers, massage therapist you need this 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 posterior to anterior
sacroiliac joint mobilization. I'm going to have my friend Melissa come out she's
going to help me demonstrate. Now Melissa is going to lie prone, you'll notice that I
have the table fairly low because I want to be able to get my chest over her
sacrum with arms straight, so that I can use my torso and not my hands or my
arm strength to try to manhandle this technique, that's going to wear me out very
fast. Now before we start this mobilization we need to have good palpatory
skills and palpatory skills basically comes down to practice and
anatomy, like you have to know your Anatomy.
If you haven't looked at the sacroiliac joint in a little while it's good to
review maybe an Anatomy textbook, look at those illustrations start identifying
various landmarks and how they relate to one another, and if you can get a hold of
one of these plaster cast models, I know they're not perfect and the
standard plaster cast model is of a fairly small person I would have to
guess, maybe somebody who is like 5 foot 4, or 5 foot 3 and Melissa here's like
almost 5 foot 8 so it's not quite perfect, but it'll do and it'll
definitely teach us quite a bit. I'll give you a couple landmarks that you
probably should be aware of. Every time I'm looking to do the sacroiliac joint
posterior to anterior mobilization realizing that I'm going to be pressing
on the sacral base, what I'm going to try to find is my PSIS. And I know that if I
fall immediately medially and I had to practice that now, immediately
medially off the PSIS, the posterior superior
iliac spine, I end up roughly on the S2 S3 segment of my sacroiliac joint. Well
okay maybe you're not great at finding the PSIS how would I do that? Well maybe
you start with the iliac crest, and the iliac crest is fairly easy to palpate
right that's the top of your pelvis, the top of what people call their
hips where they wear their pants. So you could follow your iliac crest to your PSIS
and I personally like to find the under that corner, hook underneath the
PSIS, so I hit the same point every time and I don't end up on this. Alright so I
want to be able to hook underneath the PSIS, maybe I have to start at the iliac
crest. Maybe you want to take it a step further,
what does your iliac crest line up with as far as what spinous process of the
lumbar spine? Well it lines up with roughly L3-L4 spinous process so I
should be able to find those spinous process, work my way down, know that L5 is
going to feel a little hidden and then I'm going to have a divot all right like a
little fold there and then I'm going to go on to the alligator back of the sacrum.
And sure enough if you tried to find that I think you guys would find that it
feels a lot like I'm describing to you right, like I can feel like this little
divot in here right which is like this part represented right here. Another
thing you might want to be able to identify is you know where the ischial
tuberosity relative to the iliac crest. Where are the where's the coccyx
relative to the rest of the sacrum relative to the iliac crest? You kind of
want to have a good visual model in your head of where all these landmarks are,
where your hands are, and how to get back to what you're trying to palpate, which
in this case is the sacral base. I would definitely recommend practicing on one
of these plaster cast models by closing your eyes, choosing a landmark, laying
your hands down and forcing yourself to work through those landmarks until you
end up on whatever you chose. Let's say I said sacroiliac joint here
and then when I open my eyes am I on the sacral base, and I'm sure enough I am. You
might want to even test yourself by choosing some of those other points.
Can I find my coccyx right, and sure enough I found the tip of my coccyx. The
reason being is people are not all shaped the same, you're going to be
working through various techniques so you want to be able to go from one
technique to the other as smoothly as possible.
And when you lay your hands down you have no way of knowing boom there's my
PSIS, you might get lucky, and the better you get the closer you'll
get over time. But it is always helpful to kind of have a step by step
process here. Let's use the simplest of these processes I'm going to
find the iliac crest, I'm going to follow my iliac crest to my boney notches being
my PSIS. I'm going to hook my thumb's underneath the PSIS so I find those
corners, that corner will lead me right to the S2-S3 segment of the sacral base
which is exactly where my thumb's need to be to do this mobilization. So
there you have it, we have all of our palpation leading to the landmark we
need. Now notice I kept saying S2-S3 segments of the sacral base, it's kind of
odd and I can't totally explain why from a biomechanics standpoint. Despite the
fact that the sacrum is fused segments of the spine right they don't move
separate from each other, it is helpful to mobilize the segments like they
aren't fused, if you're with me. Maybe it just has to do with the breadth of the
joint, like our thumbs aren't wide enough to mobilize the whole thing at once.
Maybe it has to do with the way the bumps are right, like those joints
aren't two smooth surfaces together, they're kind of bumpy, right they fit
together like with bumps and grooves. Maybe so maybe we're mobilizing
different bumps and different grooves as we move through the segment, but kind of
keep in mind that if you find the S2 to S3 segment you're probably going to have to
move up at least one segment, and you are probably going to have to move down at
least one segment maybe two. So you could start your mobilizations however if
you want you can start on the S2 segment, work up one
and then go back down two's to your S3-S4 segment and maybe go down one more. Or
you could find S2-S3 segment and try to start at the top of the sacral base and
work your way down. Whatever you want to do just understand that you're probably
going to have to mobilize a few segments before you feel like you've got good
mobility back into what was an assessed stiff SI joint if you're doing this
mobilization. Now let's talk about hand position, this is one of those techniques
that works best with your thumbs which is really unfortunate, because this is a
very stiff joint which means it's going to take a lot of strength, it's going to
take a lot of force to get a little bit of motion and that's all you're really
looking for, is a little bit of motion. So again if I find her PSIS I fall off, my
go-to technique is going to be just like this thumb touching thumb. I'm going to try
to find my first resistance barrier which is right there, and then my end
which is right there. These are very close alright the first resistance
barrier and the end, there's not a whole lot of motion. So trying to determine the
difference between a grade three and a grade four immobilization for example is
going to be very hard if not impossible. Generally speaking I try to find the end
range, I back off and then I mobilize. I think if I'm doing grade three it's a
little less intense and more mobility, grade four I'm really kind of digging in
and doing small oscillations at end range and I just kind of leave it at
that. Trying to find the 50% mark or 75% mark for a joint that has very little
motion to begin with is going to be very challenging.
Now just to kind of go back over the same techniques we've been doing through
all these mobilizations; first resistance barrier, end resistance, barrier back off,
do my one to two oscillations a second kind of going from that first resistance
barrier into roughly 50% until I get an increase in mobility, and then as I
mentioned I'm going to have to move segments. So I actually started on the S2-S3
segment here, I might want to move up one and then move down a couple. Try to
get all that mobility back that I possibly can, but this is just one hand
position. Now I'm going to show you another hand position that I've been
working on that I have a hard time with, and I think you might have a hard time
with it too but I'm challenging both of us to try this technique, and that's to
use pisiform hamate on the sacral base. The reason I think this is a challenge
is because the PSIS actually hangs over the sacral base a
little bit, and it's actually kind of challenging to get your hand, the thicker
part of your hand on to the sacral base. Now maybe it's just me and I've
mentioned before I do have bigger than normal hands right, and Melissa's well
Melissa is kind of an average-sized individual with average dimensions. Maybe
my hands are just too big to to get in there and you guys will have an
easier time, maybe it's a feel thing like I don't feel things as well here
as I do the tips of my fingers. Either way it's worth trying because of how
hard this joint is to mobilize, how delicate our thumbs are, and of course if
we're trying to extend our careers I've mentioned several times that if you can
find a way not to use your thumbs don't use your thumbs. There's too many
techniques already that are totally dependent on us being able to use our
thumbs. The other big tip for this technique or I guess the big tip for
this technique is don't try to go on the same side, this probably won't work. If
you go to the other side it'll work better. Now this happens to be Melissa
stiff side, and just as a pointer more often than not, in fact almost
always you only have one stiff SI joint they usually both don't get stiff.
This happens to be her stiff side if I was going to keep working on her with this
pisiform hamate grip I'd walk around the table, for you I'm just going to show
you on her opposite side. I want to try to get underneath her PSIS
and push down on her sacral base. So I'm going to find the PSIS, use my fingers to
find where I want to be, put my pisiform hamate
over my fingers and then go this way. And you can already see this would be a lot
less pressure on me physically. I think this feels okay. I'm not sure I have got
the same outcomes from it as I do with my thumbs, but I'm going to keep practicing.
I want you to keep practicing because I think this could be a career
saver long term. How's that feel Melissa, this probably feels a lot better than me
pushing on your other side huh? Yeah so her stiff side is this side which is why
it's a little a little bit more tender for her. So just a quick repeat of what I
showed you. This posterior to anterior mobilization for the sacroiliac joint is
definitely my go-to for sacroiliac joint dysfunction. Look for the stiff side, do
my PA's, see if I can increase mobility, tends to have a pretty big effect on my
outcomes. I did this mobilization by finding iliac crest, using my iliac crest
to find my PSIS, hooking my fingers underneath my PSIS, dropping off
immediately medially all right onto my sacral base, that's S2-S3 great. I can do
this thumb technique, or I can challenge myself walk around the table and use my
pisiform hamate because I know that'll be better for my career long term, and
then of course I have to remember that I probably should move up and down
segments, and treat the SI joint like it has several segments similar to how I
would like the lumbar spine as a whole. Alright I have the plaster cast
model set up here so you can see where we're trying to get our hands when
we do these two different techniques, the the thumb over thumb technique for the
same side, or we're trying to do that pisiform hamate on the opposite side. So
here's the PSIS on the plaster cast model, we would fall right off immediately
medially onto the sacral base and do our PAs goin segment by segment. Or we would
try to get our pisiform hamate down into this space here on the opposite side,
that would be the other way to do this technique. Now I've had Melissa
roll down her belt line here just a little bit so that that we're palpating
directly on skin. So you can see here if I follow the ilium down
I find her PSIS right about here, so right just above her backside there and
then if I fall off immediately medially I'm now on sacral base. So now
I can get my hands in position and I can find the first resistance barrier, last
resistance barrier just quite a bit of force, and then I can back off a little
bit and do my one to two oscillations per second. Now don't forget you're not
just going to do one segment quote-on-quote of the sacral base here, you're going to
have to move up a little bit, make sure that you don't have stiffness higher,
you're going have to move down a little bit and almost treat the sacroiliac
joint like it's multi segmented like the lumbar spine.
Now what I've challenged all of us to do is to not just use our thumbs which is
kind of the easy way out although very hard on our thumbs, and try to teach
ourselves to feel with this part of our hand, go to the opposite sacral base by
falling off immediately medialy once again, onto that sacral base, and then
trying to use that point of our pisiform portion of our hand to try to get some
some good mobilization of the sacrum here on the ilium. Alright so you got
your thumb over thumb technique which of course you need to learn. Of course it's
a lot easier to palpate but once you get that down don't forget to keep working
on this one, just to save your thumbs and add a little longevity to your career. 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 have 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 a 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.