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 the upper
cervical spine manipulations. I'm going to have my friend a Yvette come out, she's
going to help me demonstrate. Now keep in mind if I'm doing a manipulation I'm
doing it as part of an integrated intervention routine that's going to
include things like soft tissue techniques and exercise, and of course
follow up with a whole exercise program and I'm basing this on more than just
subjective assessment. Although upper cervical spine manipulation we might be
able to think symptoms would be cervical spine or maybe cervicogenic related, we
still want to have movement assessment to be able to reassess if we had any
effectiveness. We're still going after stiffness in these joints so don't
forget about your visual range of motion exams with like rotation, flexion-
extension, lateral-flexion, maybe lateral-flexion goniometry.
I know your upper cervical segments don't laterally flex much, that doesn't mean that
stiffness in the upper cervical spine won't change muscle activity enough to
affect lateral flexion goniometry, and then two ranges of motion to think about
a little bit are jut, or forward head, and nod or chin tuck. If
somebody can't get to the ends of range of motion for these right,
the very extreme end range of motion, they're restricted, that's a good sign
that some upper cervical stuff is going on, because it's your upper cervical
spine that allows you to extend your head as your lower cervical spine is
flexing, and then as your lower cervical spine is extending it's also your upper
cervical spine that allows you to tuck your chin. So these two ranges of
motion can be very indicative of upper cervical spine restriction outside of
just like maybe rotation. Now before we go into this technique, a teaching tip if
you're new to manipulations, don't start here. Go ahead and go back to our
cervical manipulation video, in that video I go over mid and lower cervical
manipulations. Those techniques are much easier for several reasons, including
blocking out the lower segments is easier because you have more to grab on
to, finding the lock out position is easier because there's more motion to
work with, and then actually getting the manipulation is a little easier because what
your palpating during that is not so small. I think if you started here you're
going to have a hard time palpitating what you need to palpate, moving in the tiny
ranges of motion that you need to move, and feeling that walkout position is not
the easiest thing in the world on this particular technique. Now to get into
this particular technique I can tell you that if you're familiar with the
cervical manipulation video we're still using this basic motion. So that's
lateral flexion away, rotation toward with a little extension. Some differences
we're going to do a little bit more of a forward head jut, we're also going to do
a little bit more of a side glide than just pure lateral flexion. So
before we get into the extension thing we need to come
into this forward head position. Before we just laterally flex we want to side
glide as much as we can. Now other weirdnesses, rather than being
able to use, yeah I made up a word weirdnesses, all right
second MCP, rather than being able to use my second MCP to lock out the spinous
process and then bend over it to find locked position. I could only do that if
I'm C2 and up, right because C2 has a spinous process but C1 doesn't. So
maybe you want to try second MCP, find the highest spinous process, you can try
to get your MCP there, jut, side bend and then you know I use cradle grip on
my cervical manipulations. You could use open hand if you want to, but since I use
cradle grip on my other manipulations I tend to like to use it here. Once I get
side glide, jut, blocked out for C2 then I could side-bend then rotate a little
bit, maybe a little traction I find helps, get her all locked up and then I can do
my manipulation. But here's the tricky part what if I need to do C1, what if I want
to do C1 on the occiput, right the atlanto-occipital joint, the a/o joint. I
don't have a spinous process to use my second MCP on. I need something else, and
the way to go is to block the transverse process of C1. Now if you've never
palpated the transverse process of C1 it is just underneath the mastoid process.
So here's what I'm going to recommend you do, find your earlobe, find your mastoid
process, go just underneath your mastoid process if you don't feel a bump like a
peg coming at you into your finger side bend away, and that transverse process
should pop right into your finger. Once you do that on yourself try
that little trick on hopefully your friend or colleague
when you start, not a flared up patient I do not recommend practising these on
flared up patients. So there's her transverse process of C1 right there,
transverse process of C1 right there, right underneath each mastoid process.
Great, so now I know what they are what do I do with them? Well what I'm going to
do is if I'm trying to do a manipulation on this side, I'm actually going to wrap my hand around
so i can use a comfortable hand position, because I'm usually using that second
MCP. But this time I'm going to use my middle finger, and I'm going to push it into
the back of the transverse process of C1, and push up this way to block out that
vertebra. So that when I go to do my manipulation, this is blocked and I'm twisting
on this blocked out vertebra. So the way that would look is here,
find my transverse process, I can use both hands
you got it locked in. Now I can use this palm to help control her head a
little bit. Alright I can get into my quasi-cradle grip here, jut, side-bend,
good. Now I can laterally flex, rotate, extend or flex, and I find a little
traction helps a lot, and once I get her all locked up right if I feel like she's
tense I'll have her do the breath thing.
Breathe in, breathe out and then rotation is my primary movement, just like that.
You notice I just tip. Alright so I tipped here, I did keep pressure with my
forearm against her head right so that I got a little bit of lateral flexion too.
At the very least when I rotated I don't want her coming out of lateral flexion.
I'll show you what that looks like on the other side. All right so I'm going to
find her transverse process, and remember you can use both hands. It's okay, take
your time. Setup is 99% of this. I keep saying 90 in
the other videos, I think 99% is where it's at, because even when I'm watching the
videos I'm like I spent 15 minutes talking about setup, and the actual manipulation
was nothing. So there's her transverse process, I'm
going to make sure my fingers there right I can use this palm still to help control
her head a little bit. I'm going to use this kind of quasi-cradle grip here. I'm
going to jut a little bit, side glide this way, all right so I'm kind of, you
can think of like kind of opening up the joint that you're trying to manipulate, side
glide, rotate this way, lateral-flexion some extension on this side, I'm just
kidding we're going to save that one for the close-up recap. So there you
have it C1, fingertip via transverse process, C2 you can use your second
MCP just like you did on the mid-cervical techniques. The only difference
is it's harder to get on that spinous process because it's so close to the
occiput, and you have to jut and side glide first to really make this technique
work for you. Stay tuned for our close-up recap. For the close-up recap
I'm going to show you the atlanto-occipital joint manipulation. I think you
have the blocking of C2 with your second MCP down pretty good, but
this ability to block out the C1 transverse process with the middle
finger is a little complicated. So my suggestion is use both hands to find
first the mastoid process and then the transverse process of C1, and you
can use a little lateral flexion away to have that poke you right in the
finger, and then I'm going to use this finger to get underneath that transverse
process so that I can really get underneath it and like block it. Like
right now I can, not that this would be great technique for a mobilization, but I
can literally mobilize C1 on her occiput. Alright so if I feel like I got
that type of purchase, that's when I'm ready to do this manipulation. So now I would
jut, alright so pull her into a little bit of this forward head position, and
I've removed the pillow this time just to make it a little easier for you
to see. I'm now going to side glide towards the camera,
alright so towards you and I'm going to try to use open hand technique
here so you can the motions that I'm doing, because if I
do cradle grip this close to the camera I'm going to block everything. But I'm going to
keep my finger there, forward, side-glide, lateral flexion, rotation, get
her all locked up; and then once I know I have her locked up maybe a little
traction, and I can just rotate, and that's the manipulation. All right so I'm not
quite as good as that open hand technique, for me and be a little bit
more comfortable to get in here. Remember you're only going to go ahead and do your
high-velocity thrust when you feel lock, and deep breath, and just like so. All
right so a little scary for Yvette there, but no pain right. All right
so practice that, remember you have your fingertips here, that you have to
block the joint out with. A little bit of forward, a little bit of side glide, and a
little bit of traction really helps with this technique, which then you can do
your normal cervical manipulation motions; and then I would
say the other big difference with this manipulation is it's almost totally a
rotation for the actual manipulation. 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. Nost 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 then 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 and 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.