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.