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 therapists, 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 lateral hip mobilization, this is a great general
technique for reducing arthrokinematic stiffness of the hip joint. I'm going to
have my friend Melissa come out, she's going to help me demonstrate. Now if I'm
doing a joint mobilization for the hip there might be several indicators that
led me to believe that a mobilization may be effective, and first and foremost
we could use something like the overhead squat assessment; because the hip is so
involved in several of our functional tasks and motions, something like the
overhead squat is going to give me an indication with signs like knees bow in,
knees bow out, anterior pelvic tilt, posterior pelvic tilt, maybe an excessive
forward lean, or an asymmetrical weight shift all could be indicators that somethings
up with a hip. I could then go to goniometery, something like internal
and external rotation of the hip. If I have stiffness I may get a reduction in
rotation, whereas I can almost be guaranteed that if rotation is normal
hypomobility, arthrokinematic hypomobility is probably not an issue. The
last thing I personally rely on is passive accessory motion exams in this
case. I know that is the traditional method for determining whether we need a
joint mobilization, but with the hip we're dealing with so much soft tissue
and this is a very strong soft tissue, it makes it much harder to feel normal
versus abnormal joint play. Now we could go to convex on concave rules and start
talking about why this mobilization is traditionally
used, but in reality we're dealing with femoral spin and a lateral distraction-
our lateral mobilization is actually distraction. So convex on concave
rules don't apply real well here, although these are generally this
technique I'm showing you is generally used to increase flexion and internal
rotation. I've personally found that this is such a general mobilization probably
most affecting the posterior structures of the hip, which have a propensity
towards adaptive shortening like our posterior capsule, that I have seen
increases in external rotation, internal rotation, flexion. I've seen increases in
adduction range of motion all from doing this one technique. Again with all the
techniques we do we have to be careful getting too specific with our
biomechanics and we should always assess, or address and then reassess. So I'm
going to do whatever assessment I'm going to do -the overhead squat, goniometry,
I'm going to do my mobilization, and then I'm going to go to
my reassessment to see if that technique was effective.
Now Anatomy in this case, you guys can't feel the hip, I'm sorry like you're not
going to reach in and and palpate the hip joint. You'd have to get through
a lot of tissue and and that would be problematic and probably painful, so
let's not do that. A couple things you are going to want to be able to find
though is you're going to want to be able to find that inguinal line right, so
you got to find that crease because either the belt which we're going to
show that technique, or your hands are going to end up there. You probably want
to be able to find the ASIS right so that anterior superior iliac spine. I'm
going to show you guys how to kind of palpate joint motion, in the sense that
if you put your hand down on the ASIS and the greater trochanter, it makes it
somewhat easy to feel how much joint play you're getting. Other than that
we're going to find that this technique is more like hug the leg.
So I'll never forget my one of my clinical
instructors coming up in school and of course an instructor for the the
Maitland Institute Rob Flugel, telling me that manual therapy is a full-contact
sport, and I think the biggest mistake I see with with this particular
mobilization is people will use the strap and then stand about this far away,
and start trying to do the mobilization. You're not going to feel anything, you're
not going to get a real controlled motion that way, and we want to be as
specific as we possibly can. So I'm going to show with the strap
first because this is the technique I prefer, and then I'll show it again of
course using just my hands for those people who the strap is actually
uncomfortable on them, and or for those who just don't have a strap -for example
maybe you do home care and you forgot your strap at home that day. Alright so
I'm going to wrap this around my backside not my low back, alright we
want to make sure that I'm not putting myself at risk here, and then I'm going
to clip it around Melissa's side. Melissaf if you could
scoot a little closer to me that would be great.
Alright I'm going to have Melissa go ahead and position this strap all the
way down as far as she can, because we want to be as close to the joint line as
we possibly can. Now obviously the strap is close to some sensitive tissues, my
guys know this is the adjust and guard technique. You might have to ask people
to kind of use a hand to kind of move some stuff over and then they can block
if they need to, that's especially handy when you personally are using your hands
on this technique, you know that that way they they feel safe and comfortable and
trust me if you get any of your sensitive skin underneath this strap or
somebody's hands doing a lateral mobilization, you will have them talking
falsetto. We are going to use a fairly large amount of force the hip is a
fairly large joint. Now what I'll usually do is bring somebody into flexion, and
then I'm going to go ahead and hug Melissa's leg like this. Alright so you
guys can see here I kind of like like you were doing a headlock
around the knee, but I'm going to have her thigh against my chest have her leg
underneath my arm, and what this allows me to do is I can control not only how
much flexion but how much rotation as well, and I mentioned in one of the other
videos we seem to have a bit of research coming out that states that maybe we
should be doing mobilizations at the end of the range that we're trying to get. So
if I want more internal rotation maybe I shouldn't be doing it in open packed
position, but doing this mobilization at the end of their pain-free internal
rotation. Well I can do all that now right like I have her leg completely
locked up, I'm good I'm in control here. Now I'm going to apply all the force
with the strap by just sitting back here in a second, so that gives me an open
hand. What am I going to do with this hand, well just like I explained in the
knee mobilization video this is a great chance for you to try to be able to
palpate joint motion, which is going to make it easier to follow through with
those protocols that we talked about a couple times where you're trying to get at
about 50 percent, well 50 percent between initial resistance and end of arthro-
kinematic range. In this case what I usually do is I'll go thumb on ASIS -or
maybe I'll turn that around I'll go fingers on ASIS and then thumb on
greater trochanter, and I think if you guys kind of get them in to end range
here and this is just first resistance barrier I'm not pushing her too hard,
remember we want pain free alright first resistance barrier, and then if I sit
back into the strap I can actually feel the greater trochanter moving into my
finger while the ASIS stays in place right, so that's all arthrokinematic
range I'm getting. So now I can kind of pull back on the strap and go oh
there there it's started moving, and now it's stopped moving and it seems like no
matter how far I sit back now if I keep pulling her ASIS comes with me. I'm not
I'm not increasing the distance between greater trochanter
ASIS anymore. Alright so that that helps me feel beginning of resistance
and end of arthrokinematic range and now I can back off to 50%, and here's the
tough part guys, how do i do my oscillations? I don't want to be like
trying to manhandle her thigh and I have this strap here, but what I see people do
with the strap is they start like throwing their butt back like they're
twerking or something, like that that's not going to be good for your
back don't twerk for mobilizations. It does help if you have a mirror in your
office to watch yourself. What you want to do is get into a staggered stance and
you want to try to rock, and you want all of you to rock so as the the the straps
coming back you also want the knee to come back with you,, otherwise this isn't
completely a lateral distraction, it would end up being like a lateral
distraction with anterior rotation and adduction of the femur. We want pure
lateral distraction. So what I'm doing here is I'm pushing back with my front
leg onto my back leg right, and I'm just kind of going back and forth between my
two legs. So this isn't this isn't twerking, this isn't using my upper body.
You guys can see here like I'm just rocking back and forth and I could do
this all day, maybe not all day but I could do this
for quite a long time. I'm just using the strength in my legs in kind of this
quasi-lunge position or split-stance position to get all of my force. Alright
So now that I've got this rocking motion down let's go back to where I was, I'm
going to hug Melissa's leg, first resistance barrier, flexion and internal
rotation. I'm going to use this hand to feel ASIS and greater trochanter. I'm
going to sit back, alright so there's my first resistance barrier, there's arthro-
kinematic end range right there, back off to 50%, and now I can either do
my grade three or my grade four mobilization, lets do grade three at this
point. So I'm going to come back to first resistance barrier alright this is my
larger amplitude oscillation, and I'm going to keep doing that one to two
oscillations per second until I feel a decrease in joint stiffness. So notice
guys like I'm very relaxed, I can keep talking to you there's no problem okay
could do this all day. Now if you happen to use other protocols, you don't use the
1 to 2 oscillations per second like the the Maitland protocols that I use that's
okay, just make sure that you are looking for first resistance barrier, you know
where arthrokinematic end range is, your setup is good and that you follow
through with your protocols. As I've mentioned in several videos that's the
the biggest mistake I see, is people kind of start and then like halfway through a
protocol they just kind of go yeah, and then they move the leg around and they
go that's good. Right I'm going to assess, I'm going to pay close attention to my
technique, because I want to make sure that if I didn't get the result I was
looking for, that it was the wrong technique and I need to pick something
else, and not just bad form on my part. So let me review this technique one more
time, and I'm going to show you guys the hand version of this technique. So again
I took the leg up, wrapped around right I'm kind of hugging the leg with one arm,
I can get as much internal rotation I need, I could even get some extra
rotation if you guys thought you wanted that, and I can go into as much flexion
as I want. I'm going to get myself all straightened out, I'm going to palpate my
ASIS and my greater trochanter, and I'll show you guys that in the close-up recap,
and then find my first resistance barrier, my arthrokinematic end range, and
then I'm just going back and forth between my front and back legs in a
split stance position. Hand position for this if you don't have a strap, or let's
say every time I put that strap down Melissa was like that pinches right, and
we know we have like the obturator nerve in there, we have some cutaneous nerves
in here, maybe no matter what I do with the strap I keep pinching
down on that nerve, okay we need to figure something else out. Some people
just, like it pinches and digs into their skin and the straps not comfortable. So
Melissa can guard if she wants all right, so we can, go ahead and put your hands
down over yourself alright, and then I'm going to get my hands down as close
to that joint line as I possibly can. You guys can't be bashful on this, obviously
explain to your patient client what you're doing and why you're doing it, and
make sure that you're coming down from the thigh to get into position so that
you don't act, you know purposely brush up against anything, but you have to get
as close to the joint line as you possibly can, if you get up here you're
going to pull into horizontal abduction, adduction and not get your mobilization.
But once you're here, notice that my position is not that much different than
it was before, I'm still hugging the leg, now I don't have this extra hand
unfortunately, but I'm going to use my legs to pull back to arthro-
kinematic end range, you know find my first resistance barrier, kind of figure
out where I'm going, and then once I get there I can do my rock between my legs.
Notice I'm not hugging, this is the biggest mistake I see on the hands only
technique, is people just start hugging the thigh,
we're not hugging the thigh. Alright stay tuned for the close-up recap.
Alright guys showing you another view, notice that the the strap here is around
my backside, not my lumbar spine. I don't want to be giving myself a posterior to
anterior mobilization everytime I try to loosen up somebody's hip. The strap is
also down on Melissa's inguinal line here as close to her hip joint as I can
possibly get it. We're then going to take this hand wrap it around the thigh,
bringing the thigh close to the torso, so essentially we're given the thigh a hug
here. This allows us to control all of the weight of this limb just by rocking
back and forth and swaying back and forth, rather than trying to muscle it
with our arms. I know some of you guys treat individuals a lot
larger than yourselves, if any of you guys are working with professional
athletes it's not real easy to muscle a very large leg. So you guys are using
your body, you got the hugged in position here, you now have a free hand; you can
use this free hand as a barometer like we were talking about, fingers on the
ASIS thumb over the greater trochanter, that allows you to feel the greater
trochanter move into your thumb against the relatively stable ASIS. So as soon as
I sit back into the strap I can feel the greater trochanter move, even though the
ASIS is staying totally stable. So as I go into my protocol here I can feel
first resistance barrier, it's already starting to move a little bit right
there, and then I can pull all the way in to my arthrokinematic end range, and
then I can back off to 50% where I'm going to do my oscillations. If you guys
are using 25% or 75% that's fine, but you can use this hand to kind of guide how
much you're going to pull into that resistance. Now as I mentioned in the
other take you want to try to sway between your front leg and your back leg,
you're not doing rows, you're just front leg back leg, front leg back leg, front
leg back leg, allowing your whole body and their thigh to essentially move as
one as you shift your weight between your feet. Now if I was going to do this
technique at a normal tempo here, again first resistance barrier,
arthrokinematic end range, back off the 50% and then 1 to 2 oscillations per
second right about here, and I'm going to keep doing this probably for about 30
seconds, but essentially until I feel a decrease in arthrokinematic resistance.
Once I feel a decrease if I really wanted to keep working on internal
notation I could pull this way, if I was working on hip flexion I could come up a
little further this way, and then maybe do a second set. Now you don't want to
push too far before you reassess and see if you've regained normal range of
motion, but that does give you guys an idea that if you have good control of
this limb, you can kind of adjust as you go to try to get the most benefit from
this technique. Now I understand that a strap doesn't always work, like I said
some people feel pinching when they use a strap and sometimes you just don't
have a strap handy, so you can use your hands -you do lose your barometer here,
because what you're going to end up doing is taking this hand, lacing it
underneath the lower leg dropping that hand right down on the thigh as close to
the hip joint as you can possibly get, putting this hand over the top and now
you're using the same technique. Make sure you're trying to get your your
chest pretty close to vertical with your hands right, making sure that that the
leg itself is vertical; and once you're all kind of hugged in and that leg is
right up next to your torso, you're going to do the same front leg back leg, front
leg back leg, front leg back leg with your body wave. None of this, this will
wear out your arms. We want to make sure that we use our bodyweight so that we
can keep mobilizing for as long as we need to do this technique, to feel a
decrease in arthrokinematic resistance. So there you have it,
assess, address, reassess. Make sure that everytime 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 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.
Không có nhận xét nào:
Đăng nhận xét