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Thoracic Pistol Manipulation

This is Brent of the Brookbush Institute,
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 thoracic pistol manipulation, I’m going to
have my friend Yvette come out she’s going to help me demonstrate. Now keep in
mind if I’m doing a thoracic manipulation I’m basing it on more than
passive accessory motion. I have subjective complaints, maybe a Yvette has
shoulder pain, I’ve followed that up with some sort of movement exam like the
overhead squat assessment. Maybe on the overhead squat assessment I saw arms
fall and scapular elevation. I like to have a continuous interval measure so
that I can measure progress, unfortunately with the thoracic spine
goniometery doesn’t work very well, it’s not very reliable. So maybe you
could look into some of those rotation tests and at least have some sort of
visual indicator of pre and post intervention, and then the last thing
we’re going to rely on is actually our palpation skills. So the things that
might want to palpate for here, of course I could do my PA’s with my pisiform
hamate grip, like a central PA on the spinous process and look for any stiff
segments or painful segments. Painful segments might be a reason not to do
manipulation, keep that in mind. But if I find some stiff segments
that might be a reason to do manipulation, and as I’m doing
these all I’m doing is I’m taking PA, and you can look up these
mobilization videos this is just a thoracic PA, taking it all the way to end-
range. Does it feel stiff to me, I can talk to Yvette, hey how does that feel Yvette?
Pressure right, a lot of pressure. Generally the thoracic spine you have to
push pretty hard, there’s probably a lot of inherent stiffness in the thoracic
spine just because of all the rib joints too. So there’s a lot of connective
tissue and a lot of joints throughout this segment of the torso. Any pain there? What I start to notice as I’m going through the spine here,
I won’t waste your time going through the whole thing, but as I go through this
I notice that she is real real stiff in this area. So I’m going to want to take a
mental note of this is where I feel increased stiffness. I could also check
for increased tissue density, that might be an indication of over
activity, and of course I could do some like general spring type testing rather
than like a PA, just to see if I feel like anything and the ribs, do I feel
like, once again this segment definitely feels different than like when I press
down here. You okay? (Yeah). Now the pistol manipulation itself is face up, so
we’re going to go ahead and have Yvet roll over, and then I’m going to show you
how to set this up the best way I can. This is definitely one of those
techniques where people get caught up in the minutiae and then they get all
freaked out and then they stop thinking about just doing the technique alright
so scoot down a little bit more one thing you guys want to watch out for for
your own hands alright because what we’re gonna do is make a fist
underneath the vets back is you don’t want to be on seams right or or creases
in your table so I want to make sure that the portion I’m gonna manipulate is
on a nice flat seamless surface the next thing I’m gonna ask a vet to do is I’m
gonna have her interlock her fingers like this and then put them at the base
of her neck because what I’m gonna use her arms for is controlling her torso
now I guarantee this is gonna happen everybody is gonna do this so go ahead
and show them and then they’re gonna you’re gonna go put it on your neck and
they’re gonna go like this but at the bottom of their head and then they’re
gonna lay down and you’re gonna try to put their all those together and squish
their face we don’t want to squish faces besides this is just not as easy to
control but I see it all the time so again right here right so you guys all
I’m doing is interlocking like my fingers go down to the edge of my other
fingers not crossing like this and then go all the way down to the base of your
neck and now when I bring your elbows together you miss your face and of
course I have good control over your torso notice her head comes with us I
can rotate away which when I do this technique I tend to do this way I will
show you guys the other method as well now from here what I want to do is I’m
gonna wrap one hand around forearm like this and then you notice my wrist and my
other form kind of keep her elbows together pull away I’m then gonna take
my fist and place it right over that stiff part of her spine now the goal is
to put the segment that I want to manipulate just above my last knuckle
the reason this is called the pistil manip is you can do it this way all
right like you’re making a pistol with your hand right I like to do it this way
and it doesn’t matter all that matters is is this is the last segment that
you’re bracing and this segment right here is the one that gets manip we’re in
essence shearing one vertebrae over another so yeah go ahead she’s stiff up
in this area I can feel for her her spinous process
I’m gonna put the spinous process right here right between my feet our eminence
and my ip’s I’m then gonna just bring her over the top of my hand
now I have had many a patient with a nice setup like this who as soon as I
drop them back I get a cavitation right again setup is everything so be
comfortable make sure you have spinous process right
here stiff segments of the spine here make sure you’re both comfortable what
you’re gonna do is as you’re laying your hand down it helps to push a little in
this direction I’m gonna lay my chest kind of over my forearm here sorry I’m
gonna lay my my my chest over and then all I’m gonna do is have a vet take a
nice deep breath I’m gonna and as she breathes out all the way to the end I’m
gonna give a nice quick push and that was it in that particular case I
actually felt the vertebrae move but there was no cavitation big thing to
remember guys that is a successful manipulation cavitation does not mean
success increase range of motion on assessment is success and whether you
get a cavitation or not it doesn’t really seem to matter so now let me give
you guys a couple tips going back through that I have no problem with my
hands creating this type of fist putting her spine like this or spinous process
like this and pushing down some people don’t like how that feels on their
knuckles so they do this thing they either grab a pencil or a vet here was
nice enough to lend me her lip stick something I don’t particularly carry on
a regular basis but I’ve seen people use chapstick I’m only gonna give you one
bit of advice once you find something that works for you keep it on you
because if you get used to this and switch to this I guarantee you’re gonna
have a problem with your setup if you get used to this and switch
this same thing if you get used to adding something in your hands going
without anything in your hand is gonna feel a little weird the setup would be
the same let’s go ahead and have you okay the setup would be the same it
still put her spinous process between but now I can feel like I can’t crush my
own knuckles I do think in general this over complicates things
I don’t think it’s necessary for most individuals I think people just get
hooked on it in the beginning when they’re learning this technique because
they’re not real comfortable with their setup so they tend to spend a lot of
time over the top of their knuckles and then since they’re spending a lot of
time with us hock of their knuckles it gets really uncomfortable now if you’re
not larger than the person that you happen to be working on there is another
way to do this which is hand from the same side under now every all of the
same stuff would still apply so let’s go here she comes here and then all I would
do is turn her this way right so turn her away from me I would take this hand
put it under her spine and then flip her back and the same technique applies
right now for me this is a little uncomfortable because this is not the
way I actually do this technique personally but once you get set up you
can see how my fist visit is still in the same position and now all I’m gonna
do is push down this way kind of in that direction again it’s a nice little
clinical gem guys it’s not straight down it’s go that way with your force right
it’ll work the same way last variation you guys might want to try is I have
seen this done this way okay I find it a little harder to control the torso this
way but if I was gonna do this I could still grab her elbow set myself up and
now I’m kind of like trying to figure out how to position my torso and it with
a little bit more of like her this part kind of like here on my ribcage
but again the setups the same this just not as intense on the client
shoulders I think all of this once again guys is really dependent on whatever
setup you get good at do I think it’s great to experiment in the beginning but
then once you have a technique that you go to I would just keep going to it
because I think a lot of the little again minutiae of this hurts my knuckles
I can’t reach my arm around this hurts the patient’s shoulders what that’s
really a complaint of is it takes you a really long time to set up because
you’re not as well practiced as you should like if I do the pistil minutes
go ahead and do the pistol one up one more time to review here here my clients
get used to it great I’m here I know I want to be ready
nice deep breath good and that was it right so that took took a few seconds
I’m not suggesting you do things in a hurry what I’m suggesting is you
practice enough that you can kind of go into a flow with this particular
technique guys stay tuned for your close-up recap all right guys for the
close-up recap I’m gonna go ahead and have a vet change from this arm position
although this arm position for some people is very comfortable when I have
you go ahead and do the little interlaced fingers at the back of the
neck right and remember we go to the base of the neck so that I’m not
squishing her face and then from here I can use my hand over one forearm and
then I actually use my wrist on the other side of the other forearm so that
I have control and I’m gonna pull of that a little further away than I
normally would now you could go the other way don’t forget guys like
whatever is your comfort zone like whether you’re gonna wrap around you’re
gonna come from the same side you’re gonna do this arm position or the other
arm position just make sure you get comfortable the technique is still the
same we’re still gonna use our fists to go on either side of the spinous process
and then shear the top Debray over the vertebra we have
stabilized all right so what I’m gonna try to do is I’m gonna feel her spinous
process and try to put them right there you know this IP is gonna be on one side
my thinner eminence on the other I’m gonna try to set this up if you guys
prefer this technique then it would be to set this up as just below the segment
that I want on the nip and then I’m gonna pull her into as much flexion as I
can lock her out by going into flexion with cranial force at that segment so
you get this kind of combination of flexion with extension against your hand
just gonna pull up this way feel those spinous process there they are check alright maybe there’s a little
farther be careful it’s real easy when you’re not looking I just I caught the
end of the ribs there thought it was on the spinous process double checked and
now I’m on the spinous process so I’m gonna get my hand wrapped around now my
hand is there now keep in mind the direction of my force is more or less
gonna be in the direction that her forearms are currently in alright so if
I just kind of follow the direction of her forearms so anybody set all the
direction of our forearms big deep breath and that’s it guys take your time to get
set up make sure you practice this often and then whichever elbow setup you want
hand setup you want whether you want to put a pencil or or chapstick in there
whether you’re gonna wrap around or same side just get used to it practice it if
you have any questions leave them 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 manual techniques guys 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
guys 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 you

5 thoughts on “Thoracic Pistol Manipulation

  1. What do you do if the patient has pain in the front of their shoulder when crossing their fingers and putting them behind their head? It seems like something might be out of place thoracically but their feeling pain in their arm, almost as if it's affecting their rotator cuff muscles.

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