Importance of Maintaining Secondary Levers in Cervical Manipulation Techniques

Dr. Brian Melrose // #TechniqueThursday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Brian Melrose discusses the details surrounding maintaining your secondary levers on set up for more success with cervical spine manipulation techniques.

Take a listen or check out our full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

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BRIAN MELROSE I'm one of the lead faculty in the spine division, teaching both cervical and lumbar courses. And I'm here and stoked to be here on a Thursday, a clinical Thursday to talk about the number one thing that I think could dramatically improve your success utilizing cervical manipulation in the clinic. And really what that boils down to is going to be maintaining your secondary levers. And so we'll get into all the details of what I mean with the verbiage there, as well as talking about a particular technique that I think this will help with. But I got to zoom out first and kind of allude to where this comes from. And to be honest, man, it's just from being out on the road for the last couple of years, teaching about 15 to 20 courses a year and getting the opportunity to work with a lot of different physical therapists, from around the country. And those folks, you know, they have a lot of different backgrounds. They have different opinions about manipulation. Some folks have been trying cervical spine manipulation for years, whereas other folks are relatively novice with things. And so I think if you can understand how to maintain your secondary levers, it's going to help everybody. If you are more of a novice practitioner or novice with utilizing cervical manipulation in the clinic, this is the one time where I'm going to plug our courses and say, if you want everything, like if you want to know how to keep things safe, if you're wondering about if the pot matters, How hard do I thrust? The answers to all of those questions will always live in our weekend course. And I truly believe that it takes a full two days of kind of immersing yourself in that space to really understand stuff. You're not going to learn cervical spine manipulation techniques well by just cruising YouTube or Instagram. If you're a novice, make it out to one of our courses sometime this year for one of those details. But if you can absorb the concept that I kind of talked through today, that is significantly gonna help your kind of hands during the weekend and therefore your success in the clinic. So listen up, tune in and see if you can grab this one. Again, I think it'll help you dramatically when you make it out to a cervical spine ice course later this year. For those of you that are more in the middle, the folks that probably did a manipulation course at some point in their career, and you use it very occasionally in the clinic, maybe once or twice, week in and week out, but you just don't feel confident with your hands. Every time you go to set up someone's neck, maybe it feels just a little bit different. If that feels like you fall in that category, then this podcast is for you. If there's one thing that I see very often on the weekends, it's folks kind of missing or losing some of their secondary levers. And if you can understand what we talk about today with a person's neck and kind of what I show with the foam roller, again, I think that will dramatically increase your success with cervical spine manipulation and therefore your outcomes in the clinic. And so to kind of dive into things, then we really have to start with describing what a secondary lever is. And so when you set up a manipulation technique, you put on your secondary levers first. That's part of your setup for the thrust or primary lever. And so secondary levers are really designed to put tension into the system. and help lock out or isolate a particular level of the spine that we are trying to, again, isolate to thrust through. And so those secondary levers take up tension and then set us up well for our primary lever, which is in the direction with which you thrust. And so the primary lever is the last lever that you put on. It's what you explore and you kind of lean in and you're eventually going to feel a barrier. you're gonna feel something crispy. And again, if you have cracked someone's neck before, you are gonna say, ooh, like there it is. Like I'm gonna come back and I'm gonna smack right through that thing. And so that's kind of the setup that we're talking about. Now let's take this a step further and go into a very specific manipulation technique so that we're all on the same page. And I want to talk today about like a mid cervical kind of cradle hold. So again contact and non contact and you're going to put your levers on first to put some tension into the neck. And so it really depends on who you learn this from. That's one factor is what secondary levers you put on first. You may also change your secondary levers, either number one, which levers you put on, and especially how much of each lever you put on based on the patient in the clinic. Like if you have someone that's very stiff and lacks side bend, you may need less of that to get their neck in a locked out position. You have somebody that has, you know, a lot of movement in their neck, you're going to need to put on a different degree of those secondary levers so that by the time you get into rotation, you say, Ooh, there it is. And I feel confident with that. And so for the mid cervical cradle hold, typically the head's on a pillow, so the patient's a little bit flexed, and then I'm gonna introduce some degree of side bend, some degree of lateral translation, and then last, start exploring rotation. And what you're hoping for on that setup is that if you put the right amount of secondary levers on board first, i.e. side bend and lateral translation, that as you begin to rotate, you're going to feel that barrier come in relatively early in rotation. You're going to feel things crisp up there. And again, you're going to have that ooh moment where you say, there it is. So I think that's the kind of setup that we're talking about, but the problem that I end up seeing all the time on the weekends is that as folks go in, they get it set up, they find that barrier the first time they say, Ooh, there it is. And then again, we can't stick at the barrier and just thrust through it. We have to back off a little bit. And there's a technique called priming where you're going to get to that barrier a couple of times before you thrust. Now the issue is, and the moment of truth that I see happen a lot on the weekends, is folks go in, they find that barrier the first time, and then they back off. And they come in, and they check that barrier again. They back off, they check it a third time, a fourth time, a fifth time, a sixth, like it keeps going. And that's again, because they're learning the technique. There's two big problems with that though. Number one is, is when you get into the clinic, think about your patient, like they're laying there, right? They're trying to trust your hands. They're trying to relax. And if you check something three, four, five, six times, they are feeling like a sitting duck. They're going to start kind of tensing up and anticipating it. And that's the last thing that we want. And so one of the jokes that I love to make is like, you get two primes. If you've got to take a third, take a third. But after that, you've got to go for it. So that's part of the problem. The other issue though is, is that each time folks tend to kind of prime or reassess that barrier, they begin to lose some of their secondary levers. What happens then is they begin to leak some of the force, or excuse me, some of the tension that they've created in the neck. And so they'll, again, side bend, side glide, they'll begin to rotate, they feel that barrier, they say, ooh, there it is. They'll back off a bit, they'll lose some of their secondary levers, and then they go back in to check with rotation again, and they have to rotate a little bit further because they lost tension in the rest of the system. And they feel that, and they go, ah, dang, it doesn't feel right. So then they want to go check it again. They check it again, they lose their levers a little bit more, and then they have to rotate a little bit further. And so by the second, third, fourth, fifth try, they've really unbuckled a lot of the tension that they put on beforehand. The thrust that they have to keep chasing the barrier, they lose confidence with their hands. And we all know that if you don't feel confident with your hands, your patient won't relax as much. And so we really have to maintain those levers as we get going. And the best way to visualize this concept is with a foam roller. So I've already posted something to the Ice Physio Instagram account to help visualize this. But I'm going to demonstrate it with a foam roller now so that you can see it. And then I'll have my wife, Ellie, step in here. We'll show it with an actual neck. So what we're looking at here is Setting things up in this position. So let's imagine this is someone's neck. There's a cervical spine, again, is oriented down towards the foot of the table. I'm going to introduce my hands here, and I'm going to begin with a little bit of side bend. And so now what I need to imagine is that I have to maintain this axis or direction of side bend in the foam roller. When I get in and do lateral translation, the foam roller needs to stay oriented in that same plane. If I unbuckle them a little bit, again, I've already lost my levers. So side bend, side glide, and then as I begin to explore rotation, I can't lose, again, the angulation of the foam roller. If I wanna keep all of the tension I've built into the neck, it needs to stay crisp, it needs to stay clean, and I need to, again, be able to set things up for the thrust technique. And so if you can visualize that with a foam roller, then it should make sense when we do it with a patient's head. So Ellie's gonna come on in here, She's gonna lay down for us. And so the same technique kind of applies, right? The pillow is introducing a little bit of flexion, just like where the foam roller was. I get my hands in here on the neck, just like this. And then I'm going to explore, again, side bend, lateral glide, and then rotation. And what I'm doing in this forehead and her chin, maintaining that orientation, then as I spin, we're going here. But I can't unbuckle some of those other levers as I re-explore that rotation. They need to be maintained so that as I get over and I thrust, I can maintain the position and maintain the tension in the system. And so I think if you can visualize this concept in terms of putting good secondary levers on first, creating a lot of tension in the system, you have to maintain that as you prep the thrust. And again, you're just not gonna get the impulse in the right area that you want. So, in conclusion, guys, whether you're novice or whether you're a little bit more advanced in trying to kind of master techniques, the whole purpose of today is to really hammer in the point that you have to maintain those secondary levers with any manipulation technique. That's what's building kind of, again, the tension in the system. And if each time you go to kind of prime the barrier, you lose some of that, you're gonna have to go further into your primary lever, in this case, rotation, to research for that barrier. It's gonna make you feel less confident, like you don't really have it.

SUMMARY So make sure you're maintaining your secondary levers on your setups. And again, this will dramatically increase your success in the clinic, the confidence in your hands, and again, the results for your patients. Awesome. Thank you so much for having me here this morning, guys. It was great to talk about this on clinical Thursday. The last thing I want to do is just plug a couple of courses that we have coming up. Our next cervical spine courses, I'm teaching out in Kent, Washington this weekend, but we're all sold out for that. So your next chances are probably the weekend of July 13th and 14th. Jordan Berry is on his home turf out in Charlotte, North Carolina. And Miller is going to be out in Oviedo, Florida on July 20th and 21st for cervical spine. Next two lumbar courses will be in Amarillo again on that July 12th and 14th weekend. You'll be stuck with me down in Texas. And then after that, we're doing a course in San Luis Obispo out in California. Love the central coast in CA. And that will also be on July 20th and 21st. So hope to see you guys at some courses later this year. I hope you're having a great Thursday and have a great end to the week. Thanks so much.

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