OMM Ribs Lecture

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OMM Ribs Lecture

• OU-COM / CORE
• OMM CURRICULUM
• Session 6, 20052006

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Case Presentation

• A 64 year old male patient presents to the ER
  with a week-long history of cough and fevers.
  Recently, he started producing sputum that was
  colored in nature. He feels short of breath
  with minimal exertion and feels run down and
  fatigued. His cough occurs throughout the day
  and is forceful to the point of vomiting. He
  complains of pain when trying to take a big
  breath in. He is a non-smoker.

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Case Presentation

• Physical Exam
• Vitals T101.4 P126 R 24 BP115/70
• Gen Pale in appearance no acute distress but
  uncomfortable alert and oriented
• CV No murmurs tachycardic
• Pulm Rhonchi in right base, poor air movement
  throughout shallow breaths noted

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Case Presentation

• MSk/OMM
• Levator scapulae muscles and scalenes boggy and
  tender to palpation bilaterally
• T3 FRSL
• T6 bilaterally flexed
• T7-10 Neutral SRRL
• Rib dysfunction right ribs 7-10 prefer
  exhalation, left ribs 6-8 prefer exhalation
• Abdominal hemi-diaphragms limited motion on right

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Case Presentation

• Labs
• WBC 14,500 with a left shift
• Na 133
• O2 Sat 85
• ABG 7.33/66/51/29
• CXR Right lower lobe pneumonia with minimal
  effusion

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Anatomy

• Ribs and their connections to the transverse
  processes
• Note rib angles (for treatment purposes)

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Muscles of Inspiration
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Muscles of Expiration
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OMM Concepts

• Upper ribs
• Pump handle ribs
• Lower ribs
• Bucket handle ribs
• Ribs 11 12
• Caliper ribs

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Terminology For Board Review

• Think somatic dysfunction does and name the
  dysfunction for what it likes to do
• Exhalation dysfunction the ribs do not rise
  with inhalation but move easily with exhalation
• Inhalation dysfunction the ribs rise easily
  with inhalation but do not lower with exhalation

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More Terminology For Board Review

• Exhalation dysfunction
• Pump handle ribs are stuck down in the front
  and up in the back
• Bucket handle ribs are stuck down and in
• Caliper ribs are stuck pincing in
• Inhalation dysfunction
• Pump handle ribs are stuck up in the front and
  down in the back
• Bucket handle ribs are stuck up and out
• Caliper ribs are stuck pincing out

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Which is the key rib?

• When Treating Groups of Ribs
• Exhalation dysfunction treat the upper rib in
  the group (frees up all ribs below it)
• Inhalation dysfunction treat the lower rib of
  the group (this rib is holding all ribs above it
  in an inhaled position)
• Using Functional Methods Diagnosis
• This approach will lead to the key rib because
  you are comparing each rib with the one above and
  the one below. You are finding the one that
  doesnt move.

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Osteopathic Goals of Treatment

• Increase rib motion
• Enable greater air intake
• Decrease pain
• Decrease parasympathetic tone while promoting
  sympathetic tone
• Improve lymphatic drainage for the thorax and
  lungs
• Improve antibiotic access to affected lung.
• What else?

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Treatments

• Techniques
• Muscle Energy
• Rib raising
• Respiratory diaphragm facilitation/release
• Soft tissue techniques
• HVLA (consider patients age and history)
• With all techniques used, one must determine the
  patients condition/medical stability and to
  which techniques their body will best respond

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Treatment order

• Some find treating the thoracic spine before the
  ribs beneficial
• One may find the rib dysfunction resolved
• Some find treating ribs works without having to
  treat the thoracic spine
• Find what works for your patient!

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Muscle Energy

• Easy to do for your hospitalized patient on bed
  rest/limited activity
• Know which muscle groups you want to activate
  depending on the dysfunctional ribs involved
• Pectoralis minor muscle for upper ribs (3-5)
• Serratus anterior muscle for middle ribs (4-9)
• Latissimus dorsi muscle for lower ribs (7-12)

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Muscle Energy for Exhalation Dysfunction Ribs
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Muscle Energy for Exhalation Dysfunction Ribs
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Muscle Energy for Exhalation Dysfunction Ribs
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Rib Raising

• Goals of rib raising are to facilitate rib head
  movement (and, thus, facilitate full rib
  movement), increase lymphatic outflow, and
  encourage sympathetic nervous system (SNS)
  activation
• Be careful not to overdo your SNS activation!
• Initially, may locally stimulate the SNS to
  associated organs eventually leads to a
  prolonged reduction in SNS outflow from the
  treated area

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Rib Raising

• Placement of fingertips at rib angles
• Giving slow, methodical pulses anteriorly and
  laterally with the addition of caudal (or
  cranial) pressure will
• Increase motion,
• Activate SNS chain ganglia
• Improve lymphatic flow

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Rib Raising
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Diaphragms
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• Full respiratory diaphragm movement is necessary
  to enable full, unrestricted respiration
• There are many techniques to use to facilitate
  diaphragm movementyour facilitator may use one
  that you prefer over the technique you learned in
  school

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Soft Tissue

• For use in treating levator scapulae and scalene
  muscles, used as accessory muscles of respiration
• Your facilitator may demonstrate soft tissue
  techniques which you may find you prefer to those
  you learned in school

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Ribs 3-10 HVLA SupineInhalation or Exhalation
Restriction

• Hand set up
• Thumb and thenar eminence are fulcrum
• Thumb on inferior or superior aspect of rib
• Inhalation restriction- contact on superior
  aspect of rib shaft
• Carry rib caudad
• Exhalation restriction- thumb below rib
• Superior force
• Pt. grasps opposite shoulder

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HVLA Considerations in Hand Placement
Inhalation restriction
Exhalation restriction
From P. Greenman, DO Principles of Manual
Medicine 2nd Ed., p.275
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Ribs 3-10 HVLA SupineInhalation or Exhalation
Restriction

• Pt. supine - doc stands opposite dysfunctional
  rib
• Pt. grasps opposite shoulder
• Roll pt. toward you and place caudad hand on rib
  for appropriate dysfunction
• Return trunk to midline- body localizes to
  fulcrum over pt. lever arm
• Impulse-body dropped through lever arm to fulcrum
  with thumb and thenar eminence exerting a
  cephalad force for exhalation restriction and a
  caudad force for inhalation restriction
• Thrust on exhalation

Greenman pp. 303-304
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HVLA

• Hand set up is similar to thoracic HVLA but hand
  placement is on the rib angle and not on the
  transverse process
• Tips for HVLA
• When treating exhalation dysfunction, place your
  thenar eminence on top of the rib angle and
  thrust downward
• When treating inhalation dysfunction, place your
  thenar eminence below the rib angle and thrust
  upward

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SUMMARY
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Osteopathic Principles of Movement

• Upper ribs

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Osteopathic Principles of Movement

• Lower ribs

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Osteopathic Principles of Movement

• Caliper ribs
• In order to diagnose these well, patient must be
  able to achieve maximum inhalation
• Please insert OPP pics of caliper rib diagrams