Transcript Rib OMM - VCOMcc

RIB OMM
Scott Klosterman DO
OBJECTIVES
 Demonstrate screening exam for rib dysfunction.
 Identify to your faculty “pump handle” and “bucket handle” rib motion.
 Recognize exhalation and inhalation somatic dysfunction.
 Name the various muscles and muscle groups involved with diagnosing and
treatment rib somatic dysfunction.
 Diagnose, properly set up, and treat typical rib somatic dysfunctions using both
direct (ME, resp. cooperation) and indirect methods.
 Know your bony landmarks for the rib and thoracic levels
 Be familiar with the muscles of inhalation and exhalation and how to utilize these
muscular attachments for treating rib somatic dysfunction
THORACIC EXAMINATION
 Observation
 Posture
 Breathing
 Palpation
 Global Screen
 GROM
 Directed soft tissue screen
 Paraspinal red reflex
 Paraspinal hypertonic changes
 Segmental screen
 Springing
 If changes found diagnose specific area.
 If segmental dysfunction make a segmental diagnosis.
 If changes soft tissue make a soft tissue diagnosis
RIB SCREENING
 Pump handle ribs 2-5
 Bucket handle ribs 5-10
 Caliper ribs 11+12
GENERAL TX PRINCIPLES
 Treat thoracic spine first and soft tissues
 Inhalation somatic dysfunction (stuck up need to be brought to knees/down a
notch/humbled) – tx the lowest rib
 Exhalation somatic dysfunction (stuck down pull up by your bootstraps) tx
the highest rib with dysfunction
 Recheck and if not improved tx the other side with opposite technique or try
and identify the key rib (Inhalation on R maybe Exhalation on L)
Exhalation Somatic Dysfunction
Inhalation Somatic Dysfunction
RIB GROUPS: TYPICAL VS. ATYPICAL
“Typical” Ribs:
 Ribs 3-9 display both transverse axis (pump handle) and AP
axis (bucket handle) motion
 Upper 1/3 ribs- predominant pump handle type mechanics around a
transverse axis
 Middle 1/3 ribs- mix of pump and bucket handle mechanics
 Lower 1/3 ribs- predominant bucket handle mechanics around an AP
axis
“Atypical” Ribs
 Ribs 1, 2, 10-12
RIB INHALATION PUMP
 Tissue texture changes or
tenderness over costochondral
or chondrosternal junctions or
posteriorly over the rib angles
 Anterior end elevated
(cephalad)
 Superior edge of posterior angle
is prominent
 Anterior end moves cephalad
on inspiration but is
restricted on expiration
 Anterior narrowing of
interspace above
dysfunctional rib
 Breathing and/or certain
body movements esp
coughing may precipitate
pain
SUPINE, DIRECT: RESPIRATORY COOPERATION
(4821.12B) - “PUMP HANDLE” INHALATION SD
 Physician stands at head of table, Pt.
supine.
 Contact the superior aspect of
dysfunctional rib (or lowest rib of
dysfunctional group) with the lateral
margin of his/her thumb at the midclavicular line.
 Other hand slides under the patient with
fingers hooked under the inferior
margin of the posterior angle of rib.
SUPINE, DIRECT: RESPIRATORY COOPERATION (4821.12B)
- “PUMP HANDLE” INHALATION SD
 Flex the upper thorax up to the level of the
dysfunctional rib.
 Apply cephalad tension on posterior angle
of rib carrying it to restrictive barrier.
 Pt. Instructed to “Take a deep breath and
let it out forcibly”
 Anterior hand carries anterior portion of
dysfunctional rib caudad and holds rib at
new restrictive barrier.
SUPINE, INDIRECT: RESPIRATORY COOPERATION
(4821.12C)
“PUMP HANDLE” INHALATION SD (RIBS 2-10)
 Pt is seated, with physician on
side of dysfunction.
 Contact dysfunctional rib:
 Posterior: superior margin of the
angle of dysfunctional rib.
 Anterior: interspace below
dysfunctional rib.
 Lateral: Both thumbs contact rib
shaft along the mid-axillary line.
SUPINE, INDIRECT: RESPIRATORY COOPERATION
(4821.12C)
“PUMP HANDLE” INHALATION SD (RIBS 2-10)
 Postion the hands on the lowest
rib with pt rotating head and body
away to free the rib head from the
demifacets
 Use both hands simultaneously to
move both the posterior angle and
anterior end of the rib in the
direction of inhalation to the point
of balanced ligamentous tension
 Instruct patient to “inhale deeply
and hold your breath as long as
you can”
 Repeat x 2 and recheck
PRACTICE
 One up/One down
RIB INHALATION BUCKET
 Tissue texture changes and
 Lower edge of shaft
tenderness in the intercostal
prominent.
muscles at the mid-axillary line or  Shaft may move slightly
posteriorly over the rib angles.
upward on inspiration.
 Shaft approximates the rib above
 Shaft does not move on
 Intercostal space is wide below,
expiration.
greatest at the mid-axillary line.
 Usually a deep ache or pain
with respiration.
SUPINE, DIRECT: MUSCLE ENERGY (4822.12A) - “BUCKET
HANDLE” INHALATION SD (RIBS 4-10)
 Physician stands at head of table
w/ pt supine.
 Physician slides one hand under
patient from above to midscapular region while letting the
patient’s head rest on his/her
forearm.
 Physician contacts the shaft of the
dysfunctional rib at its midaxillary line with the web between
the thumb and index finger.
SUPINE, DIRECT: MUSCLE ENERGY (4822.12A) - “BUCKET
HANDLE” INHALATION SD (RIBS 4-10)
 Pt. is lifted into forward bending and side
bending toward side of dysfunctional rib
until restrictive barrier is reached.
 Pt. is instructed to “bend body back to
neutral position” against the physician’s
resistance for 3-5 sec.
 After pt. relaxes, physician takes up slack
with hand at mid-axillary line to the new
restrictive barrier.
 Repeat x 2 and recheck.
SEATED, DIRECT: MUSCLE ENERGY (4822.12B) “BUCKET HANDLE” INHALATION SD (RIBS 2-3)
 Pt is seated with physician standing
behind patient.
 Physician contacts shaft of
dysfunctional rib in the midaxillary line with the fingers of
his/her caudad hand.
 Physician uses other hand to side
bend and rotate away from side of
dysfunctional rib.
SEATED, DIRECT: MUSCLE ENERGY (4822.12B) “BUCKET HANDLE” INHALATION SD (RIBS 2-3)
 Pt. is instructed to sidebend head
towards side of dysfunction while
physician offers isometric
counterforce for 3-5 seconds
 After patient relaxes for 2-3
seconds, physician takes up slack
with the hand at the mid-axillary
line to the new restrictive barrier
 Repeat x 2 and recheck
PRACTICE
 One up/One down
RIB EXHALATION PUMP
 Tissue texture changes and
tenderness to palpation over the
costochondral or chondrosternal
junctions or posteriorly over the
rib angles
 Anterior end displaced inferiorly
(caudad)
 Inferior edge of posterior angle
prominent
 Anterior end moves (caudad)
on expiration but restricted
on inspiration
 Anterior narrowing of
interspace below
dysfunctional rib (bottom of
the group)
 Pain may be precipitatied by
breathing and/or movements
esp coughing
SUPINE, DIRECT: MUSCLE ENERGY (4821.22B)
“PUMP HANDLE” EXHALATION SD (RIBS 2-10)
 Pt supine, with doctor on side of
dysfunction.
 Hooks fingers of caudad hand over
superior margin of the angle of the
dysfunction rib
 Apply caudad tension.
 Pt rotates head away from side of
dysfunctional rib and places the forearm
of the side of the dysfunction over
his/her forehead.
SUPINE, DIRECT: MUSCLE ENERGY (4821.22B)
“PUMP HANDLE” EXHALATION SD (RIBS 2-10)
 Physician places other hand over the
patient’s elbow and forearm
 Pt applies a contractile force against the
physician’s hand
 Contraction is held for 3-5 second, while
physician offers isometric counterforce
 Physician allows tissue to relax, and takes
up the slack with the caudad hand at the rib
angle to the new restrictive barrier
 Repeat x 2 and recheck
SUPINE, INDIRECT: RESPIRATORY COOPERATION
(4821.22C)
“PUMP HANDLE” EXHALATION SD (RIBS 2-10)
 Pt is seated, with physician on
side of dysfunction.
 Contact dysfunctional rib:
 Posterior: inferior margin of the
angle of dysfunctional rib.
 Anterior: interspace above
dysfunctional rib.
 Lateral: Both thumbs contact rib
shaft along the mid-axillary line.
SUPINE, INDIRECT: RESPIRATORY COOPERATION
(4821.22C)
“PUMP HANDLE” EXHALATION SD (RIBS 2-10)
 Postion the hands on the highest
rib with pt rotating head and body
away to free the rib head from the
demifacets
 Use both hands simultaneously to
move both the posterior angle and
anterior end of the rib in the
direction of exhalation to the point
of balanced ligamentous tension
 Instruct patient to “exhale deeply
and hold your breath as long as
you can”
 Repeat x 2 and recheck
PRACTICE
 One up/One down
RIB EXHALATION BUCKET
 Tissue texture changes and
 Upper edge of shaft
tenderness in the intercostal
prominent.
muscles at the mid-axillary line or  Shaft may move slightly
posteriorly over the rib angles.
downward on expiration.
 Shaft approximates the rib below
 Shaft does not move on
 Intercostal space is wide above,
inspiration.
greatest at the mid-axillary line.
 Usually a deep ache or pain
with respiration.
SUPINE, DIRECT: MUSCLE ENERGY (4822.22A) - “BUCKET
HANDLE” EXHALATION SD RIBS 4-10
 Pt supine, with doctor on side of
dysfunction.
 Physician hooks fingers of caudad
hand over superior margin of the
angle of the dysfunction rib or the
lower rib of a group and applies
caudad/lateral tension.
 Pt rotates head away from side of
dysfunctional rib and places the
forearm of the side of the
dysfunction over his/her forehead.
SUPINE, DIRECT: MUSCLE ENERGY (4822.22A) - “BUCKET
HANDLE” EXHALATION SD RIBS 4-10
 Physician places other hand over the patient’s
elbow and forearm.
 Patient is instructed to apply a contractile force
against the physician’s hand.
 Contraction is held for 3-5 second, while
physician offers isometric counterforce.
 Physician allows tissue to relax, and takes up
the slack with the caudad hand at the rib angle
to the new restrictive barrier (Inferior, lateral
force).
 Repeat x 2 and recheck
CONTRACTILE FORCE VECTOR
The patient’s contractile force is directed as follows:
 Towards the contralateral (opposite side) nipple for upper
ribs (ribs 2-4)
 Pectoralis minor m.
 Towards the contralateral ASIS for middle ribs (ribs 5-7)
 Serratus anterior m.
 Towards the ipsilateral (same side) hip for lower ribs (ribs 8-
10)
 Latissimus dorsi m.
PECTORALIS MINOR
Pectoralis minor
SERRATUS ANTERIOR
LATISSIMUS DORSI
SCALENES
SUPINE, DIRECT: MUSCLE ENERGY (4822.22B) “BUCKET HANDLE” EXHALATION SD (RIBS 2-3)
 Pt is seated with physician standing
behind patient.
 Physician contacts shaft of the rib
below the dysfunctional rib in the
mid-axillary line with the fingers of
his/her caudad hand.
 Physician uses other hand to side
bend and rotate away from side of
dysfunctional rib.
SUPINE, DIRECT: MUSCLE ENERGY (4822.22B) “BUCKET HANDLE” EXHALATION SD (RIBS 2-3)
 Pt. instructed to “pull your head
to the side against my hand”
while physician offers isometric
counterforce for 3-5 seconds.
 After patient relaxes for 2-3
seconds, physician takes up slack
with the hand at the mid-axillary
line to the new restrictive barrier.
 Repeat x 2 and recheck
PRACTICE
 One up/One down
ATYPICAL RIBS
 Rib 1 (thoracic inlet indirect covered block 2 ME covered later)
 Rib 11-12 (inhalation ME Kimberly 140, exhalation ME Kimberly 141)
CHECK OFF