OMT of the Thoracic Spine

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Transcript OMT of the Thoracic Spine

OMT of the Thoracic Spine
Eric J. Milie D.O.
Internal Medicine Lecture Series
The physician will become comfortable with the
osteopathic manipulative treatments demonstrated during
the lecture
The osteopathic physician will be able to name thoracic
spine and rib dysfunction
The osteopathic physician will understand the complex
anatomy of the thoracic spine and thoracic inlet/outlet
Evidence Based Medicine
DR Noll, et al. Benefits of osteopathic manipulative treatment for
hospitalized elderly patients with pneumonia. JAOA • Vol 100 • No
12 • December 2000 • 776-782
Showed that hospitalized pt’s treated with OMT required significantly
shorter courses of intravenous antibiotics and also had a significantly
shorter hospital stay
Andersson GB, Lucente T, Davis AM, Kappler RE, Lipton JA,
Leurgans S. A comparison of osteopathic spinal manipulation
with standard care for patients with low back pain. N Engl J
Med.1999; 341:1426 –1431
Patients treated with OMT required less analgesics than
patients treated with “standard medical therapy” alone, and were
more satisfied with their care
Evidence Based Medicine cont.
Hoehler FK, Tobis JS, Buerger AA. Spinal manipulation for low back
pain. JAMA.1981; 245:1835 –1838
Showed that patients treated with OMT received equal benefit
compared to patients receiving analgesics and soft tissue massage
Licciardone JC, Stoll ST, Fulda KG, Russo DP, Siu J, WinnW, et
al. Osteopathic manipulative treatment for chronic low back
pain: a randomized controlled trial. Spine.2003; 28:1355 –1362
Patients with chronic back pain who received osteopathic
manipulation reported greater improvements in back pain,
greater satisfaction with back care throughout the trial, better
physical functioning and mental health at 1 month, and fewer
cotreatments at 6 months compared to the control group
Rule of Three’s
Spinous Process
Location with
Regards to
Vertebral Body
Process Location
with Regards to
Vertebral Body
Over the body of
The same horizontal
corresponding vertebra plane
Over the intervertebral
space below
½” superior and lateral
Over the body of the
vertebra below
1” superior and lateral
Over the body of the
The same horizontal
corresponding vertebra plane
Thoracic Motion
Upper and middle thoracic: Rotation>
flexion/extension> sidebending
Lower Thoracic: Flexion/ extension>
sidebending> rotation
Main motion of T-spine: Rotation
Splanchnic Nerve
Collateral Ganglia
Organs/ Structures
Cervicothoracic, middle, Head and neck
and superior cervical
Heart and Lungs
Greater Splanchnic
Celiac Ganglion
Upper GI
Lesser Splanchnic
Superior Mesenteric
Lower GI
Least, Lumbar
Least, Lumbar
Inferior Mesenteric
L Colon, ureter,
prostate, genitals,
Anatomical Landmarks
Spine of scapula- T3
Inferior angle of scapula- T7
Sternal notch- T2
Sternal angle (angle of Louis)- T4, attaches
to 2nd rib
Nipple- T4 Dermatome
Umbilicus- T10 dermatome
The motion of the 1st and 7th ribs in A, ordinary expiration;
B, quiet inspiration, and C, forced expiration
Rib Motion with Respiration
Bucket-Handle Motion -- Characteristic rib
motion, primarily of the lower ribs, that occurs
during respiration. The effect is to increase the
transverse diameter of the thorax during
inspiration. This involves ribs 7-10
Pump-Handle Rib Motion -- Characteristic rib
motion, primarily of the upper ribs, that occurs
during respiration. The effect is to increase the
anteroposterior diameter of the thorax during
inspiration. This primarily effects ribs 1-6.
Caliper motion: Ribs 11, 12
Bucket-Handle Motion
Pump-Handle Motion
Exhalation vs Inhalation Ribs
Exhilation Rib: A somatic dysfunction usually characterized
by a rib being held in a position of exhalation such that motion toward
exhalation is more free and motion toward inhalation is restricted.
Also called “inhalation restriction.”
Inhalation Rib: somatic dysfunction usually characterized by
a rib being held in a position of inhalation such that motion toward
inhalation is more free and motion toward exhalation is restricted. Also
called “exhalation restriction.”
In exhalation dysfunction, the “key rib” is uppermost rib of
dysfunction, in inhalation dysfunction, it is the lowermost rib
Exhalation Rib Somatic Dysfunction
Acts Upon
Ribs 1-2
Pectoralis Minor
Ribs 3,4,5
Serratus Anterior
Ribs 7,8,9,10
Latissimus Dorsi
Ribs 9,10,11,12
Quadratus Lumborum
Rib 12 Indirectly
Forced Inhalation
Inhalation Rib Dysfunction
Acts Upon
Quadratus Lumborum
Rib 12 indirectly
Forced Exhalation
Rib Raising
Reduces constriction of large lymphatic
Stimulates regional sympathetic efferent
Results in prolonged reduction in
sympathetic outflow
Excursion of chest is increased and
lymphatic flow is improved
Rib Raising cont.
Patient Position: Supine
Physician Position: Standing or seated at
the patient’s side
Rib Raising Procedure
Palms placed under patient’s thorax, so that pads
of fingers at rib angles
Flex fingers, apply traction to the rib angle
While applying traction, bend knees/ lower trunk
to raise ribs (lever/fulcrum action) Do not bend
Move hands so that subsequent ribs treated
Treat opposite side of rib cage in same manner
Respiratory Diaphragm Release Technique
Dysfunction: Tension and reduced excursion of
the respiratory diaphragm and the lower thoracic
Objective: To three-dimensionally balance the
thoracic spine, and the costo-diaphragmatic
Physician Position: At the head of the patient or
the side of the patient
Patient Position: Lying supine
Respiratory Diaphragm Release
Patient seated or supine
Physician standing behind patient or at patient’s side
Physician’s hands around thoracic cage, fingers under the
costal margin
Check motion by gently rotating thoracic tissues
Treatment Phase: Hold thoracic tissues in the direction in
which they move freely. Allow fascia to unwind, until it
settles into a rhythmic vertical motion
Diaphragm Release
Diaphragm Release
Thoracic Outlet
Roughly 4cm area boundaried anteriorly by
the manubrium of the sternum, laterally by
the 1st rib and its costal cartilage, and
posteriorly by the body of T1
Covered by Sibson’s fascia, surrounded by
the scalenes, SCM, and the trapezium
Subclavian vein and artery, brachial plexus,
and lymphatics run through these structures
Thoracic Outlet Release
Purpose: To relax soft tissue restrictions and
enhance lymphatic drainage from the head
and neck
Physician Position: Sitting at head of table
or side of patient
Patient Position: Lying supine
Thoracic Outlet Release technique
Place one hand posterior to the thoracic inlet (transversely) at the
level of the first and second ribs.
Place the other hand at the same level on the anterior chest wall.
The area is motion tested for myofascial restrictions. These motions
include a side-to-side movement, a rotational or twisting movement,
a superior or inferior movement, or an angular movement.
The area is treated directly (barrier engagement) or indirectly
(position of fascial ease). Having the patient take three deep breaths,
can facilitate a release.
The physician waits for a release and the area is re-evaluated.
Modification: Both hands can also be placed on the anterior thorax.
With this position, the thumbs contact the trapezius muscle and
posterior upper two ribs. The fingers lie on the anterior chest wall
and spread out.
Lymphatic Pumps
Dysfunction: Lymphatic Stasis
Objective: Improve lymphatic flow by
altering intrathoracic pressure
Technique: Several different variations,
including thoracic and pedal pump
Pedal Pump
“Fun With Alex” Lots of good action in this video. Alex is behind the wheel
of a Ford F150. There is pumping, driving, revving in sneakers, white socks
and barefeet. Alex is a hottie and knows how to pump it
Lymphatic Pump Technique: Thoracic
Place your hands on the patient's anterior chest wall over the
patient's pectoralis major muscles. The heels of your hands should
lie on ribs 2-4.
With your elbows straight, have the patient breathe in through their
open mouth and exhale passively. As the patient exhales, follow the
exhalation motion downward and maintain the end point. This
applies a compressive force.
With each following breath, slightly resist inhalation and maintain
your pressure at the end position of exhalation.
One third of the way through the fourth or fifth inhalation, briskly
remove your hands from the chest wall, as a rush of air will enter the
patient's lungs.
Pedal Pump
A venous and lymphatic drainage technique
applied through the lower extremities
Rhythmic plantar and dorsiflexion of the
lower extremities
Physician at foot of patient, patient supine
Rate 30-45 cycles/minute
Kirksville Krunch
Patient Position: Supine
Physician Position: Side of patient, opposite side of
posterior transverse process
Patient crosses arms, “opposite over adjacent”
Thenar eminence under posterior transverse process of
dysfunctional segment
Patient rolled onto table to the point where flexion is felt at
level of dysfunctional segment
Sidebend to engage restrictive barrier
Pt takes deep breath and exhales
At end of exhalation, HVLA thrust is applied straight down
to fulcrum (thenar eminence)
Question 1:
A 34 year old female comes to the office complaining
of mild left sided thoracic pain. The pain started about a
week after she began driving a new sports car with very
low riding seats. The pain is worse with inhalation. On
PE, ribs 3-5 on the left are more caudad and lag behind
during inhalation.
How would you name the above somatic dysfunction?
A. Left ribs 3-5 inhalation dysfunction
B. Left ribs 3-5 exhalation dysfunction
C. Right ribs 3-5 inhalation dysfunction
D. Right ribs 3-5 exhalation dysfunction
Question 2
In the previous case, which rib would be the “key rib”
through which to direct treatment?
A. Rib 2
B. Rib 3
C. Rib 4
D. Rib 5
E. Rib 6
Question 3
If you choose to treat the previous patient with the
“Kirksville Krunch” HVLA, in which direction
would the thrust be applied?
A. Cephalad
B. Caudad
C. Straight down towards your fulcrum
D. HVLA contraindicated in the prior patient
because she is a female of child bearing age
"Randy Works the Cavalier" Socks & Barefoot
Randy is from the midwest and worked his Cavalier in socks and
barefoot. There is pumping and driving in this video with some cool