OMM Ribs Lecture - Mercy.com

OMM Ribs Lecture Objectives

SAM DETWILER, DO  To understand the autonomic nervous system
BUTLER HEALTH SYSTEM FASTERCARE balance and the role of rib dysfunction with organ
function and systemic disease
[email protected]
 To review basic rib anatomy and function
 To understand the approach to Osteopathic Rib

Dysfunctions
 To review basic OMT techniques for rib dysfunctions

Differential Diagnosis of Chest Pain Differential Diagnosis of Chest Pain

 Potentially life-threatening causes of chest pain  Common non-life-threatening causes of chest pain
 Acute coronary syndromes  Gastrointestinal
 • Acute myocardial infarction  • Biliary colic
 • ST segment elevation AMI  • Gastroesophageal reflux
 • Non-ST segment elevation AMI  • Peptic ulcer disease
 • Unstable angina  Pulmonary
 Pulmonary embolism  • Pneumonia
 Aortic dissection  • Pleurisy
 Myocarditis (most common cause of sudden death in the  Chest wall syndromes
 young)  • Musculoskeletal pain
 Tension pneumothorax  • Costochondritis
 Acute chest syndrome (in sickle cell disease)  • Thoracic radiculopathy
 Pericarditis  • Texidor’s twinge (precordial catch syndrome)
 Boerhaave’s syndrome (perforated esophagus)  Psychiatric
 • Anxiety
Case Presentation  Shingles

A 64 year old male patient presents to Case Presentation
the ER with a week-long history of cough
and fevers. Recently, he started  Physical Exam:
producing sputum that was colored in  Vitals: T=101.4 P=126 R= 24 BP=115/70
nature. He feels “short of breath” with  Gen: Pale in appearance; no acute distress but
minimal exertion and feels “run down” uncomfortable; alert and oriented
and fatigued. His cough occurs  CV: No murmurs; tachycardic
throughout the day and is forceful to the  Pulm: Rhonchi in right base, poor air movement
point of vomiting. He complains of pain throughout; shallow breaths noted
when trying to take a big breath in. He is
a non-smoker.

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Case Presentation Case Presentation

 MSk/OMM:  Labs:
 Levator scapulae muscles and scalenes boggy and tender to  WBC: 14,500 with a left shift
palpation bilaterally  Na: 133
 T3 FRSL  O2 Sat: 90%
 T6 bilaterally flexed  CXR: Right lower lobe pneumonia with minimal effusion
 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

Ribs Affect Sympathetic Tone

 Autonomic Nervous System
 Visceral-Somatic Reflexes
 Somato-Visceral Reflexes

Segmental sympathetic nerve
supply for the viscera

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Anatomy

 Ribs and their
connections to
the transverse
processes

 Note rib angles
(for treatment
purposes)

Muscles of
Inspiration

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Muscles of OMM Concepts
Expiration
 Upper ribs
 Pump handle ribs

 Lower ribs
 Bucket handle ribs

 Ribs 11 & 12
 Caliper ribs

Osteopathic Principles of Movement Osteopathic Principles of Movement

 Upper ribs  Lower ribs

Osteopathic Principles of Terminology – For Board
Movement Review

 Caliper ribs  Think “somatic dysfunction does” and name the
dysfunction for what it likes to do:
 In order to diagnose  Exhalation dysfunction: the ribs do not rise with
these well, patient inhalation but move easily with exhalation
must be able to  Inhalation dysfunction: the ribs rise easily with
achieve maximum inhalation but do not lower with exhalation
inhalation
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 Please insert OPP pics of caliper
rib diagrams

More Terminology – For Board Which is the ‘key rib’?
Review
 When Treating Groups of Ribs:
 Exhalation dysfunction:  Exhalation dysfunction: treat the upper rib in the group (frees up all
ribs below it)
 Pump handle: ribs are stuck down in the front and up in the back  Inhalation dysfunction: treat the lower rib of the group (this rib is
 Bucket handle: ribs are stuck down and in holding all ribs above it in an inhaled position)
 Caliper: ribs are stuck pincing in
 Using Functional Methods Diagnosis:
 Inhalation dysfunction:  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
 Pump handle: ribs are stuck up in the front and down in the back one that doesn’t move.
 Bucket handle: ribs are stuck up and out
 Caliper: ribs are stuck pincing out

Increased Sympathetic Tone:

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.

Parasympathic Tone Effects

Treatments

 Techniques:

 Muscle Energy
 Rib raising
 Respiratory diaphragm facilitation/release
 Soft tissue techniques
 HVLA (consider patient’s age and history)

 With all techniques used, one must
determine the patient’s
condition/medical stability and to which
techniques their body will best respond

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Treatment order Muscle Energy

 Some find treating the thoracic spine before the ribs  Easy to do for your hospitalized patient on bed
beneficial rest/limited activity
 One may find the rib dysfunction resolved
 Know which muscle groups you want to activate
 Some find treating ribs works without having to treat depending on the dysfunctional ribs involved
the thoracic spine  Pectoralis minor muscle for upper ribs (3-5)
 Serratus anterior muscle for middle ribs (4-9)
 Find what works for your patient!  Latissimus dorsi muscle for lower ribs (7-12)

Muscle Muscle
Energy for Energy for
Exhalation Exhalation
Dysfunction Dysfunctio
Ribs n Ribs

Muscle Rib Raising
Energy for
Exhalation  Goals of rib raising are to facilitate rib
Dysfunction head movement (and, thus, facilitate full
Ribs 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 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

Soft Tissue Ribs 3-10 HVLA Supine
Inhalation or Exhalation Restriction
 For use in treating levator scapulae and scalene
muscles, used as accessory muscles of respiration  Hand set up
 Thumb and thenar eminence are fulcrum
 Your facilitator may demonstrate soft tissue  Thumb on inferior or superior aspect of rib
techniques which you may find you prefer to those
you learned in school  Inhalation restriction- contact on superior aspect of rib shaft
 Carry rib caudad

 Exhalation restriction- thumb below rib
 Superior force

 Pt. grasps opposite shoulder

HVLA: Considerations in Hand Placement Ribs 3-10 HVLA Supine
Inhalation restriction Inhalation or Exhalation Restriction

Exhalation restriction  Pt. supine - doc stands opposite dysfunctional rib
 Pt. grasps opposite shoulder
From  Roll pt. toward you and place caudad hand on rib
P. Greenman, DO
Principles of for appropriate dysfunction
Manual Medicine  Return trunk to midline- body localizes to fulcrum
2nd Ed., p.275
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 SUMMARY

 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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