OMM Ribs Lecture SAM DETWILER, DO Objectives To understand the autonomic nervous system balance and the role of rib dysfunction with organ function and systemic disease To review basic rib anatomy and function To understand the approach to Osteopathic Rib Dysfunctions To review basic OMT techniques for rib dysfunctions BUTLER HEALTH SYSTEM FASTERCARE [email protected] Differential Diagnosis of Chest Pain Potentially life-threatening causes of chest pain Acute coronary syndromes • Acute myocardial infarction • ST segment elevation AMI • Non-ST segment elevation AMI • Unstable angina Pulmonary embolism Aortic dissection Myocarditis (most common cause of sudden death in the young) Tension pneumothorax Acute chest syndrome (in sickle cell disease) Pericarditis Boerhaave’s syndrome (perforated esophagus) 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. Differential Diagnosis of Chest Pain Common non-life-threatening causes of chest pain Gastrointestinal • Biliary colic • Gastroesophageal reflux • Peptic ulcer disease Pulmonary • Pneumonia • Pleurisy Chest wall syndromes • Musculoskeletal pain • Costochondritis • Thoracic radiculopathy • Texidor’s twinge (precordial catch syndrome) Psychiatric • Anxiety Shingles Case Presentation Physical Exam: Vitals: T=101.4 P=126 R= 24 BP=115/70 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 1 Case Presentation MSk/OMM: Levator scapulae muscles and scalenes boggy and tender to palpation bilaterally Case Presentation Labs: WBC: 14,500 with a left shift 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 2 Anatomy Ribs and their connections to the transverse processes Note rib angles (for treatment purposes) Muscles of Inspiration 3 Muscles of Expiration OMM Concepts Upper ribs Lower ribs Ribs 11 & 12 Osteopathic Principles of Movement Upper ribs Caliper ribs In order to diagnose these well, patient must be able to achieve maximum inhalation Bucket handle ribs Caliper ribs Osteopathic Principles of Movement Osteopathic Principles of Movement Pump handle ribs Lower ribs 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 Please insert OPP pics of caliper rib diagrams 4 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 Osteopathic Goals of Treatment 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 doesn’t move. Increased Sympathetic Tone: 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 5 Treatment order Some find treating the thoracic spine before the ribs beneficial Some find treating ribs works without having to treat the thoracic spine Find what works for your patient! One may find the rib dysfunction resolved Muscle Energy for Exhalation Dysfunction Ribs Muscle Energy for Exhalation Dysfunction Ribs 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) Muscle Energy for Exhalation Dysfunctio n Ribs 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 6 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 Ribs 3-10 HVLA Supine Inhalation or Exhalation Restriction 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 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 Exhalation restriction- thumb below rib HVLA: Considerations in Hand Placement From P. Greenman, DO Principles of Manual Medicine 2nd Ed., p.275 Superior force Pt. grasps opposite shoulder Ribs 3-10 HVLA Supine Inhalation or Exhalation Restriction Inhalation restriction Exhalation restriction Carry rib caudad 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 7 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 SUMMARY 8
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