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OMM Ribs Lecture

OMM Ribs Lecture. OU-COM / CORE OMM CURRICULUM Session 6, 2005–2006. Case Presentation.

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OMM Ribs Lecture

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  1. OMM Ribs Lecture OU-COM / CORE OMM CURRICULUM Session 6, 2005–2006

  2. 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.

  3. 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

  4. 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

  5. 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

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

  7. 0 Muscles of Inspiration

  8. Muscles of Expiration

  9. OMM Concepts • Upper ribs • Pump handle ribs • Lower ribs • Bucket handle ribs • Ribs 11 & 12 • Caliper ribs

  10. 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

  11. 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

  12. 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.

  13. 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?

  14. 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

  15. 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!

  16. 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)

  17. 0 Muscle Energy for Exhalation Dysfunction Ribs

  18. 0 Muscle Energy for Exhalation Dysfunction Ribs

  19. Muscle Energy for Exhalation Dysfunction Ribs

  20. 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

  21. 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 Rib Raising

  22. 0 Rib Raising

  23. 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

  24. 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

  25. HVLA: Considerations in Hand Placement Inhalation restriction Exhalation restriction From P. Greenman, DO Principles of Manual Medicine 2nd Ed., p.275

  26. 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

  27. 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

  28. SUMMARY

  29. Osteopathic Principles of Movement • Upper ribs

  30. Osteopathic Principles of Movement • Lower ribs

  31. 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

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