Thoracic spine and rib osteopathy

Summary

The thoracic spine, composed of 12 segments, is the longest subsection of the vertebral column. Each segment has an articulation with a rib, giving rise to an important relationship between structure and function in this region. Therefore, somatic dysfunction in the thoracic spine will affect the rib cage, and somatic dysfunction in the rib cage will affect the thoracic spine. While this region is of major importance to respiration and circulation (including lymphatic flow), its functional capacity is also important in relation to the autonomic nervous system due to the location of the sympathetic chain ganglia. Treatment involves articulatory techniques, muscle energy, and high-velocity low-amplitude.

Anatomy

Thoracic spine

Bones

Osteopathic landmarks

Ribs

Bones

Osteopathic landmarks

Motion

  • Upper division (ribs 1–5)
    • Pump-handle motion
    • Anterior-posterior diameter increases during inhalation
  • Lower division (ribs 5–10)
    • Bucket-handle motion
    • Transverse diameter increases during inhalation
  • 11th and 12th ribs
    • Caliper motion
    • Down and out motion during inhalation

Rib dysfunctions

Diagnosis

  • Ribs can be restricted in motion during inhalation or exhalation
  • They are diagnosed via static examination based on the motion of a rib or group of ≥ 2 adjacent ribs (some institutions teach a group of ≥ 3 adjacent ribs).
  • Within a group of dysfunctional ribs, a key rib is identified, which represents the major restrictor.
Inhalation dysfunctions Exhalation dysfunctions
Diagnosis
  • Rib or group of ribs is restricted during exhalation
  • Rib or group of ribs is restricted during inhalation
Key rib
  • Bottom-most rib within the group of ≥ 2 adjacent ribs
  • Top-most rib within the group of ≥ 2 adjacent ribs
Outcome
  • Restriction in rib motion during exhalation
  • Restriction in rib motion during inhalation

BITE: Bottom rib, Inhalation; Top rib, Exhalation

Static examination

  • Position: seated or supine
  • Procedure
    1. Palpate ribs in accordance with their primary motion.
      • Rib 1
        • Motion: pump-handle
        • From the head of the table, place your index fingers and thumbs on the anterior and posterior aspect of the 1st rib, respectively.
      • Ribs 2–5
        • Motion: pump-handle
        • From the head of the table, place the hypothenar eminences on the sternum.
      • Ribs 6–10
      • Ribs 11–12
        • Motion: caliper
        • From behind the patient, place your hands at the level of the 11th or 12th rib.
    2. Identify inhalation versus exhalation dysfunction.

Treatment

  • Consists of either muscle energy or HVLA
  • Thoracic spinal dysfunctions should be treated first.
  • Each rib is treated individually.
  • In group dysfunctions, treatment begins with the key rib.

Inhalation dysfunctions

Muscle energy

Exhalation dysfunctions

Muscle energy

  • Treated via four mechanisms:
    1. Begins with the most superior rib
    2. Inhalation
    3. Movement of the head, elbow or arm against equal resistance
    4. Inferior traction on the posterior aspect of the affected rib

High-velocity low-amplitude

  • Treated similarly to thoracic spinal dysfunctions
  • Rib 1 and ribs 2–10 are treated differently.

Rib inhalation dysfunction

Rib 1

Muscle energy

  • Position: supine
  • Procedure
    1. Place finger pads onto the superior aspect of the 1st rib (supraclavicular fossa) and apply inferior force.
    2. Flex the patient's head until motion is felt at the 1st rib (relaxes scalenes).
    3. Ask patient to take a deep breath.
    4. Upon exhalation, follow the rib inferiorly (into its barrier).
    5. Upon inhalation, resist the upward motion of the 1st rib.
    6. Repeat for 3–4 breaths.
    7. Reassess.

High-velocity low-amplitude

  • Position: prone
  • Procedure
    1. Place thenar eminence over the posterior rib.
    2. Bring the patient's ipsilateral arm cephalad to cup their chin.
    3. Apply an anterior pressure onto the posterior rib.
    4. Bring the patient's elbow superiorly (help flatten thoracic spine).
    5. Bring the patient's head away from the affected rib.
    6. Ask patient to inhale.
    7. At the end of exhalation, apply a downward thrust through the thenar eminence.
    8. Relax.
    9. Reassess.

Ribs 2–5

Muscle energy

  • Position: supine
  • Procedure
    1. Place palm on the superior aspect of the costal cartilage of the affected rib and apply inferior force.
    2. Flex patient's head until motion is felt at the affected rib.
    3. Ask patient to take a deep breath.
    4. Upon exhalation, follow the rib inferiorly (into its barrier).
    5. Upon inhalation, resist the upward motion of the affected rib.
    6. Repeat for 3–4 breaths.
    7. Reassess.

High-velocity low-amplitude

  • Position: supine with examiner on the opposite side of the dysfunction
  • Procedure
    1. Perform myofascial technique.
    2. Have the patient cross the arms.
    3. Push elbows down and tuck under your abdomen while maintaining downward pressure.
    4. Lift the patient's head and torso towards you.
    5. Place the thenar eminence over the posterior rib angle.
    6. Ask patient to fully inhale and exhale.
    7. Slowly isolate the rib by rolling the patient over your hand.
    8. Apply a downward thrust through the posterior rib angle using your weight.
    9. Reassess.

Ribs 6–10

Muscle energy

  • Position: supine
  • Procedure
    1. Place palm on the lateral aspect of the affected rib and apply inferior force.
    2. Flex and side bend the patient's head and torso until motion is felt at the affected rib.
    3. Ask patient to take a deep breath.
    4. Upon exhalation, follow the rib inferiorly (into its barrier).
    5. Upon inhalation, resist the upward motion of the affected rib.
    6. Repeat for 3–4 breaths.
    7. Reassess.

High-velocity low-amplitude

Rib exhalation dysfunction

Ribs 1–2

Muscle energy

  • Position: supine
  • Procedure
    1. Grasp affected rib angle underneath patient.
    2. Apply inferolateral traction.
    3. Place the dorsal aspect of the patient's ipsilateral wrist onto their forehead.
    4. Ask patient to inhale while you continue to apply inferolateral traction.
    5. Ask patient to hold their breath for 3–5 seconds while bringing their head up against equal resistance.
    6. Relax for 5 seconds.
    7. Re-engage barrier and repeat

Ribs 3–5

Muscle energy

  • Position: supine
  • Procedure
    1. Grasp affected rib angle underneath the patient.
    2. Apply inferolateral traction.
    3. Abduct the patient's ipsilateral shoulder.
    4. Ask patient to inhale while you continue to apply inferolateral traction.
    5. Ask patient to hold their breath for 3–5 seconds while bringing their elbow upward against equal resistance.
    6. Relax for 5 seconds.
    7. Re-engage barrier and repeat.

Ribs 6–9

Muscle energy

  • Position: supine
  • Procedure
    1. Grasp affected rib angle underneath the patient.
    2. Apply inferolateral traction.
    3. Abduct the patient's ipsilateral shoulder and elbow to 90 degrees with their wrist facing upward.
    4. Ask patient to inhale while you continue to apply inferolateral traction.
    5. Ask patient to hold their breath for 3–5 seconds while pushing their arm upward against equal resistance.
    6. Relax for 5 seconds.
    7. Re-engage barrier and repeat.

Ribs 10–12

Muscle energy

  • Position: supine
  • Procedure
    1. Grasp affected rib angle underneath the patient.
    2. Apply inferolateral traction.
    3. Abduct the patient's ipsilateral shoulder to about 180 degrees.
    4. Ask patient to inhale while you continue to apply inferolateral traction.
    5. Ask patient to hold their breath for 3–5 seconds while abducting their elbow against equal resistance.
    6. Relax for 5 seconds.
    7. Re-engage barrier and repeat.

Thoracic spine dysfunction

Diagnosis

Rule of threes

Thoracic vertebrae Transverse process location Example

T1–T3

&

T12

T4–T6

&

T11

T7–T9

&

T10

Static examination

Treatment

Type 1 thoracic (group curve) dysfunction (T1–T10)

Muscle energy

  • Position: seated
  • Procedure
    1. Stand on the side of the convexity (side of rotated segments).
    2. Monitor apex of the curve.
    3. Place the apex of the group curve into its side bending and rotational barriers.
    4. Ask patient to side bend towards the opposite side against your equal resistance for 3–5 seconds.
    5. Relax for 5 seconds.
    6. Re-engage barrier and repeat.
    7. Reassess.

Type 2 thoracic dysfunctions (upper segments: T1–T4)

Muscle energy

  • Position: seated
  • Procedure
    1. Stand opposite of the posterior transverse process.
    2. Monitor rotated segment.
    3. Place the segment into its flexion or extension, side bending, and rotational barriers.
    4. Ask patient to rotate the head towards their freedom against your equal resistance for 3–5 seconds.
    5. Relax for 5 seconds.
    6. Re-engage barrier and repeat.
    7. Reassess.

High-velocity low-amplitude

  • Position: supine with examiner on the opposite side of the dysfunction
  • Procedure
    1. Perform myofascial technique.
    2. Have the patient cross the arms.
    3. Push elbows down and tuck under your abdomen while maintaining downward pressure.
    4. Lift the patient's head and torso towards you.
      • Flex, rotate, and side bend away.
    5. Place the thenar eminence over the posterior transverse process (or just medial to the posterior rib angle).
    6. Ask patient to fully inhale and exhale.
    7. Slowly isolate the segment by rolling the patient over your hand.
    8. Apply a downward thrust through the posterior segment using your weight.
    9. Reassess.

Type 2 thoracic dysfunctions (lower segments: T5–T12)

Muscle energy

  • Position: seated
  • Procedure
    1. Stand opposite of the posterior transverse process.
    2. Monitor rotated segment.
    3. Place the segment into its flexion or extension, side bending, and rotational barriers.
    4. Ask patient to side bend torso towards their freedom against your equal resistance for 3–5 seconds.
    5. Relax for 5 seconds.
    6. Re-engage barrier and repeat.
    7. Reassess.

High-velocity low-amplitude

  • Same as type 2 thoracic dysfunctions of the upper segments
last updated 07/31/2019
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