Diagnosis & Treatment of Ribs 1-12- Inhalation Somatic Dysfunction: Muscle Energy Model

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Burns

When would do suspect rib dysfunction?

-Remote Hx of Rib trauma that has healed but still has pain with Breathing, Coughing, or Motion
-Hx of Acute or Chronic Respiratory Tract Disease
-Hx of Neck pain & or Headache
-Numbness / tingling /coldness in upper extremity
-Upper /Lower Extremity Edema
-Hx of Gastroesophageal reflux (GERD)
-Hx of any disease that involves organs with Viscero-somatic reflex levels T1-T12
-Hx of Back or sacropelvic pain

What do assess in TART for rib dysfunction?

-Rib cage Asymmetry: A/P & lateral
-Trunk / Axial Spine
-Pelvis unlevel
-Stance uneven
-Arches of feet ueven

What is the relationship between the pelvis and the ribs?

A crooked pelvis equals crooked ribs and vice versa.

Why is the treatment of rib dysfunction so important?

Everything is connected through the ribs, treating rib dysfunction can resolve issues in other parts of the body.

What are the major body regions associated with the ribs?

-Thoracic inlet
-Thoracoabdominal diaphragm
-Sacro-pelvis
-Lower extremity restrictors

How can OMM for rib dysfunction benefit the patient?

It can treat nearly all systems:
-Venous /Lymphatic
-Autonomic
-Biomechanical
-Pain / Nociception
-Psychosocial

Describe the diagnosis of rib somatic dysfunction.

-Screen: Does this person have SD of ribs?
-Scan: Which rib(s) or group of ribs has SD?
-Segmental diagnosis: What kind of SD do these ribs have?

What position is the patient in for treatment of rib dysfunction?

Supine.

What are the motion of the pump handle ribs during inhalation?

Superior in front, inferior in back.

What are the motion of the bucket handle ribs during inhalation?

Lateral, anterior and superior in front.

What are the motion of the caliper ribs during inhalation?

Posterior, lateral and a little superior.

Where is the proper hand placement when diagnosing and treating pump handle (1-3) ribs?

Treat patient seated at their head with hands over the anterior aspect of the ribs.

Where is the proper hand placement when diagnosing and treating bucket handle (4-10) ribs?

Treat patient standing, palpate on the lateral aspect of the ribs on either side.

Where is the proper hand placement when diagnosing and treating caliper (11 and 12) ribs?

Place hands lateral and posterior, palpate on the posterior aspect of the ribs.

What is compared when screening?

-Springiness of left ribs compared with the right
-Movement of ribs during breathing

What is the diagnosis of rib somatic dysfunction when a rib is restricted in both inhalation and exhalation?

It is a non-physiologic somatic dysfunction.

What is the segmental diagnosis of a rib that displaced anteriorly when the patient is supine?

Anterior rib.

What is the segmental diagnosis of a rib that displaced posteriorly when the patient is supine?

Posterior rib.

How is non-physiologic rib SD diagnosed?

When the rib articulations are not in their proper physiologic relationship. They are usually displaced anterior or posterior due to trauma.

What is the distinctive TART pattern found with non-physiologic rib dysfunction?

There is an articulation protruding in the anterior side and a sunken joint in the posterior or vice versa. The costochondral joint is anterior and the costovertebral joint is posterior or vice versa.

Why is muscle energy technique not used on non-physiologic rib dysfunction?

They do not respond well to OMT.

What are the physiologic types of rib somatic dysfunction?

-Inhalation
-Exhalation

How do you confirm your segmental diagnosis of physiologic rib dysfunction?

By comparing the motion of the rib with inhalation versus exhalation.

How does physiologic rib dysfunction differ from non-physiologic rib dysfunction?

The articulations are in their proper physiologic relationship.

When are TART changes most noticeable in physiologic rib dysfunction?

During the physiologic motions of respiration.

Describe inhalation somatic dysfunction.

A Rib or Group of Ribs:
-Able to move freely during INhalation
-Unable to move freely during EXhalation
-Ease is Inhalation
-Diagnosis is inhalation

Describe exhalation somatic dysfunction.

A Rib or Group of Ribs:
-Able to move freely during EXhalation
-Unable to move freely during INhalation
-Ease is EXhalation

How do you determine if there is a single or a group physiologic rib dysfunction is present?

By assessing the adjacent pair of ribs for physiologic rib dysfunction.

When is a single rib dysfunction diagnosis made?

If in the rib adjacent to the previously diagnosed rib:
There is no SD or the SD is different.

When is a group rib dysfunction diagnosis made?

If adjacent to the previously diagnosed rib:
There is the same type of physiologic rib dysfunction

How do you identify the boundaries of the group dysfunction?

Keep assessing the adjacent pair of ribs until:
-The adjacent rib no longer has the same dysfunction as the group
-You run out of ribs

What is the key rib?

The etiology of the dysfunction. It's the one keeping the rest of them from moving properly.

What is the key rib in inhalation somatic dysfunction?

The most inferior of the group.

What is the key rib in exhalation somatic dysfunction?

The most superior of the group.

Describe primary rib dysfunction.

-Tx the rib and its dysfunction resolves
-The rib itself is the primary dysfunction

Describe secondary rib dysfunction.

-Tx Rib and it does not fully resolve
-Rib problem is secondary to (a result of) some other somatic dysfunction

What is the most likely culprit in secondary rib dysfunction?

Vertebral somatic dysfunction.

What other diagnosis should also be checked be when diagnosing rib dysfunction?

Vertebrae.

What are the indications for muscle energy for ribs?

-Patient unable to relax well
-For Somatic Dysfunction with fibrotic, shortened tissues: Hx of chronic injury; repetitive strain, repetitive abnormal postures
-For Somatic Dysfunction with a muscle spasm component
agonist/ antagonist muscles
-If Tx using ease hasn't worked
-Big, strong patient versus smaller doc
-It's all you know / you're good at it

What are the absolute contraindications for muscle energy of the ribs?

-Fractures and severe neuromuscular injuries /surgery to potential Tx sites
-Inability of patient to cooperate: too young or unresponsive

What are the relative contraindications for muscle energy of the ribs?

-Patients w/ low vitality, who could be further compromised by active muscular exertion: Post surgical or ICU /CCU patients
-Recent Myofascial injury: Sprain/Strain or may tolerate gentler forms of ME such as reciprocal inhibition

What are the physiologic mechanisms of muscle energy?

-Post isometric relaxation
-Joint mobilization using muscle force
-Respiratory assistance

How is respiratory assistance used as a mechanism of muscle energy?

Breath provides the isometric contraction.

Why do we need to use joint mobilization in addition to respiratory assistance when treating ribs 11 and 12?

The motions of ribs 11 and 12 during exhalation are medial, anterior and inferior.

Give an overview of treatment of inhalation rib dysfunction with muscle energy.

-Hold breath for 5 sec - once fully inhaled
-Exhale, listen for tissue release -2 sec
-Take rib to new barrier - feather edge
-Repeat until No further Improvement
-Recheck

What is the hand contact needed to move ribs 11 and 12 to the EXhalation barrier when treating inhalation dysfunction?

Posterior surface of rib, on rib angle.

What are the force vectors utilized to move ribs 11 and 12 to the EXhalation barrier?

-Hand provides anterior motion primarily
-Quadratus lumborum pulls it inferiorly

What is the importance of arm position and the use of when treating treating inhalation rib dysfunction of ribs 11 and 12?

Arm position alongside body slackens latissimus dorsi and takes tension off ribs.

What technique can be used to bring the rib to the barrier?

Moving the trunk or pelvis can be used to pull rib to barrier via quadratus lumborum.

Give an overview of muscle energy treatment of ribs 11 and 12 with inhalation dysfunction.

-Move arm alongside body to give rib slack -allows rib to move inferiorly toward exhalation
-Slide patients legs toward you to pull rib inferiorly toward exhalation
-Grasp ASIS & pull inferiorly and rotate toward you a little to pull rib inferiorly to feather's edge

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