Continuing Education Activity

Rib dysfunctions can lead to chest wall pain, musculoskeletal pain, thoracic outlet syndrome, and intercostal neuralgia. Decreased rib motion can lead to excess lymphatic fluid in the subcutaneous tissues as well as the worsening of respiratory pathology. This activity reviews inhalation rib dysfunctions and how they can be treated to improve rib pain. It will cover the clinical presentation, treatment options, contraindications, and benefits of osteopathic manipulative treatment for rib inhalation dysfunctions.

Objectives:

• Outline the indications for the treatment of inhalation rib dysfunctions.

• Review the contraindications to performing certain osteopathic manipulative techniques for inhalation rib dysfunctions.

• Identify clinical relevance in diagnosing and treating inhalation rib dysfunctions.

• Summarize how to perform four of the common treatment modalities for inhalation rib dysfunctions.

Introduction

Rib dysfunctions occur in many forms. This article aims to identify, diagnose, and discuss the treatment of inhaled rib dysfunctions with direct and indirect osteopathic treatments. Rib dysfunctions can lead to chest wall pain, musculoskeletal pain, thoracic outlet syndrome, and intercostal neuralgia. Decreased rib motion can lead to excess lymphatic fluid in the subcutaneous tissues as well as the worsening of respiratory pathology.[1] Inhaled rib dysfunctions occur when a set of two or more ribs are displaced cephalad (toward the patient's head) with associated physiologic motion dysfunction. The physiologic manifestation of an inhaled rib dysfunction presents when ribs are elevated in inspiration and do not move freely into a neutral position on expiration.

When treating inhaled rib dysfunctions, the provider must identify the key rib to release the dysfunctional segment into normal physiologic motion.[2] Osteopathic treatments include direct and indirect treatments to restore physiologic motion. Direct treatments move the dysfunction into its physiologic barrier. Indirect treatments move the dysfunctional segments into their position of ease.[3] Osteopathic manipulative treatment of inhaled rib dysfunctions aims to relieve patient discomfort, improve lymphatic flow, and restore physiologic chest wall motion.[4]

Anatomy and Physiology

The thoracic cavity encloses and protects the body’s vital organs. There are twelve sets of rib pairs that make up the thoracic cavity. Anteriorly, ribs attach to the sternum, costal cartilage of an adjacent rib, or have no attachment and are known as floating ribs.[5] Posteriorly, ribs attach to costovertebral articulations of the spine.[6][7] Anteriorly ribs articulate with the hyaline, or costal, the cartilage of the adjacent rib.[5] Ribs 1 to 7 are true ribs and connect anteriorly to the sternum, including the sternal notch, manubrium, and sternal body. Ribs 8, 9, and 10 attach anteriorly to the hyaline cartilage of the rib above them and are known as false ribs.[5] False ribs do not have a bone-to-bone anterior articulation. Ribs 11 and 12 are floating ribs, denoting there is no anterior articular attachment to hyaline cartilage or the sternum.[5] Ribs 11 and 12 are otherwise known as caliper ribs because of their lack of anterior attachment.

Bony rib anatomy consists of the anterior portion for attachment to the hyaline cartilage or sternum and the posterior portion for articulation with the spinal column.[5] The anatomy of the posterior rib attachment includes a head, neck, articular facet, and tubercle.[5] The anterior rib anatomy includes the rib head, which is a flat portion for hyaline or sternal articulation.[5]

Muscular attachments to the ribs include the scalenes, internal intercostals, external intercostals, and the diaphragm.[8] During inhalation and exhalation, the ribs move up and down as levers when pulled by their muscular attachments to expand the thoracic cavity, creating a negative pressure space, activating airflow into the lungs.[9] During the inhalation and exhalation, ribs 1 to 4 move in pump handle motion, meaning they are moving up (nuchal) or cephalad and down (caudal) or caudad. Ribs 1 to 4 on their anterior articulations move up and down. Ribs 5 to 10 are called bucket handle ribs because the shaft of the rib body on the lateral aspect of the chest wall moves up and down. 

Each rib has muscular attachments to facilitate inhalation and exhalation.[9] The first rib has muscular attachments at is base of the anterior and middle scalene, which elevate the first rib during inspiration.[9] The anterior scalene muscle originates from the C3-C6 transverse processes and attaches to the first rib.[9] The posterior and middle scalene originate from the posterior tubercles of C2-C6 and attach posteriorly to the subclavian groove on the first rib. The posterior scalene attaches to C2, elevating it during inspiration. Together with the first rib, they create the inter-scalene triangle. The scalenes side bend and flex the neck to their side of attachment. Intercostal muscles include the external, internal, innermost, and subcostal muscles.

The diaphragm moves in inspiration and expiration by expanding and re-doming as the diaphragm contracts and relaxes.[10] It is composed of two muscles, costal and crural, with innervation from the phrenic nerve C3-C5.[10] When the costal muscle of the diaphragm contracts, it expands the thoracic cage in the coronal plane with the pump handle ribs and sagittal plane with inhalation of bucket handle ribs.[11][10] During inhalation, the diaphragm relaxed the dome shape of the muscle flattens, allowing for decreased intra-thoracic pressure and air to fill the lungs.[12] The diaphragm is key in returning lymph and venous blood to the heart.[10] This action moves lymph through the body from the subcutaneous tissues bringing it back into the intravascular system.

Indications

Myofascial Release

• Elderly
• Acutely Ill
• Degenerative diseases
• Down syndrome
• Pregnancy
• Can not tolerate a direct technique
• Bleeding disorders
• Lymphedema or need for improved lymphatic flow
• Asymptomatic patients

High-Velocity Low Amplitude

• No underlying medical pathology
• Unsuccessful manipulation with other indirect techniques
• Stubborn dysfunctions 

Muscle Energy 

• Post-surgical patients
• ICU patients
• Anyone who can not participate in active muscle contraction
• Asymptomatic patients for stretching

Contraindications

Myofascial Release or Re-doming the Thoracic Diaphragm

• Rib fractures
• New surgical skin incisions near the area of treatment
• Metastatic cancer where increasing lymphatic flow and spread could worsen the patient's health

High-Velocity Low Amplitude Techniques

• Anyone suffering from degenerative bone disease
• Rib fractures
• Acute muscle sprains
• Vertebrobasilar disease
• Ligament laxity, such as in Down syndrome
• Concerns for possible contraindications noted by the physician provider when obtaining a patient's medical history
• Pregnancy
• Bleeding disorders
• Do not place thrusting pressure on costovertebral articulations with acute fractures or bone metastasis from cancer

Rib Raising

• Acute rib fractures
• Recent spinal surgery
• Overlying areas of skin infection
• Erythema
• Swelling overlying the skin

Equipment

Manual manipulative techniques involve a patient sitting upright or lying supine while they are passively manipulated or actively engage in the manipulative technique with their provider. A patient, the physician provider, and preferably a cushioned manipulation table are best for successful osteopathic manipulative treatments. If an appropriate treatment table is unavailable, it is possible to perform osteopathic techniques from a supine floor or seated position.[11]

Personnel

• Patient
• Clinician provider

Preparation

Obtain verbal and/or written consent from all patients receiving osteopathic manipulative treatments. Explain the procedures in full and where your hand placement will be before beginning any hands-on patient care. Cover the risks and benefits of different kinds of treatment and how that pertains to the patient’s specific needs. Make sure to perform a thorough medical history and physical exam for new patients along with necessary radiologic imaging before performing high-velocity low amplitude treatments.

Technique or Treatment

Diagnosing inhaled rib dysfunctions can be started by assessing the patient's chest wall motion. With the patient lying supine or seated, the physician provider can place their palms flat on the patient's right and left anterior chest wall, careful not to touch delicate breast tissues. With hands stable on the chest wall, ask the patient to breathe in and out. Assess for symmetry in the rise and fall of the chest wall.[13] The physician provider can do this again by placing hands lower down on the right and left rib cage to assess for physiologic or dysfunctional motion.[13] Inhaled rib dysfunctions will present on physical assessment with increased intercostal space below the dysfunctional segment and a decreased intercostal space above the dysfunctional segment. Once the provider identifies the key rib, they can localize it for treatment. There are many techniques used to manipulate dysfunctional ribs back into place.[14]

Rib Raising: Rib raising is an articular technique that places pressure on a restrictive barrier of the rib angle against the spine. It is a non-invasive, passive technique that can be useful with acutely ill, hospitalized patients.[3] During treatment, the patient lies supine or is seated and does not actively participate. This technique emphasizes the placement of a repetitive force to increase the range of motion of the posterior rib articulations, lessening somatic dysfunction of the spine. This technique stretches myofascial structures and increases chest wall motion, and normalizes the parathoracic sympathetic ganglia.[13][14]

• To perform rib raising, the physician provider places their finger pads under the posterior rib angle and pushes upward, applying gentle pressure and traction on the rib angle, which the clinician does until there is release. Reassess for an increased articular range of motion; this inhibits sympathetics from the thoracic chain ganglia to the ribs and increases chest wall expansion and negative intrathoracic pressure.[15] This process increases the capacity for inhalation and improves lymph flow.[14]

Myofascial release: increases lymphatic flow, releases muscle tension, and can be performed on acutely ill patients. Re-doming the diaphragm is an indirect myofascial technique that increases lymphatic flow and increases the mechanics of inspiration and expiration.[16] By re-doming, the diaphragm, the provider increases a patient's lymph return by optimizing thoracoabdominal pressure gradients.[3] Myofascial release has its basis in treating the fascia overlying the muscles and bones by placing a direct or indirect force on the tissues.[3] This approach, in turn, benefits inhaled rib dysfunctions by increasing the ability of the thoracic cage to move without restriction.[13][14]

• To perform myofascial release to the thoracic diaphragm with the patient seated, the physician provider can stand behind the patient and wrap hands around their infra-costal margin until anteriorly palpating the fascia of the thoracic tissues.[3] The provider will place fingers into the tissues and palpate with traction infra-laterally to determine the restricted side.[13][14] The restricted side will have less tissue softness and mobility.

• To perform myofascial release to the thoracic diaphragm with the patient supine, the physician provider can place their thumbs under the costal margins, beneath the xiphoid process, on the right and left. To assess the restricted side, the physician provider should press with the thumbs on the right and left of the diaphragm, gently pressing with infra-lateral traction. For an indirect approach to treatment, hold the thumb into the side of the tissue to ease where the tissues move more freely and allow the fascia to release, gently unwinding. Always reassess after treatment for bilateral tissue softness and increased diaphragmatic range of motion.[3]

HVLA: High-Velocity Low Amplitude (HVLA) techniques are direct manipulative techniques bringing the dysfunctional segment into the restricted plane of motion. When performing HVLA, the physician provider is thrusting a short distance through the inhibited plane of motion of the dysfunctional segment.[14][13] When using this technique, patients can receive treatment in prone, seated, and supine positions.

• To perform HVLA on the first rib inhalation dysfunction (exhalation restriction): The physician provider is at the head of the bed. The patient lays supine. Assess for right or left first rib inhalation dysfunction (exhalation inhibited). The dysfunctional side will palpate as firmer and cephalad. Side bend the patient's head toward the side of dysfunction and rotate away from the dysfunctional rib. The physician provider places their thenar eminence on the side of dysfunction. The patient participates by inhaling, then exhaling. On the patient's exhalation, the physician provider administers a thrust caudad. Then reassess the patient's first rib.[17]

• HVLA to the thoracic ribs 2 through 10 can be performed by using the Kirksville Krunch.[14] This method is where the physician provider stands to the opposite side of the key dysfunctional rib. The patient is lying supine on a table approximately waist-high. Ask the patient to overlap their arms on their chest with the arm on the side of the key treatment rib under their non-treatment side. The clinician provider, standing on the opposite side of the patient's key rib, places their arm over the patient, and with the thenar eminence of that hand, presses on the posterior rib angle under the key rib. They then flex the patient so that the thoracic segment engages at the level of the key rib and gently side bend away. Ask the patient to breathe in and out. On exhalation, deliver a direct thrust with your chest onto their crossed arms, angling the energy to your thenar eminence on the posterior rib angle of the key rib.

Muscle Energy: Muscle Energy is a direct and active technique where a patient is placed into their restrictive barrier by a physician provider then participates in the treatment.[3] This treatment can apply to any part of the human body where a patient has a decreased range of motion.[13][18] When the patient is placed into their restrictive barrier, they participate by actively moving back into a neutral position while the physician provider holds an isometric counterforce.[19] This looks like a physician provider placing a patient into a designated position of restriction, then placing a counterforce on the patient as the patient pushes against the physician provider. Then the relaxation of the patient allows the physician to move the patient into a passive stretch.[19] This action should be repeated three to five times, with the patient holding the isometric contraction against the physician provider for approximately 3 to 5 seconds each round.[18] After each round of isometric contraction, there is a relaxation phase. During relaxation, the clinician provider pushes the patient into their new restrictive barrier.[13][19]

• To perform muscle energy to a group of ribs with an inhalation dysfunction, place the patient supine on a waist-high cushioned treatment table if available. Identify the key rib; it will be the rib on the bottom of a group of dysfunctional ribs.[18] Once again, this is assessable by placing hands on the patient's thoracic cage while having them actively inhale and exhale. The key rib is on the bottom of the dysfunctional segment and will remain elevated in expiration. Treatment is directed toward this rib. Once the key rib is identified, the physician provider will stand toward the patient's head, facing their feet to begin treatment. The physician provider places the fingers of their hand on the side of dysfunction on the key rib towards the superior aspect. The physician provider uses their free hand to flex and side bend the patient. If the key rib is a pump handle rib (ribs 2 through 5), the physician provider will flex the patient's head and neck until the level of the rib is engaged. The physician provider will then ask the patient to take a deep breath in and out. Have the patient hold their exhalation for 3 to 5 seconds; this is the active participation part of the treatment. When the patient breathes out, the physician provider holds them into their restrictive barrier and adds slightly more flexion. When the 3 to 5 seconds are over, the patient can take another deep breath, but the clinician should hold continuous caudad pressure on the superior aspect of the key rib to prevent movement into inhalation.

• To perform muscle energy on bucket handle ribs (6-10), follow the steps above. However, when asking the patient to breathe out and hold their exhaled breath for 3 to 5 seconds, have them reach for their knee on the side of the dysfunction. Follow the steps above to repeated rounds of treatment.

Clinical Significance

Chest pain is a common presentation to any clinic or acute care facility. To determine cardiac vs. pulmonary vs. musculoskeletal origin is essential in ruling out deadly pathology. Assessing the chest wall and managing musculoskeletal complaints is beneficial to the medical community in reducing hospital admissions, cost of diagnostic testing, and length of inpatient stay.[20][21][22] Reducing the hospital length of stay includes decreasing the use of inhaled steroids, statins, and IV antibiotics to treat inflammatory lung diseases like pneumonia, asthma, and non-inflammatory diseases, such as COPD and emphysema.[23][15] 

Lymphatic pump techniques have been shown to decrease hospital stays, antibiotic use for pneumonia, and increase immunity.[24][25] Treating rib dysfunctions benefits patients suffering from intercostal neuralgia, slipping rib syndrome, cystic fibrosis, decreased lymphatic flow, decreased respirations, and lymphatic congestion.[8][26] Articular techniques such as rib raising increase chest wall compliance and have been shown to benefit patients with viral pneumonia.[27][25]

Thoracic outlet syndrome is one common pathology seen in a clinical setting. It is a syndrome in which a person experiences numbness or tingling and loss of motor function or sensation in one of their upper extremities.[8] It can result from anomalies in cervical ribs, be induced by a trauma to the neck or shoulder, be simply musculoskeletal in nature, and secondary to callus of bone after fractures heal. Thoracic outlet syndrome can be improved with cervical rib treatments when secondary to musculoskeletal somatic dysfunction.[8] 

The brachial plexus is a set of nerves and vasculature that gives motor and sensory function to the upper extremity.[8] The anterior branch of seven crosses within the triangle made between the cervical rib head with anterior and middle scalene attachments can be the source of upper extremity anesthesia secondary to compression on the brachial plexus.[9]

According to a recent study, the most common OMM inpatient consultations were for chest pain, rib pain, spinal pain, and adjunctive treatment for lower respiratory infections.[28] However, this study also noted, whether treated with myofascial release, rib raising, or thoracic lymphatic pump, there were no benefits in pulmonary function tests posttreatment.[28] Patients overall stated subjectively they benefitted from the osteopathic manipulative treatments and stated they had improved respiratory symptoms.[28]

Enhancing Healthcare Team Outcomes

Coordinated patient care is key to the treatment of any disease. For patients with persistent chest pain, multiple emergency room visits, and numerous cardiology workups, osteopathic manipulative techniques need to be at the forefront of a provider's next treatment plan. Patients can be evaluated and assessed for underlying pathology while also being evaluated for musculoskeletal dysfunctions.

Clinicians should take responsibility for patient referrals to osteopathic providers when deadly underlying pathologies have safely been ruled out. Patients benefit from a well-rounded treatment approach that includes pharmacology, diagnostic testing, physical medicine, and manipulative treatments. This was shown in a clinical trial using rats where the lungs of rats diagnosed with Streptococcus pneumoniae had reduced levels of bacteria after receiving lymphatic pump techniques along with antibiotics compared to controls.[25] 

It is essential for all patient providers, including nurses, urgent care workers, primary care physicians, emergency medicine physicians, and pharmacists, to communicate openly to formulate a healthy treatment plan. This approach will help to better monitor patients with chronic pain to reduce opioid and other substance abuse. All of these methods of providing patient care will deliver a well-rounded systemic approach to healing patients with musculoskeletal discomfort from inhaled ribs and ruling out underlying deadly disease processes.