Continuing Education Activity

The muscle energy technique is a versatile and practical option for treating somatic dysfunctions used by osteopathic physicians, osteopathic manual practitioners, physical therapists, and some massage therapists. Depending on the patient's comfort, the technique can be applied directly or indirectly and passively or actively. The muscle energy technique can be used in most body articulatory joints, including the costovertebral joint, to affect its motion during respiration. Dysfunction in rib motions can often lead to chest pain and shortness of breath, leading to unnecessary medical workups. This activity describes the treatment of exhaled ribs and explains the healthcare team's role in treating exhaled ribs. In addition, this activity describes the anatomy, physiology, and pathology of an exhaled somatic dysfunction. Finally, it explains the role of the healthcare team in evaluating and treating patients diagnosed with exhalation rib somatic dysfunction.

Objectives:

• Identify the signs and symptoms of somatic dysfunction in exhaled ribs, recognizing specific rib dysfunctions and their effects on the patient's overall health and musculoskeletal system.

• Screen patients for the appropriateness of osteopathic muscle energy procedures, considering contraindications, medical history, and other factors affecting treatment outcomes.

• Implement muscle energy techniques to address exhaled ribs, using appropriate positioning, patient instructions, and gentle manual techniques to achieve optimal results.

• Communicate with patients, explaining the rationale for muscle energy procedures, addressing any concerns or questions, and providing post-treatment instructions for self-care and follow-up.

Introduction

This activity explains the procedure for treating exhaled ribs using the muscle energy osteopathic manipulative treatment (OMT) method. For example, OMT can be used with various techniques, including high velocity/low amplitude, muscle energy, strain-counterstrain, and myofascial release.[1]  

These techniques can be direct or indirect and passive or active. A direct technique is when the restrictive barrier is engaged, while indirect techniques occur when forces are applied away from the restrictive barrier. Passive techniques are ones in which the operator does the work and the patient is in a relaxed position, and an active technique is one in which the patient is helping with the treatment.[2]  

Muscle energy is a direct and active technique where the patient is placed into their restrictive barrier and participates in treatment. There are multiple approaches to the muscle energy technique; however, the most commonly used is muscle energy with post-isometric relaxation: the patient is placed into their restrictive barrier, and they participate by actively moving towards the neutral position. At the same time, the clinician holds an isometric counterforce.[3]

Rib dysfunctions can cause multiple symptoms, including musculoskeletal or chest pain, thoracic outlet syndrome, difficulty taking a full breath, and worsening respiratory pathology.[4] Diagnosing and managing rib dysfunction may also benefit patients with respiratory disorders such as asthma, chronic obstructive pulmonary disease (COPD), and pneumonia. Adequate respiration requires normal movement of the diaphragm, ribs, and sternum, which increases and decreases the size of the thorax, generating positive and negative pressure needed for proper respiration and oxygen exchange.[5] When treating somatic dysfunctions of the ribs, it is essential to identify the key rib holding up the dysfunction. A rule of thumb is that during an inhalation dysfunction, the key rib is the bottom rib of the rib group; in an exhalation dysfunction, the key rib is the topmost rib.

Exhaled rib dysfunctions occur when two or more ribs are displaced or stuck “down” or caudad. This means that the rib is restricted during inhalation and cannot move up, preventing the ribs from moving during inhalation. In this case, the topmost rib within the group of ≥2 adjacent ribs is the key rib, thus targeted for treatment.[6]

Anatomy and Physiology

There are twelve sets of ribs in the human body. Anteriorly, these are attached to either the sternum or the costal cartilage of adjacent ribs or have no anterior attachment. Posteriorly, the twelve sets of ribs are connected to the spine at the costovertebral articulations.[7] The ribs are further broken down into true, false, and floating ribs. Ribs 1 through 7 are considered true ribs as they attach anteriorly to the sternum. Ribs 8 to 10 are known as false ribs as they connect to the cartilage of ribs 1 through 7 and not directly to the sternum, and ribs 11 to 12 are considered floating ribs as they do not have an anterior attachment.[7]

The motion of the ribs also varies slightly based on their attachment. The first five ribs are considered pump-handle and move anterior-posteriorly, increasing during inhalation and decreasing during exhalation. Ribs 5 to 10 are deemed bucket-handle ribs and move transversely with increased diameter during inhalation and reduced diameter during exhalation. Finally, ribs 11 to 12 are caliper or pincer-type ribs and move in a down-and-out motion during inhalation and up-and-in during exhalation.[8] 

Ribs are connected to specific muscle groups, essentially the target for muscle energy. Each rib or set of ribs moves into inhalation and exhalation based on the contraction of specific muscles or muscle groups. The origin of the anterior and middle scalene is on the cervical vertebrae (CII-CVII), while the insertion is to the first rib—the posterior scalene inserts at Rib 2. The pectoralis minor muscle originates on ribs 3 to 5 near the costochondral junction and inserts at the medial border and superior surface of the coracoid process of the scapula. The serratus anterior originates at ribs 6 to 8 and inserts at the scapula's costal aspect at the medial margin. Part of the origin of the latissimus dorsi is from ribs 9 to 10, while the insertion is at the intertubercular groove of the humerus.[9][10] 

Finally, ribs 11 and 12 are free-floating ribs that move in a caliper fashion during respiration. Appreciating the intercostal muscular layers between each rib and the attachment of the thoracic diaphragm at the bottom 6 ribs is important. Finally, a thin muscle called transversus thoracis is located on the inner surface of the ribs at the anterior chest wall.[11]

Indications

Muscle energy of the ribs has many indications. This technique can be used in older or acutely ill patients without contraindications. The technique can also be used in chronic conditions such as COPD, asthma, or interstitial lung disease. Data shows osteopathic manipulative treatments such as muscle energy can benefit post-surgical or ICU patients.[12] Finally, any individual with an exhalation somatic dysfunction can benefit from this technique, including those who stretch and open their chest for optimal physiologic movement.

Contraindications

Contraindications for a technique such as muscle energy include patients who cannot actively participate in the treatment or are unwilling to do so. Rib fractures, recent spinal injury, or known ligament laxity is another contraindication to this technique. Finally, active skin or underlying muscle infection is another contraindication, as is metastatic cancer, which could spread due to muscle energy to the ribs.[13]

Equipment

The muscle energy technique requires a patient to sit upright or lie supine and be able to participate in the treatment. A patient, a trained provider, and a cushioned manipulation table are needed to complete this technique.

Personnel

A trained practitioner and a patient willing and able to undergo treatment are the required personnel for this treatment. 

Preparation

To complete this technique, verbal and written consent is required. In addition to consent, an understanding of the procedure and hand placements should be explained, along with the reason for completing the technique and any available alternate techniques. Finally, the patient is required to be willing to undergo the procedure.

Technique or Treatment

Before treating the ribs, the clinician must ensure that any somatic dysfunctions in the associated thoracic vertebrae are treated. Very frequently, treatments to the ribs will not hold if the thoracic vertebrae have a somatic dysfunction. For muscle energy ribs 1 to 2, the patient is positioned supine, and the provider stands at the head of the table. Provider grasps the affected rib angle underneath the patient and places the dorsal aspect of the patient's ipsilateral wrist onto their forehead. At the same time, it is turned 40 degrees away from the side of dysfunction to place tension on the ipsilateral scalene muscles. While the patient inhales, apply inferolateral traction to the rib angle. Ask the patient to hold their breath for 3 to 5 seconds while lifting their head towards the ceiling, as the provider administers equal resistance. Then, ask the patient to relax for 5 seconds. Next, engage the rib barrier and repeat the steps mentioned above until a desirable outcome is achieved.

The patient is supine for muscle energy ribs 3 to 5, and the provider stands contralateral to the affected ribs. Provider grasps the affected rib angle underneath the patient and abducts the patient's ipsilateral shoulder. While the patient inhales, apply inferolateral traction to the rib angle. Ask the patient to hold their breath for 3 to 5 seconds while bringing their elbow, pushing their arm towards the opposite hip to engage the pectoralis minor as the provider administers equal resistance. Then, ask the patient to relax for 5 seconds. Engage the rib barrier and repeat the steps mentioned above until a desirable outcome is achieved.

The patient is positioned supine for muscle energy ribs 6 to 8, and the provider stands contralateral to the affected ribs. The provider grasps the affected rib angle underneath the patient and abducts the patient's ipsilateral shoulder and elbow to 90 degrees with their wrist facing upwards. While the patient inhales, apply inferolateral traction to the rib angle. Ask the patient to hold their breath for 3 to 5 seconds while pushing their arm anteriorly to engage the serratus anterior as the provider administers equal resistance. Then, ask the patient to relax for 5 seconds. Engage the rib barrier and repeat the steps mentioned above until a desirable outcome is achieved.

The patient is positioned supine for muscle energy ribs 9 to 10, and the provider stands contralateral to the affected ribs. Provider grasps the affected rib angle underneath the patient and abducts the patient's ipsilateral shoulder to 180 degrees. While the patient inhales, apply inferolateral traction to the rib angle. Ask the patient to hold their breath for 3 to 5 seconds while adducting their elbow as the provider administers equal resistance by activating the latissimus dorsi. Then, ask the patient to relax for 5 seconds. Engage the rib barrier and repeat the steps mentioned above until a desirable outcome is achieved.[13]

The patient is positioned prone to muscle energy in ribs 11 and 12, and the provider stands contralateral to the affected ribs. The patient abducts their ipsilateral shoulder 180 degrees to engage the latissimus dorsi muscle. The provider's caudal hand will grasp the patient's ASIS, and the medial aspect of the cephalad hand will be placed on the inferior part of the rib being treated. The patient will be asked to inhale, where the cephalad/superior motion of the ribs will be encouraged. During exhalation, the caudad/inferior movement of the ribs will be restricted. Repeat steps at least three times.

Complications

Patients should be warned that muscle and joint soreness are possible after manipulation. If a patient frequently experiences muscle soreness after manipulation, they can be instructed to take an over-the-counter pain reliever before the manipulation. While rare, serious complications can occur.[14]  

Clinical Significance

Unfortunately, few studies investigate the efficacy of muscle energy, and a systematic review of randomized control trials from multiple disciplines that practice physical manipulations for muscle energy in patients with COPD was inconclusive.[15][16] However, while not specifically regarding muscle energy, the American College of Physicians strongly recommends that manipulation, among other therapies, be attempted as a first-line measure for acute and chronic back pain.[17]

One of the best-known and used osteopathic medicine approaches is the Muscle Energy Technique (MET).[18] The MET was conceived by Fred Mitchell Sr. about half a century ago; this approach aims to improve muscle function, restore physiological length to a shortened contractile district, improve joint movement, and reduce inflammatory symptoms.[19]

The effectiveness of the technique will depend on some factors, such as the correct positioning of the joint and the proper muscle tension, an exact diagnostic path, a force put by the operator sufficient to change the muscular behavior of the area, and an adequate repositioning of the articulation after the manual procedure.[19] MET is also indicated in cases of muscle stiffness, for example, after thoracic surgery, and to counteract trigger points.

The clinical mechanisms that explain the positive response to the technique have yet to be fully understood. MET could stimulate mechanoreceptors and send muscular-articular afferents to inhibit nociceptive afferents, as in a reflex circuit, by varying the mechanical and metabolic environment of the treated area. The technique could stimulate reciprocal inhibition, making the activated muscles more relaxed and stretch, with a gain in joint movement. Another hypothesis is improving fluid drainage, improving the metabolic environment, and lowering inflammatory indices and nociceptive substances.[19]

When should clinicians choose to perform a MET? This technique has no side effects. The concept of this approach is to exploit the force that the patient can express, respecting the physiological limits without creating pain or discomfort. The technique can also be used to prepare for other techniques, such as high-velocity low-amplitude (HVLA) or more demanding stretches, and prepare the ribs for more effective work on the diaphragm muscle. For example, after a sternotomy cardiac surgery, patients may present positional changes in the rib joints, causing pain. To improve the function of the respiratory muscles and the muscles that affect the rib cage, respecting the sternal wound, it is possible to perform a MET. When the pain has improved, other more comprehensive approaches (such as unwinding or more challenging rehabilitation exercises) can increase the patient's ability to breathe and move. 

A scar due to previous trauma or surgery can alter the movement of a rib and the surrounding muscles. In this case, the treating clinician must know that MET can increase the rib's range of motion (ROM), improving the afferent/efferent picture of the treated area. Still, precisely because of the scar presence, it is likely that the reduction of the ROM can return. In this situation, it is not wrong to reschedule visits for the patient and periodically carry out this manual technique to obtain more lasting maintenance of muscle and joint movement.

To conclude, MET can be used as the only technique if the result is the complete restoration of joint and muscle function, or the technique can be used to prepare for more demanding techniques for the patient.

Enhancing Healthcare Team Outcomes

The key to treating any disease is identifying an illness or dysfunction, investigating appropriate treatment strategies, and ensuring the patient is willing and eligible for any specific treatment. In terms of muscle energy of exhaled ribs, coordinated patient care is essential to ensure that the patient is treated for the correct dysfunction. For example, a coordinated approach with the patient’s primary care physician and an emergency room physician can help extrapolate the root cause of chest pain as cardiac or musculoskeletal. An appropriate referral can then be made to ensure accurate diagnosis and treatment.

Following treatment, the whole healthcare team, including nurses, home health aides, primary care clinicians, and the treating provider, needs to care for the patient to formulate an appropriate treatment plan and reduce pain. A pharmacist can also be involved if the patient requires pain medications to monitor an increase or reduction in the number of drugs combined with Osteopathic Manipulative Treatment. It is also essential for the interprofessional healthcare team to ensure that none of the contraindications mentioned above apply to a patient. Such methods would provide a well-rounded systematic approach to treating patients with underlying musculoskeletal complaints while ruling out other disease processes.