OMT Workshop Techniques.hohner

8/10/2019 OMT Workshop Techniques.hohner

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IOA OMT WORKSHOP TECHNIQUES

EXERPTED FROM MWU OMM PROCEDURE MANUAL

PAGE TECHNIQUE

2-9 HVLA THORACIC SUPINE

10 HVLA THORACIC SEATED

11-14 HVLA KNEE IN BACK

15-16 HVLA EPIGASTRIC THRUST

17-18 HVLA THORACIC PRONE

19 RIB RAISING

20-21 ARTICULATION EXHALED RIB

22 ARTICULATION INHALED RIBS

23-27 COUNTERSTRAIN RIBS

28 FPR FIRST RIB

29 FPR RIBS

30 HVLA FIRST RIB

31-32 HVLA 2ND- 4THRIBS

33-36 INDIRECT RIB BALANCING

37-41 MUSCLE ENERGY RIBS

42 MFR RIB INDIRECT

43 THORACIC INLET RELEASE


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739.2 HVLA - THORACIC - PATIENT SUPINE - METHOD 1 - HANDS BEHIND NECK- EXTENDED (KIRKSVILLE KRUNCH)

Dysfunction: T5on T6, extended, side bent right and rotated right; T5ERSR.

Objective: Improve flexion, left rotation, and left sidebending.

Discussion: Osteopathic physicians commonly use this technique. There are numerousvariations regarding physician hand placement (over posterior transverse process; on segmentbelow, opposite side, over rib angle for treating ribs), patient arm placement (hands behindneck, arms folded across chest), and whether or not the physician controls the patients head.Foundations lists four versions. The pictures are similar; however, none of these techniquedescriptors matches the Chicago approach. In the real world, physicians learn to make thetechnique work (disregarding mechanics). This technique is used for type I group curves, type IIdysfunctions, and rib dysfunctions. In many cases, the diagnosis is done at the time oftreatment, in which the physician develops skill in localizing force at the restrictive barrier. TheChicago version of this technique is intended for Type II mechanics. It can be used for flexedor extended dysfunctions. In either case, the physicians hand is placed on the segment below,side opposite the posterior component. The physician stands on the side of the posterior

component. (See illustrations for patient arm position.) Having the patients hands behind theirneck works well for a patient with long arms and a thin torso, this is the positioning described inthe description below. Having the patients arms folded across their chest is more appropriatefor a stocky patient with short arms. A pillow placed between patient's elbows and your chest isof great value to protect your chest. Kirksville Krunch is a natural for treating flexeddysfunctions because the fulcrum (physicians hand) will provide extension. However, whentreating extended dysfunctions, a special effort must be made to maintain flexion.


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Patient Position: Supine.

Physician Position: Standing at the side of the table, facing the patient, on the side of theposterior component. (Stand at the right side of the patient at the level of the patient's waist, "onthe somatic dysfunction side").

Procedure:

1. Ask patient to clasp their hands behind their neck and bring their elbows close together.

2. Grasp the patient's elbows with your left forearm and hand. This will allow you to controlthe patients upper torso when introducing sidebending and extension.

3. Roll the patient's upper torso toward you.

4. Palpate the inter-spinous area between T5and T6with your right hand.

5. Place the thenar eminence of your right hand in contact with the left transverse processof T6. Extend the fingers of your right hand so that the fingers contact the right paraspinalmuscles. Do not make a fist under the patient's back.

6. Allow the patient's body to roll back, over your right hand. Keep the patients uppertorso flexed.This will introduce flexion and rotation, between T5and T6.

7. Sidebending and additional flexion may now be introduced through your control of thepatients upper torso as described in step 2 above.

8. FINAL THRUST: Apply a quick downward thrust further introducing flexion androtation/sidebending to the left.

9. Reassess.


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739.2 HVLA - THORACIC - PATIENT SUPINE - METHOD 2 - ARMS ACROSS CHEST- EXTENDED (KIRKSVILLE KRUNCH)

Dysfunction: T5on T6, extended, side bent right and rotated right; T5ERSR.

Objective: Improve flexion, left rotation, and left sidebending.

Discussion: Osteopathic physicians commonly use this technique. There are numerousvariations regarding physician hand placement (over posterior transverse process; on segmentbelow, opposite side, over rib angle for treating ribs), patient arm placement (hands behindneck, arms folded across chest), and whether or not the physician controls the patients head.Foundations lists four versions. The pictures are similar; however, none of these techniquedescriptors matches the Chicago approach. In the real world, physicians learn to make thetechnique work (disregarding mechanics). This technique is used for type I group curves, type IIdysfunctions, and rib dysfunctions. In many cases, the diagnosis is done at the time oftreatment, in which the physician develops skill in localizing force at the restrictive barrier. TheChicago version of this technique is intended for Type II mechanics. It can be used for flexedor extended dysfunctions. In either case, the physicians hand is placed on the segment below,side opposite the posterior component. The physician stands on the side of the posterior

component. (See illustrations for patient arm position.) Having the patients hands behind theirneck works well for a patient with long arms and a thin torso, this is the positioning described inthe description below. Having the patients arms folded across their chest is more appropriatefor a stocky patient with short arms. A pillow placed between patient's elbows and your chest isof great value to protect your chest. Kirksville Krunch is a natural for treating flexeddysfunctions because the fulcrum (physicians hand) will provide extension. However, whentreating extended dysfunctions, a special effort must be made to maintain flexion.


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Procedure:1. Ask patient to place their arms across

their chest such that the arm oppositethe side the physician is standing onis on top.

2. Grasp the patient's folded arms withyour left forearm and hand. This willallow you to control the patientsupper torso when introducingsidebending and extension.

3. Roll the patient's upper torso towardyou.

4. Palpate the inter-spinous areabetween T5and T6with your righthand.

5. Place the thenar eminence of yourright hand in contact with the lefttransverse process of T6. Extend thefingers of your right hand so that thefingers contact the right paraspinalmuscles. Do not make a fist under thepatient's back.

6. Allow the patient's body to roll back,over your right hand. Keep the patients upper torso flexed.This will introduce flexionand rotation, between T5and T6.

7. Sidebending and additional flexion may now be introduced through your control of thepatients upper torso as described in step 2 above.

8. FINAL THRUST: Apply a quick downward thrust further introducing flexion androtation/sidebending to the left.

9. Reassess motion.


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739.2 HVLA - THORACIC - PATIENT SUPINE - METHOD 1 - HANDS BEHIND NECK- FLEXED (KIRKSVILLE KRUNCH)

Dysfunction: T5on T6, flexed, side bent right and rotated right; T5FRSR.

Objective: Improve extension left sidebending, and left rotation.

Discussion: This technique is commonly used by osteopathic physicians. There arenumerous variations regarding physician hand placement (over posterior transverse process; onsegment below, opposite side, over rib angle for treating ribs), patient arm placement (handsbehind neck, arms folded across chest), and whether or not the physician controls the patientshead. Foundations lists four versions. The pictures are similar, however, none of thesetechnique descriptors matches the Chicago approach. In the real world, physicians learn tomake the technique work (disregarding mechanics). This technique is used for type I groupcurves, type II dysfunctions, and rib dysfunctions. In many cases, the diagnosis is done at thetime of treatment, in which the physician develops skill in localizing force at the restrictivebarrier. The Chicagoversion of this technique is intended for Type II mechanics. It can beused for flexed or extended dysfunctions. In either case, the physicians hand is placed on thesegment below, side opposite the posterior component. The physician stands on the side of the

posterior component. (See illustrations for patient arm position.) Having the patients handsbehind their neck works well for a patient with long arms and a thin torso, this is the positioningdescribed in the description below. Having the patients arms folded across their chest is moreappropriate for a stocky patient with short arms. A pillow placed between patient's elbows andyour chest is of great value to protect your chest.


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Procedure:1. Ask patient to clasp their hands behind their neck

and bring their elbows close together.

2. Grasp the patient's elbows with your left forearmand hand. This will allow you to control thepatients upper torso when introducing sidebending and extension.


4. Palpate the inter-spinous area between T5and T6with your right hand.

5. Place your thenar eminence of your right hand in contact with the left transverse process

of T6. Extend the fingers of your right hand so that the fingers contact the right paraspinalmuscles. Do not make a fist under the patient's back.

6. Allow the patient's body to begin to roll back, over your right hand.

7. Localization of sidebending down to the dysfunction is achieved by using the patientselbows.

8. Next, localization of rotation and extension occurs by rolling the patients torso over yourfulcrum hand.

9. FINAL THRUST: Apply a quick downward thrust (which introduces) extension and

rotation/sidebending to the left.

10. Reassess motion.


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739.2 HVLA - THORACIC - PATIENT SUPINE - METHOD 2 - ARMS ACROSS CHEST- FLEXED (KIRKSVILLE KRUNCH)

Dysfunction: T5on T6, flexed, side bent left and rotated left; T5FRSL.

Objective: Improve extension right sidebending, and right rotation.

Discussion: This technique is commonly used by osteopathic physicians. There are numerousvariations regarding physician hand placement (over posterior transverse process; on segmentbelow, opposite side, over rib angle for treating ribs), patient arm placement (hands behindneck, arms folded across chest), and whether or not the physician controls the patients head.Foundations lists four versions. The pictures are similar, however, none of these techniquedescriptors matches the Chicago approach. In the real world, physicians learn to make thetechnique work (disregarding mechanics). This technique is used for type I group curves, type IIdysfunctions, and rib dysfunctions. In many cases, the diagnosis is done at the time oftreatment, in which the physician develops skill in localizing force at the restrictive barrier. TheChicago versionof this technique is intended for Type II mechanics. It can be used for flexedor extended dysfunctions. In either case, the physicians hand is placed on the segment below,side opposite the posterior component. The physician stands on the side of the posterior

component. (See illustrations for patient arm position.) Having the patients hands behind theirneck works well for a patient with long arms and a thin torso, this is the positioning described inthe description below. Having the patients arms folded across their chest is more appropriatefor a stocky patient with short arms. A pillow placed between patient's elbows and your chest isof great value to protect your chest.


Physician Position: Standing at the side of the table, facing the patient, on the side of theposterior component. (Stand at the left side of the patient at the level of the patient's waist, "onthe somatic dysfunction side").

Procedure:1. Ask patient to place their arms across their

chest such that the arm opposite the sidethe physician is standing on is on top.

2. Grasp the patient's folded arms with yourright forearm and hand. This will allow youto control the patients upper torso whenintroducing sidebending and extension.


4. Palpate the inter-spinous area between T5and T6with your left hand.

5. Place the thenar eminence of your left handin contact with the right transverse processof T6. Extend the fingers of your left hand sothat the fingers contact the left paraspinalmuscles. Do not make a fist under thepatient's back.


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6. Allow the patient's body to begin to roll back, over your left hand.

7. Next, localization of rotation and extension occurs by rolling the patients torso over yourfulcrum hand.

8. FINAL THRUST: Apply a quick downward thrust (which introduces) extension androtation/sidebending to the left.

9. Reassess motion.


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739.2 HVLA - THORACIC - LATERAL CURVE - PATIENT SEATED

Dysfunction: A normal group curve convexity right in the lumbar area extending from the 1sttothe 5thlumbar vertebrae.

Objective: To mobilize the apex of the lateral curve.

Discussion: This technique can be used for any lateral curve in the lumbar and lower thoracicareas.

Patient Position: Seated astride the table.

Physician Position: Standing behind and to the left side of the patient.

Procedure:1. Instruct the patient to clasp their hands behind their neck.

2. Place your left arm beneath the patients leftaxilla andreach across their chest and grasp the patients right armat the shoulder.

3. Laterally flex the patients lumbar spinal column to theright by upward pressure from your own left arm in thepatients axilla. Be sure to keep the patients ischialtuberosities on the table at all times.

4. With the spinal column laterally flexed to the right, placethe heel of your right hand over the right transverseprocess of the 3rdlumbar vertebra (the apex of the curvein this example).

5. Rotate the entire spinal column to the left by simplywalking around behind the patient until the forcesaccumulate at the 3rdlumbar vertebra.

6. The corrective movement is a sharp thrust forward andmedially through your right hand to the apex of the curve.This force is designed to rotate the lumbar vertebralcolumn left.


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739.2 HVLA - THORACIC - KNEE IN BACK - EXTENDED

Dysfunction: T4on T5extended, side bent right and rotated right; T4ERSR. This technique isuseful for extended dysfunctions from T2 through T12.

Objective: Improve flexion, rotation left, and sidebending left, of T4on T5.

Discussion: For EXTENDED thoracic dysfunctions, the knee is positioned on the posteriortransverse process of the superior segment of the dysfunction. (X marks the spot)

Patient Position: Seated.

Physician Position: Standing behind the patient.

Procedure:1. Place your right thumb on the posterior

component/transverse process (T4on the right).

2. Place your right foot on the table with your knee incontact with the posterior component (T

4right).

3. Place a pillow between your knee and the posteriorcomponent.

4. Bring your hands under patient's axillae and over theirforearms bilaterally. Rest your hands lightly upon thebacks of the patients wrists.

5. Have the patient clasp their hands behind their neck.

6. Hold your knee firmly against the patients backand ask the patient to drop their elbowsforward. Pull posteriorly against their axillaewith your forearms. This will snug the patientsupper torso into your knee, while introducingflexion between T4andT5.

7. Engage the barrier by translating T4to the right.The translation is accomplished by shifting thesegment to the right by using a translatory forcethrough your knee and forearms, at the axillae.Maintain the flexion down to T4.

8. Minimally rotate the upper torso to the left downto T4on T5.

9. The final corrective force is applied as a quick thrust directed upward and laterally with thephysicians knee (plantar flexing the right foot and ankle) combined with increasing theamount of traction through the back of your hands and forearms (through the patient'saxilla). The forces from above and below must meet at the dysfunctional segment.

10. Reassess motion.


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CONSIDERATIONS:1. Don't grasp patient's wrists firmly or apply too much forward bending stress to the neck

and upper thoracic spine.

2. Always use a pillow.

3. Keep the patient balanced over their pelvis.

4. The technique may be more effective for T2 -T6, with patient sitting with their legsextended on the table.

5. Keep the patient's weight balanced over his/her ischial tuberosities. Don't forget toengage the barrier with lateral translation. It will introduce proper side bending "frombelow".

KEY POINT: Flexion may be attained most easily by asking the patient to "let elbows drop andslump forward" while bringing the patient's shoulders posterior in translatory movement.


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739.2 HVLA - THORACIC - KNEE IN BACK - FLEXED

Dysfunction: T4on T5, flexed, rotated right, and sidebent right; T4FRSR. This technique isuseful for flexed dysfunctions from T2 through T12.

Objective: Improve extension, rotation left, and sidebending left, of T4on T5.

Discussion: For flexed thoracic dysfunctions, the knee is positioned on the lower segment of thedysfunctional vertebral unit on the side opposite the posterior component.


Physician Position: Standing behind the patient.

Procedure:1. Place your right thumb on the posterior

component of the dysfunction (T4on the right).Using this as a landmark, find the left transverseprocess of T5and place your left thumb on it.

2. Place your left foot on the table with your leftknee contacting your left thumb. Replace yourthumb with the corner of a pillow.

3. Bring your hands under the patient's axillae,bilaterally, and over the forearms to rest lightly onthe back of the wrists.

4. Have patient clasp their hands behind their neckand bend forward.

5. Hold your knee firmly against the patient and askthe patient to drop their elbows forward. Ask thepatient to "sit up straight" and hold the newposition. Translate the patient posteriorly againstthe holding force of your knee.

6. Engage the barrier by translating T4to the right.This is accomplished by translating T4on T5tothe right using a combined translatory motionthrough the knee and forearms at the axillae.

7. Minimally rotate the upper torso to the left downto T4on T5.

8. The final corrective force is applied as a quickthrust directed upward and medially with yourknee, combined with increased upward tractionwith your hands and forearms through thepatient's axillae.

9. Reassess motion.


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CONSIDERATIONS: 1. Don't grasp the patient's wrists firmly or apply too

much forward bending stress to their neck andupper thoracic spine.

2. Always use a pillow.

3. Keep the patient balanced over their pelvis.

4. The technique may be more effective for T2 -T6,with the patient sitting on the table with their legsstraight out on the table.

5. Don't forget to engage the barrier by lateraltranslation to the right. This will achieve the properside bending "from below".

KEY POINT: Extension may be attained most easily by asking the patient to "let elbows drop andsit up straight" accompanied by translation of the patient's shoulders posteriorly over your knee.


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739.2 HVLA - THORACIC - EPIGASTRIC THRUST - EXTENDED

Dysfunction: T6extended, rotated right, sidebent right; T6 ERSR. This technique may be usedon mid-thoracic dysfunctions.

Objective: To restore motion in flexion, left rotation, and left sidebending.

Discussion: The barrier is primarily engaged with lateral translation. Keeping your knee on thetable helps stabilize your forces, so you do not hurt your own back. The localization pillow mayalso be placed in a diagonal position contacting the posterior component and the transverseprocess of the segment below, opposite side.


Physician Position: Standing behind the patient with one knee on the table on the side of theposterior component.

Procedure:1. Instruct the patient to sit comfortably on the table

and clasp both hands behind their neck.

2. Fold a small pillow in half, place it in directcontact with the left transverse processes of T7ina horizontal position and hold it there firmly withyour epigastrum.

3. Pass your left hand under the patients left axillaand grasp the back of the patients left forearm.Pass your right hand under the patients rightaxilla and grasp the back of the patients rightforearm.

4. Flex the patients upper thoracicarea down toand including T6. This is done by having themslump while bringing their torso posteriorly thruthe axillae, in a translatory movement. Keep thepatients upper torso centered over their pelvisduring this procedure.

5. Engage the barrier by translating T6right.

6. Rotate the upper thoracic area to the left makingsure you localize forces down to T6upon T7.

7. The final corrective force is a quick thrust withshort forward motion of the pillow/epigastrumcoordinated with an increase in the amount oftraction through the patients axillae.Avoid over-rotating the patient.

8. Reassess.


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739.2 HVLA - THORACIC - EPIGASTRIC THRUST - FLEXED

Dysfunction: T6flexed, rotated left, sidebent left; T6FRSL. This technique may be used on mid-thoracic dysfunctions.

Objective: To restore motion in extension, right rotation, and right sidebending.

Discussion: The barrier is primarily engaged with lateral translation. Keeping your knee on thetable helps stabilize your forces, so you do not hurt your own back. The localization pillow mayalso be placed in a diagonal position contacting the posterior component and the transverseprocess of the segment below, opposite side.


Physician Position: Standing behind the patient with one knee onthe table on the side of the posterior component.

Procedure:1. Instruct the patient to sit comfortably on the table and clasp

both hands behind their neck.

2. Fold a small pillow in half, place it in direct contact with theright transverse processes of T7in a horizontal position andhold it there firmly with your epigastrum.

3. Pass your left hand under the patients left axilla and graspthe back of the patients left forearm. Pass your right handunder the patients right axilla and grasp the back of thepatients right forearm.

4. Extend the patients upper thoracic area down to andincluding T6. Keep the patients upper torso centered overtheir pelvis during this procedure.

5. Engage the barrier by translating T6left.

6. Rotate the upper thoracic area to the right making sure youlocalize forces down to T6upon T7. Avoid over-rotating thepatient.

7. The final corrective force is through the pillow/abdomenagainst the engaged barrier. It is an accentuation of theaccumulated motions.

8. Reassess.


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739.2 HVLA - THORACIC - CROSS HAND PISIFORM THRUST - PATIENT PRONE(TEXAS TWIST)

Dysfunction: T5flexed, rotated right, sidebent right; T5FRSR(posterior component right - T5FRSR).

Objective: Improve extension, left sidebending, and left rotation.(Foundations1sted. pg. 672)

Discussion: REMEMBER: Diagnose a dysfunction before attempting a thrust! This techniqueis useful for flexed dysfunctions, but is not appropriate for an extended dysfunction. There are anumber of variations in this technique. The placement of hands varies. Some physicians preferto stand on one side of the table and treat dysfunction on either side of the spine. Amodification of this technique may be used to thrust on the rib angle. PRECAUTION: Excessiveforce may crack ribs, particularly if osteoporosis is present. This technique is contraindicatedfor osteoporotic patients or for an extended dysfunction.

Patient Position: Prone.

Physician Position: Standing at the side of the table, opposite to the posterior component.

Procedure:1. Place your right thenar eminence over

the right posterior transverse processof T5.Place your left hypothenareminence on the opposite side of thespine contacting the left transverseprocess of T6.

2. With firm contact over the transverseprocesses (refer to Figure A) pushdown (anterior) and superiorly on T5

right while simultaneously pushingdown (anterior) and inferiorlyon the left.

3. Downward pressure introducesextension.

4. Now translate the lesion right whicheffectively localizes the sidebendingbarrier and applies a twist tothe softtissues.

5. Final corrective force: With yourelbows locked, apply a quick, light;high velocity- low amplitude thrustanteriorly, predominately on theposterior transverse process of T5.

6. Reassess motion.

Figure A


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739.2 HVLA - THORACIC - CHIN PIVOT

Dysfunction: T3on T4flexed, rotated and sidebent left. (T3FRS left)

Objective: Improve extension, rotation, and sidebending right of T3on T4

Discussion: This technique is useful for flexed type II dysfunctions from T1-T4of the thoracic

spine. It may be used for extended type II dysfunctions as well but a table that drops down intoflexion is necessary. The technique may also be used for rib dysfunctions (R1-4). The techniquemay be applied to the transverse process of the dysfunctional segment, or to the transverseprocess of the lower segment side opposite and one below.(See Waltons Manual)

Patient Position: Prone, with their head resting midline on their chin.

Physician Position: Standing at the head of the table.

Procedure:1. Place your pisiform bone of your left hand

in contact with the prominent posteriortransverse process of T

3. (For ribs, the

contact is made more laterally on the ribangle).

2. Apply a slight downward (anterior)pressure to hold the segment steady.

3. Contact the patients cervical area withthe palm of your right hand allowing yourfingers to project down the left side of thepatients neck to splint the cervical spine.

4. Gently sidebend the patients neck to theright, pivoting their head on their chin,until motion is perceived at the T3segment.

5. Take up any slack in the tissues byapplying a little more pressure with eitherhand.

6. Now while your right hand stabilizes thecervical spine, apply a quick downward(anterior) and lateral directed highvelocity-low amplitude thrust to thetransverse process of T3.

7. Move their head and neck back to the initial position.

8. Reassess motion.


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739.8 ART - RIB - RIB RAISING

Dysfunction: Decreased chest cage compliance.

Objective: Improve chest cage motion, ease of respiration.

Discussion: This technique is useful for the hospitalized or bedridden patient with a chest cageexhibiting general decreased freedom or range of motion. It is also thought to help decreasesympathetic tone and improve respiration and gastrointestinal function.

Patient Position: Lying supine.

Physician Position: Standing or sitting at the patients side that is to be treated.

Procedure:1. With the patient lying supine on the

treatment table or in bed, the physicianslides their hands, palms up, under thepatient's thorax. The hands are positionedso that the finger pads contact the posterioraspect of the ribs (just lateral to the costo-

transverse articulation area).

2. The physicians fingers are then moderatelyflexed and held firmly against the patient'sback. An anteriorly directed springing forceis then applied to the rib cage. This may beaccomplished through hand/wrist effort. Thetechnique may be more efficiently andcomfortably accomplished by the physicianusing their arms and trunk as a unit. This isdone by holding your fingers, hands, wrists,and volar surfaces of your forearms as a

fulcrum. The physician bends their kneeslowering their trunk which (by fulcrum/lever-action) causes the hands to move upward,deeply articulating the rib cage.

3. The position of the hands is shifted alongthe rib cage until each area has been satisfactorily treated. The physician then appliesthe same treatment to the opposite side.

4. The technique may be done from the other side of the table or bed if practical.

5. As may be the case in many hospital and home beds, if the other side of the bed is

inaccessible due to being too close to a wall or equipment, it may be necessary to treatfrom only one side. The fingers are simply moved across the midline to contact theopposite side posterior rib area and the procedure applied in a similar manner as above.It is apparent that treating the patient from only one side of the bed is less efficient thanfrom both sides, however, this may be necessary.


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739.8 ART - RIB - EXHALED RIB DYSFUNCTION - PATIENT ON SIDE

Dysfunction: Right rib 10 freer in exhalation, restriction of inhalation. The ribs anterior aspectis positioned inferiorly; the posterior aspect is positioned superiorly (down in front, up in back)with tissue reactivity overlying the costovertebral, costochondral and/or costosternal area.

Objective: To improve motion of rib 10 in inhalation.

Discussion: Associated thoracic somatic dysfunctions usually should be treated beforeproceeding with treatment of the rib dysfunction. Exhaled rib dysfunction is commonly seen withflexed thoracic type II somatic dysfunction. A common cause of exhaled rib dysfunctions isprolonged coughing or sneezing. This technique is most useful for ribs 4 through 10.

Patient Position: Lying on left side, somatic dysfunction side up.

Physician Position: Standing at the head of the table, facing the patient.

Procedure:1. Abduct the patient's top arm and place it over your ipsilateral shoulder (right arm over

right shoulder in this case). The arm may be stabilized in this position by resting thepatient's antecubital area on your shoulder with the elbow bent and/or by grasping thepatient's arm between your head and shoulder.

2. Position your trunk and shoulder as to place tension on the patient's pectoralis andserratus anterior muscles. This will help to bring the anterior aspect of the rib into aposition of relative inhalation.

3. Place the heel of your right hand against thesuperiorly displaced posterior aspect of thedysfunctional rib.

4. On the anterior chest wall grasp the inferiorlydisplaced dysfunctional rib over its bonyaspect with the fingers of your left hand in ahook-like manner.

5. Apply an inferiorly and anteriorly directedpressure through your right hand. With yourleft hand apply a moderate pressure to elevateand move the anterior rib cephalad. Thismotion engages the restrictive barrier. Themajority of the force should come from theheel of the hand over the posterior rib aspect.

6. Instruct the patient to take slow deep breaths. As the patient inhales, follow the motion ofthe dysfunctional rib into an inspirational position by applying a constant pressure. As thepatient exhales, the dysfunctional rib is firmly held in a position of inhalation and exhalationis resisted. An additional amount of corrective stress may be applied through traction onthe patient's elevated arm.


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7. After the rib is maximally "conditioned" by this procedure, the position is held, and thepatient is asked to breathe deeply one final time. The final corrective effort is a quick,gentle thrust directed inferiorly over the posterior aspect of the rib and superiorly overthe anterior aspect of the rib at the beginning of exhalation (as this is the relaxed passivephase of respiration).

8. Reassess.


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739.8 ART - RIB - INHALED RIB DYSFUNCTION - PATIENT ON SIDE

Dysfunction: Right rib 4 freer in inhalation, restriction of exhalation. The ribs anterior aspect ispositioned superiorly; the posterior aspect is positioned inferiorly (up in front, down in back) withtissue reactivity overlying the costovertebral, costochondral and/or costosternal area.

Objective: To improve motion of rib 4 in exhalation.

Discussion: Associated thoracic somatic dysfunctions usually should be treated beforeproceeding with treatment of the rib dysfunction. Inhaled rib dysfunction is commonly seen withextended thoracic type II somatic dysfunction. A common cause of inhaled rib dysfunctions arewhiplash-type motor vehicle accidents (MVAs). This technique is most useful for ribs 4-10.

Patient Position: Lying on left side, somatic dysfunction side up.

Physician Position: Standing at the foot of the table, facing the patient.

Procedure:1. Place the heel of your left hand on

the posterior-inferior aspect of thedysfunctional rib.

2. On the anterior chest wall grasp thesuperiorly displaced dysfunctional ribover its bony aspect with the fingersof your right hand in a hook-likemanner.

3. Through the heel of your left hand,apply a superiorly directed force overthe posterior rib aspect.

4. Through the fingertips of your righthand, apply an inferiorly directed force over the anterior rib aspect. This motion engagesthe restrictive barrier. The majority of the force should come from the heel of the hand overthe posterior rib aspect.

5. Instruct the patient to take slow deep breaths. As the patient exhales, follow the motionof the dysfunctional rib into exhalation by applying a constant pressure. As the patientinhales, the dysfunctional rib is firmly held in a position of exhalation, and inhalation isresisted.

6. After the rib is maximally "conditioned" by this procedure, the position is held, and thepatient is asked to breathe deeply one final time. The final corrective effort is a quick,gentle thrust directed inferiorly over the anterior aspect of the rib and superiorly over theposterior aspect of the rib at the beginning of exhalation (as this is the relaxed passivephase of respiration).

7. Reassess.


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739.8 CS - RIB - ANTERIOR (DEPRESSED) TENDER POINTS R1-R5 - PATIENTSUPINE

Dysfunction: Anterior 1strib tender point right; AR1R.

Objective: Decrease tenderness of the tender point.

Discussion: The anterior rib tender points are located bilaterally over the anterior aspect of the

chest. Rib 1 is located at the costosternal junction, just inferior to the sternoclavicular junction.Rib 2 is located over the 2ndrib at the midclavicular line. Ribs 3-10 are located over therespective ribs along the anterior axillary line.


Physician Position: Standing at the side of the patient on the side of the tender point.

Procedure:1. Place two or three pillows under the

patients head to achieve flexion of theneck.

2. Place the patients left hand underneaththeir head and sidebend the patientsupper torso to the right.

3. Place the pad of your left thumb on thetender point with the fingers of the lefthand resting over the shoulder. This isyour monitoring hand and shouldremain in place throughout theprocedure. Use a 0-10 pain scale toassist you to zero-in on the proper

position. Remember, the initial startpoint is 10 and 0 is no pain.A smallamount of sidebending (or rotation) ofthe head/neck to the right may help.

4. Grasping the patients right forearm withyour right hand, fine tuning can beaccomplished by internally rotating andadducting the patients right arm, whilesimultaneously depressing andprotracting the right shoulder with yourleft hand.

5. Hold this position 90 seconds andslowly return the patient to the originalposition. It is important that the patient remains passive throughout the procedure.

6. Reassess.


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739.8 CS - RIB - ANTERIOR (DEPRESSED) TENDER POINT - PATIENT SEATED

Dysfunction: Tender point over the 3rdrib anteriorly on the right; AR3R.

Objective: To decrease tenderness at the tender point.

Discussion: The anterior rib tender points are located bilaterally over the anterior aspect of thechest. Rib 1 is located at the costosternal junction, just inferior to the sternoclavicular junction.Rib 2 is located over the 2ndrib at the mid-clavicular line. Ribs 3-10 are located over therespective ribs along the anterior axillary line.


Physician Position: Standing behind the seated patient.

Procedure:1. Locate the tender point with pad of

the index finger of your right hand.Monitor the tender pointthroughout the technique. Use a 0-10 pain scale to assist you to

zero-in on the proper position.Remember, the initial start point is10 and 0 is no pain.

2. Instruct the patient to place theirleft foot under their right knee.

3. Place your left foot on the table.Place the patient's left arm overyour left knee. Instruct the patientto drop their right arm off the tablebehind them with the arm internally rotated.

4. Translate the patient left by moving your left knee laterally until tissue tension begins todecrease at the tender point.

5. Fine-tune the tender point through a combination of right rotation, right sidebending, andflexion of the patients head and neck. Use your left hand to control the patient's headand further decrease tissue tension at the tender point.

6. Hold this position for 90 seconds. Slowly return the patient to the original position. It isimportant that the patient remain passive throughout the procedure.

7. Reassess.


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739.8 CS - RIB - POSTERIOR (ELEVATED) TENDER POINT - PATIENT SUPINE

Dysfunction: Posterior rib 3 tender point on the right; PR3R.

Objective: Decrease tenderness of the tender point.

Discussion: The posterior rib tender points are located bilaterally over the rib angles.


Physician Position: Standing at the side of the patient on the side of the tender point.

Procedure:1. Place your left hand under the patient's scapula with

the pad of your index or middle finger contacting the3rdrib tender point. Use a 0-10 pain scale to assist youto zero-in on the proper position. Remember, theinitial start point is 10 and 0 is no pain.

2. Your right hand contacts the patients right wrist orforearm and flexes the right glenohumeral joint.

3. A decrease in tissue tension is usually palpated as thetenderness decreases.

4. Fine tuning includes adding more or less flexion,abduction/adduction, internal/external rotation, and/oranterior/posterior translation to find the position ofmaximum comfort.

5. Hold this position for 90 seconds. Slowly return the patients arm to the original position.It is important that the patient remain passive throughout the procedure.

6. Reassess.


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739.8 CS - RIB - POSTERIOR - PATIENT SUPINE

Dysfunction: Posterior rib 5 tender point on the right.

Objective: To alleviate posterior rib tender points.

Discussion: This technique is useful for one tender point, or multiple tender points in a verticalrow. It is also useful for patients who have an ipsilateral shoulder problem in which the physiciancannot move the arm in treatment of the tender point.


Physician Position: Standing facing the patient.

Procedure:1. With your left hand, reach underneath your supine

patient and find the posterior rib tender point with yourmiddle finger. Use a 0-10 pain scale to assist you tozero-in on the proper position.Remember, the initialstart point is 10 and 0 is no pain.

2. With your right hand grasp the left wrist of your patientand place their arm outstretched from their body.

3. Have the patient bend their knees and put their feet onthe table.

4. Now grasp both knees with your right hand/arm andflex their hips until tension diminishes under yourpalpating finger. Check the tender point. It should beless tender. If not, flex the hips a little more.

5. Now, allow the hips and pelvis to rotate to the patients

left away from you until all tenderness is gone from thepoint.

6. Wait in this position for 90 seconds.

7. Slowly bring the hips and pelvis back to the table andhave the patient lower their legs.

8. Now reach over with your right hand and slowly bringtheir left arm back to the table.

9. Reassess the tender point.


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739.8 FPR - RIB - FIRST RIB

Dysfunction: 1strib posterior (elevated or superior) on the right.

Objective: Improve motion of the 1strib.

Discussion: The most common error in this technique is the loss of the vector force throughoutthe technique. Localization is extremely important. This technique is avoided in the patient with

frozen shoulder, shoulder instability, or impingement of the tendons ofthe rotator cuff.

Patient Position: Lying supine.

Physician Position: Standing beside the table on the side of thedysfunction, facing the patient.

Procedure:1. The physician places his right hand over the patients 1st

rib with the fingertips on the posterior aspect of the 1stribwhere it articulates at T1.

2. The patient places his right arm across his chest such thatthe palm of the right hand is in contact with the sternum.

3. The physician places his left hand on the patients flexedelbow.

4. The physician localizes motion to the rib articulation byintroducing a slight abduction and internal rotation of thehumerus. The patients right arm should remain under thephysicians right forearm.

5. The physician introduces a compression vector force from

the patients elbow down a theoretical vector ending at thephysicians monitoring fingers over the rib attachment.

6. The physician moves the elbow in a backward arc until thearm passes the patients ear and then carries the elbowoutward towards the table and down.

7. The release is typically felt shortly after the arc startsoutward.

8. The position is released and the dysfunction isreevaluated.


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739.8 HVLA - RIB - FIRST RIB

Dysfunction: Elevated 1strib on the right. The posterior portion of right rib 1 is elevated andresists downward motion from above, with surrounding tissue texture change and tenderness.

Objective: To restore physiologic motion to the rib 1 costovertebral joint.

Discussion: An elevated 1strib on the right is associated with dysfunction of T1 in which T1 issidebent and rotated left. Variations exist to treat this dysfunction in the supine and pronepositions.


Physician Position:Standing behind the patient.

Procedure:1. Place your left foot on the table several inches

to the left of the patients left hip and drape thepatients left arm over your knee.You mayneed to place a pillow between your knee andthe patients axilla. To keep their shoulderslevel, place the metacarpophalangeal joint ofthe index finger of your right hand over theelevated 1strib.

2. Place your left elbow over the patients leftshoulder and use your forearm to stabilize thepatients neck/head. Your hand drapes over thetop of the patients head. This allows greatercontrol and localization. Physicians with largehands, or long forearms, may elect to contactthe patients face/cheek.

3. With your left forearm and hand slowly rotateand sidebend the head and neck to the rightdown to T1localizing force to the rib.

4. Simultaneously apply downward pressure onthe rib with your right hand.

5. Using the combined holding force of your righthand and left knee, translate the patients uppertorso to the left to aid in localization.

6. The final corrective force is a downward,medial, and anterior (HVLA) thrust through yourright hand, against the dysfunctional 1strib.

7. Reassess.


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739.8 HVLA - RIB - REVERSE RIB

Dysfunction: Left 3rdrib is prominent with tissue texture abnormality and restricted motion toan anterior and inferior applied force. Associated limitation of right rotation and sidebending ofT2on T3is present.

Objective: To restore normal motion to the rib and associated thoracic segment.

Discussion: This technique may be used for 2nd, 3rdand 4thstructural rib dysfunctions. Thisrib dysfunction is associated with a primary thoracic dysfunction. This technique is mosteffective with a flexed upper thoracic dysfunction and less effective with extended dysfunctions.

As such, the primary thoracic dysfunction should be treated first before you employ thistechnique in the situation in which the left 3rdrib is dysfunctional, T2is rotated and sidebent leftwith the body of T2pushing against the head of rib 3, straining the costo-transverse articulation.


Physician Position: Standing behind the seated patient.

Procedure:1. Place your right foot on the table several inches

to the right of the patients right hip. Place yourright knee under the patients right axillaanddrape the patients arm over your knee. Place apillow between your knee and the patients axilla.The patients left arm may be drawn acrosshis/her lap. This moves the scapula laterally toimprove access to the area of the posterior ribangle. Stabilize the patient against your leg andtorso. Maintain the patients shoulders parallel tothe table.

2. Drape your left hand over the patients left

shoulder with your thumb contacting the angle ofthe dysfunctional 3rdrib. Apply a firm fixing forceinferiorly and medially over the rib.

3. Place your right hand, with widespread fingers,over the right side of the patients neck, cheekand zygoma. Your 3rddigit should contact theface just inferior to the zygoma.

4. With your right hand translate the cervical spineas a unit, posteriorly until motion is noted at theT2-3spinal level. Gently extend the cervical spine

until motion is appreciated at the T2-3 spinal level.Rotate the patients head to the right until forcesaccumulate at the level of T2. You may makeminor adjustments to further enhancelocalization. These can include small amounts ofsidebending or rotation to help localize the barrier.


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5. The final corrective force is a quick increase inright rotation of the patients head and neck whilemaintaining firm fixation with your left hand onthe rib. A counter-thrust is not executed on therib. The corrective force has moved T2in relationto T3and to the head of rib 3. The rib is usuallyfelt to become suddenly freer following theexecution on the technique. Instructing thepatient to shake their head no before applying

the final correcting thrust may enhance results.

6. Reassess motion.


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739.8 INDIRECT - RIB - BALANCING OF MULTIPLE RIBS - EXHALED - PATIENT SEATED

Dysfunction: Exhaled group rib dysfunctions - 5thto 7thribs left (Restriction of inhalation).

Objective: Improve motion of exhaled group with melioration of accompanyingtenderness/pain.

Discussion: The key rib in an exhalation group would be the top rib, preventing the group frommoving into an inhaled position. The primary focus would be on the key rib. The thoracic spine

may also be restricted. If you can sense this restriction, move the thoracic segments into aposition of ease as well as the ribs.


Physician Position: Seated upon the table at the dysfunctional side, facing the patient.

Procedure:1. Contact the left 5th-7thribs with both hands focusing on the 5 thrib or key rib. This is

accomplished by placing the pads of your left index, middle, and ring fingers on themedial ends of ribs 5, 6, & 7 anteriorly, allowing the palmar aspect of your fingers, hand,and thumb to follow the course of the respective ribs laterally to the mid-axillary line.

Your right hand contacts the posterior aspect of the ribs in an analogous manner.

2. Follow the ribs into their freer motion of translation (anterior/posterior, cephalad/caudad,and lateral) and rotation until a position of maximal release of tension is appreciated.

3. Have the patient slowly exhale and follow the ribs into their exhaled position (down infront and up in back) until a position of maximal release of tension is appreciated, holdand wait for a release.

4. Reassess.


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739.8 INDIRECT - RIB - BALANCING OF MULTIPLE RIBS - INHALED - PATIENTSEATED

Dysfunction: Inhaled group rib dysfunctions - 5thto 7thribs left (Restriction of exhalation).

Objective: Improve motion of inhaled group with melioration of accompanying tenderness/pain.

Discussion: The key rib in an inhalation group would be the bottom rib, preventing the groupfrom moving into an exhaled position. The primary focus would be on the key rib. The thoracicspine may also be restricted. If you can sense this restriction, move the thoracic segments into aposition of ease as well as the ribs.



Procedure:1. Contact the left 5th-7thribs with both hands focusing on the 7 thrib or key rib. This is

accomplished by placing the pads of your left index, middle, and ring fingers on the

medial ends of ribs 5, 6, & 7 anteriorly, allowing the palmar aspect of your fingers, hand,and thumb to follow the course of the respective ribs laterally to the mid-axillary line.Your right hand contacts the posterior aspect of the ribs in an analogous manner.

2. Have the patient slowly inhale and exhale. Follow the ribs into their inhaled positionsfocusing on the key rib (up in front and down in back).

3. During subsequent respiratory cycles, further fine tune the ribs inhaled positions usingtranslation (anterior/posterior, cephalad/caudad, and lateral) and rotation until a positionof maximal release of tension is achieved. Hold this position and wait for a release.

4. Reassess.


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739.8 INDIRECT - RIB - BALANCING OF SINGLE RIB - EXHALED - PATIENTSEATED

Dysfunction: Exhaled 7thrib left (Restriction of inhalation).

Objective: Improve motion of 7thrib with melioration of accompanying tenderness/pain.

Discussion: This involves the principles of indirect release technique by moving the rib awayfrom the restrictive barrier into a direction of freer motion (exhalation); find the proper positionfor release; hold and wait for release. If a combined method is used, after release occurs movethe rib into the original restrictive barrier (inhalation).



Procedure:1. Contact the left 7thribs with both hands in such a way that the pads of your left index and

middle fingers touch the medial end of the rib anteriorly, allowing the palmar aspect ofyour fingers and thumb to follow the course of the rib laterally to the mid-axillary linewhile your right hand contacts the posterior aspect of the rib in an analogous manner.

2. Follow the rib into its freer motion of translation (anterior/posterior, cephalad/caudad,and lateral) and rotation until a position of maximal release of tension is appreciated.

3. Have the patient slowly exhale and follow the rib into its exhaled position (down in frontand up in back) until a position of maximal release of tension is appreciated and hold.

4. Reassess.


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739.8 INDIRECT - RIB - BALANCING OF SINGLE RIB - INHALED - PATIENTSEATED

Dysfunction: Inhaled 5thrib left (Restriction of exhalation).

Objective: Improve motion of 5thrib with melioration of accompanying tenderness/pain.

Discussion: The principles of indirect release technique involving moving the rib away from the

restrictive barrier into a direction of freer motion (inhalation); find the proper position for release;hold and wait for release. If a combined method is used, after release occurs move the rib intothe original restrictive barrier (exhalation).



Procedure:1. Contact the left 5thribs with both hands in such a way that the pads of your left index and

middle fingers touch the medial end of the rib anteriorly, allowing the palmar aspect ofyour fingers and thumb to follow the course of the rib laterally to the mid-axillary line

while your right hand contacts the posterior aspect of the rib in an analogous manner.

2. Have the patient slowly inhale then exhale. Follow the rib into its inhaled position duringinhalation (up in front and down in back).

3. During subsequent respiratory cycles, further fine tune the ribs inhaled position usingtranslation (anterior/posterior, cephalad/caudad, and lateral) and rotation until a positionof maximal release of tension is achieved.

4. Reassess.


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739.8 ME - RIB - RIBS 1&2 - EXHALED DYSFUNCTION - PATIENT SUPINE

Dysfunction: Exhaled ribs 1-2 (inhalation restriction). (see Greenmanpg. 261, Foundationspg. 892)

Objective: To improve respiratory motion of the dysfunctional rib(s).

Discussion: An exhaled (exhalation) rib is positioned in exhalation, completes a full exhalation

cycle, but stops early in inhalation. The physical finding of stops early is the usual basis ofinterpreting motion testing of ribs. For an inhaled group, the bottom rib is the key rib. For anexhaled group, the top rib is the key rib. (Mnemonic BITE: Bottom for Inhaled rib, Top forExhaled rib).


Physician Position: Standing at the side opposite the rib dysfunction and face the patient.

Procedure:1. The patient is directed to rotate his head 300 away from the side of the dysfunctional rib.

2. Place the patients arm on the side of the dysfunction so that the dorsum of his wristrests on his forehead.

3. Place your cephalad hand on the patients wrist and your caudal hand on thedysfunctional rib angle, introducing a continuous lateral and caudal traction.

4. Instruct the patient to take in a deep breath (inhalation engages the barrier) and at thesame time raise his head straight up toward the ceiling as you resist this effort. The 300rotation of the head is maintained during this process.

5. The contraction is held for 3-5 seconds.

6. The patient is then directed to exhale and relax as you relax your counterforce.

7. Wait 2 seconds and repeat procedures 3-6.


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739.8 ME - RIB - RIBS 3-5 - EXHALED DYSFUNCTION - PATIENT SUPINE

Dysfunction: Exhaled ribs 3-5 (inhalation restriction). (see Foundations pgs. 892-893;Greenman pg 262)


Discussion: An exhaled (exhalation) rib is positioned in exhalation, completes a full exhalationcycle, but stops early in inhalation.The physical finding of stops early is the usual basis ofinterpreting motion testing of ribs. For an inhaled group, the bottom rib is the key rib. For anexhaled group, the top rib is the key rib. (Mnemonic BITE: Bottom for Inhaled rib, Top forExhaled rib).


Physician Position: Stand at the side opposite the rib dysfunction and face the patient.

Procedure:1. Place the patients arm on the side of the dysfunction so that the palm of

his hand rests behind his head.

2. Place your caudal hand under the patient and grasp the angle of the dysfunctional riband exerting a continuous lateral and caudal traction.

3. Place your cephalad hand on the patients flexed elbow on the side of the dysfunction.

4. Instruct the patient to take in a deep breath (inhalation engages the barrier).

5. At the same time, have the patient raise his elbow across his body against yourcounterforceas you pull inferiorly and laterally with your lower hand placed at theposterior angle of the rib being treated.

6. Hold this position for 3-5seconds.

7. Direct the patient to exhaleand relax as you cease yourcounterforce.

8. Wait 2 seconds and repeatsteps 4-7 three times.

9. Reassess.


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739.8 ME - RIB - RIBS 6-10 - EXHALED DYSFUNCTION - PATIENT SUPINE

Dysfunction: Exhaled Ribs 6-10: The dysfunctional rib(s) exhibit restriction in either inhalationor exhalation (see Foundations pg. 893; Greenman pg. 263).


Discussion: Rib dysfunctions or lesions are grouped into two general categories: RespiratoryDysfunction Ribs and Structural Dysfunction Ribs. Respiratory dysfunction ribs exhibit motionrestriction in the movement of inhalation/exhalation. Structural dysfunction ribs exhibit restrictionassociated with thoracic spine restriction. Like other somatic dysfunctions, there is asymmetry ofmovement. An exhaled (exhalation) rib is positioned in exhalation, completes a full exhalationcycle, but stops early in inhalation. The physical finding of stops early is the usual basis ofinterpreting motion testing of ribs. For an inhaled group, the bottom rib is the key rib. For anexhaled group, the top rib is the key rib. (Mnemonic BITE: Bottom for Inhaled rib, Top forExhaled rib). Ribs may be treated with a pump handle or bucket handle emphasis via smallpositional changes during the application of the technique.


Physician Position: Standing at the same side as the dysfunctional rib.

Procedure:1. Abduct the patients arm on the side of the dysfunction to a 900angle.

2. Grasp the angle of the dysfunctional rib with your caudal hand and introduce acontinuous anterior, lateral and inferior traction. This disengages therib.

3. Grasp the abducted arm at the level ofthe elbow with your cephalad hand.

4. Instruct the patient to take a deepbreath.

5. At the same time, have the patient pullhis arm straight down against your hip(hip holds the counterforce) as youpull inferiorly and laterally on thedysfunctional rib angle. Directing thepatient to push their elbow towardstheir opposite hip (pump handle) or topull down toward their side (buckethandle) can be accomplished throughpatient instruction.

6. Hold this position for 3-5 seconds.

7. Direct the patient to exhale and relax as you cease your counterforce.

8. Wait 2 seconds and repeat steps 4-7 three times.

9. Reassess.


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739.8 ME - RIB - RIBS 2-6 - INHALED DYSFUNCTION - PATIENT SUPINE

Dysfunction: Inhaled ribs 2-6. (see Foundations pg. 891; Greenman pg. 265).


Discussion: An inhaled rib is positioned in inhalation, and completes a full inhalation cycle, butstops early in exhalation. The physical finding of stops early is the usual basis of interp reting

motion testing of ribs. For an inhaled group, the bottom rib is the key rib. For an exhaled group,the top rib is the key rib. (Mnemonic BITE: Bottom for Inhaled rib, Top for Exhaled rib). Ribsmay be treated with a pump handle or bucket handle emphasis via small positional changesduring the application of the technique.


Physician Position: Standing at the head of the patient to the side of the dysfunction.

Procedure:1. Place the thumb and thenar eminence of one hand on the intercostal space above the

dysfunctional inhaled key rib on its anterior, superior surface.

2. Support the patients neck in flexion with your other hand.

3. Instruct the patient, take a deep breath in and out through your mouth.

4. On exhalation, exaggerate the pump handle motion of the dysfunctional rib by pushinginferiorly on the dysfunctional rib. To exaggerate the bucket handle motion of the ribmarked sidebending of the cervical spine and trunk (down to the rib) is used.

5. Hold the rib at its new position as the patient inhales deeply. This action acts as theisometric contraction.

6. Follow the inhaled rib in its further caudal movement during the next exhalation and hold.

7. Wait 2 seconds and repeat this procedure 3 times and re-evaluate.


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739.8 ME - RIB - RIBS 7-10 - INHALED DYSFUNCTION - PATIENT SUPINE

Dysfunction: Inhaled ribs 7-10 (exhalation restriction) (see Foundations pg. 891; Greenmanpg. 264)


Discussion: An inhaled rib is positioned in inhalation, and completes a full inhalation cycle, butstops early in exhalation. The physical finding of stops early is the usual basis of interpret ingmotion testing of ribs. For an inhaled group, the bottom rib is the key rib. For an exhaled group,the top rib is the key rib. (Mnemonic BITE: Bottom for Inhaled rib, Top for Exhaled rib).


Physician Position: Standing at the side of the table near the head of the patient.

Procedure:1. Sidebend the patients upper torso to the side of the dysfunction until tension is taken off

of the dysfunctional rib.

2. Place the thumb and index finger on the lateral aspect of the superior-lateral aspect ofthe dysfunctional rib.

3. Instruct the patient to inhale and exhale deeply.

4. On exhalation, exaggerate the bucket handle motion of the dysfunctional rib.

5. On inhalation, resist the motion of the rib.

6. Wait 2 seconds and repeat the procedure 3 times and reevaluate.


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739.8 MFR - RIB - INDIRECT RIB RELEASE

Dysfunction: Restriction of rib motion.

Objective: To restore normal rib motion by improving motion at the costovertebral articulation.

Discussion: Normal rib motion is essential for proper lymphatic flow. Rib motion may berestored through direct methods of articulating the ribs and through an indirect release of theribs. This technique is a gentle indirect release of the rib through the costovertebral articulation.

Patient Position: Supine, head lying in the midline.

Physician Position: Seated at the side of the patient, at chest level and on the side of the ribrestrictions.

Procedure:1. With your palms up, slide your hands under the patients thorax and place the pads of

your fingers just medial to the rib angles. You should be in contact with thecostovertebral articulation.

2. Using your finger tips, place a gentle lateral traction on the ribs, increasing the tractionuntil the traction matches the resistance you feel in the tissue.

3. Now, while maintaining the traction, have the patient SLOWLY turn their head to theopposite direction. The patient should be directed to stop when you feel movement atthe costovertebral junctions.

4. Hold in this position until a release is felt.

5. Return to neutral.

6. Reassess.


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739.2 MFR - THORACIC - BILATERAL THORACIC INLET - DIRECTDysfunction: Bilateral thoracic inlet fascial restriction.Objective: Improve the motion of the fascia and soft tissues of the thoracic inlet toimprove lymphatic drainage from the head and neck.Discussion: The thoracic inlet has complex motion patterns. It can be treated with atwo-hand technique for each hemi-thorax individually, or both simultaneously with bothhands placed anteriorly. During inhalation the posterior inlet moves caudad, the anteriorinlet cephalad as the A-P diameter increases. If this motion is not bilaterally symmetric,

dysfunction exists. Motion testing for restriction also is appropriate. This is done in aclockwise/counterclockwise, side-to-side, and front to back motion.Patient Position: Supine.Physician Position: Seated at the patients head.Procedure:1. Place your hands on the patients

thoracic inlet with your thumbscontacting the posterior portion of thetransverse process of T2and the headof the 2ndrib.

2. Your index fingers should contact thesternoclavicular joint and your middlefingers should contact the 2ndrib.

3. Your ring fingers and pinkies shouldlie between the clavicle and 1

strib.

4. The palm of your hand rests on theapex of the thoracic inlet.

5. Move the tissues into the direction of the restrictive barrier in all planes of motion. Thismay be a very small amount of motion. Wait for an inherent relaxation/release of thetissues. If the tissues are slow to respond, have the patient take three large breaths andfollow the release through the exhalations.

6. Reassess motion.

Note:Alternate contact to performtechnique.

OMT Workshop Techniques.hohner

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