Cage And Ribs

The ribs and thorax present certain of their own particular problems from the point of view of efficient performance of technique. These problems mainly relate to the variations in shape of the thoracic curve in different individuals and the need to modify approaches accordingly. There are several pathological conditions that need particular care. Although this is not the place to be detailing all these, the reader is encouraged to think in particular about osteochondrosis, osteoporosis, scoliosis, and myeloma. All these are examples of the type of conditions where special consideration as to type of approach is needed as there will be deficiency of bone strength.

The rib articulations are rarely dysfunctional by themselves, and it has been stated that in a given case, the thoracic spine should receive attention first and subsequently the ribs. If rib articulations are addressed first, they may be disturbed again when any thoracic spinal technique is performed thereby rendering the rib work ineffective.

Although there are usually twelve pairs of ribs, they vary progressively from above down, in shape and movement possibility; technique will inevitably vary according to the area being worked. The techniques, therefore, are divided broadly into those applicable on the lower, middle and upper ribs. Naturally these demarcations are artificial, and there will be some overlap.

Technique classifications have often referred to the nature of movement of ribs. They demarcate the 'bucket-handle' type of movement from the 'pump-handle' type. This classification is not used here as rib dysfunction is considered simply in respect of good function or lack of it. The choice of technique is by the quality and quantity of the dysfunction found rather than by any pre-conceived notion of specific functional movement possibilities. Although this does not accord with traditional thinking when working on ribs, it is no less effective in actual practice, and considerably simpler to apply.

Due to the springy nature of the ribs in normal subjects, it is usually necessary to absorb some of that spring in performing techniques. This is done by using several vectors of force of compression in more than one direction. This can be either along or across a particular rib so that the amplitude of a force applied need not be too great. Torsion with this method of approach is less necessary, and discomfort is reduced with these carefully applied compressions.

The control of rhythm is clearly necessary, particularly in rhythmic techniques that have to be repeated several times. Phases of breathing also need to be taken into consideration. Many techniques require either exhalation to induce relaxation or, alternatively, inhalation to create a firming up of the part and improving the access to the optimum motion barrier.

The choice of position to perform the technique, such as supine, sidelying, etc., is going to be governed by the most comfortable position for the patient at the time, and the position most effective for the requirements of the treatment and technique being given. As a rule, sidelying is more comfortable than supine, and supine is more comfortable than prone. Sitting is better where larger movements are necessary, but this requires more cooperation from the patient and control by the operator. It is preferable to avoid the necessity of changing the patient's position excessively during treatment and the relative size of operator and patient may also determine the optimum position in which most techniques can be performed.

Because of the deep nature of the intercostal muscles, direct soft tissue work is less effective here than in some regions, and stretching and articulation will be more useful. Thrust techniques have a particular use when there has been a traumatic onset to a particular syndrome. They play a smaller part in more chronic conditions, except at the outset, to break fixation and pave the way for more rhythmic approaches later. Care should always be taken of the aesthetic nature of the procedure being used. This is particularly true when working on female patients so as not to put pressure on breast tissue which could be embarrassing and possibly painful.

18.1 • Articulation of mid ribs supine Hold the patient's arm in extension, and use internal rotation to put the shoulder capsule on tension. Apply the applicator thumb and thenar eminence to the costal interspaces. Rock from one foot to the other and apply a careful pressure to the lower of a pair of ribs so it is possible to increase their spacing and mobility. This hold can be used from twelfth to third rib.

Tips: Most useful in kyphotic patients where the ribs will be in close apposition. Least useful in large-breasted women where it may be impossible to get to the ribs without intruding on the breasts. Extra considerations: It may be useful to use different phases of respiration.

18.2 • Articulation of upper ribs Stand at the head of the table with the patient's arm extended and internally rotated. Apply a force through the shoulder and ribs by rotating your body. Keep the patient's arm held firmly into your side so that the rotation movement causes rib articulation forces to develop.

Tips: Most useful where the first three or four ribs are involved in a dysfunction syndrome. Least useful where there is any shoulder problem making the arm movement difficult in this plane. Extra considerations: With tension maintained try using a harmonic oscillation in this position.

18.3 • Articulation of lower ribs Apply a slight compressive force to the thoracic cage and use the thumbs to carefully hold the ribs being worked towards the pelvis while you rhythmically lean back. The patient here is holding a towel between her hands as the stretch round the operator to clasp her hands may be too great.

Tips: Least useful in patients where shoulder movement of this amplitude may be a problem. Extra considerations: Try using a harmonic oscillation in this position.

18.4 • Articulation of mid ribs Apply a slight lateral compression force to the upper thorax to limit movement there, then, with the back of the hands resting on the table, apply an anterior force to the shafts of the ribs. At the same time apply a traction by leaning back and, thereby, produce a stretch from the patient's linked hands.

Tips: Most useful in kyphotic patients where rib 'spreading' is an important element of treatment. Least useful where the shoulders cannot adopt the position. Extra considerations: Try using different phases of respiration.

18.5 • Articulation of lower ribs The patient links her hands behind her head and then you apply a resistive force to her elbow. You can lift the lower ribs by twisting your own body with relatively fixed arms.

Tips: Most useful where there is a need to elevate and spread the lower ribs strongly. Least useful where the shoulder cannot be used in this range of movement. Extra considerations: Try using varied phases of respiration.

18.6 • Articulation of mid ribs With the patient's hands linked behind her neck you apply a lifting and spreading movement to the mid ribs on the opposite side. This is particularly effective in patients who have a very flexed thoracic spine, for example from age, osteoporosis or osteochondrosis. It will only be effective as far as the sixth or seventh rib, as the scapula intervenes.

Tips: Least useful in large subjects where the reach may be too great for smaller operators. Extra considerations: Try using varied phases of respiration and varied amounts of preliminary sidebending of the patient's body.

18.7 • Articulation of mid and upper ribs This hold uses initial patient positioning as the opposite leg is flexed at the hip and adducted to produce some rotation of the pelvis toward the operator. The arm is placed under the side of the patient. Apply the thenar eminence to the angle of the rib. With the other hand, hold down the shoulder and pronate the applicator forearm to apply the mobilizing force. Stabilize the patient's folded arms with a traction force applied with your own chest if required.

Tips: Most useful in very tight subjects where the springing force developed in this way will help mobilize the individual joints effectively. Least useful if the rib heads are very tender to pressure. Extra considerations: Try using varied phases of respiration and head rotation to optimize the tension.

18.8 • Articulation of mid to lower ribs The applicator here is the border of index finger and second metacarpal. They apply an extension and separating force, while the patient's shoulder is held down with the other hand and the elbow of your applicator hand rotates the patient's pelvis towards you.

Tips: Most useful where a strong mobilizing force is required. Least useful where rotation in the thorax may be a problem. Extra considerations: Try using different phases of respiration and varying the patient's initial position to help localize the force.

18.9 • 'Stretching' mid ribs sitting Hold down on the rib being worked while straightening your knees and sidebending the patient with your other hand. Apply rib stretching or articulation. Note that the patient's head is kept in the midline above the pelvis so that the maximum stretch can be applied to the rib. If the patient's body is taken out of the midline there will tend to be more of a compressive force on the other side. This will be uncomfortable and tend to dissipate the forces into other tissues than the area intended.

Tips: Least useful in very flexible subjects where it would be difficult to localize the force. Extra considerations: Try using different phases of respiration and try circumducting the patient's body around the fixed applicator hand as an alternative approach.

18.10 • Articulation of mid to lower ribs sitting

This hold can be used where there is a scoliosis, as the ribs can be worked on the convexity. It requires a firm compression between the bodies of the operator and the patient, and whilst the hands are held relatively fixed the oscillation of body movement will perform the articulation. Extra considerations: Try using varied phases of respiration and different amounts of active flexion and extension in the patient.

18.11 • Articulation of upper ribs sitting Apply the hand to the costo-chondral junction and keep it relatively fixed while you abduct and externally rotate the shoulder to a comfortable limit. Then, hold the shoulder and perform the articulatory force by pressing forwards against the scapula to induce a force localized to the rib. Sometimes a slight increase of traction through the arm assists the technique. Extra considerations: Try using varied phases of respiration.

18.12 • (bottom left) Articulation of costo-chondral joints Hold back on the sternum and apply a traction, external rotation and abduction force to the shoulder. Then lean forward against the patient's scapula to produce a gapping force. Lower down the rib cage, more initial rotation needs to be induced in the patient's body to establish localization.

Tips: Least useful in cases where shoulder dysfunction would cause pain in this position. Extra considerations: Try using different phases of respiration.

18.13 • Articulation of mid to lower ribs Side-bend the patient over your padded knee and compress her firmly against your side. The mid ribs will require more extension of the patient's body than the lower.

Tips: Least useful if the patient is very large and the operator very small. Extra considerations: Try using varied phases of respiration.

18.14 • Articulation of mid ribs sidelying Use your upper hand to apply a posterior to anterior force while your elbow maintains the patient's shoulder in extension, abduction and external rotation. This transmits the force to just below your fingertips where the other hand applies a slight compressive force and holds down on the rib towards the pelvis. It is possible to reach up to about the fourth or fifth rib except in very mobile subjects, where the scapula gets in the way.

Extra considerations: Try using varied phases of respiration.

18.15 • Articulation of mid to lower ribs sidelying Apply a downward force through both forearms on the lateral border of the scapula and the pelvis. Use a small component of postero-anterior force and then, while maintaining these, separate your hands slightly to produce the required direction of force.

Extra considerations: This position can be used for harmonic technique where the focus is made with the hands and then the whole patient's body rocked around them. Try using varied phases of respiration.

18.16 • Articulation of mid ribs prone Extend and abduct the shoulder and then, while the rib is held toward the pelvis with the fingertips and thumb, further abduct the shoulder to reach the fixation point so that articulation can be performed.

Tips: Least useful in patients where prone lying is a problem and where there is shoulder dysfunction. Extra considerations: Try using varied phases of respiration.

18.17 • Thrust first rib prone Sidebend the neck toward the rib and rotate it away. Produce a component of sideshifting with the stabilizing hand. Form an apex by pressure of your metacarpo-phalangeal joint as close to the head of the rib as possible. When you have taken up the slack, the direction of force will be approximately toward the opposite axilla. The hand holding the head is a stabilizer in this technique and does not enter into the thrust. As the technique is mostly used on ribs that have been fixated relatively superiorly by the pull of the scaleni, it is normally performed as the patient exhales.

Tips: Most useful where a treatment table headpiece can drop below horizontal to take the whole neck into some flexion. Least useful where the patient is over the age of 40, where neck extension and rotation may be limited. Extra considerations: Avoid this technique where there is a brachial nerve compression syndrome on the same side, as it may aggravate nerve root pressure.

18.18 • Thrust hand position first, second and third rib

18.19 • Thrust first, second or third rib supine

Use the hand hold shown in the photograph. Apply your hand to the head of the rib, keeping it in some pronation so that the thenar eminence is applied to the angle of the rib. Apply the other hand just lateral to the costo-chondral junction, and use your thorax to push downwards on the folded arms and toward the head, to produce traction and some compression. As the patient lifts her head from the pillow, barrier sense will accumulate on the thenar eminence. It is then necessary to make a small increase of pressure toward the table with the upper hand, and a further sharp pronation with the table hand to complete the thrust.

Tips: Most useful in very tight subjects where neck levers are best avoided. Extra considerations: If excessive pressure is applied to the rib head too early, the patient will be unable to lift the head. Try using varied phases of respiration.

18.20 •Thrust mid ribs sitting Pull the patient's body into extension and apply a localized force using your thumb directed to the angle of a rib. Sidebend the spine over that thumb and then rotate it away to produce locking of the spinal column. Then apply a short amplitude thrust in an upward and forward direction which will break fixation in the costo-vertebral or costo-transverse articulations, depending on the amount of preliminary rotation. More rotation directs the force laterally to the costo-transverse articulation.

Tips: Least useful in very flexible subjects where it is difficult to produce localization. This technique may be impossible in large patients as the reach for the operator may be too great. Extra considerations: The patient may be more comfortable with a pillow between her arms and the operator's shoulder. Try using different phases of respiration.

18.21 • Thrust starting position for mid ribs sitting Apply the hypothenar eminence to the angle of the rib and stretch the other arm across the thorax to compress the ribs slightly from front to back. This compression of the chest makes the thrust point more accessible. Then rotate your and the patient's body, pushing the rib forward. At the last moment introduce a sidebending toward the rib with enough extension to focus the forces. The extension is produced partly by pressure on the rib angle, and partly by asking the patient to extend her head and neck. Most techniques do not require a specific order of components. However, in this hold it is far too easy to over-lock if the balance between the components is wrong. If the order described is used there is a greater probability of balance between comfort and effectiveness.

18.23 • Thrust for middle ribs sitting This shows essentially the same technique as photograph 18.22 but an alternative hand hold across the thorax has been taken and the patient is sitting across the table rather than astride.

Tips: This hand hold may be better as it avoids the breast area in female patients.

18.22 • Thrust for mid ribs The operator has applied the rotation away from the rib and the side bending down to it until the forces accumulate as in photograph 18.21. The patient then extends her head. Apply a compressive force between the two hands and perform the thrust with the pisiform vertically on the angle of the rib. If the thrust force is more anterior than vertical, pain will be induced and the technique will be less effective.

Tips: Least useful where the operator is smaller than the patient and where the reach around may be a problem. Extra considerations: This is one of the few thrust techniques where generally it is better not to apply very much in the way of soft tissue procedures first. It is often difficult to accumulate useful tension if the structures have been previously relaxed. Try using varied phases of respiration. (The sitting astride position shown here is not an essential part of the technique.)

18.24 •Thrust for mid ribs sidelying This is a modified lumbar roll position with hand applied directly over the costo-transverse articulation on the side of the thorax closest to the table. Use the other hand to compress the pectoral girdle directly toward the table and prevent forward rotation of the body. Apply the force with the whole of the thrusting arm and hand and use a direct compressive force anteriorly and slightly superiorly to produce gapping of the joint.

Tips: Most useful in tight subjects as their stiffness helps to produce a localization more easily. Least useful where the operator is small and it may be difficult to apply sufficient compressive force for localization. Extra considerations: Try different phases of respiration.

18.25 • Thrust to mid ribs sidelying shown on skeleton The exact positions of the fingers of the thrusting hand in the previous illustration are seen more clearly here. Although this may seem a rather unusual way of reaching the mid ribs, it is particularly useful where excess torsion would be a problem. The controlled compressive force allows the target rib to be reached. If a pure rotation force were to be used instead of the compression, the whole lumbar spine would be at risk of strain.

18.26 • Thrust to lower ribs sidelying shown on skeleton A modified lumbar roll position has been applied and the finger tips of the thrusting hand have been directed toward the table. This will reduce spinal movement. A force is applied then toward the operator to gap the rib articulations while the other hand holds back on the spinous processes. The critical element in this technique is the control of compressive force to focus the forces accurately.

Tips: Most useful where torsion of the whole thorax is best avoided as compression substitutes for rotation. Least useful in the presence of lumbar or sacro-iliac dysfunction as some stress inevitably occurs at these regions.

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