Do you Treat Ribs? The Role Between the Axial and Appendicular Skeleton

Your Presenters: Eric S. Furto, PT, DPT, MTC, FAAOMPT Larry Yack, PT, DPT, MTC

Ribs 2-9, 12 articulations 2 Intervertebral 10 Innervated synovial 6 rib 4 facet with meniscus Anatomy

Where is the research? PubMed Search for studies involving humans in the past 5 years: Keyword: Ribs = 667 studies Keyword: Thoracic = 35,818 studies Keyword: Lumbar =10,390 studies Keyword: Cervical = 66,388 studies

Bilateral Arm Elevation: Thoracic spine goes into extension lower thoracic > upper thoracic Ribs rotate posteriorly Single Arm Elevation: Sidebending towards the side of the elevating arm. Ipsilateral upper thoracic rotation occurs towards the elevation side. Ipsilateral Rib Rotation to side of elevation. Significantly more motion in upper thoracic spine than lower thoracic spine.

Regional Interdependence

Focuses on impairments in distal or proximal regions of the painful region, but does not include referred pain. Patient presents with lumbar pain, address hip impairments Will have both neurophysiological and biomechanical benefits

Regional Interdependence is NOT: Treating TMJ pain with ankle manipulations

Rather: Patient has low back pain without Radiculopathy Treat hip Impairments Role of the hip on the Lumbar Spine: 1. Tight Hip Capsule > Neighboring lumbar instability 2. Myofascial Tightness ->Lumbar Instability 3. Hip Weakness -> Lumbar Instability

21 Subjects received thoracic or rib manipulation in the presence of shoulder pain. 51% reduction in shoulder pain 30-38 degree increase in shoulder elevation Increase in GROC score of 4.2 Biomechanical or neurophysiological?

47 subjects with shoulder impingement received either sham treatment or thoracic and rib manipulation Shoulder pain reduction was clinically significant. Increase in scapular kinematics in the thoracic/rib manipulation group. Biomechanical or neurophysiological?

Two cases of anterior lateral shoulder pain that responded to Gr III manipulation of the 2 nd rib on the affected side. Patient s symptoms were clearly shoulder in nature with painful AROM, positive Hawkins & Kennedy tests and empty can tests. Pain was significantly reduced after manipulation of 2 nd rib. Biomechanical or neurophysiological?

A validation study that showed patients with neck pain benefitting in the short and long term from thoracic manipulation The study did not validate the initial CPR, rather proved that patients with neck pain benefit from thoracic spinal manipulation regardless of their status of inclusion with the CPR.

Two different manipulations created a cavitation sound in the thoracic and lumbar spine but not at a specific targeted spinal segment. In the lumbar region, cavitation was recorded at least one vertebra away from the target (5.29 cm). Results were slightly better when comparing cavitation in the thoracic spine (3.5 cm). In most cases, multiple cavitation s (2 to 6) resulted from the manipulative procedures.

Hypoalgesia responses to spinal manipulation is influenced by expectation. A negative expectation of spinal manipulation plus spinal manipulation yielded hyperalgesia. Results speak to the variable of nocebo. Actual or perceived skill in performing manipulation Rib may be easier for novice clinician

How does Regional Interdependence Impact Clinical Practice? Potential Effects of Manipulation / Manual PT 1. Mechanical Effects 2. Neurophysiological 3. Non Specific

Methods of Relieving Physical Causes of Pain Original Theory With Today s Evidence and Changing Nomenclature

So why manipulate ribs?

Benefit of Manipulating Ribs Ease of Performance -Ribs are easier to locate, palpate, and manipulate. This ease is of benefit to novice clinicians Greater force can be generated through a longer lever arm. Evidence in regional interdependence suggests good outcomes with rib manipulation

Rib Angle 4.0 cm 2.0 cm

Summary Regional Interdependence suggests manipulating neighboring body regions improve pain and dysfunction Evidence suggests increase in AROM after manipulation of neighboring structure Validity studies of manipulation accuracy are limited Patient can benefit from both biomechanical and neurophysiological benefits of manipulation.

QUESTIONS??