3. Rib Counterstrain Flashcards
What are steps in CS? (8)
- Perform structural exam to find SD
- Find a significant tender point in that area
- Establish pain/tenderness scale
- Wrap the patient around the tender point, while monitoring
- Reduce pain by at least 70% (pt in position of comfort)
- Hold for 90 seconds
- Passively return to neutral
- Recheck/reassess
if > 1 TP of similar tenderness, which TP do we treat?
Most central/proximal
if thoracic and rib TP, treat ______ 1st
Thoracic
When do you push on TP?
Monitor and observe changes under your finger.
Do not push on TP until you have positioned correctly.
In counterstrain, pt position is geared to ______.
Reduce strain by putting them in the position of ease.
- ANTERIOR rib TP usually indicative of a ______ rib
- POSTERIOR rib TP usually indicative of an _______ rib
- ANTERIOR rib TP = DEPRESSED rib
- POSTERIOR rib TP = ELEVATED rib
What is the motion of a ANTERIOR RIB TP vs a POSTERIOR RIB TP?
- Anterior rib TP = depressed rib = ribs depress with exhlation
- Posterior rib TP = elevated rib = ribs elevate with inhalation
Anterior R1 TP
Lateral to manubrium & inferior to clavicle on rib 1 (directly below SC joint)
AR2 TP
1.5 in. lateral to manubrium on rib 2, below mid-clavicular line; (may also be found deep in axilla)
AR3-10 TP
Anterior axillary line on ribs 3-6 (slightly anterior to mid-axillary line)
Posterior TP are found on what part of the rib?
Angle of ribs
PR1 TP
Posterior margin of rib head below margin of trapezius (lateral to costotransverse articulation)
PR2-10 TP
Superior surface of angles of ribs, at medial border of scapula, about 2.5 inches lateral to midline
When treating posterior ribs, what can we do to move scapula out of the way?
Have pt pull arms over their chest.
Posterior ribs are typically less prominent ______ and more prominent when _______.
- Less prominent = ELEVATED
- More prominent = DEPRESSED
Which ribs move in a bucket handle motion; pump handle motion; caliper?
- Bucket handle move superior and laterally, ↑ transverse diamter = Ribs 1, 7-10
- Pump handle move superior and anterior, ↑ AP diameter = Ribs 1, 2-6
- Caliper: move inferior and posterior, ↑ transverse/vertical diameter = Ribs 11-12
Name the SD: likes inhalation, restricted to exhalation
Inhalation SD
Name the SD: likes exhalation, restricted to inhalation
Exhalation SD
If the rib on the symptomatic side is statically cephalad and on inhalation has greater cephalad movement
Inhalation SD
If the rib on the symptomatic side is statically cephalad and on exhalation has less caudad movement
Inhalation SD
If the rib on the symptomatic side is statically caudad and on inhalation has less cephalad movement
Exhalation SD
If the rib on the symptomatic side is statically caudad and on exhalation has greater caudad movement
Exhalation SD
Inhalation restriction = ______ SD
Inhalation restriction = Exhalation SD
Exhalation restriction = ______ SD
Exhalation restriction = inhalation SD
If you have a group of ribs, which one do you treat FIRST?
BITE
- Inhalation SD => treat bottom rib
- Exhalation SD => treat top rib
Muscles to Utilize During Treatment of Exhalation Dysfunctions
- Rib 1: Anterior/medium scalene
- Rib 2: Posterior scalene
- Ribs 3-5: Pec minor
- Ribs 6-8: Serratus anterior
- Ribs 9-10: Lat. dorsi
- Ribs 11-12: Quadratus lumborum
Inhalation SD (Exhalation Restriction)
Treatment rules?
- Ribs 1-10: depress key rib with exhalation
- Ribs 11-12: Quadratus lumborum
Name the HVLA movement to treat:
- Upper ribs 1-4
- Rib 1 inhalation SD
- Ribs 3-10 inhalation SD
- Ribs 3-10 exhalation SD
- Posterior ribs
- Chiv pivot
- J stroke
- Kirksville crunch cradle
- Kirksville crunch cradle
- Kirksville crunch
Contraction of pec minor muscle can cause what?
Anterior (inhalation) rib SD.
Engaging pec minor muscle can help treat ____ rib SD.
Exhalation
When scapula is fixed in place (COPD pt grasping on bedrail), what is the accessory muscle of inhalation?
Serratus anterior muscle
Upper Ribs 1-4 HVLA (Chin Pivot)
- Pt= prone; doc = at head of table, opposite side of the dysfunction
- Pt cups their chin with hand ipsilateral to SD
- Doc places thenar/hypo eminence at dysfunctional rib with one hand
- Doc moves pts elbow cephalad (SB head and neck away), until motion is palpated
- Doc places other hand on pts head, rotating it toward the side of dysfunction into the barrier
- Pt inhales & moves into barrier on exhalation.
- At end of exhalation, doc applies a rapid anterolateral thrust into dysfunctional rib => do NOT thurst on patients head.
In Chin Pivot to treat Upper Ribs 1-4 what do we want to be sure of about the head?
Do NOT thrust into head, we are only stabilizing it to maintain SB/rotation.
Seated 1st rib inhalation dysfunction (J stroke)
- Pt seated; doc standing behind
- Doc places foot on table opposite the dysfunction and pt drapes their arm
- over physician’s knee
-
Docs Hands:
- Doc contacts dysfunctional rib with second MCP joint of one hand;
- The top of the pts head with the other
- Doc engages barrier by SB the head toward the dysfunctional rib
- Pt inhales, and with exhalation, the doctor loads into first rib
- At end of exhalation, physician applies a thrust inferiorly/medially on superior rib
Ribs 3-10 Bucket Handle Inhalation and Exhalation Dysfunction HVLA (Kirksville crunch cradle)
- Pt supine; Doc opposite side of dysfunctional rib
-
Pts postition
- Pt crosses arms over body with arm on side of dysfunctional rib on top
-
Docs Hands:
- Caudad hand: Doc places thenar eminence on posterior/superior (inhalation) or inferior (exhalation) to the angle of the dysfunctional rib
- Cephalad hand: pts elbows or may be used to elevate pts head/neck
- Doc applies a pressure through the pts elbow localizing at the dysfunctional rib angle
- Pt inhales and with exhalation, load further into barrier
- At the end of next exhalation, doctor applies a posterior thrust directed toward the
- thenar eminence (inhalation) or
- slightly caudal to the physician’s thenar eminence (exhalation)
Posterior Rib Head (modified Kirksville crunch)
- Pt supine; doc opposite the side of the dysfunction
-
Pt Position:
- Pt crosses arms over body-arm on side of dysfunction grasps opposite ASIS while contralateral arm grasps opposite shoulder
-
Docs Hands:
- Caudad hand: Thenar eminence on the angle of the dysfunctional rib.
- Cephalad hand: Pts elbows or may be used to elevate the pts head and neck
- Doc applies a pressure through the patient’s elbows localizing at the dysfunctional rib angle
- Pt inhales and with exhalation, doc loads further into the barrier
- At the end of the next exhalation, the doctor applies a posterior thrust toward the thenar eminence
