3. Rib Counterstrain

Question 1

What are steps in CS? (8)

Answer 1

1. Perform structural exam to find SD
2. Find a significant tender point in that area
3. Establish pain/tenderness scale
4. Wrap the patient around the tender point, while monitoring
5. Reduce pain by at least 70% (pt in position of comfort)
6. Hold for 90 seconds
7. Passively return to neutral
8. Recheck/reassess

Question 2

if > 1 TP of similar tenderness, which TP do we treat?

Answer 2

Most central/proximal

Question 3

if thoracic and rib TP, treat ______ 1st

Answer 3

Thoracic

Question 4

When do you push on TP?

Answer 4

Monitor and observe changes under your finger.

Do not push on TP until you have positioned correctly.

Question 5

In counterstrain, pt position is geared to ______.

Answer 5

Reduce strain by putting them in the position of ease.

Question 6

• ANTERIOR rib TP usually indicative of a ______ rib
• POSTERIOR rib TP usually indicative of an _______ rib

Answer 6

• ANTERIOR rib TP = DEPRESSED rib
• POSTERIOR rib TP = ELEVATED rib

Question 7

What is the motion of a ANTERIOR RIB TP vs a POSTERIOR RIB TP?

Answer 7

• Anterior rib TP = depressed rib = ribs depress with exhlation
• Posterior rib TP = elevated rib = ribs elevate with inhalation

Question 8

Anterior R1 TP

Answer 8

Lateral to manubrium & inferior to clavicle on rib 1 (directly below SC joint)

Question 9

AR2 TP

Answer 9

1.5 in. lateral to manubrium on rib 2, below mid-clavicular line; (may also be found deep in axilla)

Question 10

AR3-10 TP

Answer 10

Anterior axillary line on ribs 3-6 (slightly anterior to mid-axillary line)

Question 11

Posterior TP are found on what part of the rib?

Answer 11

Angle of ribs

Question 12

PR1 TP

Answer 12

Posterior margin of rib head below margin of trapezius (lateral to costotransverse articulation)

Question 13

PR2-10 TP

Answer 13

Superior surface of angles of ribs, at medial border of scapula, about 2.5 inches lateral to midline

Question 14

When treating posterior ribs, what can we do to move scapula out of the way?

Answer 14

Have pt pull arms over their chest.

Question 15

Posterior ribs are typically less prominent ______ and more prominent when _______.

Answer 15

• Less prominent = ELEVATED
• More prominent = DEPRESSED

Question 16

Which ribs move in a bucket handle motion; pump handle motion; caliper?

Answer 16

1. Bucket handle move superior and laterally, ↑ transverse diamter = Ribs 1, 7-10
2. Pump handle move superior and anterior, ↑ AP diameter = Ribs 1, 2-6
3. Caliper: move inferior and posterior, ↑ transverse/vertical diameter = Ribs 11-12

Question 17

Name the SD: likes inhalation, restricted to exhalation

Answer 17

Inhalation SD

Question 18

Name the SD: likes exhalation, restricted to inhalation

Answer 18

Exhalation SD

Question 19

If the rib on the symptomatic side is statically cephalad and on inhalation has greater cephalad movement

Answer 19

Inhalation SD

Question 20

If the rib on the symptomatic side is statically cephalad and on exhalation has less caudad movement

Answer 20

Inhalation SD

Question 21

If the rib on the symptomatic side is statically caudad and on inhalation has less cephalad movement

Answer 21

Exhalation SD

Question 22

If the rib on the symptomatic side is statically caudad and on exhalation has greater caudad movement

Answer 22

Exhalation SD

Question 23

Inhalation restriction = ______ SD

Answer 23

Inhalation restriction = Exhalation SD

Question 24

Exhalation restriction = ______ SD

Answer 24

Exhalation restriction = inhalation SD

Question 25

If you have a **group of ribs**, which one do you treat FIRST?

Answer 25

**BITE** ## Footnote * **Inhalation SD** =\> treat **bottom** **rib** * **Exhalation SD** =\> treat **top rib**

Question 26

Muscles to Utilize During Treatment of **_Exhalation Dysfunctions_**

Answer 26

* **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

Question 27

**_Inhalation SD (Exhalation Restriction)_** Treatment rules?

Answer 27

* **Ribs 1-10:** depress key rib with exhalation * **Ribs 11-12:** Quadratus lumborum

Question 28

**_Name the HVLA movement to treat:_** 1. Upper ribs 1-4 2. Rib 1 inhalation SD 3. Ribs 3-10 inhalation SD 4. Ribs 3-10 exhalation SD 5. Posterior ribs

Answer 28

1. Chiv pivot 2. J stroke 3. Kirksville crunch cradle 4. Kirksville crunch cradle 5. Kirksville crunch

Question 29

**Contraction of pec minor muscle** can cause what?

Answer 29

**Anterior (inhalation)** rib SD.

Question 30

**_Engaging_ pec minor muscle** can help treat ____ rib SD.

Answer 30

**Exhalation**

Question 31

**When scapula is fixed in place** (COPD pt grasping on bedrail), what is the **accessory muscle of inhalation?**

Answer 31

**Serratus anterior muscle**

Question 32

**_Upper Ribs 1-4 HVLA (Chin Pivot)_**

Answer 32

1. Pt= **prone;** doc = **at head of table, opposite side of the dysfunction** 2. Pt cups their chin with hand _ipsilateral_ to SD 3. Doc places thenar/hypo eminence at dysfunctional rib with one hand 4. Doc moves pts elbow cephalad (SB head and neck _away_), until motion is palpated 5. Doc places other hand on pts head, rotating it _toward_ the side of dysfunction into the barrier 6. Pt inhales & moves into barrier on exhalation. 7. _At end of exhalation_, doc applies a rapid _anterolateral_ thrust into dysfunctional rib =\> **do NOT thurst on patients head.**

Question 33

In **Chin Pivot** to treat **Upper Ribs 1-4** what do we want to be sure of about the head?

Answer 33

**Do NOT thrust into head**, we are only stabilizing it to maintain SB/rotation.

Question 34

**Seated 1st rib inhalation dysfunction (J stroke)**

Answer 34

1. Pt seated; doc standing behind 2. Doc places foot on table _opposite_ the dysfunction and pt drapes their arm 3. over physician’s knee 4. **Docs Hands:** 1. Doc contacts dysfunctional rib with _second MCP joint of one hand_; 2. The _top of the pts head_ with the other 5. Doc engages barrier by _SB the head toward_ the dysfunctional rib 6. Pt inhales, and _with exhalation,_ the doctor _loads_ into first rib 7. At end of exhalation, physician applies a thrust **_inferiorly/medially_** on **_superior_** rib

Question 35

**Ribs 3-10 Bucket Handle** **Inhalation** and **Exhalation** Dysfunction HVLA **(Kirksville crunch cradle)**

Answer 35

1. Pt supine; Doc opposite side of dysfunctional rib 2. **Pts postition** 1. Pt crosses arms over body with _arm on side of dysfunctional rib on top_ 3. **Docs Hands:** 1. Caudad hand: Doc places thenar eminence on _posterior/superior (inhalation)_ or _inferior (exhalation)_ to the angle of the dysfunctional rib 2. Cephalad hand: pts elbows or may be used to elevate pts head/neck 4. Doc applies a pressure through the pts elbow localizing at the dysfunctional rib angle 5. Pt inhales and with exhalation, load further into barrier 6. At the end of next exhalation, doctor applies a _posterior_ _thrust_ directed toward the 1. thenar eminence (_inhalation_) or 2. slightly caudal to the physician’s thenar eminence (_exhalation_)

Question 36

**Posterior Rib Head (modified Kirksville crunch)**

Answer 36

1. Pt supine; doc opposite the side of the dysfunction 2. **Pt Position:** 1. Pt crosses arms over body-arm on side of dysfunction grasps _opposite ASIS_ while _contralateral arm grasps opposite shoulder_ 3. **Docs Hands:** 1. Caudad hand: Thenar eminence on the angle of the dysfunctional rib. 2. Cephalad hand: Pts elbows or may be used to elevate the pts head and neck 4. Doc applies a pressure through the patient’s elbows localizing at the dysfunctional rib angle 5. Pt inhales and with exhalation, doc loads further into the barrier 6. At the end of the next exhalation, the doctor applies a _posterior thrust toward the thenar eminence_