(OSCE) Ribs

Question 1

Inhalation Somatic Dysfunction

Rib 1

Answer 1

Position: Patient supine; Doctor at head of table

Procedure:

1. Thumb ipsilateral to dysfunctional rib placed on anteromedial aspect of dysfunctional rib
2. Contralateral hand maneuvers the head into flexion, sidebent towards and rotated away from dysfunctional rib
3. Follow rib down and forward into exhalation
4. As patient inhales, resist the motion of the dysfunctional rib
5. Repeat 3-5 times or until motion is maximally improved

Question 2

Inhalation Somatic Dysfunction

Ribs 2-6

Answer 2

Position:

• Patient supine, sidebent toward dysfunctional rib
• Doctor at head of table

Procedure:

1. Web of ipsilateral thumb-index finger is placed in the intercostal space superior to the dysfunctional rib
2. During exhalation: doctor exaggerates the motion
3. During inhalation: doctor resists the motion
4. Repeat 3-5 times or until motion is maximally improved

Question 3

Inhalation Somatic Dysfunction

Ribs 7-10

Answer 3

Position:

• Patient: supine with ipsilateral shoulder adducted (abduction is shown only to illustrate proper hand placement)
• Doctor: stands on side of dysfunctional rib

Procedure:

1. Ipsilateral thumb and index finger on superior surface of dysfunctional rib
2. Sidebend to the level of dysfunctional rib
3. During exhalation: doctor exaggerates the motion
4. During inhalation: doctor resists the motion
5. Repeat 3-5 times or until motion is maximally improved

Question 4

Inhalation Somatic Dysfunction

Ribs 11-12

Answer 4

Position:

• Patient: prone with legs sidebent 15-20^o towards the dysfunction
• Doctor: stands opposite the dysfunctional rib

Procedure:

1. Cephalad hand: hypothenar eminence medial and inferior to the angle of the dysfunctional rib
2. Caudad hand: grasps ASIS ipsilateral to dysfunction to shorten quadratus lumborum
3. Apply sustained lateral and cephalad traction to dysfunctional rib
4. During exhalation: doctor exaggerates the motion
5. During inhalation: doctor resists the motion
6. Repeat 3-5 times or until motion is maximally improved

Question 5

Exhalation Somatic Dysfunction

Ribs 1-2

Answer 5

Position:

• Patient: supine, head rotated 30^o away from dysfunctional rib with dorsum of ipsilateral wrist on forehead
• Doctor: stands contralateral to dysfunctional rib

Procedure:

1. Cephalad hand: placed on top of patients hand on forehead
2. Caudad hand: grasps the superior angle of the dysfunctional rib
3. While applying caudad, lateral traction with caudal hand instruct the patient to flex the head and neck (while maintaining rotation) and apply counterforce
4. Maintain isometric contraction 3-5 seconds then have patient relax
5. Increase caudad, lateral traction and repeat steps of muscle energy

Question 6

Exhalation Somatic Dysfunction

Ribs 3-5

Answer 6

Position:

• Patient: supine with arm ipsilateral to dysfunctional rib fully flexed
• Doctor: contralateral to dysfunctional rib

Procedure:

1. Cephalad hand: rests on patients arm
2. Caudad hand: grasps the superior angle of the dysfunctional rib
3. While applying caudad, lateral traction on the affected rib with the caudad hand, instruct patient to push elbow against doctors cephalad hand while applying a counterforce
4. Maintain isometric contraction 3-5 seconds then have patient relax
5. Increase caudad, lateral traction and repeat steps of muscle energy

Question 7

Exhalation Somatic Dysfunction

Ribs 6-8

Answer 7

Position:

• Patient: supine with ipsilateral shoulder flexed to 90^o
• Doctor: ipsilateral to dysfunctional rib

​Procedure:

1. Cephalad hand: grasps the superior angle of the dysfunctional rib
2. Caudad hand: maneuvers elbow
3. While exerting caudad, lateral traction with cephalad hand, instruct patient to push elbow towards the ceiling (scapular protraction) and apply counterforce
4. Maintain isometric contraction 3-5 seconds then have patient relax
5. Increase caudad, lateral traction and repeat steps of MET

Question 8

Exhalation Somatic Dysfunction

Ribs 9-10

Answer 8

Position:

• Patient: supine with arm on dysfunctional side abducted
• Doctor: ipsilateral to dysfunctional rib

​Procedure:

1. Cephalad hand: abducts ipsilateral shoulder to 90^o and stabilizes elbow
2. Caudad hand: grasps the superior angle of the dysfunctional rib
3. Instruct patient to push their elbow caudally (into adduction) and apply counterforce
4. Maintain isometric contraction 3-5 seconds then have patient relax
5. Increase caudad, lateral traction and repeat steps of MET

Question 9

Exhalation Somatic Dysfunction

Ribs 11-12

Answer 9

Position:

• Patient: prone with legs sidebent 15-20^o away from dysfunction
• Doctor: stands contralateral to dysfunctional rib

​Procedure:

1. Cephalad hand: stabilizes rib superior to the dysfunctional rib
2. Caudad hand: grasps iliac crest ipsilateral to dysfunctional rib
3. Cephalad hand exerts cephalad pressure while patient pulls iliac crest ipsilateral to the dysfunction towards the ipsilateral shoulder while physician applies counterforce
4. Maintain isometric contraction 3-5 seconds then have patient relax
5. Increase caudad, lateral traction and repeat steps of MET