Rib Lab

Question 1

Inhalation Dysfunction

Answer 1

If the rib on the symptomatic side is statically cephalad and on inhalation has greater cephalad movement, it is classified as an inhalation rib dysfunction

Question 2

Exhalation Dysfunction

Answer 2

If the rib on the symptomatic side is statically caudal and on inhalation has less cephalad movement, it is classified as an exhalation rib dysfunction

Question 3

Palpation of ribs 1-2

Answer 3

1) pt lies supine, and the physician sits or stands at the head of the table
2) physician palpates 1st ribs at their infraclavicular position at the sternoclavicular articulation
3) physician monitors the relative superior and inferior relation of the pair and on the symptomatic side, determines whether that rib is prominent or not and positioned superiorly or inferiorly
4) pt instructed to inhale and exhale deeply through mouth as physician monitors ability of pairs of 1st ribs to move
5) physician next palpates the 2nd ribs lateral to the sternal angle and repeats steps 2 to 4

Question 4

Palpation of Ribs 3-6

Answer 4

1) pt lies supine
2) physician places two fingers just lateral to sternum on costal cartilage of each rib set
3) physician monitors relative cephalad or caudal relation of the pair; determines whether the rib is more or less prominent or superiorly or inferiorly positioned
4) pt instructed to inhale and exhale deeply through the mouth as the physician monitors the relative movements of each rib with the palpating thumbs and fingertips
5) physician next palpates ribs 4-6 and repeats above steps

Question 5

Palpation of ribs 7-10

Answer 5

1) pt supine, physician stands on side
2) palpate for bucket handle movements at the mid axillary line
3) physician monitors movement
4) instruct pt to inhale and exhale

Question 6

Inhalation Dysfunction ribs 11-12

Answer 6

if patient’s rib moves more posteriorly and inferiorly with inhalation and less anteriorly and superiorly with exhalation, it is classified as an inhalation rib dysfunction

Question 7

Exhalation Dysfunction

Answer 7

if patient’s rib move more anteriorly and superiorly with exhalation and less posteriorly and inferiorly with inhalation, it is an exhalation dysfunction

Question 8

Palpation of ribs 11-12

Answer 8

1) pt lies prone, and physician stands so the dominant eye is over midline
2) physicians thumb and thenar eminence palpate the shaft of each 11th rib
3) pt is instructed to inhale and exhale
4) note any asymmetry

Question 9

How do you diagnose ribs?

Answer 9

1) screen rib for gross motion dysfunction and TART
2) palpate group of ribs to determine inhalation/exhalation dysfunction
3) palpate individual ribs of the group to determine key rib

Question 10

Key ribs

Answer 10

Inhalation: bottom rib
Exhalation: top rib

Question 11

Inhalation Dysfunction treatment rules

Answer 11

Ribs 1-10: depress key rib with exhalation

Ribs11-12: quadratus lumborum

Question 12

Exhalation Dysfunction treatment rules

Answer 12

Rib 1: ant/med scalene
Rib 2: posterior scalene
Ribs 3-5: pectoralis minor 
Ribs 6-8: serratus anterior
Ribs 9-10: latissimus dorsi
Ribs 11-12: quadratus lumborum

Question 13

Rib 1 Inhalation Dysfunction MET/ART

Answer 13

1) pt lies supine, physician at head
2) joint of index finger on superior surface of the dysfunctional rib posterior and lateral to the costotransverse articualtion
3) pt’s head is gently flexed, sidebent toward, and rotated away from the right rib to take the tension off the scalene musculature
4) during exhalation the physicians right hand follows the first rib down and exaggerates exhalation motion
5) patient is instructed to inhale deeply as the physicians’s right hand resists the inhalation motion of the first rib
6) steps 4 and 5 are repeated five to seven times or until motion is maximally improved at the dysfunctional
7) reassess

Question 14

Ribs 2-6 Inhalation Dysfunction MET/ART

Answer 14

1) pt lies supine, physicians flexed knee placed under patients upper thoracic region at the level of the dysfunctional rib
2) patients upper body is side bent to the dysfunction until tension is taken off dysfunctional rib
3) web formed by physician’s right thumb and index finger is placed in the intercostal space above the dysfunctional rib on its superior surface
4) as patient exhales, and the physicians exaggerates the exhalation motion
5) when the pt inhales, the physician’s right hand resists inhalation motion of the dysfunctional rib
6) repeat steps 4 and 5 until motion is maximally improved at the dysfunctional rib
7) reassess

Question 15

Ribs 7-10 inhalation dysfunction MET/ART

Answer 15

1) pt supine, physician stands at side of dysfunction
2) physicians hand abducts the patients shoulder and places thumb and index finger on superior surface of dysfunctional rib
3) physician side bends the patient’s thoracic spine to the level of the dysfunctional rib
4) pt inhales and exhales deeply as the physicians right hand exaggerates exhalation
5) on inhalation, physician’s hand resists inhalation motion
6) patient exhales, and physician exaggerates exhalation motion
7) repeat until motion improved
8) reassess

Question 16

Ribs 11-12 Inhalation MET/ART

Answer 16

1) pt lies prone and physician stands opposite side of affected rib; position patients legs 15-20 degrees away from physician taking tension off QL
2) physician place hypothenar eminence medial and inferior to angle of dysfunctional rib and exert gentle, sustained, lateral and cephalad traction
3) physician may grasp pt’s right anterior superior iliac spine with the right hand to stabilize pelvis
4) during exhalation, the physician exaggerates the exhalation motion of the dysfunctional rib by exerting cephalad and lateral traction
5) on inhalation, physicians hand resists inhalation motion of dysfunctional rib
6) repeat until maximally improved
7) reassess

Question 17

Ribs 1-2 Exhalation Dysfunction MET/ART

Answer 17

1) stand opp side
2) pt hand rotated 30 degrees away and dorsal surface of pt’s wrist on affected side placed against forehead
3) physician reaches under pt, grasps superior angle of dysfunctional rib, exerts caudal and lateral traction
4) physician instructs pt to flex head and neck while the physician’s hand counters; maintain contraction for 3-5 seconds and then pt relaxes
5) once pt completely relaxed, physician’s left hand exerts increased caudal and lateral traction on the angle of the dysfunctional rib
6) repeat until improved motion
7) reassess

Question 18

Ribs 3-5 Exhalation MET/ART

Answer 18

1) stand opp side
2) pt raises arm on dysfunctional side and places hand over the head
3) physician’s hand reaches under opp side, grasps superior angle of the dysfunctional rib, exerts caudal and lateral traction
4) physician’s hand placed over anterior aspect of pt’s right elbow
5) physician instructs pt to push the elbow against physician hand which applies counterforce; isometric contraction held for 3-5 seconds and pt instructed to relax
6) once pt completely relaxed, physicians hand exerts increased caudal and lateral traction on the angle of the dysfunctional rib
7) repeat until improved motion
8) reassess

Question 19

Ribs 6-8 Exhalation MET/ART

Answer 19

1) sit on same side
2) pt shoulder flexed 90 degrees; elbow may be flexed for better control
3) physicians hand reaches under pt and grasps superior angle of dysfunctional rib, exerting caudal and lateral traction
4) physician instructs pt to push elbow toward ceiling while physician applies counterforce; hold 3-5 seconds; relax
5) once pt completely relaxed, physicians hand exerts increased caudal and lateral traction on the angle of the dysfunctional rib
6) repeat until motion improved
7) reassess

Question 20

Ribs 9-10 Exhalation MET/ART

Answer 20

1) stand same side
2) physician’s cephalad hand abducts pt shoulder 90 degrees and reaches under pt and grasps superior angle of rib, exerting caudal and lateral traction
3) physician stabilizes elbow based on sitting or standing position
4) physician instructs pt to push arm against physician while physician applies counterforce; hold 3-5 seconds; pt relaxes
5) once pt completely relaxed, physician exerts increased caudal and lateral traction on the angle to the dysfunctional rib
6) repeat until motion improved
7) reassess

Question 21

Ribs 11-12 Exhalation MET/ART

Answer 21

1) pt prone, stand opposite side and position pt’s legs 15-20 degrees away from dysfunctional rib
2) physician’s cephalad hypothenar eminence is placed inferior to the 11th rib and exerts a gentle pressure cephalad to stabilize the rib
3) physician’s caudal hand grasps pt’s opposite iliac crest and gently pulls caudally
4) during inhalation, physician instructs pt to pull iliac crest toward shoulder as physician applies counterforce; maintain iso contraction 3-5 seconds; pt instructed to relax
5) once pt completely relaxed, caudal hand gently pulls caudally
6) repeat
7) reassess