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Brief Report  |   January 2019
Tolerance of Rib Raising Among Hospitalized Patients: A Pilot Study
Author Notes
  • From the Departments of Graduate Medical Education (Drs Chin, Fischione, and Shilian), Internal Medicine (Drs Walter, Bejanishvili, and Wynbrandt) and Family Medicine (Dr Ratay) at University Hospitals–Richmond Medical Center in Richmond Heights, Ohio; the Department of Internal Medicine at Case Western Reserve University School of Medicine in Cleveland, Ohio (Dr Wynbrandt); and the Department of Family Medicine at Lake Erie College of Osteopathic Medicine in Erie, Pennsylvania (Dr Rowane). 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Andrew J. Chin, DO, MS, MPH, University Hospitals–Richmond Medical Center, University Hospitals–Richmond Medical Center, 27155 Chardon Rd, Richmond Heights, OH 44143-1183. Email: andrew.chin@uhhospitals.org
     
Article Information
Osteopathic Manipulative Treatment / Pulmonary Disorders
Brief Report   |   January 2019
Tolerance of Rib Raising Among Hospitalized Patients: A Pilot Study
The Journal of the American Osteopathic Association, January 2019, Vol. 119, 19-23. doi:https://doi.org/10.7556/jaoa.2019.003
The Journal of the American Osteopathic Association, January 2019, Vol. 119, 19-23. doi:https://doi.org/10.7556/jaoa.2019.003
Web of Science® Times Cited: 1
Abstract

Context: Rib raising is an osteopathic manipulative treatment modality that can help patients with various respiratory conditions to improve their work of breathing. However, the tolerance of this technique in hospitalized patients has not been assessed in a systematic manner. We hypothesized that rib raising would be a well-tolerated treatment modality for hospitalized patients admitted for asthma, pneumonia, chronic obstructive pulmonary disease, and/or congestive heart failure.

Objective: To determine hospitalized patients’ tolerance of rib raising through a prospective pilot study.

Methods: The study included patients at University Hospitals–Richmond Medical Center and University Hospitals–Bedford Medical Center who were admitted for asthma, pneumonia, chronic obstructive pulmonary disease, and/or congestive heart failure between November 1, 2016, and October 31, 2017. Each patient was treated with rib raising, which was performed in a standardized fashion. Immediately after treatment, patients were asked to rate their tolerance of the procedure on a scale of 0 to 10, where 0 represented no discomfort and 10 represented maximum discomfort.

Results: The study population consisted of 87 hospitalized, non–intensive care unit patients. The mean tolerance score for rib raising was 1.18, and the median score was 0. The score was between 0 and 3 in 80 patients (92.0%), between 4 and 6 in 6 patients (6.9%), and between 7 and 10 in 1 patient (1.1%).

Conclusion: Rib raising was shown to be well tolerated by the majority of the patients in the study population.

Osteopathic manipulative treatment (OMT) is an effective treatment modality for many medical conditions, including chronic low back pain, postpartum pain, and postoperative ileus.1-4 It involves various techniques, and its goals include reducing symptoms, increasing function and functional movement, increasing the blood supply to affected areas, ensuring sufficient lymphatic return, relieving pain, and removing barriers to nerve transmission.5 
The benefits of OMT were documented as early as the early 20th century. During the Spanish influenza epidemic of 1918, antibiotics were not widely available to treat bacterial pneumonia that often occurred as a complication of viral illness. In a study referenced by Kuchera and Kuchera6 including more than 100,000 patients, those who received OMT while being treated for influenza had a 0.25% mortality rate, compared with a 5% mortality rate for patients in the standard treatment group who did not receive OMT. Furthermore, among patients in whom pneumonia developed, the mortality rate in the OMT group was 10%, compared with 30% to 60% in the standard treatment group.6 
More recently, several studies have looked at the effects of OMT in patients with chronic obstructive pulmonary disease (COPD). Noll et al7 reported that OMT increased residual volume and total lung capacity and decreased respiratory effort but worsened air trapping immediately after treatment. Rocha et al8 demonstrated that the manual diaphragm release technique significantly improved diaphragmatic mobility and improved the 6-minute walking distance over the course of treatment. Yao et al9 demonstrated the effectiveness of OMT as an adjunctive treatment modality for patients with pneumonia. 
The principles of OMT can be applied to patients in a variety of settings. When deciding on the most appropriate treatment modality, it is important to consider the patient's age and physical condition, the acuity or chronicity of the problem, the patient's treatment setting (inpatient or outpatient), and the effectiveness of prior therapy.10 Hospitalized patients, particularly those with respiratory conditions, are often being treated for an acute exacerbation of a chronic condition. Acutely ill patients are often less able to withstand aggressive therapy.9 With these patients, it is therefore helpful to use gentle and conservative manual treatment techniques, ideally indirect rather than direct, to minimize the risk of injury and maximize the tolerability of treatment. 
One particular OMT technique, rib raising, has been shown to be effective in relieving respiratory symptoms.10 Rib raising is a mild articulatory technique that can be used in patients with respiratory symptoms with a noncompliant or “resistant” chest wall. Although the technique's underlying mechanism is still not fully understood, it is hypothesized that it works by inhibiting the hypersympathetic influence to the bronchial epithelium and respiratory mucosa, which in turn increases the blood supply to the lungs.11 Goblet cells within the bronchial epithelium have been demonstrated to produce thick mucus with prolonged sympathetic stimulation.12 Rib raising reduces sympathetic activity to the lungs, which leads to thinning of secretions; it also increases chest wall compliance and improves lymphatic return.13 
In hospitalized patients, rib raising is performed with the patient lying supine and the physician seated at the patient's side. The physician places his or her hands underneath the patient's thorax, in contact with the rib angles. With the wrist as a fulcrum, the physician's fingers are used to raise and lower the patient's ribs in conjunction with the patient's respirations (Figure A and Figure B).14,15 The technique can be repeated multiple times on both sides of the thorax. Typically, muscle tension and motion restriction decrease throughout the treatment, and patients experience an improvement in their symptoms.12 
Figure.
Physician hand position in the rib raising technique with the patient in a supine position. (A) The physician's forearms rest flat on the treatment table or hospital bed with his or her hands underneath the patients thorax, in contact with the rib angles (A and B). With the wrist as a fulcrum, the physician's fingers are used to raise and lower the patient's ribs in conjunction with the patient's respirations. Reprinted from Rowane MP, Evans P. Basic Musculoskeletal Manipulation Skills: The 15-Minute Office Encounter. Indianapolis, IN: American Academy of Osteopathy Publications; 2012:109. Used with permission.
Figure.
Physician hand position in the rib raising technique with the patient in a supine position. (A) The physician's forearms rest flat on the treatment table or hospital bed with his or her hands underneath the patients thorax, in contact with the rib angles (A and B). With the wrist as a fulcrum, the physician's fingers are used to raise and lower the patient's ribs in conjunction with the patient's respirations. Reprinted from Rowane MP, Evans P. Basic Musculoskeletal Manipulation Skills: The 15-Minute Office Encounter. Indianapolis, IN: American Academy of Osteopathy Publications; 2012:109. Used with permission.
Although OMT has been demonstrated to be an effective treatment modality for a variety of medical conditions, there has been little research regarding patient tolerance of various OMT techniques, particularly among hospitalized patients, who are often much more frail and weak than those seen in the outpatient setting. The purpose of the current study was to determine the tolerance of rib raising among hospitalized patients in a prospective pilot study. We hypothesized that rib raising would be well tolerated among patients admitted for respiratory conditions, such as asthma, pneumonia, COPD, and congestive heart failure (CHF). 
Methods
Patients were recruited into the study between November 1, 2016, and October 31, 2017, at University Hospitals–Richmond Medical Center (UH-RMC) and University Hospitals–Bedford Medical Center (UH-BMC). These 2 hospitals, known collectively as University Hospitals–Regional Hospitals, are medium-sized, university-affiliated community hospitals in the Cleveland metropolitan area in Northeast Ohio, and they serve as clinical training sites for Case Western Reserve University School of Medicine and Lake Erie College of Osteopathic Medicine. This study was submitted to and approved by the Institutional Review Board of University Hospitals of Cleveland. 
Patients were recruited into the study if they met the following inclusion criteria: age older than 18 years, mentally intact (alert and oriented to person, place, and time), and admission to the teaching service with a diagnosis of asthma, pneumonia, COPD, and/or CHF. Patients admitted as inpatients (anticipated hospital stay >48 hours) as well as those admitted for observation (anticipated stay <48 hours) were recruited into the study. Critically ill patients admitted to the intensive care unit, patients with rib fractures, patients who did not speak English, and patients who were admitted under the care of a private physician were excluded from the study. 
After being informed about the study and giving informed consent, each patient was treated with rib raising by 1 of 3 osteopathic physicians in residency training (A.J.C., A.D.F., and R.S.). The technique was performed in a standardized fashion with the patient lying supine. The physician's finger pads were then placed under the patient's back in the area where the ribs meet the transverse processes. A gentle rocking motion was applied to that area in an anterior, lateral, and cephalad direction until the physician felt a release of myofascial tension. Immediately after treatment, patients were asked to rate their tolerance of the procedure with the following question: “On a scale of 0 to 10, where 0 is completely no discomfort and 10 is maximum discomfort, how would you rate the treatment that you just received?” The data were collected and analyzed using Microsoft Excel software, version 1810. 
Results
Study Population
Eighty-seven hospitalized, non–intensive care unit patients at UH-RMC and UH-BMC were included in the study (Table). Of these patients, 34 (39.1%) were male and 53 (60.9%) were female. The patients ranged in age from 19 to 93 years. Reasons for admission included asthma in 16 patients (18.4%), pneumonia in 26 (29.9%), COPD in 42 (48.3%), and CHF in 44 (50.6%). 
Table.
Characteristics of Hospitalized Patients With Respiratory Conditions Who Received Rib Raising
Characteristic Patients, No. (%)
Hospital
 UH-RMC 56 (64.4)
 UH-BMC 31 (35.6)
Sex  
 Male 34 (39.1)
 Female 53 (60.9)
Age, y
 18-35 5 (5.7)
 36-55 22 (25.3)
 56-75 37 (42.5)
 >75 23 (26.4)
Reason for Admissiona
 Asthma 16 (18.4)
 Pneumonia 26 (29.9)
 COPD 42 (48.3)
 CHF 44 (50.6)

a Some patients had more than 1 reason for admission.

Abbreviations: CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; UH-BMC, University Hospitals–Bedford Medical Center; UH-RMC, University Hospitals–Richmond Medical Center.

Table.
Characteristics of Hospitalized Patients With Respiratory Conditions Who Received Rib Raising
Characteristic Patients, No. (%)
Hospital
 UH-RMC 56 (64.4)
 UH-BMC 31 (35.6)
Sex  
 Male 34 (39.1)
 Female 53 (60.9)
Age, y
 18-35 5 (5.7)
 36-55 22 (25.3)
 56-75 37 (42.5)
 >75 23 (26.4)
Reason for Admissiona
 Asthma 16 (18.4)
 Pneumonia 26 (29.9)
 COPD 42 (48.3)
 CHF 44 (50.6)

a Some patients had more than 1 reason for admission.

Abbreviations: CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; UH-BMC, University Hospitals–Bedford Medical Center; UH-RMC, University Hospitals–Richmond Medical Center.

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Tolerance of Rib Raising
The mean tolerance score for rib raising was 1.18, on the scale of 0 to 10, and the median score was 0. Tolerance was scored between 0 and 3 by 80 patients (92.0%), between 4 and 6 by 6 patients (6.9%), and between 7 and 10 by 1 patient (1.1%). More specifically, the tolerance score was 0 for 48 patients (55.2%), 1 for 9 patients (10.3%), 2 for 14 patients (16.1%), 3 for 9 patients (10.3%), 4 for 2 patients (2.3%), 5 for 1 patient (1.1%), 6 for 3 patients (3.4%), and 8 for 1 patient (1.1%). No patients rated their tolerance score as 7, 9, or 10. 
Discussion
To our knowledge, this pilot study is the first of its kind to prospectively analyze the tolerance of a specific OMT technique among hospitalized patients. Although OMT has many benefits for a variety of medical conditions and can be used in both inpatient and outpatient settings, it is used more commonly in the latter setting, typically in a physician's clinic or office. Physicians may have more limited time with hospitalized patients, who are likely to be more fragile and have more complex diagnoses than those seen in the outpatient setting. The current study clearly showed rib raising to be well tolerated by patients who had been admitted to the hospital for asthma, pneumonia, COPD, and/or CHF. 
All of the patients in this study were admitted for at least 1 of the following diagnoses: asthma, pneumonia, COPD, and CHF. These 4 specific diagnoses were chosen for the specific OMT technique that was studied. Rib raising is often used to help relieve respiratory symptoms, and these 4 admission diagnoses have a component of respiratory dysfunction that may be improved with the technique. In our study population, the most common reason for admission was CHF, which was present in more than half of the patients. The least common reason for admission was asthma. Of note, all of the patients in the study were treated with the standard of care (antibiotics for pneumonia, diuretics for CHF, etc) along with rib raising. 
We analyzed tolerance of rib raising using a “tolerance scale,” whereby patients rated their tolerance of the procedure on a scale of 0 to 10. This scale is similar to the pain scale that health care providers often use to assess a patient's pain level, where 0 represents no pain and 10 represents the maximum amount of pain. By using a tolerance scale, we could easily and quickly assess a patient's tolerance of the treatment. 
Several limitations should be considered when interpreting our findings. First, the outcome variable that we measured was subjective. Patients were asked to rate their tolerance of rib raising on a scale from 0 to 10. Second, rib raising was not performed at a standard point in the patient's hospital course; in some patients it was performed at the beginning of their hospital stay, and in others, toward the end. This timing may have affected patients’ tolerance of the procedure. Third, patients had different diagnoses (asthma, pneumonia, COPD, and/or CHF), and the underlying causes of the different respiratory conditions (ie, bronchoconstriction for asthma, infection and inflammation for pneumonia, obstruction for COPD, and fluid congestion for CHF) may have influenced how they tolerated the procedure. We also did not differentiate between patients who were admitted for a single respiratory condition and those admitted for multiple conditions. Fourth, the rib raising procedures were performed by 3 osteopathic physicians in residency training. Although they were all trained to perform the procedure in a standardized manner, there may have been subtle differences in performance, and the statistical analysis did not differentiate between the physicians. Finally, the same physician who performed the procedure also conducted the survey immediately after the procedure. It is possible that this part of the protocol may have biased the results if the patients did not answer questions truthfully to avoid disappointing the physician who performed the procedure. This possibility could have been avoided by having patients fill out an anonymous survey, on paper or online, after the procedure. 
Conclusion
Rib raising was shown to be well tolerated by the majority of the patients in the study population. The majority of the patients stated that they experienced minimal to no discomfort with rib raising. Based on our findings, we encourage physicians to use OMT in the inpatient setting if they believe their patients will benefit. Further studies are needed to assess patient tolerance of other common OMT techniques, such as myofascial release, strain-counterstrain, muscle energy, and high-velocity, low-amplitude techniques, in both inpatient and outpatient settings. 
References
Licciardone RC, Gatchel RJ, Aryal S. Targeting patient subgroups with chronic low back pain for osteopathic manipulative treatment: responder analyses from a randomized controlled trial. J Am Osteopath Assoc. 2016;116(3):156-168. doi: 10.7556/jaoa.2016.032 [CrossRef] [PubMed]
Licciardone RC, Gatchel RJ, Aryal S. Recovery from chronic low back pain after osteopathic manipulative treatment: a randomized controlled trial. J Am Osteopath Assoc. 2016;116(3):144-155. doi: 10.7556/jaoa.2016.031 [CrossRef] [PubMed]
Hastings V, McCallister AM, Curtis SA, Valant RJ, Yao S. Efficacy of osteopathic manipulative treatment for management of postpartum pain. J Am Osteopath Assoc. 2016;116(8):502-509. doi: 10.7556/jaoa.2016.103 [CrossRef] [PubMed]
Baltazar GA, Betler MP, Akella K, Khatri R, Asaro R, Chendrasekhar A. Effect of osteopathic manipulative treatment on incidence of postoperative ileus and hospital length of stay in general surgical patients [published correction appears in J Am Osteopath Assoc. 2013;113(4):271]. J Am Osteopath Assoc. 2013;113(3):204-209. [PubMed]
DiGiovanna EL, Schiowitz S, Dowling DJ. An Osteopathic Approach to Diagnosis and Treatment. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:396-397, 618-623.
Kuchera ML, Kuchera WA. Osteopathic Considerations in Systemic Dysfunction. Rev 2nd ed. Columbus, OH: Greyden Press; 1994:42-44.
Noll DR, Degenhardt BF, Johnson JC, Burt SA. Immediate effects of osteopathic manipulative treatment in elderly patients with chronic obstructive pulmonary disease. J Am Osteopath Assoc. 2008;108(5):251-259. [PubMed]
Rocha T, Souza H, Brandão DC, et al. The manual diaphragm release technique improves diaphragmatic mobility, inspiratory capacity and exercise capacity in people with chronic obstructive pulmonary disease: a randomised trial. J Physiother. 2015;61(4):182-189. doi: 10.1016/j.jphys.2015.08.009 [CrossRef] [PubMed]
Yao S, Hassani J, Gagne M, George G, Gilliar W. Osteopathic manipulative treatment as a useful adjunctive tool for pneumonia. J Vis Exp. . 2014;(87). doi: 10.3791/50687
DeStefano LA. Greenmans Principles of Manual Medicine. 5th ed. Philadelphia, PA: Wolters Kluwer; 2017:46-47.
Chila AG, executive ed. Foundations of Osteopathic Medicine. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.
Rogers DF. Motor control of airway goblet cells and glands. Respir Physiol. 2001;125(1-2):129-144. [CrossRef] [PubMed]
Henderson AT, Fisher JF, Blair J, Shea C, Li TS, Bridges KG. Effects of rib raising on the autonomic nervous system: a pilot study using noninvasive biomarkers. J Am Osteopath Assoc. 2010;110(6):324-330. [PubMed]
Nicholas A, Nicholas E. Atlas of Osteopathic Techniques. 3rd ed. Philadelphia, PA: Wolters Kluwer; 2016:104-105.
Rowane MP, Evans P. Basic Musculoskeletal Manipulation Skills: The 15-Minute Office Encounter. Indianapolis, IN: American Academy of Osteopathy Publications; 2012:108-109.
Figure.
Physician hand position in the rib raising technique with the patient in a supine position. (A) The physician's forearms rest flat on the treatment table or hospital bed with his or her hands underneath the patients thorax, in contact with the rib angles (A and B). With the wrist as a fulcrum, the physician's fingers are used to raise and lower the patient's ribs in conjunction with the patient's respirations. Reprinted from Rowane MP, Evans P. Basic Musculoskeletal Manipulation Skills: The 15-Minute Office Encounter. Indianapolis, IN: American Academy of Osteopathy Publications; 2012:109. Used with permission.
Figure.
Physician hand position in the rib raising technique with the patient in a supine position. (A) The physician's forearms rest flat on the treatment table or hospital bed with his or her hands underneath the patients thorax, in contact with the rib angles (A and B). With the wrist as a fulcrum, the physician's fingers are used to raise and lower the patient's ribs in conjunction with the patient's respirations. Reprinted from Rowane MP, Evans P. Basic Musculoskeletal Manipulation Skills: The 15-Minute Office Encounter. Indianapolis, IN: American Academy of Osteopathy Publications; 2012:109. Used with permission.
Table.
Characteristics of Hospitalized Patients With Respiratory Conditions Who Received Rib Raising
Characteristic Patients, No. (%)
Hospital
 UH-RMC 56 (64.4)
 UH-BMC 31 (35.6)
Sex  
 Male 34 (39.1)
 Female 53 (60.9)
Age, y
 18-35 5 (5.7)
 36-55 22 (25.3)
 56-75 37 (42.5)
 >75 23 (26.4)
Reason for Admissiona
 Asthma 16 (18.4)
 Pneumonia 26 (29.9)
 COPD 42 (48.3)
 CHF 44 (50.6)

a Some patients had more than 1 reason for admission.

Abbreviations: CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; UH-BMC, University Hospitals–Bedford Medical Center; UH-RMC, University Hospitals–Richmond Medical Center.

Table.
Characteristics of Hospitalized Patients With Respiratory Conditions Who Received Rib Raising
Characteristic Patients, No. (%)
Hospital
 UH-RMC 56 (64.4)
 UH-BMC 31 (35.6)
Sex  
 Male 34 (39.1)
 Female 53 (60.9)
Age, y
 18-35 5 (5.7)
 36-55 22 (25.3)
 56-75 37 (42.5)
 >75 23 (26.4)
Reason for Admissiona
 Asthma 16 (18.4)
 Pneumonia 26 (29.9)
 COPD 42 (48.3)
 CHF 44 (50.6)

a Some patients had more than 1 reason for admission.

Abbreviations: CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; UH-BMC, University Hospitals–Bedford Medical Center; UH-RMC, University Hospitals–Richmond Medical Center.

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