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Neuromusculoskeletal Medicine (OMT)  |   October 2020
Osteopathic Manipulative Treatment for Inhaled Rib Somatic Dysfunction
Author Notes
  • From The University of New England College of Osteopathic Medicine in Biddeford, Maine. 
  • Financial Disclosures: None reported. 
  • Support: This video was produced by The University of New England. 
  •  *Address correspondence to Stacey Pierce-Talsma, DO, 11 Hills Beach Dr, Biddeford, ME 04005-9526. Email: spiercetalsma@une.edu
     
Article Information
Neuromusculoskeletal Disorders / Osteopathic Manipulative Treatment
Neuromusculoskeletal Medicine (OMT)   |   October 2020
Osteopathic Manipulative Treatment for Inhaled Rib Somatic Dysfunction
The Journal of the American Osteopathic Association, October 2020, Vol. 120, 696-697. doi:https://doi.org/10.7556/jaoa.2020.109
The Journal of the American Osteopathic Association, October 2020, Vol. 120, 696-697. doi:https://doi.org/10.7556/jaoa.2020.109
  
Osteopathic Manipulative Treatment for Inhaled Rib Somatic Dysfunction
eVideo. Osteopathic diagnosis of the ribs may help differentiate rib somatic dysfunction from referred pain originating from thoracic viscera, providing diagnosis and management options.
Patients with noncardiac chest wall pain may have symptoms that become chronic or recurrent, yet often lack adequate diagnosis and treatment plans leading to further disability, decreased physical activity, anxiety, and depression.1 Abnormal rib biomechanics may be a cause of chest wall or upper abdominal pain and should be considered after visceral causes have been ruled out.2,3 
Osteopathic diagnosis of the ribs may help differentiate rib somatic dysfunction from referred pain originating from thoracic viscera, providing diagnosis and management options (video). Previous studies have demonstrated that osteopathic manipulative treatment (OMT) has proven beneficial in providing pain relief and improved thoracic motion in patients with costochondritis, costovertebral joint dysfunction, and poststernotomy rib dysfunction.4-6 
Ribs move in pump-handle (ribs 1-5), bucket-handle (ribs 6-10), and caliper-like motions (rib 11-12) to alter the dimensions of the thorax during respiration.7 The motion between rib heads and facets of the vertebral bodies is small but creates relatively large excursions at the anterior end of the ribs for adequate ventilation.8 The innervation to the thoracic cage is by the ventral rami of T1- 11 (intercostal nerves) and the ventral ramus of T12 (subcostal nerve). These nerves exit the intercostal spaces and course between the internal intercostal and innermost intercostal muscles along the inferior aspect of each rib.8 They provide motor innervation to the intercostal muscles and give rise to the cutaneous and nociceptive nerves to the anterior body wall.8 
Several types of rib somatic dysfunction could contribute to noncardiac chest wall pain; these can be categorized as either structural or respiratory rib dysfunctions based on findings of tenderness, asymmetry, restricted range of motion, and tissue texture changes.2,7,9 Respiratory rib dysfunction occurs when 1 or more adjacent ribs do not move through their normal range of motion during inhalation or exhalation.7,9 These restrictions may be more myofascial in origin and can lead to pain from stretching of intercostal muscles and pressure on neurovascular bundles.2,9 An OMT technique that may help address and treat rib pain and biomechanical motion is the muscle energy technique, using respiratory assistance for ribs with an inhalation dysfunction.2,7,9 
Contraindications include but are not limited to individuals who are unable or unwilling to cooperate, patients who are severely ill or have low vitality, or treatment over areas of infection, fracture, hematoma, osteoporosis, or metastatic disease.7 
OMT may be effective in treating noncardiac musculoskeletal chest wall pain as it addresses rib mechanical motion, diaphragm motion, and tenderpoints associated with musculoskeletal or visceral dysfunction.3,7 It is important to also diagnose and treat anatomically related areas that may cause or refer pain to the chest wall such as the sternum, cervical spine, thoracic spine, lumbar spine, diaphragm, and shoulder, among other local and distal areas.3,7,9 The OMT performed in this video is not intended to treat any specific clinical condition but is only 1 aspect of the diagnosis and treatment plan an osteopathic physician may use to address the whole patient. 
Acknowledgments
We thank Lee Cote and David Dadiego for their video contributions. 
References
Stochkendahl MJ, Christensen HW. Chest pain in focal musculoskeletal disorders. Med Clin North Am. . 2010;94(2):259-73. doi: 10.1016/j.mcna.2010.01.007 [CrossRef] [PubMed]
Germanovich A, Ferrante FM. Multi-modal treatment approach to painful rib syndrome: case series and review of the literature. Pain Physician. 2016;19(3):E465-71. [PubMed]
Hussain MS, de Vries K, Terzella MJ, Yao SC. Osteopathic considerations in the management of chest pain. Osteopath Fam Physician. . 2016;8(3):20-26.
Aspegren D, Hyde T, Miller M. Conservative treatment of a female collegiate volleyball player with costochondritis. J Manipulative Physiol Ther. 2007;30(4):321-325. doi: 10.1016/j.jmpt.2007.03.003 [CrossRef] [PubMed]
Fruth SJ. Differential diagnosis and treatment in a patient with posterior upper thoracic pain. Phys Ther. 2006;86(2):254-68. [PubMed]
Racca V, Bordoni B, Castiglioni P, Modica M, Ferratini M. Osteopathic manipulative treatment improves heart surgery outcomes: a randomized controlled trial. Ann Thorac Surg. 2017;104(1):145-152. doi: 10.1016/j.athoracsur.2016.09.110 [CrossRef] [PubMed]
Seffinger MA, ed. Foundations of Osteopathic Medicine. 4th ed. Wolters Kluwer; 2018:800, 1256-1257, 1582-1583.
Standring S, Anand N, Gray H. Gray's Anatomy: The Anatomical Basis of Clinical Practice. 41st ed. Elsevier Limited; 2016: 895-904.
Greenman PE, DeStefano LA. Greenman's Principles of Manual Medicine. 4th ed. Lippincott; 2011: 262-265, 287.
  
Osteopathic Manipulative Treatment for Inhaled Rib Somatic Dysfunction
eVideo. Osteopathic diagnosis of the ribs may help differentiate rib somatic dysfunction from referred pain originating from thoracic viscera, providing diagnosis and management options.