Rib Mobilizations Kat Hayes, SPT

A) Anatomy a. 12 i. Superior facet facets anteraior/lateral ii. Inferior facet facets posterior/medial iii. Plane of motion alows more lateral flexion but limited due to iv. T2-10 have a superior and inferior demifacet where articulates with two vertebrae b. 12 Ribs i. Costovertebral facet 1. T2-10 rib head has an inferior and superior facet to articulates with 2 vertebrae 2. T1, T11-12 articulates with only one costal facet 3. Kinematics: gliding and rotation ii. Costotransverse 1. Tubercle of rib articulates with on transverse processes 2. Kinematics: gliding wih some rotation

c. i. Ribs 1-7 attach at sternum via ii. Ribs 8-10 articulate to iii. Ribs 11, 12 are not attached

B) Young et al. mapped referral patterns for patterns a. 8 asymptomatic male subjects b. Received consecutive, same day injections to either right T2,4,6 or to their left T3,5,7 c. OmnipaqueTM was injected using fluoroscopy into joint d. Subects were asked to desribe the pian using given descriptors and also VAS including description of referred pain C) Indications a. Rib or Thoracic hypomobility b. Pain c. Shallow breathing D) Contraindications a. Rib fracture b. Osteoperosis c. Hypermobility d. Malignancy e. Systemic inflamitory disease f. Ligamentous laxity E) Precautions a. Pulmonary Disease b. Severe Scoliosis c. Spinal fussion d. Pregnancy

F) Assessment a. While patients sitting, assess breathing patern and palpate ribs for movement during inhilation/exhalation i. Are they a chest or belly breather ii. Observe superior ribs move anterior/superior to posterior/inferior (pump moition) iii. Observe inferior ribs move more laterally upon inhalation (bucket handle motion) b. Generally assess motion of ribs while patient is prone c. Run hand/thumb perpedicular along ribs to assess if any are restricted and/or raised d. Palpate intercostal muscles with 2nd and 3rd finger so compare spacing between ribs and assess myofascial restrictions e. Assess mobility of thoracic spine f. If a raised rib is found, assess the contralateral rib i. Is it raised, is the thoracic spine kyphotic or hypomobile? g. Posture

G) Mobilizations a. Prone, arms hanging off plinth i. Find transverse proces (may be a half level or full level up from spinous process) and then will find a divot, then the rib. The divot is the end of the transverse process and where the costotransverse process can be found. ii. Place one hand on ipsilateral transverse process (preventing T-spine segment from rotating) iii. Place other hand’s hypothenar emience on costotransverse joint and rib iv. Use hypotherar eminence to direct an anterior mobilization 1. Can also supinate to get the inferior rotation v. Can also cross hands and mobilize both sides at the same time vi. Can switch hand position to work on oposite rotation of rib along long axis

b. Sitting i. Can have the patient place hands behind neck to use arms as a lever ii. Can facilitate sidebending or rotation in this position 1. Rotation measuremnt can be guestemated by having patient sit on corner of plinth and rotate 2. If there shoulders are in line with the length of the plinth than that is about 45o iii. If there is a raised rib, can mobilize rib with movement while sitting 1. Place ulnar border of your hand on the raised rib and have patient rotate ipsilaterally while you block the ribs movement 2. Blocking gives an anterior/lateral/superior mobilization 3. 2 sets of 10 reps, then reassess iv. If patient is tender to palpation, mobilization with movement may be more tolerable than the prone mobilization

H) Exercises/Self Mobiliation – Deep inhale can be utilized to aid mobilization during exercises or during PT directed mobs a. Rainbow stretch i. Can be a progression of open book ii. Sideline and reaching out to create an arc over one’s head (180o) 1. Focus on extending fingertips as far out as possible 2. Starts and ends with rotation to thoracic spine b. Quadraped thoracic rotation i. Horizontal abduction of one arm to rotate thoracic spine ii. Follow hand with eyes to get cervical rotation iii. Can also do this as a progression of plank c. Ballarina stretch i. Sidebending while reaching ii. Maintain neutral spine and level hip iii. Tball can be utilized d. Sidebending (standing or supine) e. Foam roller or tennis ball i. Half crunches to mobilize segments

Lehmkuhl, L. Don, PH.D., and Laura Smith, PH.D. Brunnstrom's Clinical Kinesiology. 4th ed. Philadelphia: F.A. Davis, 1985. Print. "Technique Highlight: Rib Functional Mobilization." Start Here. Modern Manual Therapy, n.d. Web. 02 Aug. 2016. .

Young BA, Gill HE, Wainner RS, Flynn TW. Thoracic costotransverse joint pain patterns: a study in normal volunteers. BMC Musculoskeletal Disorders. 2008;9:140. doi:10.1186/1471-2474-9-140

Image: "LAB - Axial Osteology - Biology 108 with Doyle at Bellarmine University - StudyBlue." StudyBlue. N.p., n.d. Web. 30 July 2016. .

Image: " and - StudyBlue." StudyBlue. N.p., n.d. Web. 30 July 2016. .

Image: "JOURNAL ARTICLE REVIEW." Category. N.p., n.d. Web. 09 Aug. 2016. .

Image: "Pectoral Region - Basic Sciences Ga1 with Carlos at Southern California University of Health Sciences - StudyBlue." StudyBlue. N.p., n.d. Web. 30 July 2016. .