An Osteopathic Approach to Rib Somatic Dysfunction in Respiratory Disorders

OMT Minute: An Osteopathic Approach to Rib Somatic Dysfunction

eVideo. Balanced ligamentous tension can improve respiratory function in patients with a variety of respiratory disorders.

Osteopathic diagnosis and management of rib dysfunction may be beneficial to patients with respiratory disorders such as pneumonia, asthma, chronic obstructive pulmonary disease (COPD), and emphysema.

Chronic obstructive pulmonary disease, which is a major public health threat and a significant cause of morbidity and mortality, causes airflow limitations due to damage to airway and lung anatomical structures.¹ Symptoms typically include cough, shortness of breath, and production of sputum. Pharmacologic treatment for patients with COPD targets the pathology within the lung, bronchus, and alveoli itself and includes bronchodilators, inhaled or oral steroids, or antibiotics, if needed. Further prevention and treatment focuses on reducing flares by means of risk factor modifications, smoking cessation, vaccinations, pulmonary rehabilitation, physical activity, nutritional support, and oxygen supplementation, if needed.¹

Respiration is a biomechanical endeavor, and adequate respiration requires the normal motion of the diaphragm, ribs, and sternum. These structures move so as to increase or decrease the size of the thorax, generating the positive and negative pressures necessary for respiration.² Ribs 1-5 move in a mostly pump handle motion, ribs 6-10 in a bucket handle motion, and ribs 11-12 in a pincer-type motion.² Diseases such as COPD that alter the size and shape of the thorax (including hyperinflation of the lungs and an increased anterior/posterior diameter) have a significant effect on anatomical structures and respiratory mechanics.² The diaphragm, which connects to ribs 6-12, becomes flattened with altered length tension relationships, decreasing its ability to contract and its inspirational efficiency.²

Osteopathic manipulative treatment (OMT) may be beneficial for patients with COPD through its effect on the musculoskeletal aspects of the thoracic cage. Somatic dysfunction may impede function in the work of respiration. Diagnosis of somatic dysfunction in the ribs, thoracic spine, diaphragm, and accessory muscles of respiration should be performed.³

A review of the literature has demonstrated few studies with mixed benefit from OMT in patients with COPD. One small study⁴ found that OMT in conjunction with pulmonary rehabilitation improved exercise capacity (6-minute walk test) and reduced residual volume over pulmonary rehabilitation alone. Careful consideration must be taken: one study demonstrated an increase in residual volume attributed to the active component of the thoracic lymphatic pump, which promotes a large inhalation.⁵

One technique that may be used to improve rib somatic dysfunction is balanced ligamentous tension (video). This gentle technique can easily be used in the office or hospital setting as a direct or indirect technique in any age group. Diagnosis can first be made in the seated or supine position by observing quiet respiration and looking for areas of decreased rib motion. A gentle springing motion can then be used on each rib to assess for compliance and ability to move. The bucket handle, pump handle, and caliper ribs may be assessed for motion in inhalation and exhalation, with the operator looking for inhaled rib dysfunctions (those that remain inhaled during the patient's active exhalation) or exhaled rib dysfunctions (those that remain in exhalation during the patient's active inhalation).⁶

Contraindications for balanced ligamentous tension include fracture of the rib, bony metastasis, and infection, postsurgical sites, arterial lines, or drains near the area. This OMT technique is very gentle and uses rib biomechanics and inherent forces, including respiration, to restore motion, improve respiratory mechanics, and potentially decrease pain. Use of OMT in patients with COPD as an adjunctive treatment option allows osteopathic physicians to address both the lung parenchymal disease as well as the biomechanics of the thorax, both of which are important for adequate respiration.