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Rib troubles
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Rib troubles - January 16, 2008 7:23:37 AM
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yearnin2learn
Posts: 1
Joined: January 16, 2008
Status: offline
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Has anyone got experience with fixing rib troubles?
PC: pain in back & chest
Hx:
3 week history of sleeping in different bed (travelling).
Possible contribution of connubial activities.
Functional problems:
pain 5/10 L sneezing / coughing centred on L post / post-lat rib #4
pain 4/10 L deep breath same location
TOP ++ area of L rib #4
AROM:
L SF 5cm > R SF R2
L rot approx. 15 degrees < R rot R2
pain on R rot w OP 4/10
Palpation:
pain 6-7/10 L rib #4
PAIVMs:
bilateral (transverse processes):
- R2: no noticeable diff. in T1,2,3,4,5
- pain 3/10 T2; 4/10 T3; 5/10 T4; 5/10 T5
ribs:
- P2: at 1/3 range R & L ribs 3,4,5
- pain 8/10 L rib 4
- pain 7/10 L rib 3 & 5, R rib 4
- pain 6/10 L rib 2, R rib 3, 5
Any ideas about Dx or Rx?
< Message edited by yearnin2learn -- January 16, 2008 10:25:45 AM >
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RE: Rib troubles - January 16, 2008 10:55:07 AM
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gerry
Posts: 238
Joined: July 6, 1999
From: Montgomery, AL, USA
Status: offline
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Any x-rays? Presentation similar to when I had a broken rib. It was actually missed on the initial x-ray and picked up later on a bone scan.
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RE: Rib troubles - January 19, 2008 7:38:27 PM
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kiwi PT
Posts: 75
Joined: December 2, 2007
From: MI, USA (dreaming of New Zealand)
Status: offline
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People seem to be afraid to touch these rib posts. Perhaps the lack of evidence in this area makes it just not very sexy. I tried searching literature on “manual therapy” and “ribs” and couldn't find a whole lot except a case study using rib mobs or MET in conjunction with several other treatments. Several manual therapy theories claim to have effect on the rib cage including: Strain Counterstrain, Muscle Energy, other mobilization/manipulation theories. If anyone knows of any research related to manual therapy and the rib cage supporting or refuting please post something here.
I suspect from reading other posts on the SI joint some people here probably also don't think “rib dysfunctions” exist, or at least that manual therapy cannot change them. I was taught in school that some author's say all rib dysfunctions are caused by T-spine dysfunctions and if you address the the T-spine you will solve the rib problem however they also taught us some ribcage muscle energy techniques.
I am a relatively new PT and make no claim of being a expert but I will share my experience. I have had 2 pts, teenage girls, in the last 6 months referred to me specifically with “rib torsions” on the script (granted I've also seen pts with sciatica on script who really had trochantaric bursitis). I spent a lot of time reviewing the muscle energy techniques presented in Greenman's Principles of Manual Medicine (MSU Osteopath). I used some of these techniques and found them helpful and both pts improved. I recognize that these pts might have improved had I thrown rocks at them or pranced around chanting. The palpation involved in determining treatment probably has poor interrater reliability (no idea if this has ever been tested). In the absence of good evidence (or perhaps lack of knowledge or experience) I tried to look for comparable signs: test, treat, retest. I'm sure that sometimes I “fooled myself” but don't think I always did. One of these pt's had had gradually worsening pain for 2 years and had received chiropractic treat addressing T-spine only with no aggravation or relief and had 8 weeks of physical therapy at another clinic which had no effect. After 4 visits with me pain was 50% reduced and after 10 visits in 5 weeks she reported that she was pain free and was d/c'd. I must note though that the PT she received at the other location sounded like sh** therapy: run through a few exercises by an aide and a little “massage”. So was it the muscle energy techniques or my other interventions addressing posture etc that made a difference... or did she just get better in spite of me? I don't know, but my hunch is that those techniques played a part.
I would love see discussion from some of the more active members on this forum who seem to be tip-toeing around this one as to whether or not you attempt to address the ribcage via manual therapies. If so how? If not what do you do instead if you have a pt that has pain with a deep breath in the upper back or anterior chest and tenderness at rib angles or interspaces? Also does treating the ribcage make you hunger for barbecued ribs (It does me)?
Kyle PT
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RE: Rib troubles - March 2, 2008 11:13:40 PM
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kiwi PT
Posts: 75
Joined: December 2, 2007
From: MI, USA (dreaming of New Zealand)
Status: offline
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quote:
ORIGINAL: kiwi PT
I would love see discussion from some of the more active members on this forum who seem to be tip-toeing around this one as to whether or not you attempt to address the ribcage via manual therapies. If so how? If not what do you do instead if you have a pt that has pain with a deep breath in the upper back or anterior chest and tenderness at rib angles or interspaces? Also does treating the ribcage make you hunger for barbecued ribs (It does me)?
Kyle PT
Over a month and nothing... I guess no one else here has anything to offer such a pt.
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RE: Rib troubles - March 3, 2008 8:45:39 AM
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Dr.Wagner
Posts: 1242
Joined: January 24, 2003
From: Indianapolis
Status: offline
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Rib function played a huge part in my osteopathic education...but it has been so long...I would need to get out a book to review the manual techniques.
_____________________________
Dr. Wagner DO
Moderator of Medical Complexity Forum
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RE: Rib troubles - March 3, 2008 12:08:32 PM
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Shill
Posts: 1097
Joined: February 13, 2003
From: Madison WI USA
Status: offline
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Kiwi, I would just like to commend you on your thought processes. Its refreshing that you reflectively think about what you do, as some dont, and just blindly follow. I dont see patients with rib pain frequently enough to address this specific topic, or to really have an opinion that anyone should listen to. However, I think the way you handled these patients was quite appropriate, sound decision making.
_____________________________
Steve Hill PT
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RE: Rib troubles - March 4, 2008 7:17:49 PM
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Chocco
Posts: 58
Joined: September 5, 2006
Status: offline
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The last mulligan course I went to with BRian Mulligan in october of last year, He started doing post rib mobilisations. Looks a lot like unilateral reverse nags with a little different hand placement and with the shoulder abducted to clear the scap.
( sorry for the name drop)
Chocco
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RE: Rib troubles - March 4, 2008 7:38:12 PM
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jma
Posts: 2414
Joined: August 24, 2000
From: NY
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The only ones that I ever read about were from Dr. Philip Greenman's, "Principles of Manual Medicine" but more for muscle energy, not for treatment of fractures.
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RE: Rib troubles - March 5, 2008 9:12:59 AM
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rwillcott
Posts: 436
Joined: March 20, 2006
From: Canada
Status: offline
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When it comes to a possible rib dysfunction I try to keep it simple. I don't claim to be able to determine the direction the rib is not gliding etc. since I don't believe this can be felt.
I will do my best to palpate the costotransverse joints and determine if I can reproduce there symptoms and compare to the asymptomatic side. Also, I will check PA's of the t-spne in the painful area. I will then check AROM of the t-spine and typically this person will have a restriction in active rotation.
I will then focus my treatment on Mulligan mobilizations to improve rotation with cranial glides of both the rib and spinous process of the t-spine. Ususally they will have an increase in rotation following these techniques. I will also occasionally manipulate the t-spine in sitting and supine. I like to tape the rib in the acute stages since people tend to find this gives them pain relief.
In terms of an exercise program I keep it simple and provide AROM rotation of the t-spine, postural exercises, middle and lower fibers of trapezius exercises in prone etc. I've also had patients that found relief with ultrasound and laser of the costotransverse joints.
I try to keep things as simple as possible.
Rob
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