Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs

Anatomy and Physiology

Normally there are 12 ribs bilaterally in the human body. Each rib corresponds with each of the 12 vertebrae of the thoracic spine. The head of each rib articulates posteriorly with the bodies of the vertebra at its own level and of the one above it, except for the first rib, which only attaches to the first thoracic vertebra.[4][5] Ribs 1 to 7 are considered "true ribs" because they connect anteriorly to the sternum via costal cartilages. Ribs 8 to 10 are considered "false ribs" because they connect indirectly to the sternum through the seventh costal cartilage. Ribs 11 and 12 have the name "floating ribs" because they do not connect to the sternum at all.[5]

Muscles that are associated with rib movement include the diaphragm, pectoralis major, pectoralis minor, external abdominal oblique, rectus abdominis, subclavius, serratus anterior, external intercostal, internal intercostal, innermost intercostal, quadratus lumborum, transversus thoracis, latissimus dorsi, anterior scalene, middle scalene, posterior scalene, serratus posterior superior, and serratus posterior inferior.[5][6]

Normal respiration is required for optimal lymphatic drainage to occur. The thoracic duct drains lymph from the left head and neck, the left thorax, the left upper extremity, and the rest of the lower body into the venous system at the junction of the left internal jugular vein and left subclavian vein. The right lymphatic duct drains the right head and neck, right thorax, and right upper extremity into the venous system.[7] A study by Noll et al. in 2016 suggested that OMT in reducing the length of stay (LOS) and mortality in a select population.[8] 

Osteopathic physicians describe ribs by their motion with respect to the thoracic spine. Ribs fall into three categories; pump handle motion (ribs 1 to 5), bucket handle motion (ribs 6 to 10), and caliper motion (ribs 11 and 12). The diaphragm connects to ribs 6-12 and is domed cephalad at rest.[9] During inhalation, the diaphragm contracts resulting in increased lung volume and displacement of the rib cage.[10] Optimal respiration may be affected by any disturbance in the normal motion of these musculoskeletal structures. Rib somatic dysfunction can result from excessive physical activity, cough, poor posture, and increased kyphosis.[11] In an inhalation dysfunction, the dysfunctional rib will move freely cephalad but will have restriction to moving caudally during exhalation. Conversely, in an exhalation dysfunction, the dysfunctional rib will move freely caudal but will have restriction to moving cephalad during inhalation.[9] 

The inferior scapular angle (ISA) can serve as a landmark for the spinous process of the T7 vertebra, but in a literature review of anatomical studies by Cooperstein et al., it was concluded that the ISA is not an acceptable landmark for identifying spinal levels.[12] 

Indications

HVLA is indicated to treat somatic dysfunction of the thoracic cage, the thoracic vertebrae, and the ribs at the posterior rib angles. Somatic dysfunctions of the ribs are described as either inhalation and exhalation dysfunctions. Acute chest pain is a frequent chief complaint of patients presenting to the emergency department; however, the leading cause of chest pain is musculoskeletal in origin in patients without evidence of acute myocardial ischemia or infarction.[13] 

HVLA, solo or in combination with other OMT techniques, is another option when conventional treatment such as pharmaceutical pain medications are either contraindicated or not tolerated well.[14]

Contraindications

HVLA has the most contraindications of all OMT techniques. The following are contraindications for HVLA techniques, including its application to the ribs:[15]

• Anticoagulant therapy (relative contraindication)
• Connective tissue disease
• Fracture
• Malignancy (if local metastasis)
• Osteoporosis
• Patient uncooperative
• Severe rheumatoid arthritis 
• Surgery (if local)

Indirect OMT techniques such as muscle energy, myofascial release, rib raising, and soft tissue techniques are a few alternative options to consider when HVLA is contraindicated. For example, in a recent study by Chin et al., the rib raising technique was used in 87 hospitalized non-intensive care unit patients admitted for respiratory issues, and the procedure was well tolerated.[16]

Personnel

The technique requires a doctor of osteopathic medicine, a doctor of chiropractic, or a doctor of medicine certified to perform OMT. To successfully perform OMT, the patient must be cooperative and also comfortable enough to be placed in the proper positioning for treatment set up and execution. Also, the physician should be cognizant of the patient's position and set up to not injure themselves.

Preparation

OMT is considered a procedure and thus must have consent from the patient prior to the procedure.

Technique or Treatment

Kasten et al. best describe the use of HVLA for rib somatic dysfunction. and Pierce-Talsma et al. describe it for ribs 2 to 10:[9][11]

• The patient is placed in a supine position with the physician on the opposite of the dysfunctional rib; the angle of the rib will feel more posterior since it is "stuck" either up or down in comparison to the rib above and below.
• The patient crosses their arms across their chest such that the arm on top is the same side as the posterior rib.
• The healthcare provider then rolls the patient towards them and places their thenar eminence on the dysfunctional rib between the transverse process and the rib angle.
• Then the patient is rolled back onto the thenar eminence. The clinician flexes the patient to the posterior transverse process just below the dysfunctional rib with their opposite hand.
• The patient takes a deep breath in, and as they exhale, apply force from the healthcare provider's abdomen through the patient's elbow to the posterior rib.
• At the end of exhalation, just prior to the patient inhaling, apply an HVLA thrust from the healthcare provider's abdomen straight down to the posterior rib.
• The thenar eminence against the posterior rib will feel a thrust, and the articulation may be palpated.
• A "popping" or "cracking" sound may also be heard
• After the HVLA technique is complete, the healthcare provider should reassess the area of somatic dysfunction.
• The technique may be repeated if additional somatic dysfunction is found.

Complications

Most patients tolerate OMT well if they have adequate screening for contraindications.[17][18]

Common side effects can include tenderness or soreness to the area of treatment. The recommended approach is for patients to take a warm shower and drink plenty of water after a treatment session.

Two previous reviews by Terrettl and Laughlin concluded that manipulation was very safe if performed by skilled practitioners.[19]

Enhancing Healthcare Team Outcomes

Respiration is a biomechanical wonder that requires normal motion of fascia, diaphragm, ribs, and other thoracic cavity structures to function optimally. Somatic dysfunction may negatively affect respiration, especially if other disease processes are present such as musculoskeletal disorders, chronic obstructive pulmonary disease (COPD), pneumonia, and asthma. HVLA, which is a type of OMT technique, can be utilized by a proficient healthcare provider when somatic dysfunction is present. In a pilot study by Zanotti et al., OMT was shown to improve exercise capacity in patients with severe COPD compared to soft manipulation.[17] However, in another study by Noll et al., elderly patients with COPD were found to have increased air trapping 30 minutes after receiving OMT. The results of having air trapping post-OMT were likely secondary to their use of a technique called thoracic lymphatic pump with activation that includes taking multiple deep breaths.[18]

One major weakness of both of these studies was that the number of patients receiving HVLA was not reported in their publication. Furthermore, in the study by Noll et al., a thorough description of how they performed HVLA was not reported, unlike seven of the other techniques that they used.

All doctors of osteopathic medicine and doctors of chiropractic receive training in performing OMT. Doctors of chiropractic commonly use HVLA.[20] Allopathic physicians can become certified to perform OMT if they take the appropriate steps. The curriculum for physician assistants, for example, does not include osteopathic principles.[21]

An osteopathic physician is a graduate of an osteopathic medical school. A survey done in the United States by Teng et al. found that third and fourth-year medical students that had additional OMT clinical exposure increased their comfort level with the underlying topic of musculoskeletal disorders and their comfort level with OMT.[22] Another survey in Michigan found that 57.1% of osteopathic students thought their musculoskeletal curriculum was adequate compared to 26.8% of allopathic students.[23]

Musculoskeletal pain remains a major reason patients present to emergency departments and primary care settings in both developed and developing countries.[23][24] When it comes to treating disorders of the thorax, HVLA is another tool in the toolbox of treatments. Nursing can help by monitoring hospitalized patients for improvement in symptoms or complications of OMT. Pharmacists can refer patients to an appropriate healthcare provider for OMT when conventional pharmacologic agents are not enough to control symptoms. Respiratory therapists who see patients for pulmonary rehabilitation can refer to an appropriate clinician for patients that need additional support. In conclusion, HVLA can be utilized by a proficient healthcare provider to treat rib somatic dysfunction. [Level 2]