Presentation on theme: "RIBS: Post-Sternotomy Pain"— Presentation transcript:
1 RIBS: Post-Sternotomy Pain Developed for OUCOM COREby: Shannon McAfee, D.O.Edited by: Clay Walsh, D.O.and theCORE Osteopathic Principles and Practices CommitteeSession #7 – Series B
2 Sternotomy Full Median Sternotomy Central incision through the length of the sternumStandard approach for CABGPartial Median SternotomyCentral incision from sternal notch to the 4th-5th ribCommonly used for valvular surgeries
3 Full Midline Sternotomy: Incision and Repair heartlungdoc.com
5 Retractor use during surgery Positioning during surgery Implications for PainBased on the previous pictures and your hospital experiences, discuss how the following could cause post-surgical pain in a post-sternotomy patient?Sternal incisionRetractor use during surgeryPositioning during surgerySternal incision repair using wire loops
6 Somatic Dysfunction Respirations Movement Rehabilitation What would be your expected musculoskeletal findings in a post-sternotomy patient?What impact would these somatic dysfunctions have on this patient during:RespirationsMovementRehabilitation
7 Somatic DysfunctionWhat are the potential causes of vascular or lymphatic congestion in a post-sternotomy patient?What are the potential causes of autonomic imbalance in this post-surgical patient?
8 Costal Cartilage Segments (Chondrals) Ribs Appropriate Osteopathic assessment of a post-sternotomy patient should include the following highest yield regions:SternumCostal Cartilage Segments (Chondrals)Ribs
9 Assess the sternum for: Deviation or fascial dragRespiratory responsePain-related response (tenderpoints)What somatic findings would you expect at the sternum in a post-sternotomy patient?What treatments could you use in a post-sternotomy patient if you found a sternal dysfunction (acute inpatient vs. outpatient)?
11 ChondralsChondral segments can exhibit dysfunction independently from rib dysfunctionAssess for structural or respiratory dysfunction and/or pain response while monitoring chondral segments
12 ChondralsWhat somatic findings would you expect at the chondral segments in a post-sternotomy patient?What treatments could you use in a post-sternotomy patient if you found a chondral dysfunction (acute inpatient vs. outpatient)?
13 Possible Chondral Treatments: Post-Sternotomy Acute InpatientFunctional MethodsStrain-CounterstrainOutpatient (healing complete)Treatments listed aboveFacilitated Positional ReleaseMuscle Energy
14 Inhalation & Exhalation are primary rib motions Rib Motions Ribs 1-10Inhalation & Exhalation are primary rib motionsPump-HandleAnterior aspect of rib moves superiorly like a pump-handle on inspiration and caudad on expirationBucket-HandleLateral aspect of rib moves superiorly like a bucket-handle on inspiration and caudad on expiration
15 All Ribs have BOTH pump & bucket-handle motions Rib Motions Ribs 1-10All Ribs have BOTH pump &bucket-handle motionsCephalic ribs have more pump-handle motionCaudal ribs have more bucket-handle motion
16 dimension by upper ribs; Pump- Handle Motion Increase in A-Pdimension by upper ribs; Pump- Handle Motionmywebpages.comcast.net/wnor/respap.gif
17 Increase in transverse dimension by lower ribs; Bucket-handle motion mywebpages.comcast.net/wnor/respap.gif
18 Caliper motion is primary motion: Rib Motions Ribs 11 & 12No anterior articular attachments and no costotransverse articulations posteriorlyCaliper motion is primary motion:Move posterior and lateral on inhalationMove anterior and medial on exhalation
19 Limiting factors to Rib motions Muscular attachments contributing to respiratory dysfunctions:Scalenes to ribs 1-2External & Internal intercostalsPectoralis minor ribs 3-5Serratus anterior ribs 3-9Diaphragm to inner surface ribs 6-12Quadratus lumborum to rib 12Ligamentous strainCosto-transverse & costo-vertebral articulationsChondral dysfunctionThoracic vertebral dysfunction
20 Ciba Clinical Symposia “Thoracic-outlet Syndrome" is Volume 23 Number 2, 1971
21 There are 2 types of motion dysfunction within the ribcage: Rib DysfunctionsThere are 2 types of motion dysfunction within the ribcage:Respiratory Rib DysfunctionsInhalation RestrictionExhalation RestrictionStructural Rib DysfunctionsSubluxationsCompressionTorsions
22 Respiratory Rib Dysfunctions Diagnosed when asymmetry of motion exists while palpating rib cage excursion during respiratory effortSingle rib or a group of ribs can demonstrate restriction during inhalation or exhalation
23 Respiratory Rib Dysfunctions Inhalation RestrictionRib (s) that do not rise with inhalation, but move freely during exhalationIn group dysfunction, the Key Rib is the uppermost ribAlso termed: Exhalation DysfunctionExhalation RestrictionRib (s) that do not lower with exhalation, but move freely during inhalationIn group dysfunction, the Key Rib is the bottommost ribAlso termed: Inhalation Dysfunction
24 Respiratory Rib Dysfunctions After determining the phase of respiratory restriction, assess whether pump-handle or bucket-handle motion is most restricted.What treatments would you use in a post-sternotomy patient if you found a respiratory rib dysfunction (acute vs. chronic)?
25 Structural Rib Dysfunctions Diagnosed while assessing rib anglesRib subluxations are the most commonly diagnosed structural dysfunctions and will subsequently be reviewed.3 types:Anterior subluxationPosterior subluxationSuperior 1st rib subluxation
26 Structural Rib Dysfunctions Anterior Rib Subluxation Diagnosis:Rib angle tenderRib angle less prominent posteriorlyProminence of anterior portion of ribMarked motion restriction for both inhalation and exhalationPosterior Rib Subluxation Diagnosis:Rib angle more prominent posteriorlyAnterior portion of rib less prominent
27 Structural Rib Dysfunctions Superior 1st Rib Subluxation Diagnosis:Palpation of superior aspect of 1st rib shows dysfunctional side to be 5-6mm cephalic compared to other sideMarked tenderness of superior aspect of first ribRestriction primarily during ExhalationWhat treatments would you use to treat your post-sternotomy patient if you found a structural rib dysfunction (acute inpatient vs. outpatient)?
29 Osteopathic Goals of Treatment Improve and synchronize sternal motionImprove rib motionDecrease pain experienced by patientBalance autonomic toneImprove diaphragmatic functioningOther goals?
30 Specific Treatments: Sternal Balancing Patient supine –Physician should contact body of sternum either standing beside patient or from the head of the bedCarry the sternum to the point of balanced ligamentous tension (utilizing as many planes of motion as are necessary)Test respirations and ask patient to hold their breath in the phase providing the best ligamentous balanceRepeat until maximal response is obtainedRecheck
31 Specific Treatments: Sternal Balancing Greenman (p.139)Kimberly Manual (p.145)
32 Specific Treatments: LAR for Ribs Patient seated –Physician seated contacting dysfunctional rib:Middle finger of one hand on rib angleMiddle finger of other hand on anterior aspect of rib shaftThumbs placed laterally in mid-axillary line on ribPatient instructed to carry shoulder opposite the side of lesion posteriorlyDoctor instructs patient to stop & hold position when they feel balanced tension through monitoring fingersPatient instructed to inhale and hold breath for correction of lesionSlowly return to neutral & re-check
33 Specific Treatments : LAR for Ribs The Osteopathic Techniques of Wm. G. Sutherland, D.O. by H.A. Lippincott, D.O
34 Specific Treatments: Counterstrain Identify sternal, chondral, or rib tenderpointsTreat patient in seated or supine position based on point location and patient comfortPress on the point and tell the patient: “This is a 10 on a 1-10 pain scale”Passively move the patient utilizing flexion/extension, sidebending, and rotation until the patient reports the pain is 0-3Hold this position 120 seconds if treating a rib tenderpoint; otherwise hold for 90 secondsMonitor for warmth, softening, or a pulsationSlowly return to neutral and recheck
35 Specific Treatments: Counterstrain Note: PosteriorRib Pointsare locatedover rib anglesStrain and Counterstrain by Lawrence H. Jones,D.O., FAAO