Internal Medicine I

Lower Respiratory Infections

OMM Workshop
2021
David G Harden DO FAAFP NMMOMM
 Learning Objectives

• Identify the structural areas affected by sympathetic viscerosomatic reflex

• Define “Work of Breathing” as it pertains to the pulmonary system
• Recognize the Osteopathic “Models” of treatment
• Identify the structural areas which may play a role in Vagal nerve facilitation
• Identify the common rib dysfunctions found as a result of paroxysmal coughing
• Describe the pulmonary effects of increased parasympathetic tone
• Describe the pulmonary effects of increased acute sympathetic activation
• Describe the pulmonary effects of increased chronic sympathetic activation
• Identify the spinal segments most likely to become facilitated with lung dysfunction
• Identify the anterior Chapman’s points for lung dysfunction
• Recognize and identify an appropriate OMT treatment plan in lower respiratory
infections.
• Content and reading references included in this workshop will tested
during the next End of Rotation OMM quiz.
• You will be responsible for this content whether you are present in
today’s workshop, or received an excused absence.

• You may review all or some of the included techniques as a group;

however, you will be expected to be knowledgeable of all the
included techniques on the quiz.
 Case
• Chief Complaint
• 54-year-old male presents to your clinic with cough and mild dyspnea
What is your differential based on current
information?
• What are the most likely diagnoses?
• What are the “don’t miss” diagnoses?
• A couple other possibilities…
 Differential diagnoses?
Diagnoses:
• Bronchitis
• Pneumonia
• Postnasal drip syndrome
• Gastroesophageal reflux (GERD)
• Asthma
• ACE inhibitor use
• Allergies

• Don’t Miss Diagnoses:

• Heart failure
• Pulmonary embolism (PE)
• Lung cancer
• Pneumothorax https://www.uptodate.com/contents/ac
ute-bronchitis-in-adults?
 How to start narrowing down your
differential
• History! History! History!

• What are some of the things you would like to know? Remember,
your differential will help guide these questions.
 His History
• 54-year-old male presents to clinic with 10 day history of cough(at
times severe), malaise and dyspnea. Has not taken his temperature
but states that he has been feeling feverish for the past 7 days. Patient
has mildly productive cough with yellow sputum. States it started with
a head cold but seems to have gone into his lungs. He is living with
family that includes a 3-year-old granddaughter, who is currently in
day care. He has taken some leftover Amoxicillin ,unknown strength,
from URI illness 2 years ago; took it 3 times daily for 2 days, no effect.
 History
• Allergies: NKDA
• Meds: Tylenol as needed for pain, Vit. C 500 mg daily, Captopril daily,
unknown dose.
• Medical History: Hypertension for 3 years; Open cholecystectomy, 1984;
Appendectomy, age 14
• Family Medical History: Father deceased age 56, myocardial infarction;
Mother alive and well; 3 siblings, one with diabetes mellitus,
hypertension; uncle with tuberculosis
• Social History: Unemployed, Welder, Single, No religious affiliation,
Tobacco: 1/2 packs of cigarettes daily for 5 years. Alcohol: occasional;
denies drug use, no exercise, sedentary, poor to fair diet/nutrition habits
 His History
• Review of Systems:
• Gen-No night sweats, no weight loss,+ malaise
• HEENT-occasional postnasal drip, occasional headaches
• Neck-no difficulty swallowing
• Cardiac-slight sharp chest pain with coughing,no nocturnal dyspnea, no extremity
swelling
• Pulm-Mild dyspnea, cough, mildly productive
• Abdominal, negative, colonoscopy negative 3 years ago
• Skin-no rash
• Neuropsych- insomnia, anxiety
• Musculoskeletal-some back and lateral rib pain, no erythema or swelling of joints
 Does he need studies?
• Does he need Imaging?
• Does he need lab?
• Any other studies acutely or chronically?
 His Diagnostics

• CBC with differential

• Chem-7 (basic metabolic panel)
• EKG
• Troponin
• Chest x-ray
CBC
Basic Metabolic Profile
CXR of our patient
CXRs that might change your approach

Pleural Effusion

Lobar Consolidation

Non-Small Cell Lung Ca

Rib Fracture
Tension Pneumothorax
 His Physical Exam

• 5' 10" 190 lbs, T-102; BP- 154/92; R-26; HR 86

• General : Alert and oriented to person, place and time in mild distress,
dehydrated, mucous membranes slightly dry; appears nourished and well
developed.
• Skin: Warm, dry without lesions or rashes 
• HEENT: Head is normocephalic, atraumatic; pupils equal, round, reactive to
light and accommodation; external ocular muscles intact; nares without
discharge, turbinates engorged, no sinus pressure tenderness, no epistaxis;
oropharynx without discharge or exudates, tonsils small, no exudates,
uvula midline; and Weber and Rinne tests are non-lateralizing.
• Neck: No adenopathy, thyroid not enlarged; trachea midline and moveable
and no masses.
 His Physical Exam : Cont.

• Lungs: mildly decreased breath sounds at bilateral bases with

intermittent end inspiratory crackles at bilateral bases and
intermittent but scattered rhonchi. Inspiratory crackles noted at Right
middle Lobe
• Heart : RRR w/o m, Normal S1 and S2
• Abdomen: Scars well healed, consistent with surgical history; bowel
sounds present in all 4Q ; abdomen soft, protuberant, no masses,
tenderness, or rebound.
 His Structural Exam
• Patient examined in the seated and supine positions
• Head: The right temporal bone is internally rotated, tender right occipito-mastoid
suture.
• Neck: Tenderness mid-cervical area with C4RRSR; plus focal tenderness right OA with
OAESLRR
• Chest: Respiratory excursions decreased BLT especially in ribs T4-10, also elevated left
first rib with tenderness located lateral to the sternoclavicular junction.
• T4-5 ERSR
• Abdomen/Thoracolumbar: diaphragmatic restriction on right side; T10-L2 paraspinal
muscle tension increased on the right. Lumbosacral: General decreased regional
mobility with decreased spring compliance at the lumbosacral junction in extension.
• Extremities: Right scapula myofascial tension, right hip inflare with internally rotated
right hip. No swollen joints. No fractures or dislocations.
Now what is your assessment?
 Assessment
• RML Pneumonia
• Somatic Dysfunction of
• Cranial
• Cervical
• Costal/Rib
• Thoracic
• Lumbar
• Sacrum
• Pelvis
• Upper and Lower extremities
• Hypertension, mild, on medication
• Situational anxiety, possible depression
• Tobacco abuse
 Plan
• Patient education
• OMT
• Medications- Mucolytics (Guaifenesin),ABX, consider steroids and or
beta-agonist if signs of reactive airway disease
• Increased hydration
• Smoking cessation
Anatomy and Physiology Pertinent to
Structural Evaluation and Treatment
of the Pulmonary System
 Phrenic and Sympathetic innervation
• Note
• Phrenic Nerve (C3-5)
• Cervical chain ganglia(sympathetic)
• Scalene muscles and attachments
to first and second rib
• Note
• Anterior and
posterior thoracic
cavity
• Lung and parietal
pleura
• Cool plastinated
model
 Control of Breathing

Exhalation

Inhalation

Inspiration is active
Neural impulses from respiratory centers in the
brainstem-stimulate diaphragm and intercostal
muscles-lowers pressure
Expiration is passive
Recoil of lungs
Anatomic connection b/w shoulder, thoracic cage through pecs ,serratus, lats
Pelvis and lower extremities through diaphragmatic crura and psoas and quadratus lumborum.
Configuration of the Thorax
 Pleura
Visceral
• Adheres to the lung surface
Parietal
• Encases visceral pleura
• Adjacent to chest wall
• Pleural space- can be filled with air
(pneunothorax)
• Fluid (pleural effusion)
• Blood (hemothorax)
 In the respiratory tract
• Respiratory passages coated in mucus, periciliary fluid and
surfactant

• Keeps surface moist

• Traps small particles
• Decreases surface tension

• Ciliated epithelium (about 200 cilia per cell) beat at 10-20 X/sec
towards the pharynx
Cells of the mucociliary clearance system
• Pseudostratified ciliated columnar epithelial cells
• Secrete periciliary fluid (5 um layer)
• Rhythmic beating of cilia

• Goblet cells (surface secretory cells) (1:5 to goblet: epithelial )

• Produce mucus (increase in smoking/pollution)
 Pulmonary Circulation
Provides nourishment Deoxygenate
Does not get oxygenated blood from
Arise from aorta- right heart
supply larger airways Terminate in
alveolar
capillaries

Princiles of Physiology; Berne & Levy; Mosby, 2000

Neurologic Model
 Autonomic Balance
• Sympathetic Parasympathetic
• Determines cellular makeup of
respiratory epithelium
• Goblet cells (sympathetic)
• Thick, sticky
• Ciliated epithelial cells
(parasympathetic)
• Thin nasal secretions
• Create muscous blanket, moves in
cephalad to clean and moisturize
bronchial passaged
 Sympathetic
• Head and Neck – T1-4
• Heart and Lungs T1-6
• Upper GI Tract-T5-9
• Sm Int / Rt Colon-T10-11
• Left Colon/Pelvis-T12-L2
• Kidney/Adrenal-T10-11
• Upper Ureter-T10-11
• Lower Ureter-T12-L1
• Bladder-T12-L2
• Appendix-T12
• Chapman’s Reflexes-ICS 3 and 4 • Arms –T2-8
• Parasympathetic –CNX(OA,AA,C2)
• Sympathetic Viscerosomatic changes Parasympathetic
occur along posterior paraspinal muscles
Pupils-CNIII
at T1-6 (Lung),(T1-12 Pleura)
Lacrimal and salivary glands-CNVII
Carotid Body and sinus-CNIX,X
Thyroid to Transverse colon-CNX
These can produce muscular changes creating
(Including Lungs)-CNX
vertebral dysfunction.
Left Colon and genitourinary-S2-4
Prolonged sympathetic activation and tone
1. Vasoconstriction
• Local hypo perfusion
• Epithelial hyperplasia
2. Occurs from facilitation
• Increased goblet cells more thick mucous, difficult to expectorate
3. Quick initiation of sympathetic system causes initial
dilation of bronchi.( That’s why HVLA is a good initial
treatment for acute asthma)
Vagal Relationship to Pulmonary Physiology
Visceral afferents
• Increased sensitivity of alveolar
receptors
• Summates with somatic &
other afferent stimuli
• Posterior headache
• Somatic dysfunction OA-C2 &
OM suture
• Shallow breath/cough
Parasymp Efferents
• Profuse, thin secretions
• +/- Bronchoconstriction
Respiratory Circulatory Model
 Lymphatics
• Extrapleural lymphatics
drain to intercostal
vessels, to axillary
nodes and then to the
right or left lymphatic
duct
• Pleural sac and lung
tissues drain through
the pretracheal nodes
and then to the right
lymphatic duct.
 Areas of Narrow Passage for
Lymphatic Drainage
• Thoracic inlet
• Thoracic duct (sometimes referred to as
the L lymphatic duct) & R lymphatic duct
• Abdominal diaphragm
• Thoracic duct lies by the right crus &
passes through the aortic hiatus
• Peritoneal lymph can travel through the
diaphragm itself
• Pelvic diaphragm
• Lower pelvic structures
Osteopathic Considerations in Systemic
Dysfunction. Rev. 2nd Ed.
 OMT for Patients with Lower Respiratory Conditions

Neuro-reflexes (neurologic model)

•Impact of somatovisceral and viscerosomatic reflexes on autonomic function &
balance
•SNS increase tone=thickened secretions & bronchiole dilation (T2-T7)
•PNS increase tone=thinning secretions & relative bronchiole constriction (vagus—OA, AA, C2)
Vascular flow(respiratory circulatory model)
•Promote arterial , venous, and lymphatic flow (abdominal diaphragm and
thoracic inlet)
• Decrease congestion
• Decrease inflammation
• Increase immune response
• Optimize arterial flow (SNS)
• Endogenous and exogenous medicines

Mechanical dysfunction ( structural/biomechanical model)

• Pain (ribs from coughing; T/L from diaphragm strain)
• Motion restriction (chest wall & diaphragm)
• Diaphragm attachments: sternum, lower six ribs, L1-3
• Mechanical constriction
• Similar approaches may apply to patients with bronchitis , COPD,pneumonia,asthma.
Where to treat?
• If time is limited at least address thoracics , ribs, area.
• This would effect sympathetic and parasympathetic viscerosomatics and chest cavity
mechanics.
• Next area would be OA,AA,C2
• Balance to parasympathetic

• If time allows would also address C3-5(affects diaphragm) as well as

addressing directly diaphragms and attachments

• All treatment to decrease the work of breathing

 OMT Treatment Approaches
For Bronchitis
Area Treatment Approach Anatomic/Physiologic Basis

T2-7 Type II HVLA,ME, Still, FPR SNS balance

Thoracolumbar Junction Soft tissue Diaphragm mechanics; reduce pain

Ribs ME, Still,FPR,Rib Raising Thoracic rib cage mechanics

Rib raising Articular/stimulation SNS ganglia stimulation; respiratory mechanics

Diaphragm (doming) MFR (direct/indirect) Lymphatic drainage; respiratory mechanics

Thoracic inlet MFR Lymphatic drainage; respiratory mechanics

Cervical muscles Soft tissue Reduce pain & muscle strain

OA decompression MFR, Soft Tissue PNS (vagus) balance

3rd & 4th interspace adjacent to sternum; between T3-T4 transverse Chapman’s Reflex Neurolymphatic reflex (diagnosis & treatment)
processes

Thoracic lymphatic pump With respiratory assist Lymphatic drainage; immune response

Pedal lymphatic pump With dorsiflexion & plantar flexion Lymphatic drainage & immune response
 OMT Treatment Approaches
For Asthma
Area Treatment Approach Anatomic/Physiologic Basis

T2-7 HVLA SNS balance

T12 ME Diaphragm mechanics

Upper Extremity MFR (int/ext rotation) Respiratory mechanics

Ribs HVLA,ME, Still,FPR,Rib Raising Thoracic rib cage mechanics

Rib raising Articular/stimulation SNS ganglia stimulation; respiratory mechanics

Diaphragm (doming) MFR (direct/indirect) Lymphatic drainage; respiratory mechanics

C3-5 dysfunction ME, SCS or Still Phrenic nerve

OA decompression MFR PNS (vagus) balance

3rd & 4th interspace adjacent to sternum; between T3-T4 transverse Chapman’s Reflex Neurolymphatic reflex (diagnosis & treatment)
processes

Ribs 11 & 12 ME Diaphragm mechanics

 OMT Treatment Approaches
For Pneumonia
Area Treatment Approach Anatomic/Physiologic Basis

T2-7 Type II ME, Still SNS balance

Thoracolumbar Soft tissue Diaphragm mechanics; reduce pain

Rib raising Articular/stimulation SNS ganglia stimulation; respiratory mechanics

Diaphragm (doming) MFR (direct/indirect) Lymphatic drainage; respiratory mechanics

Ribs ME, Still,FPR,Rib Raising Thoracic rib cage mechanics

Thoracic inlet MFR Lymphatic drainage; respiratory mechanics

Cervical muscles Soft tissue Reduce pain & muscle strain

OA decompression MFR PNS (vagus) balance

3rd & 4th interspace adjacent to sternum; between T3-T4 transverse Chapman’s Reflex Neurolymphatic reflex (diagnosis & treatment)
processes

Thoracic lymphatic pump With respiratory assist Lymphatic drainage; immune response

Pedal lymphatic pump With dorsiflexion & plantar flexion Lymphatic drainage & immune response
 Approach to evaluation and treatment you
should be able to perform by end of lab
• Screen OA,AA,C2-7
• Diagnose dysfunction
• May treat with any method
• Screen Partners thoracic area
• Identify facilitated segments if present
• Rib raising
• Diagnose Vertebral dysfunctions
• Treat thoracic dysfunction if present( any technique)
• Screen Bilateral rib areas
• Identify rib dysfunctions
• Diagnose rib dysfunctions
• Treat with any method(todays practice on Muscle energy for exhalation dysfunctions
• Screen and treat any restrictions of thoracic inlet and abdominal diaphragm
• Treat with any method
• Don’t forget arcuate ligament relation with lower ribs and diaphragms
 For Todays Lab
Screen and treat Thoracics
(any method)
Screen parathoracic tissue for viscerosomatic irritation
(seated rib raising then supine rib raising to recheck success)
Screen then diagnose ribs
Treat with muscle energy
Any pearls or particular treatments proctor wants to share
Rib raising to decrease somatovisceral
irritation and to improve motion of ribs

• Supine Rib Raising-Typically taught

• Seated Rib Raising –Useful in primary offices with short tables
 Supine Rib Raising
Supine, Direct LVMA - Springing

• Pt supine and physician at side of table

• Physician places finger pads on posterior angles of ribs
• Lift rib angles anteriorly as a group until anterior
motion of chest wall is observed
• Hold until surrounding tissues relax
• May be applied once or rhythmically for several cycles
• Treat opposite side
• Recheck
 Seated Rib Raising
Seated, Direct LVMA - Springing
• Pt seated and physician on opposite side of treatment
• Pt crosses arms to grab opposite shoulders
• Physician reaches around anteriorly to grasp opposite
shoulder with one hand
• Use palm of opposite hand to contact posterior rib heads
• Apply rythmical anterior and lateral force with palm of
posterior hand
• May depress, SB and rotate upper torso with opposite
hand
• Rythmically apply the posterior kneading along the
desired region of ribs and treat bilaterally
• Recheck
 Transverse Axis “Pump Handle” Motion

• Occurs more predominately in upper ribs

• Primarily Ribs 1-5
• Occurs around a functional transverse axis
• Axis passes through the posterior tubercle and the head of the rib
• Increases AP diameter of rib cage
 Pump Handle Motion
• As Inspiration occurs:
• Anterior Rib head moves
cephalad (superiorly)
• Posterior rib head moves
caudad (inferiorly)
Exhalation Somatic Dysfunction Inhalation Somatic Dysfunction
 Treatment
• Treat thoracics with any technique based on patient’s condition and
physician ability
• HVLA is useful for temporary bronchodilation and quick increase in rib
excursion

• Treat ribs
• Common Rib dysfunctions due to paroxysmal cough are exhalation
dysfunctions
 Treatment Tip
• When treating an inhalation somatic dysfunction (“stuck in
inhalation”)
• Treat the lowest rib of the group of ribs that is restricted
• When treating an exhalation somatic dysfunction (“stuck in
exhalation”)
• Treat the highest rib of the group of ribs that is restricted
 Depressed 1st Rib
Sitting Direct ME/Patient Cooperation
• Pt is seated with physician standing behind
patient
• Physician contacts shaft of the 2nd rib in the
mid-axillary line with the fingers of his/her
caudad hand
• Physician uses other hand to side bend and
rotate away from side of dysfunctional rib
• Pt. instructed to sidebend head towards side
of dysfunction while physician offers isometric
counterforce for 3-5 seconds
• After patient relaxes for 2-3 seconds, physician
sidebends head to now restrictive barrier,
pulling 1st rib superiorly
• Repeat 3-5x as needed
 “Bucket Handle” Expiratory Lesions (Ribs 2-3)
Supine, Direct: Muscle Energy (4822.22B)
• Pt is seated with physician standing behind
patient
• Physician contacts shaft of the rib below the
dysfunctional rib in the mid-axillary line with
the fingers of his/her caudad hand
• Physician uses other hand to side bend and
rotate away from side of dysfunctional rib
 “Bucket Handle” Expiratory Lesions (Ribs 2-3)
Supine, Direct: Muscle Energy (4822.22B)
• Pt. instructed to “pull your head to the side
against my hand” while physician offers
isometric counterforce for 3-5 seconds
• After patient relaxes for 2-3 seconds, physician
takes up slack with the hand at the mid-axillary
line to the new restrictive barrier
• Repeat 3-5x
 “Pump Handle” Expiratory Lesions
Supine, Direct: Muscle Energy (4821.22B)
• Pt supine, with doctor on side of
dysfunction
• Hooks fingers of caudad hand over
superior margin of the angle of the
dysfunction rib
• Apply caudad tension
• Pt rotates head away from side of
dysfunctional rib and places the
forearm of the side of the
dysfunction over his/her forehead
 “Pump Handle” Expiratory Lesions
Supine, Direct: Muscle Energy (4821.22B)
• Physician places other hand over the
patient’s elbow and forearm
• Pt applies a contractile force against the
physician’s hand
• Contraction is held for 3-5 second, while
physician offers isometric counterforce
• Physician allows tissue to relax, and takes up
the slack with the caudad hand at the rib
angle to the new restrictive barrier
• Repeat ~ 3x
 “Bucket Handle” Expiratory Lesions
Supine, Direct: Muscle Energy (4822.22A)
• Pt supine, with doctor on side of
dysfunction
• Physician hooks fingers of caudad
hand over superior margin of the
angle of the dysfunction rib or the
lower rib of a group and applies
caudad tension
• Pt rotates head away from side of
dysfunctional rib and places the
forearm of the side of the
dysfunction over his/her forehead
 “Bucket Handle” Expiratory Lesions
Supine, Direct: Muscle Energy (4822.22A)
• Physician places other hand over the patient’s
elbow and forearm
• Patient is instructed to apply a contractile force
against the physician’s hand
• Contraction is held for 3-5 seconds, while
physician offers isometric counterforce
• Physician allows tissue to relax, and takes up
the slack with the caudad hand at the rib angle
to the new restrictive barrier (Inferior, lateral
force)
• Repeat ~ 3x
ME treatment of inhalation rib dysfunctions
Muscles Used for Inhalation Rib
Somatic Dysfunction
Muscle Acts Upon
• Scalenes • Ribs 1-2
• Pectoralis Minor • Ribs 3,4,5,(6)
• Serratus Anterior • Ribs 6,7,8,9,10
• Latissimus Dorsi • Ribs 9,10,11,12
• Quadratus Lumborum • Rib 12 Indirectly
• Intercostales • Forced Inhalation
 Contractile Force Vector
• The patient’s contractile force is directed as follows:
• Towards the contralateral (opposite side) nipple for upper ribs (ribs 2-4)
• Pectoralis minor m.
• Towards the contralateral ASIS for middle ribs (ribs 5-7)
• Serratus anterior m.
• Towards the ipsilateral (same side) hip for lower ribs (ribs 8-10)
• Latissimus dorsi m.
 Elevated 1st Rib
Supine Direct ME/Patient Cooperation
• Pt. supine and physician at head of
table
• Contact posterior margins for first
ribs with thumbs in front of trapezius
• Instruct pt. to shrug the shoulder
with the elevated rib and hold
• Maintain caudad pressure on ribs
• As pt. relaxes, take rib to new
restrictive barrier
• Repeat as necessary
 “Bucket Handle” Inspiratory Lesions (Ribs 2-3)
Supine, Direct: Muscle Energy (4822.12B)
• Pt is seated with physician standing behind
patient
• Physician contacts shaft of dysfunctional rib in
the mid-axillary line with the fingers of
his/her caudad hand
• Physician uses other hand to side bend and
rotate away from side of dysfunctional rib
“Bucket Handle” Inspiratory Lesions (Ribs 2-3)
Supine, Direct: Muscle Energy (4822.12B)
• Pt. is instructed to sidebend head
towards side of dysfunction while
physician offers isometric
counterforce for 3-5 seconds
• After patient relaxes for 2-3 seconds,
physician takes up slack with the
hand at the mid-axillary line to the
new restrictive barrier
• Repeat 3-5x
 “Pump Handle” Inspiratory Lesions
Supine, Direct: Respiratory Cooperation (4821.12B)
• Physician stands at head of table, Pt. supine
• Contact the superior aspect of dysfunctional rib
(or lowest rib of dysfunctional group) with the
lateral margin of his/her thumb at the mid-
clavicular line
• Other hand slides under the patient with
fingers hooked under the inferior margin of the
posterior angle of rib
 “Pump Handle” Inspiratory Lesions
Supine, Direct: Respiratory Cooperation (4821.12B)
• Flex the upper thorax up to the level of the
dysfunctional rib
• Apply cephalad tension on posterior angle of
rib carrying it to restrictive barrier
• Pt. Instructed to “Take a deep breath and let it
out forcibly
• Anterior hand carries anterior portion of
dysfunctional rib caudad and holds rib at new
restrictive barrier
Bucket Handle” Inspiratory Lesions (Ribs 4-10)
Supine, Direct: Muscle Energy (4822.12A)
• Physician stands at head of table w/
pt supine
• Physician slides one hand under
patient from above to mid-scapular
region while letting the patient’s
head rest on his/her forearm
• Physician contacts the shaft of the
dysfunctional rib at its mid-axillary
line with the web between the
thumb and index finger
 “Bucket Handle” Inspiratory Lesions (Ribs 4-10)
Supine, Direct: Muscle Energy (4822.12A)
• Pt. is lifted into forward bending and side
bending toward side of dysfunctional rib
until restrictive barrier is reached
• Pt. is instructed to “bend body back to
neutral position” (brown arrow)against
the physician’s resistance for 3-5 sec.
• After pt. relaxes, physician takes up slack
with hand at mid-axillary line (blue
arrow) to the new restrictive barrier
• Repeat 3-5x
 Pump Handle & Bucket Handle Rib
SD
Supine, Direct HVLA
• Pt supine and physician on opposite side of dysfunction
• Cross pt’s arms as in thoracic supine HVLA
• Roll patient toward physician and place thenar eminence on posterior angle of rib
• Compression is applied through the arm and chest into the hand
• Apply a HVLA thrust through physician’s chest through elbows into the fulcrum
• May SB pt toward physician to open facets
If time allows may try any of the below
listed

• Treat thoracic inlet and abdominal diaphragm

• Thoracic Pump
 Diaphragm
Supine, Direct Myofascial Release:
Arcuate Ligament Release
• Pt supine and physician of patient
• Contact the 12th rib with guiding hand over
palpating hand
• Palpate the tension in lateral & medial
arches of arcuate ligament
• Take the rib in the direction it is pointing
by distracting the rib
• Follow this direction to feel lateral arch
release followed by the medial arch
release
• Continue technique to release the crus of
the diaphragm
 Supine, Direct: Diaphragmatic Fascial Release
• Pt supine and physician at side of table
• Grasp lateral sides of lower rib cage with palms
• Rotate the thoracoabdominal region into
restrictive barrier, adjusting for SB, rotation and
FB/BB
• Hold at barrier and use respiratory force to
help guide through barrier
• Adjust tensions through your hands until there
is equal excursion between right and left sides
of diaphragm
• Recheck
 Diaphragm
Supine, Direct: Dome Abdominal Diaphragm
• Pt supine and DO at side of patient
• Place fingers on outer aspect of inferior border
of ribs with thumbs pointed medially directly
caudad to xiphoid process
• Monitor diaphragm motion during inhalation &
exhalation
• On exhalation follow the diaphragm cephalad
with thumbs, noting asymmetry
• On inhalation provide some resistance with
thumbs
• On 2nd exhalation continue to follow
diaphragm cephalad
• Repeat steps until full and symmetric excursion
of the diaphragm occurs
 Thoracic Pump
• Pt supine and physician at head of table
• Physician places palms with thumbs at the midline and
fingers spread over pt’s chest below clavicles
• Instruct pt to “Take a very deep breath and let it all the way
out.”
• As pt exhales, physician follows thorax into full exhalation
• Gently spring against chest wall to encourage exhalation
• Maintain compressive force and instruct pt to “Take
another deep breath.”
• Resist thoracic wall during early inhalation, following chest
wall during exhalation and repeat
• After repeating several times, during inhalation suddenly
release pressure from chest wall