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Be prepared to perform grade IV - V manipulations from this list:
1) prone rib elevation
2) prone rib depression
3) upper thoracic rotation or extension (bedside move)
4) upper rib posterior to anterior manipulation prone (bedside move)
5) supine flexion ("anteriority" move)
6) alternative positioning supine flexion ("anteriority")
7) supine rotation
8) supine rib posterior to anterior manipulation

PRONE RIB ELEVATION
patient is prone, ribs are assessed
a rib is found that is stuck in an inferior position
stand on same side as rib, facing caudally
place knife edge of hypothenar eminence posterior to rib
fingertips of contact hand toward spine
tissue pull involves rotating hand edge into depression beneath rib in question
second hand: pisiform nests in anatomical snuffbox of contact hand, grasp wrist
thrust to anterior

PRONE RIB DEPRESSION
just like elevation but opposite direction

UPPER THORACIC ROTATION OR EXTENSION or RIB POSTERIOR TO ANTERIOR
bedside move
lower headrest, pt prone
find vertebra in rotation or extension restriction
if rotation restriction, find elevated TVP, which will be opposite side from restriction
stand on same side as elevated TVP, facing headward
lift pt head onto cheek facing you, hand hold head with outside hand
place inside hand pisiform such that it will be on TVP with lateral and anterior tissue pull
("inside" and "outside" refer to hand in use relative to bedside position: standing on pt right and facing head of table, right hand and shoulder are "inside")
take tissue pull and traction head
minimize rotation of neck, traction mainly axial, important to be steady and strong in this
have pt breathe and give downward pressure with inside hand on exhale
maintain steady traction on head, no trusting or extra pressure there
thrust on elevated TVP at bottom of exhale
thrust: P-A only if rotation restriction, inferior angle & force if extension restriction
IF ADJUSTING A RIB
be sure to avoid TVP and position thrusting hand with pisiform under rib edge

SUPINE FLEXION (ANTERIORITY MOVE)
both positions covered here
standard is this:
locate flexion restriction with pt prone, note location
have pt sit at end of table
this move can be performed from either side of pt
wrap pts arms tightly, using pillow on chest if needed to increase tissue tension across thoracic spine
position outside hand flat on pt spine 1-3 segments inferior to restriction (even after superior tissue pull)
place inside shoulder on flat top surface of pts elbows, and hand behind their shoulder
have pt "cry on my shoulder" and hold neck in maximum flexion against me during movement
place feet predictively, wide stance, take deep breath
take tissue pull and move pt's spine into full flexion
both exhale as lowering
roll pt spine onto table until my hand is in contact but their spine above my hand not in contact
thrust with shoulder to their elbows to increase flexion while my hand on table stabilizes lower vertebrae
roll back up to sitting
alternative position is this:
restriction located and pt sitting at end of table
cross pt arms
place my inside hand on pt spine with peripheral digits curled and heel of hand opp sps from digits
my sternum on pts elbows
my outside hand on pt head keeping it in full flexion
wide stance and exhale while lower
when my hand reaches table stop lowering, max extension and thrust with sternum
gently sit back up

SUPINE ROTATION
assess spine, find rotation restriction, if right restriction then left tvp elevated
if left tvp elevated stand on pts right so when side lying toward me elevated tvp up
pt supine, slightly inferior on table so shoulders won't roll off narrow part
cross pt's legs toward me, or bend farther leg so I can use it to roll pt my way
cross pts arms on chest
roll pt toward me
relocate elevated tvp
leapfrog contact hand: from fingertips to thenar eminence with space for lateral superior pull
take tissue pull (lateral and superior)
lay pt on hand, other hand on pt elbows
my hands in vertical line such that trunk wt is on my hand
thrust a-p through elbows while pulling p-a through contact hand

SUPINE RIB POSTERIOR TO ANTERIOR MANIPULATION
just like above except that contact hand is positioned on rib instead of on tvp
and pt may be rolled farther away from me to get weight over my contact hand

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