The relationship between various anatomical landmarks used for localizing the first rib during surface palpation

First rib dysfunction in patients with neck and shoulder pain: a Delphi investigation

BACKGROUND

First rib dysfunction is a possible cause of symptoms in patients with neck and/or shoulder pain.

OBJECTIVES

To explore therapists' perceptions of useful diagnostic criteria to identify first rib dysfunction.

METHODS

A Delphi survey over four rounds involving international manual therapy experts who were asked to agree on which items were most useful in identifying first rib dysfunction.

RESULTS

Consensus (>70% agreement) was reached on key aspects of first rib dysfunction being first rib mobility restriction, upper limb symptom distribution, and a subclassification into two subgroups was suggested. The main clinical findings suggested were: painful and restricted neck movements and shoulder girdle loading activities; positive Upper Limb Neural Test 1; direct palpation of first rib, neural structures, and scalene muscles; pain and hypomobility of first rib accessory movements with improvement after mobilization. The cervical rotation lateral-flexion test was considered a useful, although not widely used test among the experts. Its diagnostic accuracy and interpretation in isolation was questioned.

CONCLUSIONS

This Delphi study produced a cluster of clinical tests aimed to identify first rib dysfunction in patients with neck and/or shoulder conditions. However, these need to be tested out in further research to establish reliability and validity.

Accuracy of rib palpation for dry needling of deep periscapular musculature, measured with ultrasound

INTRODUCTION

Dry needling of the periscapular musculature is a procedure commonly performed by physical therapists. Needling of the deep musculature may be challenging, and use of a thoracic rib as a "backstop" is often applied to prevent inadvertent puncture of the pleura. The aim of this study was to: 1) To examine the accuracy rate of experienced physical therapists in identifying a mid-scapular thoracic rib using palpation, 2) to understand patient characteristics that affect the accuracy rate, and 3) to examine if therapist confidence levels were associated with palpatory accuracy.

METHODS

Two experienced physical therapists attempted to palpate a thoracic rib in the mid-scapular region of healthy participants (n = 101 subjects, 202 ribs), and self-reported their level of confidence in an accurate palpation. Their accuracy was verified with ultrasonography.

RESULTS

The two physical therapists were accurate on 73.3% of palpations and did not differ in accuracy (72.0% vs. 75.0%, p = 0.747). The only ultrasonographic or subject characteristic measurement that correlated with improved accuracy was a reduced muscle thickness (p = 0.032). Therapists' self-reported confidence levels did not correlate to actual accuracy (p = 0.153).

DISCUSSION

Physical therapists should be aware that palpation of a thoracic rib may not be as accurate as it may seem. The greater thickness of muscle in the area reduces the accuracy of accurate palpation.

CONCLUSION

Dry needling of the periscapular muscles should be done with caution if using a rib as a "blocking" technique.