When not covered with a large amount of adi-pose tissue, the rectus abdominis muscle gives the appearance of a washboard; it is commonly called six-pack abs. The rectus abdominis is often thought to contribute to core stability.
However, according to McGill (2007), it plays only a partial role in core stability, but it should be activated along with other core musculature to promote spinal stabilization or stiffness.
Origin: Pubic crest, pubic symphysis Insertion: Costal cartilage of ribs 5
through 7, xiphoid process Action: Flexes the spine; tilts the pelvis
posteriorly
Innervation: T7-T12 (ventral rami)
Palpation Procedure
• Place the patient supine in a supported flexed thoracic position with the knees bolstered into flexion.
• To help with the visual and tactile identification of the upper rectus abdominis fibers, instruct the patient to perform a partial sit-up.
• With the patient in a flexed and relaxed posi-tion, palpate along the costal crest formed by the xiphoid process and ribs downward toward the pubic ramus.
• Strum across the muscle’s insertion points on the xiphoid and ribs as well as across the fibers of the muscle.
• Note the location of any tender points or fas-ciculatory response along the muscle and its attachment to the ribs and xiphoid.
• Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred.
PRT Clinician Procedure
• Place the patient supine in a supported flexed thoracic position. (Thoracic flexion can be accomplished by either placing a pillow under the upper torso and having the patient lean backward onto your thighs and torso or by using a split treatment table.)
• If the patient has equal tenderness at the right and left upper abdomen, grasp both knees
External oblique Rectus abdominis Internal oblique Transversus
abdominis Upper rectus
abdominis
E6296/Speicher/Fig. 08.04/532185/JG/R1
Upper rectus abdominis palpation procedure.
with your far hand and bring them toward the patient’s chest to encourage posterior pelvic tilting. If tenderness is focused to one side, grasp the associated knee with your far hand only and move it toward the chest and opposite shoulder in a diagonal pattern.
• If you can support the patient on your thighs and torso, your thighs can be used to accentu-ate thoracic and lumbar positioning. For right and left upper abdominal tenderness, abduct your thighs to encourage thoracic cage collapse anteriorly as well as lumbar spine flexion. If tenderness is on just one side, say, the right, abduct only your left leg away from the midline of the spine to encourage right-sided thoracic cage collapse. If tenderness is on the left upper abdominis, then move your right thigh outward.
• Apply cervical and thoracic downward pressure from your torso to accentuate tissue relaxation and fine-tune the position.
• Apply femoral internal and external rotation with your far hand for fine-tuning.
• Corollary tissues treated: Hip flexors, obliques, psoas, iliacus, lower abdominals
See video 8.2 for the upper rectus abdominis PRT procedure.
Patient Self-Treatment Procedure
• Lie supine with a pillow under the upper torso and another under the posterior pelvis to encourage thoracic flexion and posterior tilting.
• Place your ankles on a stable structure such as the arm of a sofa or the edge of a chair to support the knees and hips into flexion.
• During positioning, self-palpate the upper abdominals for the presence of a fasciculatory response and optimal tissue relaxation, which will guide you in attaining the optimal treatment position.
• Grasp both knees or one knee based on the location of the tenderness and move the knee (or knees) toward the chest, diagonally to the opposite shoulder for one-sided tenderness as described in the clinician procedure.
• Apply hip rotation to fine-tune the position by rotating the knee with your hand(s).
• Maintain the treatment position until the fas-ciculatory response abates or for three to five minutes.
• This self-treatment position can also be utilized to treat the lower abdominals.
Upper rectus abdominis PRT clinician procedure.
Upper rectus abdominis patient self-treatment procedure.
Intercostals
The intercostal muscles, or spare-rib muscles, are composed of both internal and external fibers that attach to the ribs and their respective costal tissues. The external intercostals are the most superficial, and the internal intercostals are underneath them. The function of the intercostals is debatable, but both are active to one degree or another with both inhalation and exhalation, serving a primary role of assisting with res-piration and also stabilizing the rib cage.
Palpation Procedure
• Place the patient supine with the knees bol-stered into flexion.
• Start at either the inferior or superior ribs.
• With one or two fingers pads, stroke across the obliquely oriented fibers of the intercostals between the ribs.
• Also stroke over the corresponding rib margins, superior and inferior, working either away from or toward the sternum.
• Instruct the patient to take several slow, deep breaths during palpation to ascertain the quality of rib movement and chest expansion. Compare bilaterally.
• Once the anterior intercostals have been pal-pated, move the patient into either a side-lying or prone position to continue palpation around the thorax toward the posterior spine.
• When approaching the posterior, palpation of the intercostals can be challenging because of the dense posterior spinal muscles; firmer pressure is required.
• Note the location of any tender points or fas-ciculatory response along the muscle and its attachment to the ribs.
• Once you have determined the most dominant tender point or fasciculation (or both), maintain
External below and costal tubercles) Insertion: Upper border of the rib below
and the sternum via the apo-neurosis
Action: External intercostals: Assist the diaphragm with inhalation;
rotate the thoracic spine to the opposite side (unilateral); stabi-lize the rib cage
Internal intercostals: Assist with exhalation; stabilize the rib cage stabilization; 1 through 5 assist with inhalation
Innervation: T1-T11 (intercostal nerves)
Intercostals palpation procedure.
light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred.
PRT Clinician Procedure
• The patient is in a seated position on the treat-ment table or on the floor. If the patient has adequate hip and knee flexibility, position the lower torso in a hook-lying position with the knees stacked, the hips flexed, and the feet and ankles stacked and oriented toward the side to be treated. Patients who cannot obtain this position should place the lower body in a position of maximal comfort.
• Use your near hand to palpate the intercostals.
Use your near hand to manipulate the patient’s torso during positioning.
• Position yourself behind the patient, kneeling on the treatment table or floor with your knee and thigh supporting the opposite, or contralat-eral, side of the torso to be treated. The other knee should be in contact with the table or floor.
• Place the patient’s contralateral arm and torso on your knee and thigh over a pillow. An exer-cise ball can be used in place of your knee and thigh either on the treatment table or on the floor.
• Grasp the opposite arm (ipsilateral) with your far hand and bring it across the chest to the pillow, holding it at the bicep area. Place a towel or pillow over your far arm and have the patient laterally flex the head and neck to rest it on the pillow or towel.
• While palpating the anterior intercostals with the fingers of your near hand, move the supporting knee outward from the patient to promote lateral trunk flexion and collapse the ipsilateral rib cage on the side of the lesion.
• Rotate the supporting knee to encourage rota-tion and flexion of the anterior thorax toward the lesion.
• Once the thorax position of comfort is attained or a fasciculatory response is elicited, encour-age further rib and costal compression by applying a downward and anterior compression of the rib cage with the palmar aspect of your near hand.
• Corollary tissues treated: Abdominals, obliques, psoas, diaphragm, hip flexors
See video 8.3 for the intercostals PRT procedure.
Patient Self-Treatment Procedure
• An exercise ball is needed for self-treatment.
• Position yourself in a seated position on a table, on a bed, or on the floor. If you have adequate hip and knee flexibility, position the lower torso in a hook-lying position, with the knees stacked, the hips flexed, and the feet and ankles stacked and oriented toward the side to be treated.
• Rest your contralateral arm and torso on the exercise ball.
• Rest your arm on the non-affected side on the ball, then place your head on your arm. Use the fingers of your other hand to monitor the tissue fasciculation or relaxation of the tissue.
Intercostals PRT clinician procedure.
• Allow the ball to move outward and away from the tender side, which will promote the treat-ment side of the torso to collapse, or laterally flex.
• Allow your body to rotate forward on the ball, which will promote anterior thoracic flexion and rotation toward the tender lesion.
• Maintain the treatment position until the fas-ciculatory response abates or for three to five minutes.
Intercostals patient self-treatment procedure.
Xiphoid
The xiphoid is a structure of primary importance to evaluate in the presence of spinal, pelvic, or upper-quarter conditions. The xiphoid serves as an attachment site for the abdominal aponeuro-sis and is a fascial anchor for upper, spinal, and pelvic tissues. Somatic dysfunction often results in lesions at this site that produce significant tenderness and tissue restriction. Because most patients are not aware that they have lesions at this site, gentle palpation is needed when exploring this area to prevent unintentional guarding during palpation and treatment. The xiphoid is typically cartilaginous until the age of 40 and ossifies after this time; thus, greater movement of the xiphoid would be expected in patients under 40 years of age.
Jugular notch
• Place the patient in a supine position.
• Locate the sternum and trace it downward to its apex.
• Strum over the anterior and inferior aspects of the xiphoid.
• The xiphoid is often very tender when lesions are present; therefore, use gentle palpation during assessment and treatment to prevent further aggravation.
• Determine the most dominant tender point or fasciculation (or both) and maintain light pres-sure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred.
PRT Clinician Procedure
• Place the patient in a recumbent position with the knees flexed and bolstered.
• Position the patient with the torso and head resting against your knees and torso with a pillow between you and the patient, or position the patient on a split treatment table.
• Place the patient’s palms behind the head (some call this the arrest position) and position yourself behind the patient if possible. If you can, reach under and through the axilla of the patient to palpate the xiphoid with your near hand.
• Rest the patient’s arms and shoulders on your forearms for support and place the fingers of your far hand just below the fingers of your near hand.
• Apply a light cephalad translation of the tissue below the xiphoid while moving the patient into
• Collapse the upper thoracic cage anteriorly and inward toward the sternum by moving both knees outward and leaning forward to promote kyphotic positioning.
• Rotate the thorax while protracting the shoulder to fine-tune the positioning.
• Corollary tissues treated: Abdominis, obliques, psoas, diaphragm, pectoralis major and minor
See video 8.4 for the xiphoid PRT
Xiphoid palpation procedure.
Xiphoid PRT clinician procedure.
Sternum
Palpation Procedure
• Place the patient in a supine relaxed position with the head slightly flexed.
• Starting at the jugular notch, located at the top of the sternum, stroke across the sternum with the pads of the fingers, moving distally to the xiphoid.
• Explore the lateral margin of the sternum where the ribs articulate with the sternum (this site if often tender in the presence of osteochondritis).
• Note the location of any tender points or fascic-ulatory response along the bone and its articu-lation with the abdominal aponeurosis.
• Determine the most dominant tender point or fasciculation (or both) and maintain light pressure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred.
PRT Clinician Procedure
• Place the patient in a recumbent position, knees flexed, arms relaxed at the sides.
• Position yourself behind the patient, as done in the xiphoid treatment; consider using a split treatment table.
• Place the fingers of your near hand over the sternal lesion.
• With your far hand, grasp either the right or left upper arm of the patient and apply internal rotation and shoulder protraction coupled with distraction. If the patient demonstrates right-sided sternal pain, manipulate the right arm of the patient (vice versa for the left).
• Collapse the upper thoracic cage anteriorly and inward toward the sternum by moving both knees
The sternum protects the internal organs and is the central attachment point for the ribs and their respective costal cartilage. The manubrium articulates directly with the clavicles and the first and second ribs. The body of the sternum is a major site of attachment for the anterior chest wall muscles and fascia.
outward and leaning forward to promote kyphotic positioning.
• Rotate the thorax toward the lesion with your body to fine-tune the positioning.
• With the near hand, apply a slight cephalad traction force to the overlying tissue.
• The xiphoid PRT procedure can be used for the sternum when the lesion is centrally located.
• Corollary tissues treated: Pectoralis major and minor, sternocleidomastoid, anterior and middle scalenes, intercostals, rectus abdominis
Sternum palpation procedure.
Sternum PRT clinician procedure.
E6296/Speicher/Fig. 08.07/532196/JG/R5