Rib raising is a useful technique to normalize the sympathetic nervous system (“sympathetics”) in the body. It is very frequently used in practice and tested on examinations. Balanced ligamentous tension of the ribs is less commonly taught at osteopathic schools and is rarely tested on the COMLEX® exams.

Indications: Normalization of sympathetics (e.g., relief of postoperative ileus, improvement of respiratory rib excursion, facilitation of lymphatic drainage)
Contraindications: Rib fracture, spinal cord injury, infection or malignancy near the area of treatment

1. With the patient supine, sit at their side around their mid-/lower thoracic spine
2. Slide the finger pads of both hands under the paravertebral tissues on one side of the thoracolumbar region, at the vertebral levels corresponding to the dysfunctional sympathetic nervous system segments
3. Lift your fingers into the tissues, using your elbows as a fulcrum, while simultaneously drawing your fingers away from one another
4. The technique may be performed in an intermittent kneading fashion or with sustained deep inhibitory pressure
5. Repeat this technique bilaterally around the vertebral level of sympathetic dysfunction, or alternatively from T1–L2 to treat the entire sympathetic system

Example: Left rib 1 posterior elevation

1. With the patient supine, sit at the head of the table
2. Place your left thumb over the posterior aspect of the elevated left first rib at the costotransverse joint
3. Apply a moderate, caudal force through the thumb and maintain it until a release occurs (tissue is less firm or painful on palpation, and / or rib springs more easily)

Example: Left rib 9 exhalation

1. With the patient supine, stand or sit near their left ribs
2. Place both hands around the contours of the lower rib cage
3. Gently compress the tissues between both hands and move them toward the xiphoid process, feeling for a point of balanced tension within the tissues
4. Hold this position until a release is palpated

Example: Right rib 7 exhalation

1. Stand at the right side of the seated patient
2. Place your left hand over the right posterior chest wall with the fingertips of the second and third fingers directly on the seventh rib, lateral to the costotransverse joint
3. Place your right hand over the right anterolateral chest wall, maintaining contact at the upper border of the seventh costochondral junction
4. Instruct the patient to lean toward the right while you compress both hands toward the right seventh rib, pushing medially and slightly inferiorly
5. Instruct the patient to breathe deeply and hold exhalation until a balanced point of tension is achieved
6. Hold this position until a release is palpated