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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5521_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 10 / Therapeutic Applications
431
light, rhythmic, spiral-like movements to encourage the flow
of lymph. More recently, Dr. Bruno Chikly developed and
currently teaches Lymph Drainage Therapy (LDT), a technique based on the work of Dr. Vodder, and many other
physicians throughout history. LDT teaches therapists an
anatomical approach that allows them to map the vessels,
assess the quality and depth of overall circulation, and determine the best alternative pathways for draining stagnant
body fluids. Therapists use all of the finger pads to simulate
gentle, specific wavelike movements that activate lymph and
interstitial fluid circulation and stimulate immune function
and parasympathetic nervous system activity.
The main purpose of using lymphatic drainage is to
reduce edema by draining excess fluid from the body’s cells
and tissues. Lymphatic drainage is indicated for edema that
is the result of an injury such as a strain, sprain, or repetitive
overuse syndrome. As the excess lymph is removed from
interstitial spaces, the pressure it was exerting on pain receptors is reduced, and thus, pain decreases. See Box 10-4 for
a list of benefits and contraindications for enhanced lymph
drainage.
Although the methods of Drs. Vodder and Chikly require
advanced training, the beginning massage therapist can
enhance lymph drainage with techniques similar to venous
enhancement.
The movement of lymph is encouraged by deep
breathing, gravity, joint movement, muscular contraction, and
general massage.
Deep Breathing
Full, deep breaths enhance lymphatic flow. Not only do full
breaths bring more oxygen into the lungs to be delivered to
the blood, but when the diaphragm contracts for inhalation,
it also puts pressure on the lymphatic vessels and organs in
the thorax to encourage the flow of lymph. Lymphatic ves-
sels are concentrated near the diaphragm, and the full contraction and relaxation of the diaphragm during deep breathing
significantly enhances lymph drainage.
Benefits and Contraindications for Enhanced Lymph Drainage
BENEFITS
Enhanced lymph drainage can be beneficial for the following:
• Reducing edema
• Relieving pain by relieving fluid pressure on nerve endings
• Stimulating immune function
• Relieving tension headache and migraine headache pain
• Minimizing scarring
• Minimizing connective tissue restrictions following surgery
• Accelerating healing time from burns and wounds
• Relieving sinus congestion
• Reducing symptoms of fibromyalgia and chronic fatigue
syndromes
• Reducing muscle hypertonicity
• Relieving some forms of gastrointestinal distress such as
constipation, colitis, irritable bowel syndrome
• Improving relaxation to aid insomnia, stress, and loss of
vitality
CONTRAINDICATIONS
Below are some contraindications for enhanced lymph drainage:
• Systemic
• Edema not related to soft tissue injury, which could
indicate an overtaxed heart
• Liver and/or kidney congestion
• Chronic heart failure
• Angina
• Thrombosis (blood clot)
• Acute stage of contagious viral or bacterial infection
• Fever
• Toxoplasmosis (a parasitic disease)
• Local
• Local infection or signs of local infection (pain, redness,
heat and swelling)
• Swollen lymph glands
• Red streaks from an infection site to the nearest lymph nodes
• Acute inflammation
• Acute injuries (24 to 72 hours after injury)
• Recent surgery (24 to 72 hours after surgery)
• Open wounds, blisters, burns, and abrasions
• Contusions (bruises)
• Skin infections
• Rash
432 INTRODUCTION TO MASSAGE THERAPY
Gravity
You can use gravity by elevating your client’s extremities
during the session.
Alert
Be sure to maintain proper body mechanics while
you are holding and lifting the client’s extremities.
Because lymph nodes are more concentrated near
joints, movement of the joints also encourages lymph flow.
When the nodes are squeezed, as occurs with active and passive muscle movement, their valves force lymph toward the
heart even more effectively than when the lymphatic vessels
are squeezed. Joint movement goes hand in hand with muscle contraction, and isotonic contractions that create movement are more effective than isometric contractions.
Massage Strokes
Lymphatic drainage involves the application of very light
and repetitive compression and effleurage strokes, generally repeated five to seven times. The general rule for the
application of pressure is around 5 grams, or in more practical terms, the weight of a nickel resting on your skin. There
are different approaches to lymph enhancement, but 0.5- to
1-inch effleurage strokes or circular effleurage strokes are generally considered acceptable. Because the application is very
light, it is important for you to be comfortable and to keep
your body and hands relaxed. If you find yourself tensing up,
take a deep breath, ground yourself, and lighten your touch.
Deep pressure can damage lymphatic vessels, and
damaged lymphatic vessels cannot drain lymph
properly, which is why massage is contraindicated
over areas of inflammation.
Some of the specialized lymph techniques include nodal
pumping, stationary circles, and local technique. Nodal pumping involves compression to the lymph nodes at the most
proximal part of the limb. Stationary circles can be used for
larger areas of limb. These are modified compression strokes,
in which there is no slip on the skin and the therapist moves
one or both palms in circles in a rotational or spiral form.
Local technique is applied with either the ulnar border of your
hand, the web between the index finger and thumb, or with
the broad surface of your thumbs. Figure10-2 illustrates the
different specialized lymph techniques. Regardless of which
technique you choose, be sure not to apply any technique to
AB
CD
Figure 10-2. Specialized lymphatic drainage techniques. (A) Axillary nodal pumping. (B) Stationary circles. (C) Local technique using
web between thumb and index finger. (D) Local technique using broad surface of the thumbs.
Chapter 10 / Therapeutic Applications 433
BOX 10-5
• Pumping—3 rhythmic compression strokes
• Sweeping—a series of short, superficial effleurage strokes that sweep proximally
Supine Position—Neck and Head Drainage
1. Place your relaxed, flat hands on the client’s chest,
just inferior to the client’s clavicles, and apply 3 light
compression strokes with a pumping rhythm.
2. Rotate the client’s neck to the left, support the head
with your left hand, and use your right hand to apply
several sets of very light pumping and sweeping to
the neck, starting at the client’s right clavicle and
gradually moving up to the occiput.
3. Rotate the client’s neck to the right, supporting the
head with your right hand, and use your left hand to
apply several sets of very light pumping and sweeping to the neck, starting at the client’s left clavicle
and gradually moving up to the occiput.
434
INTRODUCTION TO MASSAGE THERAPY
BOX 10-5
(continued)
4. Apply several sets of pumping and sweeping to the
client’s face, starting near the chin and gradually
moving out and up to the client’s forehead.
Supine Position—Arm Drainage
1. Use flat fingers to sweep the chest, starting near the
client’s sternum and gradually moving to the right
axilla ( armpit area).
2. Gently but firmly grasp your client’s left hand, interlocking your thumb with theirs, support the client’s
elbow, and rhythmically flex and extend the client’s
left shoulder and elbow several times.
Chapter 10 / Therapeutic Applications 435
BOX 10-5
(continued)
3. Use flat fingers to sweep the left arm, starting at the
axilla and gradually moving to the hand.
4. Use flat fingers to sweep the thorax, starting at the
left axilla and moving down the left side of the rib
cage.
5. Repeat steps 1 to 4 on the right side.
436 INTRODUCTION TO MASSAGE THERAPY
BOX 10-5
(continued)
Supine Position—Leg Drainage
1. Elevate the client’s left leg with bolsters or, if possible, gently hold and support the client’s left foot
and lower leg to rhythmically flex the hip and knee
several times.
2. Use your palms or flat fingers to pump and sweep
the client’s left leg, starting at the medial thigh and
gradually moving to the ankle.
Chapter 10 / Therapeutic Applications 437
BOX 10-5
(continued)
3. Repeat for the client’s right leg.
Prone Position—Leg Drainage
Alert
Do not put pressure on the popliteal fossa at the back of knee
because it is an endangerment site.
1. Elevate the client’s ankles with a small bolster.
2. Gently and firmly grasp the client’s left ankle and
rhythmically flex the knee several times.
Y
y
438 INTRODUCTION TO MASSAGE THERAPY
BOX 10-5
(continued)
3. Use your palms or flat fingers to pump and sweep
the client’s right leg, starting at the right iliac crest
and gradually moving to the ankle.
4. Repeat for the client’s left leg.
the tissue distal to a developing scar or acute injury. Box 10-5
describes a basic lymph drainage enhancement procedure.
Alert
You should be aware that application of lymph drain-
age may cause medications to metabolize in the client’s
system more quickly than expected. Be sure to inform clients
that this may occur and that they should seek advice from their
healthcare professional before adjusting their medications.
Before applying any of these techniques, make sure
there are no contraindications for lymph drainage enhancement (see earlier Box 10-4 for some of the more common
contraindications).
Be sure not to apply lymphatic drainage directly on the site
of or distally to an acute or subacute injury as it can
increase congestion and pain in the area of injury.
Do not push fluids toward a developing scar because the
proteins in the interstitial fluid can agglomerate at the scar and
form keloids. Instead, you should only enhance lymph drainage
in areas proximal to the developing scar. If edema is present, it is
important to determine whether soft tissue injury is the cause. If
not, you should avoid lymph drainage enhancement in that area.
Alert
If you are uncertain whether you should apply
l
lymphatic techniques, do not proceed, and refer
clients to their primary healthcare provider.
This section is meant to be an introduction to lymphatic drainage; if you are particularly interested in developing
your skills in this area, you must take additional training.
To find quality training programs, consult fellow massage
therapists, reputable massage schools, or your professional
massage organization.
Chapter 10 / Therapeutic Applications 439
Neuromuscular techniques use a comprehensive system
of identifying causative factors and performing soft tissue
manipulation to achieve balance between the nervous and
musculoskeletal system, thus alleviating pain. There are
advanced courses of neuromuscular therapies that have
their own levels of certification.
At the introductory level, the two laws of neuromuscular therapy to understand are the law of cause and effect
and the law of facilitation. The law of cause and effect states
that for every action there is an equal and opposite reaction.
Applied to massage therapy, it is the idea that when you
affect the body in one area, the whole body responds. This
could be due to the body’s response to stressors and injury
and/or the application of pressure via massage techniques.
Dr. Ida Rolf, founder of the structural integration system
called Rolfing, simplifies this concept in her timeless statement, “Where you think it is, it ain’t.” The law of facilitation states that when a nerve impulse has followed a specific
pathway of nerves, it will tend to take the same path on
future occasions. The law of facilitation explains why a client may experience a familiar pain pattern after aggravating
an old injury or reinjuring an area. Essentially, the nervous
system trains itself to take the path of least resistance.
Neuromuscular therapy is indicated for hypertonic muscle
conditions such as muscle strains, whiplash, repetitive stress
injuries, temporomandibular joint dysfunction, headaches, and
back or neck pain. Conversely, neuromuscular work is contraindicated for bruised areas, phlebitis, varicose veins, open wounds,
skin infections, and broken bones. If you are unsure whether
this type of therapy is indicated, consult a massage-specific
pathology book or follow the rule, “When in doubt, don’t.”
What follows in this section is an introduction to the
concepts and some practical applications that you can master as a student and beginning massage therapist, including
proprioceptive neuromuscular facilitation (PNF) techniques,
myofascial techniques, and TrP release techniques.
Proprioceptive Neuromuscular Facilitation Techniques
Proprioceptive neuromuscular facilitation (PROH-pree-
oh-SEP-tive NOO-roh-MUSS-kyoo-lar fah-SIHL-ih-TAYshun), commonly called PNF , uses the nervous system to
reset a muscle’s resting length. PNF is a general term for a
set of techniques. Remember, the muscle spindles and Golgi
tendon organs are proprioceptors of the nervous system that
recognize stretch and tension in the muscles and tendons.
These massage techniques manipulate the proprioceptors of
the nervous and the muscular systems to facilitate a reflexive
change in the resting length of a muscle. These techniques
are also called muscle energy techniques , or METs . The
terms PNF and MET are often interchanged. PNF techniques can reduce pain, relax a hypertonic muscle, realign
postural deviations, and restore range of motion. Some of
the more common PNF techniques are direct manipulation (DM), positional release (PR), post- isometric relaxation
(PIR), and reciprocal inhibition (RI).
Some people respond well to PNF, and others do not.
Some respond better to one particular PNF technique than
to another. The results depend on the length of time the target muscle has been affected, the synergists that are involved,
any compensation patterns that are present, and the factors
that influence the client’s health and healing. Sometimes the
results can be immediate and permanent, and other times,
PNF can be unsuccessful. Most of the time, PNF is an effective
and efficient approach to specific areas of hypertonicity that
plainly demonstrates some of the benefits of massage.
Muscle Movement and Stability
Performing PNF requires a basic understanding of muscle
movement and stability. In addition to creating movement,
muscles also function to stop movement and to stabilize
joints. The muscle or group of muscles that creates a certain
movement is called the agonist (prime mover). The muscle
or group of muscles that performs the opposite work is
called the antagonist. In normal, concentric movements, the
antagonist must relax for the agonist to contract.
when the biceps brachii muscle contracts and shortens to
create flexion, the triceps brachii muscle must neurologically relax and lengthen. PNF techniques often use the antagonistic mechanism of muscle contraction to create reflexive
changes in muscle length. Muscles called synergists assist the
agonist to create the desired motion. The synergists help by
contracting in the same direction as the agonist or by stabilizing the joint to prevent another motion from occurring
during movement.
If you are trying to relax and lengthen the biceps brachii
muscle, the biceps brachii is your target (agonist) muscle.
You can use a contraction of its antagonist, the triceps
brachii muscle, to neurologically relax the biceps brachii.
Knowing the major skeletal muscles of the body and their
actions, antagonists, and synergists is important for using
therapeutic techniques. For that reason, massage students
must learn antagonistic muscle movements and the muscles
responsible for those movements (Table 10-1).
For example,
440 INTRODUCTION TO MASSAGE THERAPY
Muscles Antagonistic Actions Muscles
Levator scapula, rhomboid
major, upper trapezius,
middle trapezius
Serratus anterior, pectoralis
minor
Serratus anterior, upper
trapezius, lower trapezius
Coracobrachialis, anterior
deltoid, pectoralis major,
biceps brachii
Deltoid, supraspinatus,
biceps brachii
Posterior deltoid,
infraspinatus, teres minor
Medial deltoid, posterior
deltoid, teres minor,
infraspinatus
Elevation Depression Serratus anterior, subclavius,
lower trapezius, pectoralis
minor
Scapula
Protraction Retraction Rhomboid major, middle
trapezius, lower trapezius
Upward rotation Downward rotation Levator scapula, pectoralis
minor, rhomboid major
Shoulder
Flexion Extension Posterior deltoid, latissimus
dorsi, teres major, triceps
brachii
Abduction Adduction Latissimus dorsi, pectoralis
major, teres major, triceps
brachii, coracobrachialis,
pectoralis minor
Lateral rotation Medial rotation Anterior deltoid, latissimus
dorsi, pectoralis major,
subscapularis, teres major
Transverse abduction
(laterally rotated
humerus moves
horizontally out to
Transverse adduction
(laterally rotated
humerus moves across
chest)
Pectoralis major,
coracobrachialis
sides)
Pectoralis major, deltoids,
coracobrachialis, biceps
brachii
Biceps brachii, brachialis,
brachioradialis
Pronator teres, pronator
quadratus, anconeus,
brachioradialis
Flexor carpi radialis, flexor
carpi ulnaris, palmaris
longus, flexor digitorum
superficialis, flexor
digitorum profundus
Extensor carpi radialis brevis,
extensor carpi radialis longus,
flexor carpi radialis, extensor
pollicis brevis
Transverse flexion
(medially rotated
humerus moves
across chest)
Transverse extension
(medially rotated
humerus moves
horizontally out to sides)
Posterior deltoid,
infraspinatus, latissimus
dorsi, teres minor
Elbow
Flexion Extension Triceps brachii, anconeus
Pronation Supination Biceps brachii, supinator
Wrist
Flexion Extension Extensor carpi radialis brevis,
extensor carpi radialis longus,
extensor carpi ulnaris, extensor
digitorum, extensor pollicis
longus, extensor indicis
Abduction (radial
deviation)
Adduction (ulnar
deviation)
Extensor carpi ulnaris, flexor
carpi ulnaris
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