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The Lessons
PART
II
75
CHAPTER
an
ac
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App
tissue the
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dual clients
6
The Fundamentals—Breath and Support
avi
completed homework, classroom instruction,
is expected to be able to...
t
ly key terms and concepts related to integrated deep
ra
as related to chest, back, and spine
t
Identify anato
ncludin
ony landmarks
uscular and fascial structures
ndangerments or cautionary sites
t
Identify common postural or movement patterns associated with pain or impaired function of the chest, back, and spin Use positioning and bolstering strategies that provide
afety and comfort for clients to receive integrated dee
issue therapy to the trunk
of chest, back, and spine,
tice related to Chapter 6 of The Balanced By
Generate within-sc
elevant to the chest, back, a
Safely and effectively perform the integrated dee
herapy routines as described
rganize a single session to address the chest, back, an
spine, using the integrated deep tissue therapy approach,
mized to indivi
t Plan a series of sessions to address whole-body incorpo
ation using the integrated deep tissue therapy approach,
mized to indivi
mmendations for client self-care

The Chest

◗ GENERAL CONCEPTS
The integrated deep tissue therapy series begins with the chest. Because the overall goal of deep tissue therapy is to bring a person’s body to a condition of better balance and function, the logical place to begin is with the breathing mechanism. It is through the breath that the body receives the oxygen that is necessary to carry out its vital processes. The first breath we take marks our entry into this world, and the last breath signals our departure. How we manage all the breaths in between has much to do with determining the quality of the lives we lead.
The movement of the breath in and out establishes a primary rhythm through the body. It represents our general ability to take in and assimilate, and to give out and let go. The smooth flow of breath is also crucial to the bodywork process. During an integrated deep tissue therapy session, the recipient is called on to accept challenges in stretching and pressure, to process change, and to let go of stored tension. If the breath is restricted, this sequence of events is less effective, and the person cannot derive the full benefits of the therapy.
Tension in the muscles of the chest inhibits the movement of the lungs, diminishing the amount of oxygen that is taken into the body. Decreased access to oxygen affects metabolism all the way to the cellular level. With less oxygen available, the body’s connective tissues become thickened: a barrier to both cellular-level metabolism, and to larger-level muscular action. Over time, the fascia may constrict our musculature in a way that limits our interaction with our surrounding envi­ronment. Through observation and palpation, the integrated deep tissue therapist evaluates the patterns of myofascial con­striction that limit full breathing capacity, and then focuses on reducing or eliminating them to allow the unhindered movement of breath.
The benefits of open, full breathing are many. Contributors to guarded breathing and muscle resistance often have to do with the perception of threat. When a person can relinquish patterns of muscle resistance, overall levels of tension in the body may subside. At the same time, reducing muscular re­sistance in breathing allows more access to oxygen, and more capacity for activity: effort goes down, and energy levels and endurance may be substantially increased.
76
Chapter 6 The Fundamentals—Breath and Support 77
Free, effortless movement of the breath allows the body to shed carbon dioxide efficiently, and helps to keep the blood pressure normalized. The medulla oblongata, a structure in the brainstem, oversees the size and tone of the blood vessels. If carbon dioxide is high, the medulla elevates blood pressure (perhaps with the intended outcome that blood will be delivered to the lungs more efficiently for the necessary O2–CO2 exchange).
The movement of breath presents a clear picture of how mood may be reflected in the physical body, and vice-versa, how a person’s physical state can influence mood or percep­tion of threat. The sense of stress or physical threat raises our muscle tone, including in the thoracic cavity. Although we are designed to breathe more deeply when we are under short­term threat (the better to run away from danger), long-term, low-grade stress appears to have the opposite effect as the intercostals become locked, and diaphragm moves more shallowly, and the scalenes must do more work to raise the top ribs. This pattern can become ingrained as proprioceptors interpret it as a normal level of tension. Breathing shallowly and with resistance then reinforces any sensation of fear or threat, and the cycle becomes self-fulfilling, even to the point of hyperventilation and involuntary muscle contractions to consume dangerously high levels of oxygen in the blood.
By contrast, if a person can drop some of that unnecessary tension and mindfully expand the thoracic cavity from the floor (diaphragm), walls (intercostals), and roof (scalenes), the movement of air in and out becomes more effortless. In this situation, instead of reinforcing a sense of dread, breathing can help to create a sense of equilibrium. For this reason, deep breathing techniques are an important aspect of treatment for people with anxiety disorders, chronic pain conditions, and for those with conditions that exacerbate breathing disturbances, like asthma, chronic bronchitis, and emphysema.
◗ MUSCULOSKELETAL ANATOMY
AND FUNCTION
The chest, or thoracic cage, is one of the three major weight segments supported by the spine. It consists of 12 pairs of ribs, the 12 thoracic vertebrae, the costal cartilage, and the
sternum (Essential Anatomy Box 6-1 and Fig. 6-1). The thoracic portion of the spine is its least moveable segment, providing a stable attachment for the ribs in the back of the body. The ribs join the sternum on the anterior side by means of the costal cartilage. The cylindrical, cage-like design of the chest forms a protective housing for the heart and lungs. Refer to Figure 6-1C for an illustration of the bones of the thorax.
The pectoralis major muscle is made up of three over­lapping sections that fan across the anterior chest cavity. All three sections attach on the lateral side of the upper humerus, on the lateral side of the bicipital groove. The upper section originates on the medial half of the clavicle and is the most superficial of the three sections. The middle section attaches along the sternum. The lower section, which is also the deepest, attaches to the costal cartilages. The broad, fan-like arrangement of the pectoralis major fibers allows it to act on the arm from numerous angles. This design also distributes force coming from the arm over the entire anterior rib cage, minimizing impact stress to the thorax.
All three sections of pectoralis major contribute to horizontal flexion and internal rotation of the arm. In these actions, it is opposed by the latissimus dorsi, which powerfully extends the arm. Both muscles work together to adduct the arm, in­ternally rotate at the shoulder, and to lift the thorax toward the arm in pull-ups. Chronically contracted pectoralis major muscles are characterized posturally by a collapsed chest, with the arms drawn forward and rolled inward when hanging at the sides of the body. The subclavius muscle lies deep to the clavicular section of the pectoralis major. It attaches on the first rib and to a groove on the underside of the clavicle. It fixes the clavicle to the chest wall and depresses it.
Although 46 muscles are involved in the breathing pro­cess, the primary breathing muscle is the dome-shaped muscle is connected to the lower ribs, sternum, and lumbar spine in a rim around the body. The bases of the lungs attach to the superior surface of the diaphragm. The diaphragm forms the floor of the chest cavity and the roof of the abdominal cavity. The movement of the diaphragm lowers the floor of the thoracic cavity while other muscles expand the walls and raise the roof. This causes a vacuum, and air rushes in to fill the low-pressure area.
diaphragm. This
BOX 6-1 ESSENTIAL ANATOMY | The Chest Routine
MUSCLES
Pectoralis major Subclavius Intercostals Diaphragm Serratus posterior superior Serratus posterior inferior
BONES AND LANDMARKS
Ribs Sternum Manubrium Xiphoid process Sulcus intertubercularis Locations of vertebrae T1–T3, T11–L2 Clavicle
78 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
Pectoralis major
A
DAR
Subclavius
Pectoralis minor
External intercostal
Serratus posterior superior
Ribs:
1
2
3
4
5
6
7
8
9
10
s
11
12
DAR
Serratus posterior inferior
B
Pectoralis major (insertion)
C
5
6
7
8
9
Pectoralis major (origin)
1
2
3
4
DAR
Manubrium
Xiphoid process
Pectoralis major (origin)
Sternal angle
Sternum
FIGURE 6-1 A. Muscles of the chest. B. Posterior
breathingmuscles. C. Muscle attachments on the thorax. D.The diaphragm.
Central tendon
Diaphragm
Esophageal hiatus
Aortic hiatus
Chapter 6 The Fundamentals—Breath and Support 79
Aorta
D
FIGURE 6-1 (continued)
The diaphragm has two main portions (Fig. 6-1D). The central tendon, which is noncontractile connective tissue, forms the central roof of the dome and blends with the pericardium. The central tendon helps the diaphragm to maintain its shape parachute-like shape.
Surrounding the central tendon are muscular fibers that are arranged in a radial design like spokes on a wheel. This muscular portion of the diaphragm consists of two sections, the crural part and the costal part. The crural portion forms a muscular extension of the diaphragm that runs in two sections down the anterior surface of the lumbar spine, attaching on the vertebral bodies and discs of L1–L3 and on the aponeurotic arcuate ligament. The crura blend with superior fibers from the psoas, and form a connection for the breathing apparatus between the upper and lower spine.
When the diaphragm contracts during the inhalation phase of breathing, the fibers pull the central tendon downward toward the crura. As the diaphragm descends, the abdominal contents are pushed downward and outward; the phrase, “breathe into your belly” refers to this sense of distension.
The
external intercostal
muscles also contract during inha­lation, elevating the ribs—the walls of the thoracic cavity—and causing the lower portion of the rib cage to lift and expand laterally. The intercostal muscles attach to adjacent ribs all
the way around the circumference of the rib cage. They are extensions of the abdominal oblique muscles into the chest cavity. The fibers of the external intercostals angle obliquely downward and inward, in the same direction as the external abdominal oblique muscles.
serratus posterior superior works with the external
The intercostals to expand the ribcage during inhalation. It lies deep to the rhomboids in the upper back. Serratus posterior superior connects the C7–T3 vertebrae and ribs 2–5 at a 45° downward angle. When the serratus posterior superior contracts, it lifts the upper ribs, also expanding the walls of the chest. This muscle can be strained when a person engages in too much forceful, high chest breathing without incorporating the abdominal muscles.
The
scalenes
are the final contributors to inhalation: they pull up on the top ribs, raising the “roof” of the thoracic cavity. They are relatively minor contributors to healthy breathing, however, and they will be addressed in Chapter 10, Balancing the Upper Pole.
When inhalation has reached its peak and comes to a pause, those muscles relax and the elastin in the lungs pulls the thoracic cavity back to its original shape. The lungs are compressed, and air rushes out. To take exhalation even fur­ther than the normal passive process, the
internal intercostals
80 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
Left lung
During inspiration the diaphragm presses the abdominal organs downward and forward.
During expiration the diaphragm rises and recoils to the resting position.
contract, causing the ribs to move downward and inward and assisting in diminishing the size of the lungs. Refer to Figure 6-2 for a visual representation of the breathing process (see Box 6-2 The Mechanics of Breathing).
The
serratus posterior inferior
muscle attaches to the T11 and T12 and the L1 and L2 vertebrae. Its fibers angle upward at about a 45° angle, mirroring the serratus posterior superior, to attach to ribs 8–12. It stabilizes the lower ribs, and it assists in exhalation. Serratus posterior inferior can be strained during lifting, twisting, and reaching actions, such as stretching to grasp an item located on a high shelf. Figure 6­1A and B illustrates the muscles of the chest.
As mentioned previously, many other muscles are in­volved in the breathing process, assisting in the essential movements and stabilizing muscles and bones. Full, unre­stricted breathing is a full-body phenomenon. The breath is experienced as a pressure wave moving throughout the entire body. Watching a small baby breathe demonstrates this effect beautifully. The deep tissue massage therapist should be aware of how the client’s body is moving as he or she breathes, and where the breath is inhibited. The restoration of full-body breathing is an important goal of integrated deep tissue therapy.
◗ CHEST ENDANGERMENT SITES
r The xyphoid process is a bony prominence at the inferior
end of the sternum. It overhangs the liver, and any sharp,
downward pressure at this site may cause a bone fracture
and liver damage. r The floating ribs are not connected to the rest of the rib
cage by way of costal cartilage. Careless massage may
Left lung
FIGURE 6-2 Mechanics of normal breathing:
during inhalation the diaphragm pushes the abdominal contents downward, while the external intercostals, serratus posterior superior, and scalenes lift and expand the ribcage. During exhalation, the diaphragm relaxes and rises, while the ribcage returns to its original shape.
create an uncomfortable sensation by pinning soft tissues on the points of the floating ribs (see Fig. 6-3).
BOX 6-2 | The Mechanics of Breathing
Breathing is a vital and complex activity that involves not only all the bones and muscles of the chest area but also accessory muscles in the abdomen, shoulder girdle, and neck. These mus­cles must be free to do the coordinated actions necessary to achieve full breathing with minimal resistance.
The act of inhalation is carried out primarily by the diaphragm, the external intercostal muscles with the serratus posterior superior, and the sca­lenes. The act of exhalation is mostly a function of the elastin fibers that permeate the lungs: when the inhalation pauses, they recoil and bring the lungs (and the attached walls of the thoracic cavity) back into their original size. Extra exhala­tion, beyond this passive recoiling mechanism, is a function of the internal intercostals, transversus abdominus and serratus posterior inferior.
The breathing mechanism is so efficient that a healthy person at rest invests only 5% of his or her energy into the act of providing enough oxygen for the needs of every cell in the body. But when we develop resistance in the system through disease or inefficient muscular pat­terns, then the act of breathing claims a much larger portion of our resting energy.
Chapter 6 The Fundamentals—Breath and Support 81
◗ CONDITIONS
1.
Asthma is a respiratory disorder that is characterized by episodes of difficulty in breathing accompanied by coughing and a build-up of mucus secretion. Asthma involves permanent inflammation of the bronchial tubes and excess mucus production, and transient attacks are triggered by allergens, strenuous exertion, a sudden change in temperature, or emotional factors. Massage may be beneficial if the client is comfortable; be sure to use hypoallergenic lubricant and avoid any scents or perfumes in the treatment room. Massage therapy may help to expel excess mucus (with tapotement on the
ANTERIOR TRUNK
Common
carotid
artery
Internal
jugular vein
2.
Thyroid cartilage
Thyroid gland
Trachea
thorax), reduce tension in the chest muscles, and reduce
stresses that may contribute to attacks.
Chronic obstructive pulmonary disease (COPD) is a
condition in which the lungs are damaged due to genetic
predisposition, or long-term exposure to irritants. This
condition is often, but not always, related to smoking.
COPD has two main components: chronic bronchitis
and emphysema. In chronic bronchitis the tiny bron-
chioles that lead into the alveoli are irritated and filled
with mucus. In emphysema, the alveoli are over-inflated.
They may fuse together into larger bubbles, called
bullae. Emphysema interferes with breathing because
these bullae reduce surface area in the lungs, so less
Liver
Ascending
colon
Sigmoid
flexure
Xiphoid process
Spleen
Floating rib
Descending colon
Anterior superior iliac crest
Inguinal ligament
FIGURE 6-3 Endangerment sites of
the chest.
82 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
oxygen can enter the blood, and less carbon dioxide can leave. Breathing exercises and massage that focuses on reducing resistance in the breathing muscles may be helpful for people with COPD, if the condition is not too advanced.
3.
Acute bronchitis is an inflammation of the tubes leading from the trachea to the lungs in the upper respiratory tract. It is usually a bacterial infection that arises as a complication of cold or flu. It is typically short in duration, but can be severe. It is accompanied by coughing and heavy mucus production, along with a low-grade fever and constriction behind the sternum. Because it is an infection, it contraindicates massage until the symptoms subside and the patient starts to expel built-up mucus.
4.
Pneumonia is any infection of the lungs. It can be caused by viruses, bacteria, or other agents. Pneumonia can be contagious, and in some cases it can be life-threatening: it is the leading cause of death by infection in the United States. It contraindicates massage therapy until the patient is in recovery, at which point they may benefit from any work that helps to restore strength and vitality.
5.
Pleurisy is inflammation of the pleurae, the membranes covering the lungs. It causes the visceral and parietal layers of the pleurae to stick together, which drastically limits movement within the thoracic cavity. It causes difficulty in breathing and sharp pain under the ribs and extending into the abdomen. Pleurisy contraindicates massage therapy until the contributing factors have been resolved.
6. Rib fractures are broken bones, and best left alone until the bones have healed. They usually heal easily, but taping is sometimes required.
See Appendix A for more information on these conditions.
◗ POSTURAL EVALUATION
1.
Describe the general shape of the chest (see Fig. 6-4A–C).
r Do the right and left halves match? r Are the upper and lower portions symmetric?
2. Check the position of the sternum.
r Is it lifted? r Is it depressed?
3. Observe the position of the ribs.
r Where do the ribs appear to be squeezed together? r Where are the spaces between the ribs expanded?
4. Observe the breathing pattern. r Which phase of breath (inhalation or exhalation) is
favored, if any?
r
Which portions of the chest appear to move easily with the breath?
r Which portions of the chest appear to be rigid and
not moving with the breath?
5. Look at the region of the diaphragm, at the level of the lower ribs.
r Are the lower ribs spread apart and pulled up? r Do the lower ribs appear to be relaxed and hanging
downward?
r Are the lower ribs squeezed or drawn together?
Refer to Table 6-1 for a description of common distortions
of the chest and possible muscles involved.
◗ EXERCISES AND
SELF-TREATMENT
1.
Stretch for the Pectoralis Major Muscles. Stand in a doorway with your arms spread apart and your hands or forearms resting against the sides of the door frame

HOLISTIC VIEW

“I need to get something off my chest”
he chest serves as a container for the heart, and we identify the heart with feeling, especially with our ca-
T
pacity to experience and radiate love. Love is considered to be a warm emotion. It is often associated with fire. We feel the fires of passion burning, or the warm glow of a smoldering ember in our chest when we are in love. When the chest is open, our feeling expands outward to others and is returned to nourish our heart center.
A chest that is tight, closed, and shut off squeezes the heart, and reduces its capacity to produce warm, loving emotions. The fire has died, and we are left with the experience of cold-heartedness: the absence of both happiness and sadness.
When we let go of chronic tightness in the muscles of the chest cavity, we often feel an energizing of the heart­felt emotions. Tears may accompany the reconnection to the capacity for joy, sadness, affection, and intimacy.
The outward, expansive movement of the body that accompanies inhalation represents our capacity to give outwardly of ourselves, to share. The inward, contractive movement of expiration denotes our ability to receive, to surrender, to take in.
Balance of the mind/body system is reflected in a full, integrated breathing rhythm that allows us to shift easily between these two phases. The rib cage and abdomen are mobile, with the ability to change shape and size easily.
¢
A CB
FIGURE 6-4 Postural evaluation: anterior chest.
Chapter 6 The Fundamentals—Breath and Support 83
TABLE 6-1 | Body Reading for the Chest
Muscles That May Be
Postural Patterns
Overexpanded chest—the sternum is lifted, ribs are expanded, shoulders drawn back
Hollow chest—the sternum is depressed, upper ribs are compressed, shoulders are pulled forward
Shortened
Scalenes External intercostals Rhomboids
Pectoralis major Pectoralis minor Subclavius Internal intercostals Anterior deltoid Diaphragm Rectus abdominus
(Fig. 6-5). Shifting your weight forward from your pelvis, allow the back to arch slightly and the chest to lift and stretch. Breathe deeply. Positioning the arms higher or lower along the sides of the door frame will alter the muscle fibers being stretched.
2. Stretch for the Chest and Abdomen. Lie on your back across a bed with your midthoracic spine on the side edge of the mattress so that your upper body can hang down toward the floor, with the arms extended. Take deep breaths. Alternative surfaces are an exercise ball (Fig. 6-6), the arm of a large couch, or several blankets rolled up tightly into the shape of a cylinder at least 18 inches in diameter and fastened with belts or rope.
3.
Self-Massage for the Contracted Diaphragm and Serratus Posterior Muscles. Lie on your back on the floor. Place
FIGURE 6-5 Using a door frame to stretch the pectoral muscles.
84 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
two tennis balls on either side of the low back, at the level of the 12th rib. Slowly allow your weight to sink into the balls as you relax, and breathe fully.
◗ CHEST ROUTINE
FIGURE 6-6 Stretching the chest
and abdominal muscles.
Objectives
r To restore the chest cavity to its full volume r To resolve inhibiting factors in the breathing muscles r To integrate effective breathing patterns r To realign the shoulders and ribs
Energy
POSITION
r
The client is lying supine on the table, with a bolster under the knees.
r The therapist is standing at the side of the table next to
the client’s chest.
POLARITY
The left palm is placed over the manubrium, and the right palm slides under the back and is positioned between the shoulder blades. Envisioning the smooth, pump-like motion of the lungs, the therapist’s hands move in accordance with the rising and sinking of the client’s thorax with each breath. The position is held for at least 1 minute, allowing the client time to relax and focus on the breath.
SHIATSU
Moving to the head of the table, the therapist presses the finger pads into the intercostal spaces on both sides of the upper chest simultaneously to stimulate points on the lung, stomach, and kidney channels (Fig. 6-7). The fingers move to different spaces, covering the upper chest
DAR
FIGURE 6-7 Fingertip compressions of the intercostal spaces.
area thoroughly. Each set of fingertip compressions is held for the length of the client’s exhalation and is released as the client inhales.
Swedish/Cross-Fiber Massage
1.
Shingles Stroke on the Pectoralis Major Muscles. The therapist stands on the side of the table at the client’s shoulder level. One hand is placed on the opposite side of the upper chest from the side on which the therapist is standing, with the heel of the hand against the sternum and the fingers facing the client’s shoulder. Perform short, alternate strokes with the palms across the chest to the client’s shoulder. Repeat several times.
2.
Petrissage Strokes on the Pectoralis Major Muscles. Each side of the chest may be worked individually, or both sides may be worked simultaneously.
3.
Fingertip Raking Across the Upper Chest Muscles. Slide the fingers in both directions perpendicular to the direction