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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5548_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 9 Stabilizing the Core 195
FIGURE 9-32 Sit-down exercise to strengthen
rectus abdominus.
FIGURE 9-33 Stretch for rectus abdominus.
Energy
POSITION
r
The client is lying supine on the table, with a bolster under the
knees. Female clients are covered with a separate chest drape.
r The therapist is standing at the side of the table next to
the client’s waist.
POLARITY
Place the left palm (negative pole) on the abdomen (positive
pole). Slide the right palm (positive pole) underneath the
client’s back to contact the lumbar spine (negative pole). Your
palms should be aligned to each other vertically through the
client’s trunk. Keep your hands relaxed, allowing them to mold
to the contours of the client’s body and to be moved by the
motions generated by the client’s breathing action. During
this polarity hold, focus on feelings of trust and nurturing,
allowing the client to become accustomed to being touched
in the abdominal region. Hold for at least 1 minute.
SHIATSU
Slide the fingers of both hands under the client’s back,
palpating the lateral edge of the erector spinae in the
lumbar region with your fingertips. Straighten the fingers,
allowing the weight of the client’s trunk to rest on your
fingertips. Repeat on the other side of the back. The outer
branch of the bladder channel runs along the lateral border
of the erector spinae. This move helps to relax tightness
in the muscles of the low back, allowing the lumbar spine
to decompress.
Swedish/Cross Fiber
1. Perform circular effleurage on the abdomen.
2.
Perform two-handed petrissage on both sides of the torso,
between the rib cage and pelvis.
3.
Perform circular friction around the abdomen in a
clockwise direction.
4. Perform fingertip raking across the abdominal muscles.
196 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
Connective Tissue
Place your right palm on the abdomen, over the navel area.
Place your left palm on top of your right hand. Make a slow,
clockwise spiraling motion, moving the skin over the underlying tissues. Do not glide over the skin. Gradually increase
the size of the spiral, stretching the skin and fascia as far as
they can comfortably go.
Deep Tissue/Neuromuscular Therapy
SEQUENCE
1. Abdominal muscle attachments on the iliac crest
2. Inferior border of the costal cartilage of the ribs
3. Abdominal muscle attachments on the ribs
4. Rectus abdominus
5. Obliques—external and internal
6. Transverse abdominus
7. Quadratus lumborum
a. 12th rib attachment—tendon
b. Iliac crest attachment—tendon
c. Belly—muscle fibers
Trigger point patterns in the abdominal muscles are not as predictable as those in other
muscle groups. The referred pain from these
trigger points is often mistaken for visceral pain. Trigger
points in these muscles often cause pain bilaterally.
Check all muscle attachments thoroughly, feeling
for strings and lumps that are frequently found around
trigger points. The origin of the rectus abdominus at the
pubic symphysis often harbors trigger points, as does its
insertion along the inferior border of the rib cage, just
lateral to the xiphoid process.
Abdominal Muscle Attachments on the Iliac Crest
(External and Internal Obliques and Transverse
Abdominus)
Strokes
r Stand at the side of the table, and face the upper border
of the client’s iliac crest. Placing one or both thumbs on
the upper border of the iliac crest, apply short, side-to-side
strokes against the inner edge of the bone.
r
Continue around the pelvis as far as your hand can reach.
Inferior Border of the Costal Cartilage of Ribs 7 to
10 (Transverse Abdominus)
Strokes
r
Placing the thumbs just lateral to the xiphoid process,
apply short, side-to-side strokes along the inferior border
of the rib cage to the tip of rib 11.
Abdominal Muscle Attachments on the Ribs
See Figure 9-34 for muscle attachments on the ribs.
Rectus Abdominus
Strokes
r Place your fingers on the costal cartilages of ribs 5 to 7,
next to the xiphoid process.
r
Using short, up-and-down and side-to-side strokes with
your fingertips, try to reduce tension in the muscular
attachments.
External Obliques
Strokes
r
The attachments for this muscle are on the lower eight ribs,
interweaving with the serratus anterior. Place your fingers
on rib 5, near the sternum. Perform short, up-and-down
and side-to-side strokes on the rib.
r Continue to work the attachments on each rib, in succes-
sion. On each rib, slide your fingers a little further laterally
to make contact with the muscle insertion. Use the border
of the serratus anterior for a guideline.
Internal Obliques
Strokes
r The muscle attaches on the costal cartilages of ribs 8 to
10. Place your fingers or thumbs along the lower portion
of rib 8, just lateral to the rectus abdominus. Apply short,
side-to-side and up-and-down strokes on the attachment.
r
Moving slightly lateral, slide down to rib 9. Repeat the
same strokes on the attachment and then repeat once
more on the rib 10 attachment.
Rectus Abdominus
Origin: Medial tendon from the pubic symphysis, lateral
tendon from the crest of the pubis.
Insertion: Costal cartilages of ribs 5 to 7, xiphoid process.
Action: Flexion of the spine, posterior tilt of the pelvis;
compresses abdominal contents.
Strokes
r Place your fingers next to the midline of the upper abdo-
men, just below the rib cage.
r
Using a spreading technique, slide your fingers across
the fibers of the muscle (Fig. 9-35). Pause and work on
abnormalities in the muscle tissue with side-to-side strokes.
Address trigger points as they are found. Continue, working
in strips, down the rectus abdominus. Be sure to palpate
the tendinous sheath between each section of the muscle.
Avoid pressure on the linea alba, which is the fascial line running down the midline of the rectus
abdominus that joins its right and left halves. The
aorta runs down the center of the trunk just deep to this
area. If you feel a strong pulse under your fingers when
massaging the rectus abdominus, immediately move off it.
Rectus abdominus
External obliques
Internal obliques
Chapter 9 Stabilizing the Core 197
DAR
FIGURE 9-35 Cross-fiber technique on the rectus abdominus.
r
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QVCJDTZNQIZTJT6TJOHTIPSUTJEFUPTJEFTUSPLFTDPOUBDU
UIFBUUBDINFOUPGUIFSFDUVTBCEPNJOVT
David Rini
Be sure that the client is comfortable with this pro-
cedure before attempting it. Describe the move to
the client and establish permission in the presession interview. Then repeat this question during the session before
proceeding.
FIGURE 9-34 Abdominal
muscle attachments on the
ribs.
External and Internal Obliques
Obliquus Externus Abdominis
Origin:3JCTUPJOUFSEJHJUBUJOHXJUIUIFTFSSBUVT
BOUFSJPS
Insertion:"OUFSJPSQBSUPGUIFJMJBDDSFTUBCEPNJOBM
BQPOFVSPTJT
Action:'MFYJPOPGUIFUSVOLCJMBUFSBMMZMBUFSBMGMFYJPO
PGUIFUSVOLBOESPUBUJPOPGUIFUSVOLVOJMBUFSBMMZ
TVQQPSUBOEDPNQSFTTJPOPGBCEPNJOBMWJTDFSBBTTJTUTJO
GPSDFEFYIBMBUJPO
Obliquus Internus Abdominis
Origin:5IPSBDPMVNCBSGBTDJBMBUFSBMUXPUIJSETPGUIFJO
HVJOBMMJHBNFOUBOUFSJPSUXPUIJSETPGUIFJMJBDDSFTU
Insertion:$BSUJMBHFTPGSJCTUPBCEPNJOBMBQPOFVSP
TJTUPUIFMJOFBBMCB
198 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
Action: Flexion of the trunk (bilaterally), lateral flexion
of the trunk and rotation of the trunk (unilaterally),
support and compression of abdominal viscera; assists in
exhalation.
Strokes
r Begin lateral to the border of the rectus abdominus. Do a
spreading stroke, with your fingers across the direction of the
fibers, as described above. Remember that the fibers of the
external obliquus angle on a lateral diagonal, so cross-fiber
strokes on the muscle are performed on a medial diagonal
perpendicular to the fibers (Fig. 9-36A). The fibers of the
internal obliquus angle on a medial diagonal, so cross-fiber
strokes on the muscle are performed on a lateral diagonal
that is perpendicular to the fibers (Fig. 9-36B).
r Continue outward to the lateral border of the latissimus
dorsi on the side of the body. Cover the muscles thoroughly, pausing at tender areas and working in detail on
tissues that feel aberrant. It is important to visualize the
muscle you are working on under your fingers to be able
to palpate it effectively, because the abdominal muscles
overlap each other.
DAR
A
Transverse Abdominus
Origin: Lateral third of the inguinal ligament, anterior
two-thirds of the lip of the iliac crest, thoracolumbar
fascia, costal cartilages of ribs 7 to 12.
Insertion: Abdominal aponeurosis to the linea alba.
Action: Compresses the abdomen, assists in forced
exhalation.
Strokes
r Place your fingers next to the lateral border of the rectus
abdominus, facing in a superior direction. Apply short,
up-and-down strokes across the muscle fibers, covering
the area between the base of the rib cage and the iliac
crest thoroughly (Fig. 9-37).
Quadratus Lumborum
Origin: Inner lip of the iliac crest, iliolumbar ligament.
Insertion: Lower border of the 12th rib, transverse process
of L1–L4 vertebrae.
Action: Extension of the lumbar spine (bilaterally), lateral
flexion of the spine (unilaterally), fixation and depression of the 12th rib.
Trigger points in the superficial layer of the
muscle are located in the lateral section, with
one near the attachment on the 12th rib and
the other near the attachment on the iliac crest. Pain
from the 12th rib attachment point is referred along the
iliac crest and gluteus medius region. The referral zone
for the iliac crest attachment point is to the greater trochanter and outer thigh area.
Two trigger points in the deeper layer are found near
the transverse process of L3 and between the transverse
processes of L4 and L5. The trigger point at L3 refers
pain to the sacroiliac joints and across the upper sacral
region. The second trigger point lower down refers pain
to the lower gluteal area.
DAR
B
FIGURE 9-36 A. Cross-fiber technique on external obliques.
B. Direction of cross-fiber strokes on internal obliques.
DAR
FIGURE 9-37 Cross-fiber technique on the transverse abdominus.
Chapter 9 Stabilizing the Core 199
Position
r Place the client in side posture. Place a bolster between
the knees and a small support under the side of the head. A
bolster may also be placed between the side of the client’s
waist and the table. Have the client stretch the topmost
arm overhead.
r The therapist stands behind the client.
Strokes
r
Place your front hand on the client’s hip for support. Using
the heel of your back hand, do deep, circular friction on
the muscles from the 12th rib to the iliac crest.
r
Slide your thumbs upward, along the lateral border of the
erector spinae, until the 12th rib is felt. Using the thumbs
or a knuckle, do short, side-to-side strokes across the underside of the rib to the spine. It is likely that knotted areas
and trigger points will be found here.
r
Turn to face the iliac crest. Apply short, side-to-side strokes
along the superior border of the iliac crest with the knuckle
or thumbs, pausing at tender points.
r Standing behind the client’s waist, place both palms on
the side of the torso with the thumbs pointed downward
toward the spine. Finding the edge of the erector spinae,
slide the thumbs slightly anterior, and press downward
toward the transverse processes of the spine (Fig. 9-38). Be
careful not to push into the tips of the bones. Perform short,
up-and-down and side-to-side strokes along the quadratus
lumborum. Work between the 12th rib and the iliac crest.
STRETCH
1.
Quadratus Lumborum and Obliques. The client is lying
in side posture and slides to the edge of the table near the
therapist. The bottom leg is flexed at the knee. The top leg
is straight, and the uppermost arm is stretched overhead,
grasping the end of the table. Place one hand on the client’s
uppermost arm and the other hand on the client’s top leg.
The straightened top leg is positioned behind the bottom
leg so that it can hang off the side of the table. As you push
down on the top arm, press the leg toward the floor until
a stretch is felt in the quadratus lumborum (Fig. 9-39).
2.
Rectus Abdominus. The client is lying supine and
slides the heels toward the hips, keeping the feet flat
on the table and with both knees flexed. The arms are
stretched overhead, reaching toward the head of the table
(Fig. 9-40). If further stretch is required, a bolster may
be slid under the client’s back.
ACCESSORY WORK
1.
This work should be done in conjunction with the
pelvic session.
2. Reflexologists claim that the solar plexus reflex point is
located on the sole of the left foot slightly inferior to the
bases of the metatarsal bones of the first through third
toes (Fig. 9-41). Pressing this point is intended to bring
relaxation to the upper abdominal region.
FIGURE 9-38 Contacting the lateral
border of the quadratus lumborum.
200 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
FIGURE 9-39 Stretch for the
quadratus lumborum and obliques.
FIGURE 9-40 Stretch for the rectus abdominus.
Solar
plexus
Lumbar
spine
Chapter 9 Stabilizing the Core 201
DAR
FIGURE 9-41 Reflex zones on the foot to accompany an abdomen
session.
3. The traditionally recognized reflex zone for the lumbar
spine is along the medial side of the instep on both feet,
in the space between the first cuneiform bone and the
calcaneus. Press this point to help relieve low back stress
and pain.
CLOSING
Sitting at the foot of the table, lightly hold the heels of the
client’s feet in your hands for 30 to 60 seconds. Remove your
hands slowly to complete the session.
◗ INTESTINES ROUTINE
Swedish/Cross Fiber
POSITION
r The client is lying supine on the table with a bolster un-
der the knees. Female clients are covered with a separate
chest drape.
r
The therapist is standing at the side of the table at the level
of the client’s waist.
FIGURE 9-42 Cross-fiber fingertip raking on the rectus abdominus.
1. Perform circular effleurage on the abdomen.
2. Perform cross-fiber fingertip raking on the abdominal
muscles (Fig. 9-42).
Connective Tissue
Placing the right palm on the abdomen over the navel and
the left palm over the right hand, begin an outward spiraling,
clockwise motion, stretching the fascia of the abdomen.
Deep Tissue/Neuromuscular Therapy
Large Intestine
Strokes
r
Reach across the table, and place your fingers lateral to the
ascending colon, on the right side of the client’s abdomen
(Fig. 9-43). Gently draw the fingers inward, against the
edge of the large intestine, without gliding over the skin.
Continue tracing the border of the colon with your fingers,
pulling it away from the outer edge of the abdomen until
you reach the midline of the body. Walk around to the
right side of the table, and continue pulling the fingers
inward, along the border of the large intestine, until you
reach the left ASIS.
r
Beginning at the ileocecal valve, do slow, circular fingertip
friction over the large intestine, tracing its entire length
around the abdominal cavity (Fig. 9-44).
202 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
DAR
FIGURE 9-43 Contacting the lateral border of the large intestine.
DAR
r
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BOETJEFUPTJEFTUSPLFTXJUIZPVSGJOHFST PWFSUIFMBSHF
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Discuss your plans for abdominal massage with
your client in the presession interview, and ask permission again before beginning work in this area. Pay close
attention when applying pressure over the intestines.
Never push against resistance. Elicit client feedback often,
and move very slowly.
Small Intestine
Strokes
r $VQQJOHZPVSQBMNDVSWFBOETQSFBEUIFGJOHFST1MBDF
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1SFTTEPXOBOEDJSDMFUIFGJOHFST'JH
ACCESSORY WORK, INTESTINES
Reflex Points on the Feet
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PGUIFBCEPNJOBMPSHBOT4FF'JHVSFGPSBOJMMVTUSBUJPO
PGUIFSFGMFY[POFPGUIFMBSHFJOUFTUJOF
Ileocecal Valve Point5IJTQPJOUJTMPDBUFEPOUIFIFFM
MJOFPOUIFMBUFSBMTJEFPGUIFSJHIUGPPU4VQQPSUUIFIFFM
PGUIFDMJFOUTSJHIUGPPUXJUIZPVSSJHIUIBOEBTZPVQSFTT
UIFJMFPDFDBMWBMWFQPJOUXJUIZPVSMFGUUIVNC
Intestinal Reflex Zone5PMPDBUFUIJT[POFEJWJEFUIFTPMF
PGUIFGPPUJOUPRVBSUFSTFYDMVEJOHUIFUPFT5IFJOUFTUJOBM
FIGURE 9-44 Sequence of deep tissue strokes on the large
intestine.
David Rini
FIGURE 9-45 Massaging the small intestine.
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MJOF5PDPWFSUIFBSFBUIPSPVHIMZCFHJOBUUIFJMFPDFDBM
QPJOUPOUIFSJHIUGPPU1SFTTPOUIFQPJOUXJUIUIFQBEPG
ZPVSMFGUUIVNC.PWFUIFUIVNCTMJHIUMZGPSXBSEBOE
QSFTTPOUIFOFYUQPJOUBQQSPYJNBUFMZPOFTJYUFFOUIPG
BOJODIJOGSPOUPGUIFGJSTUQPJOU5IF UIVNC IJOHFT
TMJHIUMZGSPNUIFKPJOUPGUIFGJSTUQIBMBOY
Ileocecal
valve
FIGURE 9-46 Reflex zone for the large intestine.
Chapter 9 Stabilizing the Core 203
Energy
POSITION
r
The client is in side posture, with a small pillow under the
head. The leg lying against the table is slightly flexed. The
top leg is flexed 90°, with a bolster placed under the knee.
r The therapist is standing behind the client’s hip.
POLARITY
Place the palm of your top hand on the client’s hip and your
bottom hand on the side of the knee. Breathe deeply and
rhythmically, envisioning the client’s thigh area relaxing
between your two hands. Hold for at least 30 seconds.
SHIATSU
1.
Top Leg. Using your forearm, perform shiatsu compression
movements along the side of the hip, from the iliac crest
to the greater trochanter (Fig. 9-47). Both you and the
client should exhale each time you lean your forearm
into the hip. Continue the compression movements down
the side of the leg to the knee. The gallbladder channel
traverses this area.
2.
Bottom Leg. Using your palm or the tiger’s mouth
position of the hand (the webbing between the thumb
and index finger), perform shiatsu compression movements on the inner thigh, from the pelvis to the knee
(Fig. 9-48).
Continue to move with the thumb tip across the foot in
a horizontal direction toward the medial side, covering all
points. To access the next strip of points, begin again on the
lateral edge of the foot, above the first horizontal line. Repeat
the sequence until the entire zone is covered. Switch hands,
and repeat the entire sequence, with the exception of the
ileocecal point, on the left foot.
CLOSING
Sitting at the foot of the table, lightly hold the heels of the
client’s feet in your hands for 30 to 60 seconds. Remove your
hands slowly to complete the session.
◗ LATERAL THIGH/INNER THIGH
ROUTINE
Objectives
r
To balance the muscular action of the inner and outer thighs
r To address uneven pulls on the pelvis coming from thigh
muscles that attach on it
Deep Tissue/Neuromuscular Therapy
SEQUENCE
Lateral Thigh
1. Vastus lateralis
2. Iliotibial tract
3. Tensor fascia latae
Inner Thigh
1. Pes anserinus
2.
Adductor muscles—adductor magnus, brevis and longus;
pectineus, and gracilis
◗ LATERAL THIGH
Swedish/Cross Fiber
POSITION
r
The therapist moves to the front side of the table and faces
the client’s top leg.
204 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
FIGURE 9-47 Forearm compression down the side of the hip.
DAR
FIGURE 9-48 Tiger’s mouth position on the inner thigh.