Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5548_Библиотеки_им_академика_М_И_Перельмана.pdf
SESSION IMPRESSION
Chapter 5 Connective Tissue 55
CONNECTIVE TISSUE CHANGES
he client is a 36-year-old woman named Margaret, who
T
works in sales. She views her job as fairly high stress.
She is constantly dealing with people, either in person or
on the telephone. Although she exercises regularly, doing
stretching and aerobics at least three times a week, she
feels unable to relax fully. At times, it is difficult to take
a deep breath, because her chest cavity feels muscularly
tight and constricted. Her blood pressure is borderline
high. Her goal in seeking massage therapy is to be able
to relax and reduce the feelings of muscular tension that
build up on a daily basis.
On observation, her muscles appear to be well toned.
She was athletic in high school, having been on the swimming team, and her body still has an athletic quality. The
musculature in her upper trunk and shoulders appears
constricted. Her shoulders are medially rotated, with a slight
degree of kyphosis in the upper back, and her sternum is
depressed, causing her chest to appear somewhat sunken.
Her head projects forward, causing the T1 vertebra to be
prominent. There is a build-up of connective tissue around
the upper thoracic vertebrae. Her pelvis is posteriorly rotated, and she stands with her knees slightly flexed. This
postural stance points to short hamstring muscles. Overall,
she appears vertically compressed when standing, as if she
were carrying a heavy load on her shoulders.
The plan for the initial session was to help relieve the
feelings of muscular constriction caused by built-up stress
and to open the chest and shoulder region so that she can
experience fuller breathing. Future sessions will deal with
lengthening the spinal column and bringing the head and
pelvis into a better relationship with each other.
Soon after the session began, it became apparent that
the client was unable to accept deep, direct pressure to the
muscles. The muscles were tight. When moderate pressure
was applied, the client reported feeling uncomfortable pain,
and her upper body retreated further
into its medially rotated stance. The
therapist decided that a connective tissue
approach was the preferred treatment for this
client. The fascial compartments needed to be
stretched so that her muscles could lengthen. The
client was uncomfortable with firm pressure and did
not like sustained pressure to specific areas of soft tissue,
even when the contact was light.
Myofascial mobilization and spreading techniques
were applied to the pectoralis major, pectoralis minor,
and serratus anterior to help expand the chest region and
widen space across the shoulder girdle. The fanning stroke
was also used in the upper thoracic region to help lift the
sternum. Long Swedish strokes, combined with connective tissue spreading, were used on the rest of the body
to promote feelings of length and relaxation. Overhead
stretching of the arms was used at the end of the session
to stretch the chest.
The client reported feeling much lighter at the end
of the session. Her breathing felt much fuller without
forcing it. Her comment was, “I feel like a burden has
been lifted off of me.”
Topics for Discussion
1.
What are some indications that a connective tissue
approach should be the primary course of treatment
for a particular client?
2. Explain the reasons for performing connective tissue
strokes slowly.
3. What kind of self-care treatment would be most bene-
ficial for a client receiving connective tissue massage?
4.
How would you explain to a client why connective tissue
strokes feel different from other massage techniques
that he or she may have received?
5. Why is connective tissue therapy a useful addition to
any other form of massage treatment?
Working with Fascia
Different areas of the body have different capacities for movement and stretch. Part of this depends on a history of injury,
patterns of muscle holding, and postural habits, but much
of it is related to the density of the fascial structure, and the
ratio of collagen to elastin fibers. When the condition of fascia
is not optimal, the integrated deep tissue therapist works to
restore whatever capacity for freedom of movement might be
possible. Working to improve the quality of the fascia requires
56 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
BOX 5-1 | Fascial “Release”: What Does the Science Say?
What really happens when we sense that fascia
softens or releases? This is an interesting question,
and it is difficult to answer.
The traditional thinking has suggested that the
heat and movement associated with massage or
other manual therapies may influence the fluid medium that suspends the cells and protein fibers of
fascia to become looser (a thixotropic effect), but
research shows that this result only lasts as long as
the tissue is directly heated; the fluid medium in
connective tissue returns to a gel state almost immediately when heat is removed.
1
Another possibility is that the mechanical distortion of the fascia stimulates the many proprioceptors
located there. Among these are Ruffini receptors,
which are especially sensitive to sustained shearing
pressure. The response to these mechanoreceptors
may cause local capillary dilation, increased passage
of fluid into the local area, and a nearby reduction in
muscle tone as some motor units stop firing.
2
However, Ruffini nerve endings comprise only a small portion of the many mechanoreceptors located in fascia,
so it is probable that the much smaller and more
numerous “interstitial” receptors are also involved
in any reflex arc activity that impacts CNS signals to
motor units. However, this has not yet been demonstrated, so it is only a theory at this point.
Noting that collagen behaves like “liquid crys-
tal”, some researchers wondered whether the
changes seen in fascia might be due to the production of an electrical charge when fascia is deformed (piezoelectricity).
3
However, this theory has
never been rigorously tested, and the significance
of any fascial electrical change has never been
demonstrated.
Finally, we must consider whether some sense of
“release” comes from the reduction of adhesions
between fascial layers. Again this is difficult to
demonstrate scientifically, so we would not really
know until we have imaging technology to show
us. Research shows that massage can resolve interperitoneal adhesions after surgery in rats,
4
but
human studies have not shown such a clear result.
It is safe to say that massage therapy can have a
profound effect on certain kinds of scars,
5–7
but
whether we are manually separating layers of fascia
between or within muscles is difficult to determine.
The power of manual therapy to affect the palpable quality of fascia is clear, but the mechanisms
are still being explored. For this reason, we have
to be very careful about the language we use: “release of the fascia” may turn out to be an incorrect
description of what really happens. As we learn
more through research, we gain the tools to become increasingly effective for our clients. This is
why it is so important to stay informed about what
the science says about muscles, fascia, and massage therapy.
sensitivity to the limits of a particular area: tissue is taken
to its stretch point, and then patiently held until a sense of
softening or lengthening is perceived. Tissue is never forced
beyond its capacity to yield.
Because contractile muscle fibers and their fascial
membranes are so intricately intertwined, it is physically
impossible to touch one without affecting the other. The
therapist’s intention while manipulating tissues is the key
to distinguishing which component of the myofascial unit
is being emphasized. Helpful images for sensing softening
when working with fascia can include visions of an ice cube
Connective Tissue Routine
This description of the connective tissue procedures in this
chapter does not include the specific muscles being addressed,
slowly melting on a sidewalk, or a flower opening, or butter
melting in a frying pan.
As the therapist’s hands are placed on the body, pressure
is applied only to the point at which resistance is first felt in
the muscle tissue. This might be registered as a slight recoil
or a feeling of the tissue thickening. The therapist then waits
for a softening of the resistance, which allows his or her
hands to continue to glide through the tissue until further
resistance is encountered. This slow, methodical sensing of
the tissue’s reaction to the therapist’s manipulation assures
that the state of the fascia is being affected (see Box 5-1).
because the goal of these strokes is to stretch the fascial
membranes that wrap all of the muscles. The therapist’s focus
DAR
Chapter 5 Connective Tissue 57
FIGURE 5-2 Lifting and rolling the superficial
fascia of the upper chest.
while performing these strokes is on sensing the softening and
stretching of the tissues in response to the slow movements
of the hands.
The techniques described here are meant to be incorporated
into the lessons of the following chapters in the “connective
tissue” sections of the protocols. This will allow therapists to
provide the benefit of both fascial and muscular softening
for their clients.
The body regions are presented here in the same order as
they appear in Chapters 6 to 10.
◗ CHEST
Position
r The client is lying supine.
r The therapist is standing at the side of the table.
1. Fascial Lift and Roll Technique. Grasp the skin of the
upper chest lightly between your thumb and fingers.
Slowly, roll it superiorly toward the clavicle (Fig. 5-2).
Cover as much of the chest as you can. When working
with female clients, avoid the breast tissue.
2. Fanning Strokes on the Upper Chest. Place the fingers
of both hands on the sternum. Sink into the tissues,
and spread slowly outward from the midline with a
fanning stroke (Fig. 5-3). Repeat the stroke several times,
moving in a superior direction toward the clavicles.
3. Myofascial Mobilization of the Tissues Over the Ribs.
For female clients, drape the breast area for this section.
Beginning at the lower portion of the rib cage, place
your fingers on the lowest ribs, and slide the tissues up
and down over the rib (Fig. 5-4). Feel for areas where
the tissue either does not move or feels like it is sticking
to the rib. Work to free all the tissue. Progress up the
rib cage, working over each rib until you reach the
clavicle. Repeat on the other side of the chest.
4. Compress and Spread the Chest Tissues. Holding the
wrist, abduct the client’s arm 90°, and flex it at the elbow.
Move the arm into various stretched positions while you
compress and spread the stretched myofascial tissues of
the chest with the heel of your other hand (Fig. 5-5).
◗ BACK
Position
r The client is lying prone.
r The therapist is standing at the head of the table.
1.
Myofascial Mobilization of the Back. With your fingertips or palms, sink into the tissues enough to be able
to move the skin without sliding over it. Using a short
up-and-down and side-to-side motion, move the skin
over the underlying tissues (Fig. 5-6). Work in small
sections, and cover the entire back. This procedure
can also be performed with a rolled-up towel to move
the skin.
2.
Myofascial Spreading of the Back. Standing at the side
of the table, sink into the tissues with your fingers or
knuckles. Glide through the tissues with a spreading
58 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
FIGURE 5-3 Fanning stroke on the chest.
DAR
FIGURE 5-4 Myofascial mobilization of the tissues over the ribs.
motion, moving as the fascia softens and pausing at
resistance. Begin the stroke at the spine, and move
outward in horizontal motions across the back (Fig. 5-7).
If using the fingers, work on the opposite side of the
client’s back from the side of the table where you are
standing, and stroke from the spine away from yourself.
When using the knuckles, work on the same side of
the back, and stroke from the spine toward yourself.
3.
Myofascial Release of the Tissues Over the Bones. Using
a circular friction motion, roll the myofascial tissue over
the bones. In the upper back, roll the tissues over the
ribs and scapulae. In the lower back, roll against the
12th rib, the lumbar spine, and the iliac crest.
Back Stretch. Have the client lift up onto his or her
4.
hands and knees while under the sheet and then sit
back on the heels, resting the chest on the thighs and
the forehead on the table in front of the knees to stretch
the muscles of the back (Fig. 5-8).
◗ ARM
Position
r The client is lying supine.
r The therapist is standing at the side of the table, next to
the client’s hand.
1. Myofascial Spreading of the Palm. The client’s palm
is facing away from the therapist. Using both hands,
curve your fingers under the client’s hand, pressing
your fingertips into the palm. Slowly slide your hands
apart, stretching the tissues of the palm (Fig. 5-9).
Perform this move very slowly, and pause to allow the
fascia to stretch.
2.
Fascial Lift and Roll Technique. The client’s arm is
resting on the table. Place your hands in the skin rolling position, parallel to the muscle fibers, above the
client’s wrist. Roll and lift the tissues of the forearm,
in horizontal strips, from wrist to elbow (Fig. 5-10).
3. Myofascial Spreading of the Forearm. Flex the client’s
arm at the elbow. Place your hands around the forearm
at the wrist, with your fingers sinking into the midline
of the palmar side of the forearm using the same hand
position as described in move 1. Slowly spread the
fingers away from the midline, stretching the tissues
Chapter 5 Connective Tissue 59
FIGURE 5-5 Compressing and
spreading the myofascial tissues of the
chest.
DAR
FIGURE 5-6 Myofascial mobilization of the
back.
60 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
DAR
FIGURE 5-7 Myofascial spreading of the back.
FIGURE 5-8 Back stretch from a kneeling position.
Chapter 5 Connective Tissue 61
FIGURE 5-9 Spreading the fascia of the palm.
FIGURE 5-10 Lifting and rolling the forearm tissues.
62 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
FIGURE 5-11 Myofascial spreading of the
forearm.
(Fig. 5-11). Continue, in horizontal strips, to the elbow.
Repeat the move on the other side of the forearm.
4.
Myofascial Spreading of the Upper Arm. The client’s
arm is lying on the table. Begin the stroke just above
the elbow. Using the heels of your hands or the
broad side of your thumbs, spread the tissues evenly
from the midline out to the edges of the upper arm
(Fig. 5-12).
FIGURE 5-12 Myofascial spreading of the upper arm.
DAR
◗ FOOT
Position
r The client is lying supine.
r The therapist is standing at the side of the table next
to the client’s foot and is facing away from the client’s
head.
1.
Myofascial Spreading of the Plantar Surface of the Foot.
Stand at the side of the table, and face the dorsal side
of the client’s foot. Curve the fingers of both hands
around the underside of the foot. Sink your fingers into
the sole of the foot until mild resistance is felt. Slowly
spread your fingers from the midline to the outer edges
of the foot (Fig. 5-13).
2.
Myofascial Mobilization on the Dorsal Side of the Foot.
Standing at the base of the table, place your fingers
on the dorsal surface of the foot. Slide the tissues up
and down and side to side in small sections (Fig. 5-14).
Cover the entire surface of the foot.
3. Fascial Stretching of the Foot
a.
Grasp the client’s toes with one hand while holding
the metatarsal portion of the foot with the other
hand. Flex the toes forward and back to stretch the
foot (Fig. 5-15).
DAR
FIGURE 5-13 Myofascial spreading of the plantar surface of the
foot.
Chapter 5 Connective Tissue 63
FIGURE 5-15 Fascial stretching of the foot.
b.
Hold both sides of the client’s foot with your
hands. Shift the bones of the foot back and forth
by alternately moving one hand toward you and
the other hand away from you in a continuous
motion (Fig. 5-16).
DAR
◗ LEG
Position
r The client is lying supine.
r The therapist is standing at the side of the table next to
the client’s ankle.
1.
Myofascial Spreading of the Leg. Place the hands
around the tibia, with the heels of the hand meeting at
the midline of the leg. Slowly spread the hands apart,
with pressure against the base of the palms (Fig. 5-17).
Begin the sequence at the ankle. Moving in horizontal
strips, work your way up the leg to the knee.
2. Myofascial Mobilization of the Leg. Using the fin-
gers or knuckles, roll across the lateral leg muscles
until they slide freely over the bone (Fig. 5-18).
Begin at the ankle, and work in horizontal strips
up to the knee.
3.
Fascial Stretches for the Leg. With one hand on the
ankle and the other hand on the metatarsal, alternately
flex and extend the client’s foot. Place one palm on the
dorsal surface of the foot and the other palm on the
plantar surface of the foot. Invert the foot, and then
hold, allowing the myofascial tissues to stretch. Evert
the foot, and hold.
FIGURE 5-14 Myofascial mobilization on the dorsal side of the
foot.
◗ CALF
Position
r The client is lying in a prone position.
64 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
FIGURE 5-16 Position for foot stretch (A and B).
DAR
FIGURE 5-17 Myofascial spreading of the leg.
FIGURE 5-18 Myofascial mobilization of the leg.