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Breath of life

Respiration is arguably the most vital human function. Struggling for breath is surely the most incapacitating and soul-destroying aspect of any illness.


Respiration is arguably the most vital human function. Struggling for breath is surely the most incapacitating and soul-destroying aspect of any illness. It is gratifying to know that as massage therapists, we can make a difference for patients suffering from a respiratory condition.

This article does not pretend to teach a cure for asthma or chronic obstructive pulmonary disease (COPD). However, the important role of muscle tissue in respiration is without dispute. Hence, by treating the muscles of respiration, we can improve a patient’s quality of life.

COPD indicates disease that blocks airflow (e.g. chronic bronchitis, emphysema). Lung damage cannot be reversed, but medical treatment is aimed at treating symptoms and minimizing further damage. As with asthma, symptoms include shortness of breath, wheezing, chest tightness and chronic cough, which exacerbates respiratory muscle tightness.

As with any extreme and prolonged physical effort, muscles develop holding patterns. This can be described as a low to moderate involuntary sustained contraction of parts or all of the muscle. This is also true for the respiratory muscles. Chronic, laboured breathing compounded with coughing will put inordinate stress on muscles such as the scalenes, intercostals and the diaphragm. Consequent muscle pain referral can result in low back pain (diaphragm) and chest pain (intercostals and scalenes), compounding the patient’s misery. Respiratory illness can cause a myriad of conditions and result in extreme and often unforeseen symptoms.

Treating the diaphragm
The diaphragm is an umbrella-shaped muscle spanning the thoraco-lumbar junction. With contraction, as with any muscle, it shortens. The dome flattens and air is drawn into the lungs. The aorta and oesophagus penetrate the diaphragm. Chronic diaphragm holding will pressure these structures, especially the oesophagus which can affect digestion.

Neurological approach
An effective method of reducing diaphragm holding can be performed by the massage therapist as well as the patient on their own. This is done supine or seated, the latter with a pillow between the therapist’s torso and the patient’s back. If supine, the patient should keep the knees and hips flexed, shortening the hip flexors. This reduces abdominal tension and enables the therapist to access the diaphragm via the abdomen. Seated or supine, the therapist inserts curled fingers along the inferior rib margin and takes up the slack of the soft tissue. The posterior edge of the lower ribs may be accessed, at the very least, the inferior edge of the ribs. Regardless, work with the patient’s respiration to allow further penetration. As the diaphragm slowly relaxes, the therapist’s curled fingers will creep superior on the inside edge of the thorax. The seated patient may lean marginally forward to facilitate this process. The best location to commence is the lowest anterior edge of the ribcage. Once that site responds and further penetration has plateaued, repeat the process laterally along the ribcage, as well as medially toward the xiphoid process. With the patient seated, treatment is bilateral.

Diaphragm release 
Diaphragm release with the patient supine.


 

Experience suggests that unresponsive areas be left for later. By moving to areas that do respond, the therapist’s efficiency of time and treatment are enhanced. Obstinate areas respond better when the rest of the muscle has released. Because the liver sits in the upper right abdominal quadrant, that diaphragm region does tend to hold, and more patience may be required. Periodic breaks for the therapist may be needed as this technique can cause lactic acid in the hands. However, the gratitude of your patients will cause you to persevere and continue to produce results.

Done supine, the therapist is positioned beside the patient’s thorax facing the patient’s feet. This will enable the curled finger positioning along the ribcage. In this instance, treatment is unilateral after which the therapist switches sides.

Self-treatment by the patient is best accomplished seated. By curling their fingers and slowly leaning forward allowing their ribcage to slip slowly over their fingertips, they will achieve results. In all instances, be gentle and patient. The body does respond, but each release may take upwards of two minutes. Ten minutes in one location with no response is an indication to move on. I would assure patients and therapists alike that a release in one area alone provides some relief and should be deemed a success on which to build.

In all instances, the patient need not disrobe. He or she can be treated through the fabric of a loose-fitting shirt.

Fascial approach
Fascial release in the same region will augment treatment and should be done after the diaphragm has been released. This order of treatment is less bothersome to the patient and makes the physicality of the fascial release easier for you as a therapist.

Fascial work  
Fascial work to the intercostal muscles, supine.


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The therapist’s fingertips or thumb engage tissue along the inferior thorax. This should be done engaging laterally or medially depending where resistance is greater, so do diagnostic palpation to determine this. Your own body should be positioned to allow you to engage the tissue pushing away from you, usually beside the patient’s abdomen or thorax. Challenge the tissue a level deeper than the skin, feel the holding of the tissue on the ribs’ inferior edge. Pressure should be firm and movement slow to avoid bruising. The “plastic” quality of the fascia is what you are stretching, and this should determine how slowly you proceed. In essence, it’s the resistance you feel once the “elastic” quality is at its end-feel. Keep your fingers and wrist straight. Generate the force, as gentle as it can be, from your elbow or body. This will save your fingers. Repositioning yourself around your patient, you will address all the restricted areas along the inferior ribcage.

Fascial work can be challenging because it is associated with pressure that may be uncomfortable for the patient. The tissue will allow you to stretch it, but don’t force it. If it resists, change the angle of attack by a few degrees, or change position a few fingertips further and retry. Forewarn the patient that feeling tender is likely the day after treatment. So long as the therapist works slowly, bruising should not occur. Bear in mind, in this instance we are dealing with tissue that is sensitive and with patients that may be seriously ill. Treatment has to be modulated in accordance with the patients’ and tissues’ status. I see this not as an impediment, but rather as an indication of our versatility as massage therapists to adapt and make a difference.

Fascial work does require access to the tissue. Disrobing is not essential, but the patient will need to elevate his or her shirt above the inferior ribs in order to allow contact.

Treating the intercostals
These muscles had best be treated fascially. Their anatomical position, wedged between the ribs, precludes other techniques. Disrobing and appropriate draping will be necessary.

ntercostal muscles 
Fascial work to the intercostal muscles, seated.


 

The ribcage spans almost the entire thorax. In order to address as much of the intercostal muscles as possible, you will have to treat supine and prone. Bear in mind that respiratory challenges of the patient may preclude prone lying. In this instance treat supine only. Hopefully, as relief is achieved, this will allow a prone position. Another possibility for treating posteriorly is having the patient seated, preferably leaning forward. Ergonomically, this is not ideal for the therapist since you may have to torque your wrist and body to achieve the correct angle. But persevere if you can. Once again, use your body leverage to exert pressure, not your fingers.

This technique is performed specifically with the fingertips. Engage your thumb or finger in the intercostal space, and take up the slack in the tissue. Usually, this will be laterally. Once again, you will palpate deep to the skin level, you will feel the resistance of the fascia between the ribs. You might be able to distribute two or three fingers among the inter-rib spaces and address more than one intercostal space simultaneously. Regardless, engage the tissue and slide with it, gently stretching the tissue as slow and as far as it allows.

You can probably achieve results with one to three thorough passes over one area of tissue. Addressing the entire intercostal region, anterior, posterior and laterally, does require time. The pectorals and breast tissue lie superficial to the superior anterior intercostals. Treatment in this region is not possible.

Treating the scalenes
The three scalene muscles (anterior, medius and posterior) connect the transverse processes of the cervical spine (C2 – C7), to ribs 1 and 2. Especially with laboured breathing, they activate. Many athletes breathing heavily have felt compelled to clasp a fence to assist breathing. Unknowingly, they are stabilizing their upper body to facilitate scalene contraction and its action in elevating the ribs.

scalene muscles 
Fascial work to the scalene muscles.


 

These are treated supine with gentle direct fascial release. Should the therapist so choose, standard trigger point techniques may precede fascial work to address areas of particular tenderness first.

Bypassing the sternocleidomastoid (SCM), slide your fingertips along the transverse processes. Challenge the soft tissue inferiorly, slowly and gently as with the intercostals – or even more so. The neck is very sensitive and is a hotbed of pain referral, so consistent patient feedback is essential as you stretch the fascia.

Treatment order should follow as presented. The diaphragm is by far the major respiratory muscle. I would hope that once the diaphragm has released, the intercostals and then the scalenes will respond more willingly. One treatment may suffice for a patient recovering from a cold or cough. Patients with chronic severe respiratory distress will need more sessions. Conceivably, severe chronic cases may need regular attention to ease their ongoing symptoms.

Restoration of a patient’s respiratory comfort is invaluable. Massage therapists can offer extraordinary abilities, combining manual techniques for the muscular system, and, if necessary, mucosal drainage, and correcting elevated ribs. Fine-tuning these techniques makes for a set of skills that both patients and therapists consider to be priceless. (Special thanks to Dr. Marco Caravaggio, DC, and Melanie Tinianov, RMT, CHA, for their kind assistance with the accompanying photographs.)


Jonathan Maister is a massage therapist, sport massage therapist and athletic therapist, with a private practice in Markham, Ont. He has taught across Canada and written extensively on a variety of orthopedic, sport medicine and related topics. He assists at the committee level for the Canadian Athletic Therapists Association and the Canadian Sport Massage Therapists Association. He can be contacted at jmtherapy@JonathanMaister.com.


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