SET TALK
By Don McCann, MA, LMT, LMHC
MA3267 MH705 MM3717
ACID REFLUX and HIATAL HERNIA
It’s getting to the point that everybody
knows what the "little purple pill" is – Nexium for acid reflux.
Why? The answer is quite simple – the majority of Americans over the age of 40
have, or are experiencing, the symptoms of acid reflux and are very
uncomfortable with it. Additionally, the advertising is alluding to long-term
damage from the erosion of the esophagus due to acid reflux. Clients’ fears
are expanding, as is their awareness. This is partially due just to good old
advertising and marketing. We as massage therapists could actually thank these
people for increasing this awareness of acid reflux and hiatal hernias. However,
it is unfortunate that many massage therapists do not know that there are
effective soft tissue treatments that can eliminate the symptoms without drugs,
or any other invasive medical procedure, and, thus, have not developed the
skills to treat these conditions.
To develop the skills to treat hiatal hernia
and acid reflux we must first understand what the conditions are that trigger
these symptoms. Medical diagnosis include: "Protrusion of the stomach
upward … through the esophageal hiatus of the diaphragm" (Taber’s
Cyclopedic Medical Dictionary), the esophageal hiatus is "the opening
in the diaphragm for the passage of the esophagus and the vagus nerves" (Dorland’s
Illustrated Medical Dictionary), "sliding hiatus hernia…the gastroesophageal
junction and a portion of the stomach are above the diaphragm" (The
Merck Manual, 16th edition). Another form of hiatal hernia is a
tearing in the diaphragm that allows a portion of the stomach to protrude
through the tear. There can also be damage to the esophageal hiatus where the
esophagus empties into the stomach. When the esophageal hiatus is damaged the
sphincter valve at the top of the stomach cannot function properly, and the
contents from the stomach can then backflow up the esophagus (acid reflux),
especially when a client is prone or supine or has a full
actively digesting stomach. Acid reflux can occur even when there is no
significant damage to the esophageal hiatus. This can be due to overactive
digestion taking place in the stomach (as can result from spicy food or overeating),
or the presence of excess stomach acid. How can massage therapy
effectively treat these conditions? Well, let’s look at where the stomach is
located and what muscles have a major effect on both the esophageal hiatus and
the stomach itself.
The esophageal hiatus is located in the center
of the diaphragm. The diaphragmatic muscle attaches on the sternum, the lower
ribs, and extends all the way around to the back including the thoracic
vertebrae. This leaves it extremely reactive to any structural distortion. If
the skeletal system misaligns, that misalignment is reflected in contractions
and distortions throughout the diaphragm. The diaphragm itself is a muscle that
responds to the somatic nervous system. When people are stressed, they tend to
contract the muscle fibers of the diaphragm, which often exaggerates any
existing structural distortions. The sympathetic nervous system (which dominates
during stress) will continue to affect the diaphragm long after the initial
stressor has been reduced. If this takes place over weeks or months, the
resulting contractions will become fixed in the diaphragm via the fascia, and
exaggerate any already existing distortions. Stress and structural distortions
aren’t the only conditions that affect the diaphragm. If we add extra weight
to the structure, we have yet another distortion factor for the diaphragm. If
the esophageal hiatus is constantly stressed by these distortions and imbalances
of tension, it reacts like an "0" ring with unequal pressure on all
its sides, and cannot seal effectively.
A tear in the diaphragm that allows the
stomach to push through creating a hiatal hernia is equally stressed by
structural distortions and the somatic nervous system as described above. If
this tear is subjected to all these stresses, it often worsens allowing more of
the stomach to protrude through the diaphragm. Often a tear in the diaphragm
will occur when a person lifts weight when structural distortions or stresses in
the body are also distorting the diaphragm. It is very possible that the tearing
would not have happened had there been no structural distortion or stress.
To resolve hiatal hernia problems massage
therapists need to be able to address both the structural distortions and the
stresses that involve the diaphragm. The diaphragm has surface attachments
across the sternum and ribs that attach to the sternum, but the majority of the
body of this muscle is deep in the abdomen and below some organs. To treat this
area effectively, I recommend using the 3-step approach starting with the
surface tissue and moving progressively deeper with successive strokes (see
SET TALK article on Deep Tissue, Nov-Dec. 2001, or review the article on the
website under Publications). It is important to remember to follow the
principle of "the deeper you go, the slower you go!" You can
work around and through the organs, but you must work slowly and gently,
softening the points of your fingers to avoid creating a sharp specific edge
that could actually damage the organs. In other words, as you work deeper in the
abdomen, apply just enough pressure to sink in slowly, and only move deeper as
the client relaxes and stops resisting. Once in deeply, only move the stroke
as the tissue releases. The deeper the stroke the shorter the length of the
stroke. Do not "plow" through the tissues!
The intent of these abdominal strokes is to
release the rib cage so it can expand upward while reducing the distortion and
stress on the diaphragm. The structural distortions of the diaphragm tend to
pull down on the ribs. When body reading your client before the session, you
will notice that the ribs on one side are pulled down and tighter than on the
other. The floating rib on this side will be closer to the crest of the ilium
than on the other side. To work for structural balance, you want to release this
side first so you will not be moving the body further into distortion. There are
other structural considerations such as pelvic balancing, lumbar curvatures, and
scoliosis. However, if the diaphragm is released from the side where the
floating rib and the ilium are closer together, the other structural distortions
will be reduced as well. Then, releasing the other side will tend to bring the
ribs further into balance, and thus release the distortions of the diaphragm.
In releasing the diaphragm you are releasing
the stresses that have accumulated from both the sympathetic and parasympathetic
nervous systems. In addition, when releasing the left side of the diaphragm, you
will be releasing the pathway of the vagus nerve, which is usually very
tightened and restricted. Releasing this often results in a calming of the
stomach and reduction in the hyperacidity found with acid reflux, nervous
stomach and ulcers.
Working with your hands to release the
stresses on the diaphragm will treat hiatal hernias and acid reflux very
effectively. However, the treatment will not be complete until we have been able
to smooth the majority of the sheet-like muscle of the diaphragm. The fingers
will have worked through small areas and released ridged adhesions, but there
will be larger parts of the sheathing part of the muscles that will still be
somewhat tightened and imbalanced. This is where a softer, rounder surface than
the fingertips can smooth and integrate the diaphragm allowing even more
effective release of the esophageal hiatus allowing the sphincter valve of the
stomach to close and function properly, or take the pressure off a diaphragmatic
tear. I find holding a small hard rubber ball or tennis ball gently against the
diaphragm under the ribs and very gently rolling it along the wall of the
diaphragm to be very effective in balancing the diaphragm. Caution
– this needs to be far enough below the ribs so as not to pull down on the
ribs or in any way compromise the xyphoid process. Also, the floating ribs need
to be avoided at all costs, so you want to begin medial to the floating ribs.
The ball, like the hand in deep strokes, should be applied with the principle of
"the deeper you go the slower you go!" The ball would not be
effective if you had not first released the very tight ridging in the diaphragm
with your previous strokes. You will be amazed at how much tension release you
can feel in the soft tissue while firmly but gently using the ball to smooth and
balance the diaphragm.
Clients generally report immediate improvement
of acid reflux or hiatal hernia symptoms after just one session. This
improvement may be reported as less pain and discomfort, less intense or fewer
occurrences, or a general calming of the area. I usually work one session per
week until the client is symptom free for the week, then schedule for 10 days
until symptom free, 2 weeks until symptom free, and space out accordingly after
that.
This work is very specific. We are not curing
the condition or practicing medicine, but rather reducing the stress and
distortion found in the diaphragm and its adjoining soft tissue that allows for
a higher function within the esophageal hiatus and less pressure on the
diaphragm itself. A majority of my clients who have hiatal hernia or acid reflux
symptoms will see the end of these problems with this treatment.
I have now included acid reflux and hiatal
hernia on my intake form so that I will not miss the opportunity of helping
clients with these problems.
These techniques are deep and should only be
applied if you are comfortable and feel you know what you are doing in this
area. I suggest that you attend a workshop where techniques like these are
taught so you will be prepared to treat these problems that your clients
present.
I hope the information in this article will
increase your awareness of who you are as well as the healing power that
knowledge gives you. Keep up the good massage therapy until we communicate again
in the next installment of SET TALK.
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