Historically, Swedish massage included a good deal of attention to the abdomen. Abdominal effleurage, petrissage, kneading, vibration, and tapotement were thought to reduce muscle tension, improve local circulation, soothe indigestion, stimulate the secretion of stomach acid, increase the appetite, stimulate peristalsis, relieve constipation, and lower high blood pressure.1, 2 Today, however, many MTs devote their efforts to treating the back, neck, and other areas of high tension, while unfortunately giving little or no attention to the abdomen.
Why Abdominal Bodywork?
During my 34 years in general massage practice, I have seen many clients with bothersome conditions for which abdominal massage was the most appropriate treatment. I often found deep muscular tension, adhesions, myofascial trigger points, shallow or dysfunctional breathing, myofascial restriction, and/or musculoskeletal pain in the abdomen. There were many different causes: trauma to the abdomen, forceful vomiting, undergoing a painful manipulation of the abdominal wall to turn a breech baby, improper exercise of the abdominal muscles, sexual abuse, adhesion-forming abdominal operations, rib sprains, and pelvic fractures. Even a normal pregnancy and delivery left many women with abdominal issues, such as myofascial pain, abdominal muscle trigger points, and dysfunction of pelvic joints.Lifestyle factors such as postural habits, exercise regimens, repetitive stress at work, anxiety, depression, and emotional stress also led to abdominal tension and pain.
There are other reasons why abdominal massage truly does matter. A relaxation massage that neglects the abdomen misses a critical place where tension—perhaps the deepest tension in the body—is stored. The abdomen is more than just a muscled cage for the internal organs: it is a primal area of emotion.
How does the abdomen come to carry so much stress? Ron Kurtz and Hector Prestera, founders of Hakomi Bodywork, believe humans have two different, often opposing, drives. What they term the belly mind contains our non-rational consciousness of hunger, satiation, sexuality, and intuitive awareness of our environment and of other people, whereas the head mind specializes in more rational and logical thoughts and plans.
According to Kurtz and Prestera, conflicts that arise between the two are usually expressed by the emotions of the heart and chest: “Chatter and static fill the organism, the heart begins to pound, and the respiration may become shallow and rapid, or suspended. The belly mind, in the face of this raging turmoil, attempts to protect itself by contracting the diaphragm and the belly muscles, thereby cutting down on the emotions flooding it.”3
Neglecting abdominal massage denies clients the chance to experience their bodies as a whole. This sensation of connectedness has been called “perhaps the single most pleasant sensation of a complete massage.”4
Abdominal Anatomy
The abdominal muscles are critical to efficient movement, intimately interwoven with the digestive and respiratory functions, and are prime repositories of emotional stress. The outer abdominal wall consists of the rectus abdominis, internal and external obliques, and the transverse abdominis. Together, these muscles create various movements, support the trunk against gravity, and help hold the abdominal organs in place.
At the top of the abdomen, the wide, sheet-like diaphragm muscle performs respiratory movements and separates the abdominal and thoracic cavities, while the back of the abdomen is made up of three very important muscles: the psoas, iliacus, and quadratus lumborum. The abdominal viscera are surrounded by and intimately connected with the abdominal muscles, and the viscera may be powerfully affected when there is fascial restriction or chronic tension in the muscles.
High levels of tension in the abdominal muscles may begin very early in life—even in infancy.5 Abdominal trigger points are so common that every year, many unnecessary medical tests and procedures are mistakenly performed for appendicitis, dysmenorrhea, gall bladder disease, or low-back pain, when the pain actually originates from these trigger points.6, 7, 8 Common abdominal complaints caused or aggravated by stress include irritable bowel syndrome (IBS), heartburn, gastro-esophageal reflux disorder, upset stomach, and chronic constipation.9
Twelve percent of all visits to primary care physicians are due to the abdominal pain of IBS,10 and about 10 percent of all clients have recurring abdominal pain that has no organic cause.11 Relaxation techniques and psychotherapy can sometimes show dramatic results in relieving these complaints, indicating that there is a strong mind-body connection.12, 13, 14, 15, 16
Another widespread condition—chronic constipation—affects nearly 15 percent of the population in the United States and Canada. Two and a half million visits to doctors yearly are due to chronic constipation, while patients spend $725 million on laxatives.17 Some of these cases are linked to unresolved emotional stress.18
Other common abdominal complaints that may be related to muscle tension in the lower abdomen include dysmenorrhea and urinary frequency.19 Long-standing musculoskeletal problems can also originate in abdominal postoperative adhesions and trigger points in the scar tissue. More than 4 million abdominal surgeries are performed annually in the United States; a significant proportion of them will leave patients with postoperative adhesions.20, 21, 22, 23
often Neglected
There are various reasons why abdominal massage is so often neglected by massage therapists. First, many schools increasingly de-emphasize its importance. Fewer class hours are spent on abdominal massage, while more are devoted to the large antigravity muscles and areas that clients are more likely to complain about. Many basic massage textbooks also devote significantly less time to the abdomen than to other parts of the body.24, 25
Some schools teach students that massage of the abdomen is an optional part of a full-body Swedish massage.
The second major reason we neglect the abdomen is that many of our clients feel uncomfortable and vulnerable with touch in that region. There is an anatomical basis for this: unlike the brain and the heart, which are surrounded by bones that can protect them, the critical digestive and genito-urinary organs have no body protection. Blunt force to the abdomen (e.g., from a car accident, a fall onto bicycle handlebars, a punch in the gut) is capable of causing devastating damage to the organs underneath the abdominal wall.
For precisely this reason, pack animals such as dogs and wolves show submission by rolling over and exposing their bellies, their most anatomically vulnerable area. It is due at least partly to this vulnerability that the abdominal area often carries a great deal of nervous tension and emotional charge. When making the abdominal muscles rigid is the only way to protect internal organs from trauma, and when there is conflict between the belly mind and the head mind, it is not surprising that rigidity in the diaphragm and abdominal muscles may have also created a rigid wall against feelings. Increased awareness of the abdomen during a massage session may put clients in touch with these suppressed emotions.
The abdominal area is also close to the genitals, and some clients don’t want any area close to their genitals to be touched. Thus, abdominal massage may be perceived as risky.
Another important cause of neglect of the abdomen is the attitude of the therapist. The therapist may feel uncomfortable touching the abdomen due to personal issues of his or her own around the abdomen or genitals. It is likely that many massage therapists may themselves have been victims of unwanted sexual touch. The therapist may also be afraid that abdominal touch will be interpreted as a sexual advance.
Other negative feelings about touching the abdomen may come from the perception of the abdominal organs as distasteful. According to physician-researcher Michael Gershon, “The popular consensus is that the colon is a repulsive piece of anatomy. Its shape is nauseating, its content disgusting, and it smells bad.”26 This sentiment may mean that chronic constipation, one of the body issues for which massage is very effective, is ignored by clients or massage therapists.27, 28
Finally, clients complain rarely about abdominal problems, as compared to neck or back pain, and may not understand the relationships between the abdomen and other parts of the body. Also, many clients are ashamed of their bellies. The idea of a therapist touching or looking at their abdomen is quite frightening. Remarks such as “My stomach is so fat,” or “You don’t need to work on my front; my back is what is bothering me,” or “I just don’t want my stomach touched” may steer us away from treating or massaging the client’s body.
As a Whole
One of the most important messages a good massage can give our clients is that the body is interconnected. We would all do well to follow the advice of George Downing, the author of The Massage Book: “Never neglect the rest of the body for the sake of one or two areas of higher tension. Do economize, cutting down the amount of time you have spent on one part of the body in order to spend more on a more tense part; but don’t economize too much. The living tissue of the body is a single envelope whose various parts are much more dependant upon and responsive to one another than is commonly realized. For reducing tension, and for every other aspect of massage as well, the one rule before all others is: deal with the body as a whole.”29
Marybetts Sinclair has been a massage therapist and massage instructor in Oregon since 1975. She is the author of Massage for Healthier Children, Pediatric Massage Therapy, and Modern Hydrotherapy for the Massage Therapist. She has taught massage in special programs for disabled children in the United States, Mexico, and Ecuador and currently teaches pediatric massage and other classes at massage schools in the United States and abroad. She can be reached at www.marybettssinclair.com.
Notes
1. J. Whorton, Inner Hygiene: Constipation and the Pursuit of Health in Modern Society (New York: Oxford University Press, 2000), 149.
2. E. Kleen, Massage and Medical Gymnastics (London: J. and A. Churchill, 1921).
3. R. Kurtz and H. Prestera, The Body Reveals: How to Read Your Own Body (New York: Harpercollins, 1984).
4. George Downing, The Massage Book (New York: Random House, 1972), 109.
5. J. Travell and D. Simons, Travell and Simon’s Myofascial Pain and Dysfunction: the Triggerpoint Manual, second edition, Volume 1, Upper Body (Baltimore: Lippincott Williams & Wilkins, 1999), 20.
6. Ibid., 37.
7. D. Greenbaum et al., “Chronic Abdominal Wall Pain: Diagnostic Validity and Costs,” DigestiveDiseases and Sciences 39, no. 9 (September 1994): 1933–42.
8. F. Rivero, “Pain Originating from the Abdominal Wall: a Forgotten Diagnostic Option,” Gastroenterol Hepatol 30, no. 4 (April 2007): 244–50.
9. S. McMahon and M. Koltzenburg, eds., Wall and Melzaks Textbook of Pain, fifth edition (City: Elselvier Churchill Livingstone), 2006, chapter 30, “A Clinical Perspective on Abdominal Pain,” by H. Wong and E. Meyer, 753–77.
10. E. Krane, Relieve Your Client’s Chronic Pain (New York: Fireside, 2005), 27.
11. Available at www.digestive.niddk.nih.gov (accessed June 2008).
12. E. Krane, Relieve Your Client’s Chronic Pain.
13. C.P. Dancy et al., “The Relationship Between Daily Stress and Symptoms of Irritable Bowel Syndrome,” Journal of Psychosomatic Research 44, no. 5 (1998): 537–45.
14. D. Clarke, They Can’t Find Anything Wrong: 7 Keys to Understanding, Treating and Healing Stress Illness (Boulder, Colorado; Sentient Publications, 2007).
15. P. Latimer, Functional Gastro-Intestinal Disorders: A Behavioral Medicine Approach (New York: Springer Publishing, 1983).
16. E. Mayer, ed., Basic and Clinical Aspects of Chronic Abdominal Pain (New York: Elselvier, 1993).
17. Available at www.aboutconstipation.org (accessed June 2008).
18. D. Clarke, They Can’t Find Anything Wrong.
19. Available at www.digestive.niddk.nih.gov (accessed June 2008).
20. Incidence of Caesarean section and other abdominal surgeries such as hernia repairs, endometriosos, etc.: check national center for health statistics, infant and maternal health, publication titled Vital Health Stat, term “ambulatory and inpatient procedures in the United States,” then by year.
21. J. Barral and P. Mercier, Visceral Manipulation (Vista, California: Eastland Press, 2006).
22. Available at www.cdc.gov/mmwr/preview/mmwrhtml/mm5615a8.htm (accessed June 20, 2008).
23. H.K. Opoien, et al., “Post-Caesarean Surgical Site Infections According to CDC Standards: Rates and Risk Factors. A Prospective Cohort Study,” Acta Obstetricia et Gynecological Scandinavica 86, no. 9 (2007): 1097–102).
24. F. Tappan and P. Benjamin, Tappan’s Handbook of Healing Massage Techniques, third edition (Stamford, Connecticut: Appleton and Lange, 1998).
25. M. Braun and S. Simonson, Introduction to Massage Therapy (Baltimore: Lippincott Williams & Wilkins, 2005).
26. M. Gershon, The Second Brain: The Scientific Basis of Gut Instinct and a Groundbreaking New Understanding of Nervous Disorders of the Stomach and Intestine (New York: Harper Collins, 1998), xi.
27. M. Emly, “Colonic Motility in Profoundly Disabled People: a Comparison of Massage and Laxative Therapy in the Management of Constipation,” Physiotherapy 84, no. 4 (1998): 178–83.
28. M. Emly, “Abdominal Massage for Adults with Learning Disabilities,” Nursing Times 97, no. 30 (July 26–August 1, 2001): 61–2.
29. George Downing, The Massage Book.
After asking permission, stand at the client’s right side. Rest your hands lightly on the abdomen to help the client become accustomed to your touch, then apply oil.
Step 1. Two-Handed Abdominal Effleurage
With your right palm, make clockwise circles covering the entire abdomen. After a few circles, let your left hand join in, one hand following the other. Use gentle pressure and do not touch or put any pressure on the xyphoid process. As you stroke, feel underneath the rib cage to determine the tightness of both the abdominal muscle attachments and the diaphragm. Also feel for tightness in the muscle attachments around the pelvic bowl, inside the iliac crest, and along the upper surface of the pubic bone. This will give you information about tightness not only in the lower abdominal muscles but also in the iliacus muscle.
Step 2. Knead the Abdomen
Reach across the abdomen, and beginning above the left iliac crest, begin kneading across the abdomen. End above the right iliac crest. Cross to the other side of the table, perform the stroke from right to left, then return to your original position.
Step 3. Petrissage Along the Path of the Large Intestine
With the flat of the thumbs, begin just inside the right hipbone and stroke straight up to the rib cage, across the top of the abdomen, and down the left side. Stop just above the left hipbone. Move very slowly and thoroughly and use medium pressure.
Step 4. Tapotement and Light Pincement Along the Path of the Large Intestine
Massage the same area as in Step 3.
Step 5. Skin Rolling
Roll the skin between the fingers, up one entire side of the lateral abdomen from the lower abdomen to the costal margin. Move to the left side of the table and repeat on the right side of the abdomen. As you roll the skin, feel for any tightness in the client’s superficial fascia and evaluate any scars for adhesions that may need specific scar tissue release techniques.
Step 6. Petrissage Around the Navel to Stimulate the Small Intestine
Using the fingertips, make small circles with gentle pressure and move
all around the navel.
Step 7. Vibrate Around the Navel to Stimulate the Small Intestine
Make a shaking or trembling movement with your fingertips
and use gentle pressure.
Step 8. Back Lift Stroke
Stand facing the client’s head. Effleurage from the middle of the abdomen out to the sides, then slide your hands behind the client’s waist and end so your fingertips are touching on either side of his or her spine. Now, lifting carefully so you do not strain your back, lean back and pull firmly while your hands glide around front to the client’s navel. (This will lift the client’s midsection slightly.) Using a brisk shaking motion, vibrate your hands as you glide.
Step 9. Repeat Two-Handed Abdominal Effleurage