Diástase do Reto Abdominal
Autor: Prof. Marcus Lima | Publicado: 2017-01-06T14:44:00-03:00


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Mais uma adaptação de um artigo da ótima Kathy Dooley, de sua série: AnatomyAngel. Desta vez com um assunto que é mais comum do que parece e que, creio
eu, não recebe muita atenção.&nbsp;

Como expliquei ao final do texto, existem outras abordagens para o mesmo problema, uma, que parece eficiente e fazer sentido, é a proposta pelo DNS - Dynamic Neuromuscular Stabilization e que será tema de artigos futuros (neste espaço ou no Blog da Fortius).

Aos que quiserem ler no original em inglês: Anatomy Angel - Diastasis Recti.&nbsp;

Boa leitura aos amigos. 






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Diástase do Reto Abdominal

Kathy Dooley&nbsp;
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A diástase do reto (DR) é uma condição envolvendo a separação dos dois
ventres do reto abdominal (RA) bem na linha média, onde eles se inserem na
linha alba.




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A diástase do reto (DR) ocorre após uma expansão rápida e intensa do
abdome.



Condições que podem causá-la:

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→ Gravidez.


→ Parto através de cesariana. 

→ Cirurgias abdominais (reparo de hérnia abdominal por ex.).

→ Ganho de peso súbito e rápido.

→ Adiposidade central, devido a um processo de doença ou medicação
(Como, Síndrome de Cushing, uso de corticóides, uso de esteróide
anabólico androgênico).&nbsp;
(N.T: Síndrome de Cushing é a presença de elevadas taxas de cortisol na corrente sanguínea que levam a um aumento súbito e pronunciado de gordura na região abdominal. O uso de corticóides, derivados sintéticos do cortisol, embora importantes no combate a muitas doenças, também tem como efeito colateral ganhos significativos de peso). 

Nem todas pessoas em alguma dessas condições desenvolve uma diástase, então existe uma separação biomecânica entre quem a desenvolve e quem escapa.

A diferença é quão bem o reto do abdome é mantido no lugar por sua bainha, a bainha do reto do abdome. Essa bainha é formada pelas aponeuroses dos músculos oblíquo interno, oblíquo externo e transverso do abdome. Essas bainhas (N.T: No plural, mas no final das contas estes tecidos que passam pela frente, por trás, subdividem-se, acabam formando uma só estrutura) ancoram-se na linha alba, aonde o reto do abdome também está ancorado.&nbsp; 











 (N.T: Abaixo uma representação vista de cima dos músculos e das bainhas da região abdominal).








Nos testes musculares manuais, o foco está em testar a contração concêntrica de um músculo. Mas lembre-se, qualquer músculo ao qual falte a habilidade de alongar não conseguirá alcançar todo seu potencial para contrações concêntricas (N.T: A porção excêntrica da contração é aquela que vai dotar o músculo/conjunto de músculos do armazenamento de energia potencial elástica para posterior utilização, dessa energia armazenada, em uma contração concêntrica mais potente e com menor custo energético).




Lembre-se:&nbsp;
Quando queríamos lançar um pedaço de papel dobrado através da sala usando uma borracha com maior força (N.T: Geralmente era para acertar o pescoço do colega da frente), o que fazíamos primeiro?


Puxávamos a borracha para trás.



Na diástase do reto do abdome, geralmente o abdome está sendo mal utilizado para respiração, na construção da pressão intra-abdominal.



Muitas pessoas, especialmente mulheres grávidas, querem prevenir a diástase tanto quanto reduzir uma diástase que tenha ocorrido.



Se já existe uma diástase, mantenha um monitoramento constante da distância entre as bordas mediais do reto abdominal. &nbsp;



Uma distância aceitável entre as bordas é uma igual à largura do dedo indicador. Sempre use o dedo do indivíduo para que a medida seja arbitrária.









Para medir:



Peça ao indivíduo para que faça um abdominal (N.T: Aqueles "curtos", tipicamente usado nas academias) e encontre as bordas mediais do reto do abdome em cada lado. Meça com o dedo. Para uma medida mais acurada use uma fita métrica (N.T: Também poderia se usar um paquímetro, embora as pontas de metal sejam desconfortáveis e necessitem de algum cuidado na medição).&nbsp;


















(N.T: A imagem acima mostra a posição do teste, embora retrate um autoteste).



Uma vez que 2 entre 3 grávidas tem algum grau de diástase, devido à rápida expansão abdominal, a prevenção pode ser feita ao analisarmos alguns fatores de risco.





Fatores de Risco/Sinais para possível formação de Diástase:



1. Piercings umbilicais.



2. Cirurgias abdominais (Ex: colecistectomia - retirada da vesícula biliar, apêndice, cesariana).



3. Histórico de hérnias da parede central (Ex: Umbilical ou inguinal).



4. Histórico de disfunção respiratória.





5. "Alargamento das costelas" ao inspirar (N.T: O que os americanos chamam de "rib flare". Se alguém tiver um termo melhor do que "alargamento das costelas" sugira nos comentários) (indica fraqueza dos oblíquos do abdome - imagem ao lado).



6. Mais do que um dedo de distância entre os 2 músculos retos do abdome na linha alba.



7. Diminuição da expansão da porção lateral e inferior da parede abdominal na inspiração (indicando falta de extensibilidade do transverso e oblíquo interno do abdome durante a inspiração).



8. Inclinação pélvica anterior e/ou hiperextensão lombar, combinado com a falta de expansão da parede abdominal posterior na inspiração (falta de ativação dos multífidos na carga excêntrica).





Compensações comuns para os músculos ou estruturas expiratórias, exacerbando a Diástase do Reto do Abdome:



1. Cicatrizes, que irão limitar a expansão abdominal em 360º durante a inspiração.&nbsp;



2. Diafragma.



3. Oblíquo externo do abdome.



4. Reto do abdome.



5. Eretor da coluna toracolombar.



(N.T: Ou seja, na opinião da autora, estas são estruturas que demonstram hiperatividade e pioram o quadro. Existem outros modelos que discordam de algumas estruturas citadas).&nbsp;





Músculos aos quais comumente falham em sua capacidade de proteger a posição do reto do abdome, exacerbando a Diástase:&nbsp; 



1. Transverso do abdome.



2. Oblíquo interno do abdome.



3. Multífidos.



4. Eretor da espinha lombar.



(N.T: Estes músculos estão classificados como "inibidos" ou em outros termos: "sofrendo regulação descendente". Significando que existem falhas/atrasos de ativação. Em resumo, não estão cumprindo com seu papel).





Para avaliar compensações versus funções com regulação descendente:



1. Avalie os fatores de risco.



2. Utilize o teste de respiração na posição supinada 90/90º (veja o vídeo ao final do texto para exemplos).



3. Aplique técnicas de liberação miofascial aos músculos compensadores (N.T: Aqueles considerados hiperativos, ou em outras palavras: "sofrendo de regulação ascendente") para melhorar sua extensibilidade e a contração concêntrica dos músculos sofrendo de regulação descendente (N.T: Os que estão hipoativos, com déficit/atraso na ativação).



(N.T: Indico o curso de Anatomia Palpatória e Liberação Miofascial do Instituto Fortius aos que quiserem aprender técnicas que podem ser úteis nesses e em outros casos). 





Exemplos:



→ Um trabalho apropriado nas cicatrizes.



→ Facilitação do diafragma (para quem sofre de "alargamento das costelas" na inspiração, incluindo histórico de refluxo gastroesofágico ou problemas circulatórios).



→ Padrões de rolamento para a extremidade superior (tem como alvo os músculos oblíquos). 

(Veja os vídeos, ao final do texto, para as liberações do diafragma e cicatrizes, assim como o de padrões de rolamento) (N.T: Aos que tem dificuldades com o inglês fiz uma descrição dos vídeos).



Todo o trabalho de liberação deve estar focado em prolongar a expiração enquanto a liberação é completada. Isto promove uma regulação ascendente (N.T: Ativação) na função dos músculos expiratórios que comumente estão com uma regulação descendente (N.T: Inibição). Ex: Oblíquo interno do abdome, multífidos, transverso do abdome.&nbsp;



Pessoas com diástase do reto não precisam de exercícios mirabolantes. Precisam aprender a construir a pressão intra-abdominal de maneira correta, e então aplicar princípios de força muscular para esta meta fundamental. Então a diástase pode ser prevenida ou limitada na sua formação.



Para aprender mais sobre avaliações abdominais, que podem estar ligadas à diástase, confira nossos seminários (N.T: Os cursos que Kathy Dooley ministra, por enquanto nos EUA em sua maioria, Europa e Austrália também já receberam cursos), assim como os vídeos abaixo.



Como sempre, é com você!&nbsp;
&nbsp; 



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Diástase do Reto do Abdome:



N.T: Neste primeiro vídeo ela mostra o que é diástase, usando um recurso que é a marca registrada de seus cursos sobre anatomia, pinturas corporais de estruturas anatômicas usando modelos vivos.

Reforça o que já foi dito no texto:
→ Treinar abdominais tradicionais em pessoas com diástase é um erro.

Alguns pontos colocados:
→ Pessoas com diástase tem muita dificuldade em usar os oblíquos na expansão lateral abdominal (falha na extensibilidade/contração excêntrica).
→ Em geral essas pessoas tem uma boa expansão anterior, o que é parte do problema (em geral vejo que a ioga/pilates fazem um bom trabalho em ensinar as pessoas a como fazerem uma respiração diafragmática, porém o foco é apenas na expansão anterior).

Exercício ensinado no vídeo:
→ Deitado&nbsp; com os joelhos em 90º; cervical "alongada" (não deixar o queixo apontando para cima, em algumas pessoas é necessário um suporte para cabeça); costelas abaixadas, em posição expiratória.
→ Colocar as mãos na lateral do tronco: Inspirar empurrando as mãos para fora.
→ Expirar no dobro do tempo da inspiração (1:2).&nbsp;
→ Progressão: Levantar uma perna → Levantar as duas pernas. 
&nbsp; 
&nbsp; 




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Liberação do Diafragma:






N.T: Ela faz uma demonstração de como usar a respiração para fazer uma liberação do diafragma e melhorar a estabilidade do centro/núcleo/core (como quiserem chamar). Inicia com o histórico e depois faz uma inspeção visual para ver de que maneira a mulher do vídeo respira, tirando suas conclusões de que existe tensão no diafragma.



Liberação:

→ Estimula o ponto onde o diafragma recebe a inervação do nervo frênico (na parte lateral do abdome, em uma espécie de indentação, onde, nesses casos, se apresenta um ponto doloroso. No DNS - Dynamic Neuromuscular Stabilization esse ponto é chamado de Zona de Respiração - "Breathing Zone", imagem à direita).&nbsp;
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→ Ao mesmo tempo em que vai estimulando essa área,
pede para que a mulher respire, preenchendo a cavidade abdominal/expansão do
abdome. Dicas cinestésicas ajudam (tocando/pressionando de leve onde o
indivíduo deve preencher com ar).&nbsp;

Depois usa outra técnica de liberação:

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<![endif]-->→ Pede para que faça uma leve inclinação lateral (estendendo o braço em direção ao joelho) para o lado do diafragma que quer liberar (o direito nesse exemplo).
→ Vira a cabeça para o lado oposto.
→ Coloca os dedos (polegares) sob as costelas (do lado que quer liberar) fazendo uma leve pressão.
→ Pede para que tussa (a tosse cria uma contração excêntrica do diafragma), no momento em que ela tosse tira-se os dedos.
→ Pressionar sob as costelas e soltar quando o indivíduo tosse, gerando um reflexo que ajuda a liberar o diafragma, no caso dele necessitar de liberação.&nbsp;

→ Após a liberação, observar o indivíduo respirar, aplicando uma leve pressão nas áreas que falham no preenchimento.
→ Lembrar que a respiração é em 360º (anterior, lateral e posterior, a mais difícil de perceber).&nbsp;




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Rolamento para os Oblíquos do Abdome:






N.T: Neste vídeo ela mostra um exercício que mistura o que chamam de "respiração crocodilo" (deitado em base pronada, inspirando através do abdome, a vantagem em estar de barriga para baixo é dar ao abdome algo ao que se opor, instruindo o indivíduo a "empurrar o solo" na inspiração. Foto abaixo) com "padrões de rolamento".


&nbsp;&nbsp;

Exercício de Rolamento <!--[if gte mso 9]>
 
  
  
 
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<![endif]-->– Padrão de Flexão: 


O rolamento demonstrado é um padrão de flexão, "guiado" pelo membro superior direito.
O rolamento começa ao virar a cabeça para o lado que se vai rolar.
O olhar para onde se quer rolar é fundamental, o olho inicia, a cabeça vai atrás e depois todo corpo vem junto (assim que rola o bebê, primeiro ele olha para algo que lhe chama atenção, depois o corpo vem junto).&nbsp; 
A sequência é mostrada nas imagens abaixo.&nbsp; 




Estando na posição final (pronada), faz uma sequência de "respirações crocodilo". Após as respirações, inicia-se outro padrão de rolamento.



Exercício de Rolamento – Padrão de Extensão:&nbsp;

O rolamento demonstrado é um padrão de extensão, "guiado" pelo membro superior direito.
O rolamento começa ao virar a cabeça para o lado que se vai rolar (como anteriormente. A maior parte dos adultos com dificuldade no rolamento falha em "seguir com o olhar"-"mover a cabeça" para onde se vai fazer o rolamento).
As imagens abaixo mostram a sequência. 





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<![endif]--><!--[if gte mso 10]>

 /* Style Definitions */
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 {mso-style-name:"Tabela normal";
 mso-tstyle-rowband-size:0;
 mso-tstyle-colband-size:0;
 mso-style-noshow:yes;
 mso-style-priority:99;
 mso-style-parent:"";
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt;
 mso-para-margin-top:0cm;
 mso-para-margin-right:0cm;
 mso-para-margin-bottom:8.0pt;
 mso-para-margin-left:0cm;
 line-height:107%;
 mso-pagination:widow-orphan;
 font-size:11.0pt;
 font-family:"Calibri",sans-serif;
 mso-ascii-font-family:Calibri;
 mso-ascii-theme-font:minor-latin;
 mso-hansi-font-family:Calibri;
 mso-hansi-theme-font:minor-latin;
 mso-fareast-language:EN-US;}

<![endif]--><!--[if gte mso 9]>
 
  
  
 
<![endif]-->

<!--[if gte mso 9]>
 
  Normal
  0
  
  
  21
  
  
  false
  false
  false
  
  PT-BR
  X-NONE
  X-NONE
  
   
   
   
   
   
   
   
   
   
  
  
   
   
   
   
   
   
   
   
   
   
   
  
<![endif]--><!--[if gte mso 9]>
 <w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="false"
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  LatentStyleCount="371">
  
  
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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   Name="HTML Code"/>
  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
   Name="HTML Preformatted"/>
  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
   Name="HTML Sample"/>
  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
   Name="HTML Typewriter"/>
  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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   Name="Normal Table"/>
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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  <w:LsdException Locked="false" Priority="30" QFormat="true"
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  <w:LsdException Locked="false" Priority="19" QFormat="true"
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  <w:LsdException Locked="false" Priority="37" SemiHidden="true"
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  <w:LsdException Locked="false" Priority="39" SemiHidden="true"
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  <w:LsdException Locked="false" Priority="46"
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  <w:LsdException Locked="false" Priority="51"
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  <w:LsdException Locked="false" Priority="46"
   Name="Grid Table 1 Light Accent 6"/>
  
  
  
  
  <w:LsdException Locked="false" Priority="51"
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  <w:LsdException Locked="false" Priority="52"
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  <w:LsdException Locked="false" Priority="46"
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  <w:LsdException Locked="false" Priority="51"
   Name="List Table 6 Colorful Accent 1"/>
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   Name="List Table 7 Colorful Accent 1"/>
  <w:LsdException Locked="false" Priority="46"
   Name="List Table 1 Light Accent 2"/>
  
  
  
  
  <w:LsdException Locked="false" Priority="51"
   Name="List Table 6 Colorful Accent 2"/>
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   Name="List Table 7 Colorful Accent 2"/>
  <w:LsdException Locked="false" Priority="46"
   Name="List Table 1 Light Accent 3"/>
  
  
  
  
  <w:LsdException Locked="false" Priority="51"
   Name="List Table 6 Colorful Accent 3"/>
  <w:LsdException Locked="false" Priority="52"
   Name="List Table 7 Colorful Accent 3"/>
  <w:LsdException Locked="false" Priority="46"
   Name="List Table 1 Light Accent 4"/>
  
  
  
  
  <w:LsdException Locked="false" Priority="51"
   Name="List Table 6 Colorful Accent 4"/>
  <w:LsdException Locked="false" Priority="52"
   Name="List Table 7 Colorful Accent 4"/>
  <w:LsdException Locked="false" Priority="46"
   Name="List Table 1 Light Accent 5"/>
  
  
  
  
  <w:LsdException Locked="false" Priority="51"
   Name="List Table 6 Colorful Accent 5"/>
  <w:LsdException Locked="false" Priority="52"
   Name="List Table 7 Colorful Accent 5"/>
  <w:LsdException Locked="false" Priority="46"
   Name="List Table 1 Light Accent 6"/>
  
  
  
  
  <w:LsdException Locked="false" Priority="51"
   Name="List Table 6 Colorful Accent 6"/>
  <w:LsdException Locked="false" Priority="52"
   Name="List Table 7 Colorful Accent 6"/>
 
<![endif]--><!--[if gte mso 10]>

 /* Style Definitions */
 table.MsoNormalTable
 {mso-style-name:"Tabela normal";
 mso-tstyle-rowband-size:0;
 mso-tstyle-colband-size:0;
 mso-style-noshow:yes;
 mso-style-priority:99;
 mso-style-parent:"";
 mso-padding-alt:0cm 5.4pt 0cm 5.4pt;
 mso-para-margin-top:0cm;
 mso-para-margin-right:0cm;
 mso-para-margin-bottom:8.0pt;
 mso-para-margin-left:0cm;
 line-height:107%;
 mso-pagination:widow-orphan;
 font-size:11.0pt;
 font-family:"Calibri",sans-serif;
 mso-ascii-font-family:Calibri;
 mso-ascii-theme-font:minor-latin;
 mso-hansi-font-family:Calibri;
 mso-hansi-theme-font:minor-latin;
 mso-fareast-language:EN-US;}

<![endif]-->



O vídeo ainda mostra os padrões de rolamento de
flexão/extensão feitos a partir do membro inferior, os princípios são
exatamente os mesmos, apenas o "guia" é que muda.




Uma observação final em relação aos padrões de rolamento:

→ Fazer de maneira lenta, não usar "impulso", estimulando o uso da sequência de contrações musculares apropriada, resgatando aos poucos o engrama motor do rolamento.&nbsp;





<!--[if gte mso 9]>
 
  
  
 
<![endif]-->
<!--[if gte mso 9]>
 
  Normal
  0
  
  
  21
  
  
  false
  false
  false
  
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Respiração Supinado 90/90:






N.T: Esse exercício respiratório deve seu nome "90/90" à posição de 90º de flexão de joelho e quadril, deitado de barriga para cima.&nbsp;
Ela inicia dando uma dica de respirar com a língua no céu da boca, na verdade com a ponta da língua atrás dos dentes da frente (A explicação que ela dá para isso é essa: Ao tocar a língua no céu da boca, a língua desloca para frente e para cima, ajudando a elevar o palato mole, abrindo mais espaço para a laringe, dessa forma melhorando a entrada de ar).


Posição do exercício e dicas de execução:

→ Olhar direto e reto para o teto (posicionando bem a cabeça).
→ Pescoço "encaixado" (queixo baixo, cervical em leve flexão).
→ Baixar um pouco as costelas (colocar levemente em posição expiratória).
→ Lembrar que a respiração é em 360º (não somente anterior, como muitas técnicas ensinam).
→ Tórax não sobe (em direção) ao rosto na inspiração. Ele expande em uma direção anterior na verdade (em direção ao teto).
→ Isso ajuda a criar uma Pressão Intra-abdominal apropriada, o que por sua vez garante uma estabilização adequada da região lombar.

→ Inspirar, com a ponta da língua atrás dos dentes da frente e tocando o céu da boca, preenchendo toda cavidade abdominal: anterior/posterior/lateral.
→ Expirar por um tempo maior do que a inspiração (em geral 1:2) fazendo um som de chiado ao expirar (ela mostra isso aos 3 min. de vídeo).


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<![endif]--><!--[if gte mso 10]>

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<![endif]-->



Breve
mais artigos sobre o tema neste espaço ou no Blog da Fortius, especialmente sobre os princípios do DNS - Dynamic
Neuromuscular Stabilization na respiração/estabilização e em como lidar com a Diástase do
Reto do Abdome (que coincidem com alguns pontos levantados pela Kathy neste artigo, na verdade
ela usa princípios do DNS em seu trabalho, mas diferem em outros pontos que
ela levanta).


Em 2017 o Instituto Fortius trará mais cursos do DNS para o Brasil, basta conferir em www.fortius.com.br e na FanPage no Facebook.