Monday, December 21, 2015

The Diaphragm and the Liver Sinew Channel, Part 2

Fig 1: Typical posture often seen with
Liver Qi Stagnation. Image courtesy
Matt Callison, L.Ac.
In the last post we outlined the basic anatomy associated with the Liver sinew channel. If you have not yet read it, you might want to start with that post. In this post, we will discuss a common postural dysfunction associated with the Liver sinew channel, and we will look at common orthopedic conditions associated with this. Finally, we will discuss some treatment options. Keep in mind that many of these treatments are best learned in a class setting and that much of the discussion here will be alluding to these techniques. Others will be relatively straight forward and easily adaptable in your practice, however.

Dysfunction is observed when the Liver sinew channel (which is more posterior than the Spleen sinew previously discussed) is short and the ribcage is closer to the pelvis in the back than in the front, compressing the posterior diaphragm. This compression prevents the diaphragm from being able to descend effectively; patients often must rely more on the accessory breathing muscles, such as the scalenes, which often become tight and restricted. These patients often exhibit chest or paradoxical breathing. Many of them have the typical Liver Qi Stagnation posture seen in Fig. 1. This posture presents with a very straight, rigid spine and an anterior tilt to the pelvis. The chest is often held up in a military-style posture and the patient looks as if they are unable to exhale fully. This posture, along with several others, were presented and discussed by Matt Callison, L.Ac. at the Pacific Symposium in 2011, where he presented research which correlated Zangfu disharmony as described in Traditional Chinese Medicine with common postural patterns. (This was discussed in a previous post.)

Figure 2: Palpation of the QL at Yaoyan. Image courtesy
of Matt Callison, L.Ac. from his soon to be released book
Sports Medicine Acupuncture.
Many of these patients present with Yaoyan syndrome (often referred to as Iliac Crest Syndrome in Western circles). This presents with pain at Yaoyan. Yaoyan is level with the lower border of L4 and, depending on whether you palpate slightly more medial or lateral, will be more reactive at either the iliocostalis (the most lateral muscle of the erector spinae group) or the quadratus lumborum (QL) attachment at the iliac crest. When there is pain with palpation of the QL, I frequently find LIV-5 to be very sensitive to palpation, also. Needling LIV-5 and obtaining Daqi often reduces the pain at the QL with palpation by about 50%.

Another frequent pain condition which is seen with this posture is thoracic outlet syndrome (TOS) which involves an entrapment of the brachial plexus either between the anterior and middle scalenes, between the clavicle and ribcage, or between the pectoralis minor and the ribcage. In this posture, the scalenes and pectoralis minor are short and holding the ribcage too rigidly up (creating a very wooden spine). I associate these muscles with the Lung sinew channel, but see this as a way that excessive Liver energy can affect the channels associated with the Lung. These patients often have a paradoxical breathing pattern where they pull the abdomen in during the inhale and lift the chest. This uses accessory breathing muscles and they should be elevating the upper ribs, but with the restricted movement in the diaphragm, they have to work overtime; thus they become tight and rigid and can then compress neural structures.

Fig. 3: Brachial plexus entrapment on the left side 1) between the ribcage and clavicle, 2) between the anterior and middle scalene, and 3) under the pectoralis minor. I include the scalenes and pec. minor in the Lung sinew channel. They are listed here as Liver Qi Stagnation and the posture shown above is a common contributor of TOS.

Fig. 4: Anterior pelvic tilt.
Since an anterior tilt of the pelvis is involved with the posture in Fig. 1, it is important to address this when treating many pain patterns, especially if they are chronic. In the Sports Medicine Acupuncture Certification program run by AcuSport Seminar Series, we teach a particular needle technique at LIV-4 (paired with GB 39.5) as treatment for an anterior pelvic tilt. This is used on the most anterior side and could be part of the treatment of many back conditions such as radiculopathy, facet syndrome, and SI joint dysfunction; it can also be used with treatments for TOS and other problems. This point combination and needle technique was developed by Matt Callison through his understanding of channel theory and then refined with trial and error. I interpret LIV-4 as softening the psoas and helping relax and lengthen this muscle, which is such a strong contributor to an anterior pelvic tilt. It is mentioned here to highlight the relationship of the Liver sinew channel to the psoas major, which is heavily involved with an anterior tilt of the pelvis. 

In addition to acupuncture to distal points, direct needling of motor points to muscles such as the QL, scalenes, pectoralis minor, and other related structures can help improve alignment. Also tuina is indicated. I utilize myofascial release extensively in my practice and it can be very helpful in releasing tight fascia and allowing the body to find a more healthful balance. In Sports Medicine Acupuncture and in the KMI training, Simone Lindner teaches a very useful myofascial release technique to the lateral raphe (a fascial structure which then separates to becomes the anterior and posterior layer of the thoracolumbar fascia). This structure is at the edge of the QL; the technique involves working with a seated patient and, using this fascial structure as leverage, lifting their ribcage out and away from their pelvis in the back. Also addressing the front of the diaphragm is useful as it is pulled up. Accessing this fascia under the costal margin and bringing it down will free the breath and soften the Liver channel.

Other sinew channels have a strong relationship to the diaphragm, either directly or indirectly, and can be explored at another time. Most notably, the Pericardium sinew channel influences it via its relationship with the serratus anterior, another muscle which can act as a clamp and restrict proper expansion of the thorax. Needling SP-21 or other points which correlate with motor points of this muscle will increase the Lung pulse, for instance. The Lung sinew channel relates to the pectoralis minor and the scalenes (both discussed in this post) and has a strong relationship to the diaphragm in that these muscles are accessory breathing muscles and, when restricted, can greatly limit breathing. The Yang sinew channels also include many structures such as the abdominals and pectoral muscles that can limit expansion of the breath. Therefore, the diaphragm, with its relationship to effortless and healthful breathing, is one of those pivotal structures for vibrant health.

Note: Tom Myers has an interesting discussion on this fascial plane which I am categorizing as part of the Liver sinew channel. His post can be found here; however, it is not written from a TCM or Chinese medicine prospective.

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