Tuesday, December 8, 2015

The Diaphragm and the Spleen Sinew Channel

Fig.1: Diaphragm, Anterior and Superior view, from
Grant's Atlas of Anatomy.
This is Part One of a post that will explore the sinew channels and their relationship to the respiratory diaphragm. This post will highlight the Spleen sinew channel (and will also discuss the Chongmai). The next post will highlight the Liver sinew channel. 

The respiratory diaphragm is a large, complex and extremely influential muscle. Its unrestrained movement is essential for proper breathing. This involves not only freedom in the muscle itself for it to ascend and descend, but also freedom in related structures which, when restricted, can act as a clamp and prevent expansion of the abdomen and thorax. Structures such as the the abdominal muscles, pectoral muscles, serratus anterior, and certain cervical muscles are among those that can be particular detrimental to breathing when they are restricted. In addition, the visceral organs move with each breath, so freedom in the diaphragm requires good circulation and unrestrained mobility in the organs for proper response to the diaphragmatic movement. Cervical pain, low back pain, thoracic outlet syndrome, and hypochondriac and rib joint pain are just some of the many conditions that can occur with poor breathing due to dysfunction associated with the diaphragm.

From a Traditional Chinese Medicine standpoint, the ascending and descending of the diaphragm is important as it regulates the ascending of Spleen Qi and descending of Stomach Qi. Vietnamese educator and Classical Chinese medicine scholar Nguyen Van Nghi described the acupuncture point BL-17 from this standpoint, indicating that the reason it was both the Back Shu of the diaphragm and such an influential point of blood production was tied to the fact that it regulated the upward and downward  movement of the diaphragm, thus regulating the upward and downward movement of the Spleen-Stomach Qi mechanism, both being so integral to the production of blood.

This and the next post will look at the relationship of the sinew channels to the diaphragm, especially those of the Spleen and Liver sinew channels. I have been exploring the sinew channels for about 15 years, first as a taiji and qigong practitioner, then as structural integration practitioner (the body of work that includes Rolfing) and then as an acupuncturist. I was not thinking about these directly as sinew channels when I practiced structural integration, but was very influenced by Tom Myers' development of Anatomy Trains as these seem to relate to the 'tendons' we referred to in our 'tendon changing' exercises in taiji and qigong practice. As I transitioned into acupuncture, I noticed a lack of description of these sinew channels and have been working to develop these more thoroughly. I feel there is enormous potential in having a more detailed anatomical knowledge of them, and in using this specificity of detail to inform clinical decisions.

Much of this material is influenced by my practice first in structural integration and then in acupuncture, specifically through my work with Matt Callison and Sports Medicine Acupuncture®. This information is condensed from a lecture I have been giving in the certification program for Sports Medicine Acupuncture®. This primarily explores the sinew channels from the perspective of fascial planes, how these channels relate (internally-externally, six division, midday-midnight, five elements), and how they communicate proprioceptively through the fascia.

Fig 2: Cross section above the umbilicus which highlights the fascia anterior
and posterior to the rectus abdominis. This fascia is associated with the
Stomach and Spleen sinew channels.
The first sinew channel to explore relating to the diaphragm is the that of the Spleen. Actually, it might be better to consider this as a pair involving the Stomach and the Spleen. As in much of Chinese medicine, the physiology of the Stomach and the Spleen sinew channels are very tied together. Often internally-externally related sinew channels have an agonist-antagonist relationship when looking at how they balance a particular joint complex. With the Spleen and Stomach sinew channels, they work much more together. We will look at the anatomy of these channels in relationship to the torso in this post.

The fascia associated with the rectus abdominis muscle is particularly relevant to these channels. The fascia of the external obliques travels anterior to this musclel the fascia of the internal obliques bifurcates, half of it travels anterior, half posterior. The transverse abdominis travels completely posterior to the rectus abdominis. Note: this changes below a structure called the arcuate line, which is roughly in the region of Ren-6, at which point the rectus abdominis becomes deep to all of this fascia and continues to connect to the pelvic floor.



Fig. 3: Image from www.brucelee.com.
The fascia which travels anterior to the rectus abdominis (that of the external obliques and part of the internal obliques) comprises the abdominal portion of the Stomach sinew channel. Following this fascia superiorly reveals that the anterior fascial layer is continuous with the fascia anterior to the ribcage, especially the sternalis fascia. This fascia then connects with that of the sternal head of the sternocleidomastoid muscle (SCM). When this layer is short and tight, the abdomen is often very flat and possibly bowed concave, the sternum is pulled down, and the head is pulled forward. The build of a boxer comes to mind, but I am including an image of Bruce Lee as this is so apparent on him. The tension in the abdominal muscles hasthe capacity to prevent adequate expansion of the abdomen during an inhale and can limit a full breath. 

Fig. 4: Spleen Sinew Channel image from Deadman's
A Manual of Acupuncture.
The posterior abdominal fascia has a different trajectory, and is continuous with the costal margin attachments of the diaphragm at the inner surface of the anterior ribcage. From here, one could follow the diaphragm around to its connection to the lumbar spine. This connection is called the crus (feet) of the diaphragm and connects this muscle to the lumbar spine at L1 and L2 (Fig. 1). This would describe the Spleen sinew channel as seen in Fig. 4. 

However, one could also follow the diaphragm up to the central tendon (Fig. 1). The pericardium attaches to the central tendon on its superior surface. The pericardium is in the same fascial layer which comprises the hyoid muscles. This plane (posterior abdominal fascia-diaphragm-pericardium-hyoids) could be considered part of the sphere of influence described by the Chongmai and accessed through SP-4 (Fig. 5). Also included in this layer is the transversis thoracic muscle, an interesting muscle on the posterior surface of the ribcage that shares a similar trajectory to the portion of the Chongmai that disperses in the chest (Fig. 5). For all practical purposes, I consider the Spleen sinew channel to follow this upward trajectory in addition to the attachments at the lumbar spine. And, not surprisingly, SP-4 (paired with PC-6) is a powerful point combination to affect this region.

Fig. 5: Chongmai from
Deadman's A Manual of
Acupuncture.
When this layer is restricted, the abdomen is bowed convex and is distended (not unexpected in Spleen Qi deficiency, for instance). Also the solar plexus region is collapsed inward. Often, there is an appearance of someone being punched directly in the solar plexus. Simone Lindner, my fellow faculty member in the Sports Medicine Acupuncture Certification program and a senior instructor with KMI (the program that teaches Anatomy Trains and Kinesis Myofascial Integration), often states that when she sees this pattern, she wonders if, at some influential point in their development, this person had 'their breath taken away'. This could be physical through some direct trauma or emotional. But it is usually pretty deeply seated in their physiology. And, more important to the discussion, it obviously restricts breathing. Patients who present with this pattern generally take very shallow breaths into the belly, with very minimal movement expanding into the chest. It appears that these patients cannot take a full expansive inhale, and are stuck on the exhale portion of the breath. Fig. 6 highlights this, notably the bowing of the abdomen, the collapse of the chest and the general restriction of the ability to take an inhale expanding into the chest.






Fig. 6: Image courtesy
Matt Callison / Sports
Medicine Acupuncture
Used with permission
Releasing this posterior rectus abdominis fascia usually is rewarded with a profound release of the breathing and marked improvement in the ability to take a full inhale. This can be released manually by starting at the Spleen channel and insinuating fingers behind the rectus abdominis to reach the Kidney channel and waiting for a release. The fascia can also be lifted or dropped depending on the need. Acupuncture needles can instead be used following the same trajectory as the fingers. Upon the release of this layer, the breath is able to move from the abdomen into the chest, allowing for a full expansion in the chest.

In the Sports Medicine Acupuncture Certification program (in 2016 it will be in Chicago), we cover vertebral fixations and their treatment with mobilization techniques, specific needle techniques at Huatuojiaji points and use of extraordinary vessel points. Fixation at specific levels (certain midback and cervical regions) which are treated with SP-4, PC-6 are understood better by thoroughly comprehending the anatomy explained above. And the treatments described in this post can supplement the treatments explored more thoroughly in these classes.

Before moving on to the Liver sinew channel in the next post, it might be useful to note that the abdominal obliques do travel around the body to the lumbar region, and their fascia blends in with the thoracolumbar fascia and attaches to the spine. This accounts for the Stomach sinew channel attaching to the spine (Figures 7 and 8). This layer also needs to be open and free for a full expansive breath.










Fig. 7: Abdominal and Thoracolumbar Fascial Layers
from John Hull Grundy's Human Structure and Shape.


Fig. 8: Stomach Sinew Chanel from Deadman's
A Manual of Acupuncture.



























5 comments:

  1. There is a beautiful correlation between embryology, the emergence of the layers and organs of the body, and the acupuncture meridians. Dan Keown's work is along these lines and I look forward to a workshop he will be giving at the upcoming AAMA meeting in Anaheim. Thank you for writing this!

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  2. Thanks Anna, I will look into Dan's work.

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  3. Brian, Than you. This is very helpful.... I cannot find your article about the Liver sinew channel and the diaphragm. Are you teaching this material in NYC at all? I would love to learn more.

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    1. Thanks for the comment. Here is the link for the Liver post http://drbrianlau.blogspot.com/2015/12/the-diaphragm-and-liver-sinew-channel.html
      I will be in New York for a low back and hip class in September. Here is the info for the class. https://www.sportsmedicineacupuncture.com/products/foundational-course-schedule/treating-common-injuries-of-the-low-back-and-hip-duplicate/

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