Wednesday, December 14, 2016

Reunion Zones (Muscle Meridian Meeting Points) and Myofascial Anatomy

In Chinese medicine school, many of us have studied reunion zones, which have also been called "muscle meridian meeting points." They involve the following points:

  • Three Arm Yang: The temporal region. Points are ST-8 or GB-13 (depending on the source).
  • Three Arm Yin: Under the axilla. Point is GB-22.
  • Three Leg Yang: Cheek bone. Points are SI-18 or ST-3 (depending on the source).
  • Three Leg Yin: Above the pubic bone. Point is Ren-3.
If you are like me, you memorized these points in school, possibly seeing them on the "Big Picture" chart that you diligently memorized in preparation for the boards. Chances are, nobody explained the significance of these, where this information came from, or whether it was even relevant. Why, for instance, is GB-22, a Yang channel point, the muscle meridian meeting point for the three Yin arm sinew channels?

To answer these questions, it is important to understand where this information comes from in the first place. These reunion zones or meeting points first appear in a specific translation and commentary of the Lingshu, in Chapter 13, which discusses the sinew channels or Jingjin. I refer to paragraph 13 of this chapter, as translated by Vietnamese scholar Nguyen Van Nghi.

The interesting thing is that this paragraph from the Lingshu is quite short and Van Nghi extrapolates significantly more in his commentary than is explicit in the original information. The actual text (translated into English) of the paragraph reads:

"In cases where the Zu Yangming (ST) Jing Jin and the Shou Taiyang ) SI Jing Jin are concomitantly affected, with deviation in the face and eyes accompanied by visual disturbances... the treatment is the same as that which was previously indicated."

Leading up to this, paragraphs 1-12 have outlined the topography of the 12 sinew channels along with basic symptoms of dysfunction and treatment. Treatment mostly involves fire needling of ashi points.

Van Nghi gives four pages of commentary on this short passage. In it, he defines these reunion zones based on regions (temporal, below the axilla, etc.), but does not indicate specific points (though images he uses do show points). Looking at the basic topography allows one to see that these pairings of 3 arm and leg Yin and Yang channels would all involve the above reunion zones, as all of these channel end at these sites. Van Nghi further states that, when all of these channels are involved (all of the 3 arm Yang channels, all of the 3 arm Yin channels, etc.) together, then these reunion zones become painful. More specifically, he states that when there is invasion of pathogenic factors in these pairings, then these reunion zones are always painful.

So, what is the relevance of these points? First, it is important to note that they do not appear in the Lingshu or the classics of Chinese medicine. But they are brought forward and discussed by Van Nghi, a well-respected scholar and physician of the past century. His commentary, with its descriptions of reactivity and pain associated with these pairings of three sinew channels, appears to convey that the relevance is its value in diagnostic work. In his commentary, he further discusses the season in which disorders generally appear for these pairings (for example, "Disorders in the Jing Jin of the three Yin hand channels generally appear in the course of the three months of winter.")

I feel an understanding of the underlying anatomy gives some perspective on these regions or points, and can help guide you as to when and if to use them. At the least, the anatomy can help understand how these pairings of channels meet in these regions. Let's take GB-22 or the region under the axilla as an example.

In my listing, the three arm Yin sinew channels include the following muscles and fascia:
  • Lung sinew channel includes the pectoralis minor and the clavipectoral fascia.
  • Heart sinew channel includes the pectoralis major
  • Pericardium sinew channel includes the serratus anterior
The clavipectoral fascia (which envelopes the pectoralis minor muscle), the fascia of the pectoralis major, and the fascia of the serratus anterior all blend together in the region of GB-22. This is seen in the diagram below in the region of the suspensory ligament of the axilla which unites all of these channels and helps form the base of the axilla. GB-22 is one of several motor points of the serratus anterior (SP-21 is another). It, therefore has a direct influence on this muscle, but I feel that it influences all three muscles and associated channels. Although GB-22 is a Yang channel point, it is a motor point of a Yin sinew channel muscle (Pericardium) and exists at a region where the other Yin arm sinew channels meet.

These images highlight the merging of fascial planes of the 3 arm Yin sinew channels. The image on the left is from Netter's Atlas of Human Anatomy. The two images on the right are from Functional Atlas of the Human Fascial System by Carla Stecco.


Sunday, December 11, 2016

The Sinew Channels at the Pacific Symposium

I have not posted in a while and plan on starting up again. Below is a bit of a summary of what I have been doing and some thoughts on future posts.

On Saturday, October 29th, Matt Callison and I presented at the Pacific Symposium. We presented on the work we have been developing on the sinew channels (some of which has been featured on this blog). This presentation covered background on sinew channel study from the Lingshu to the present, and discussed what we are using to further expand this concept. This includes modern functional anatomy, fascial research, ongoing cadaver studies, and clinical observation, among other things.


We then explored a few channels (Urinary Bladder sinew channel, Liver sinew channel, Gallbladder sinew channel, Small Intestine sinew channel) and looked at some clinical examples. We performed a few demonstrations on volunteers from the audience for Iliac Crest Syndrome (we referred to this as Yaoyan syndrome, as the pain presents at the extrapoint Yaoyan) and on Levator Scapula Syndrome. In both examples, we looked at the common muscle imbalances and, through the lens of the sinew channels the channel imbalances associated with these pain syndromes individually. These pain syndromes tend to be associated with an elevated ilium (with Yaoyan syndrome) and a elevator scapula (for levator scapula syndrome). 

Finally we discussed how these two syndromes are commonly seen together, and specifically how assessment and treatment of the quadratus lumborum (part of the Liver sinew channel, Fig. 1.) and the levator scapula (part of the Small Intestine sinew channel) represents a midday-midnight channel relationship (Fig. 2).

Recently (12/1-12/4), I retook a visceral manipulation course through the Barral Institute. I have been interested and influenced by this work for a long time and plan on studying it in earnest this coming year. While this blog focuses on the development of a more anatomically precise model for the sinew channels, I believe that visceral manipulation gives much insight into how the internals relate to the myofascia (how the primary channels nourish and influence the sinew channels). This will be discussed further in a future post. For now, I will share an image of the liver and its relationship to the diaphragm and the quadratus lumborum. Jean-Pierre Barral, the developer of visceral manipulation, feels that excessive energy in the liver disperses into the quadratus lumborum and psoas muscles (Fig. 3). Again, more discussion on this is to come.




Monday, September 26, 2016

The Psoas and the Liver Sinew Channel

I recently returned from Chicago for the start of Module 3 of Sports Medicine Acupuncture Certification (SMAC). The beginning of the module involves two classes, two days each. The first class was the Anatomy/Palpation/Cadaver Lab, taught by Matt Callison, David Vavrinchik, and myself. The second was Fascial Release for Myofascial Meridians, a class that I assist with and is taught by Simone Lindner. In October, I will return to assist with two classes for this module, the Assessment and Treatment of Low Back and Hip Injuries and Postural Assessment and Corrective Exercises (PACE) III, taught by Matt Callison and Ian Armstrong.

While teaching is an opportunity to share information with the class participants, it is also a chance for learning and investigation. In this past sequence, there were many chances for exploration, but one stood out for me.

This involved a 'cross pollination' of ideas from Matt and myself and from Simone. Simone is a longtime instructor with KMI (Kinesis Myofascial Integration), which is the school of structural integration started by Tom Myers, the author of Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. She is teaching a version of this program as a part of SMAC. But, since all of the participants are acupuncturists, we are able to look at relationships between the fascial release work that they teach for the myofascial meridians and acupuncture techniques that we teach to work with the sinew channels.

One such incidence involved working with the iliacus and psoas. Simone was in the part of the class where she was working with imbalance in these extremely important structures. After assessing and before actually performing the techniques, she palpated the iliacus and psoas. She would then perform the techniques and expect to feel the tissue change. But, we decided to try acupuncture first and then see if there was change in the tissue.

The main points we used were GB-27 and LIV-4. The psoas is a tricky structure to treat directly with an acupuncture needle. You can not reach it through the front without penetrating the peritoneum and there are risks involved with accessing it through the back. Matt Callison teaches a way to treat it with a particular needle technique at GB-27. The needle technique must propagate a sensation to one of three places to be effective in changing the holding pattern of the psoas.

Distal points for the psoas could include the Liver channel, as the psoas is on the Liver sinew channel. Or it could include Kidney points, as the psoas converges with the Kidney sinew channel at the spine. I recommended LIV-4, as the model had an anterior pelvic tilt on the side being worked on and a posterior pelvic tilt on the opposite side. In this type of situation, LIV-4 can be part of the treatment for the side with the anterior tilt. This is part of a protocol we teach in SMAC for an asymmetrical pelvis. I feel that LIV-4 addresses the shortened tissue along the sinew channel coming up the medial thigh and into the the iliacus and psoas.

After needling these points, obtaining the proper Deqi sensation, and with very little retention (we would have retained longer if time had allowed), we removed the needles and had Simone reassess. She was surprised by the degree of change that occurred in the tissue from this technique. After this, her technique required much less work. This is a very good argument for performing needling first and manual therapy second, as the acupuncture can do so much to open and prepare the tissue.


Thursday, August 25, 2016

The 'Fuzz', Acupuncture, and Dissection

Many here will likely have seen this video. It's a bit of a classic. Not only is it accessible and informative, but Gil Hedley is such an oddly interesting person, that it is fun to watch. This particular version of the video also has some updated written thoughts of his based on a greater understanding of fascia since the recording of the original video. These are informative. If you have never seen this video, watch it once through without reading the commentary. Then you might watch it again and read the commentary. I have a couple of my own thoughts which can also be considered:


There is a role of the 'fuzz', these web-like fascial connections between sliding planes of tissue such as muscles. Current understanding indicates that these fascial interconnections are important for proprioception. They help link the muscular system with the nervous system and assist with coordinating complex and efficient movement patterns. So, the 'fuzz' is not bad or pathological, and Gil Hedley was not trying to indicate that it is. But it can become too densified and restrictive (for reasons described in the video). And this can disrupt the proprioceptive role of these fascial attachments, leading to inefficient movement, reduced range of motion, and pain.

Fig. 1: Image from The Science of
Stretch, by Helene Langevin.
the link to this article is in
the paragraph to the left.
In Sports Medicine Acupuncture Certification, we have the opportunity to work with fresh tissue cadavers. It is very interesting to take an acupuncture needle, especially a good quality Chinese needle like a Hwa-To, place it in this fuzz, and rotate it back and forth. This really highlights the adhesive quality of this tissue; it is fascinating to see how quickly it adheres to and wraps around the needle (Fig. 1). This tensions and stretches the fascia and can help explain much of the therapeutic benefits of acupuncture as has been so clearly described by fascial researcher, Helene Langevin (click here to read a great summary of her research).

When doing dissection, many times you are cutting through this fuzz as you separate one structure from the next. This is frequently how you navigate through the structures, as the body's compartments are organized through the fascia. Without these cleavage planes, it is often difficult to know exactly where you are (cadaver specimens are not nearly as clear as an illustration). Imagine using a scalpel to separate a section of an orange. If you veer into the pulp, it is easy to get lost. Like the membrane that contains and separates the orange section, this is one of the roles of fascia; it compartmentalizes the body.

A colleague that studied with another fascial anatomist, Todd Garcia, quoted him as saying 'the truth is in the bucket'. Meaning, in dissection, you are often cutting away this tissue, which contains so much proprioceptive information and is increasingly understood to have so much function, and discarding it. You do this to get to the 'good stuff'. Or, at least, to see the units of the body and better understand its organization. But, in doing so, much of the tissue which can explain the mechanism through which holistic practices such as acupuncture and myofascial release work is discarded.

Sunday, August 21, 2016

The Gluteus Maximus and Converging Sinew Channels



Fig. 1: Image from Functional Atlas of the Human
Fascial System by Carla Stecco
This image (Fig. 1)  is from the excellent book, Functional Atlas of the Human Fascial System, by Carla Stecco. In Manhattan two years ago, during the Sports Medicine Acupuncture Certification (SMAC) program, Matt Callison and I were preparing a fresh tissue cadaver specimen for the Anatomy/Palpation/Cadaver lab for Module 3, which addresses the lower back and hip. In this specimen, we observed an interesting fascial expansion which extended from the deep fibers of the gluteus maximus and connected to the hamstrings and sacrotuberous ligament (STL). This was in the region of BL-36. We saw this as confirmation that the gluteus maximus was part of the Urinary Bladder sinew channel.

Fig. 2: Image from
A Manual of Acupuncture
by Peter Deadman
Maybe this seems like an obvious sinew channel in which to place this muscle, but consider that the gluteus maximus also attaches to the iliotibial band (ITB) which is on the lateral leg. Also, this muscle matches the topography described in the Lingshu, which mentions that the Gallbladder sinew channel has a branch that attaches to the sacrum (Fig. 2 and 3). Both of these vectors of pull are discussed in Stecco's book and seen in Fig. 1. The black line (ITB - gluteus maximus - sacrum) describes the GB sinew channel. The red line (hamstrings - gluteus maximus - STL - thoracolumbar fascia and erector spinae) describes the BL sinew channel. So, the gluteus maximus is an example of where two sinew channels converge. Like the primary channels, this kind of convergence is something that occurs with some regularity.






Fig. 3: Image from
An Atlas of Human
Anatomy for
Students and
Physicians by
Carl Toldt
A few clinically useful things can be taken from this:

1) The gluteus maximus MP can be added to treatments that affect the GB sinew channel. These include trochanteric bursitis, iliotibial band friction syndrome, and asymmetrical pelvic tilts (contributing to a host of potential problems). Treatment can include GB distal points.

2) The gluteus maximus MP can be added to treatments that affect the BL sinew channel. These include hamstring and gluteus maximus strain, hamstring tendinopathy, coccydynia, sacroiliac joint problems, and erector spinae strain. Treatment can include BL distal points. 

3) The gluteus maximus MP has an empirical use, which is that it reduces tension in the upper cervical muscles. This is an example of treating below to affect above on the same channel. 

4) The gluteus maximus MP can be considered as a distal point when treating restriction and pain in the pectoralis muscle. The pectoralis major is on the Heart sinew channel, so this can be considered a midday-midnight (GB-HE) treatment. And, there is a branch of the BL sinew channel which also travels through the pectoralis major via the  thoracolumbar fascia - latissimus dorsi - pectoralis major - SCM branch seen in Fig 4. It is not imperative that you know which channel relationship you are affecting, and this topic can be taken up another time. 

5) Lastly, the gluteus maximus becomes bilaterally weak when there are upper cervical vertebral fixations. This is harder to explain easily; I can refer you to an article I wrote that was in the Illinois Association of Acupuncture and Oriental Medicine Newsletter (The Illinois Acupuncturist) and will be in the upcoming Florida State Oriental Medical Association newsletter. This is also posted on my blog and you can click here to see it. 

Basically, I see this problem as an interaction of the Urinary Bladder sinew channel and the Spleen and Stomach sinew channels, and an example of Earth overacting on Water. These sinew channels have an agonist/antagonist relationship. The Stomach and Spleen sinew channels become bound, which restricts the anterior portion of the diaphragm and the deep anterior myofascia (abdominals below, transversus thoracic and hyoids above). This causes tension in key regions of the spine and can lead to vertebral fixations. Certain muscles on the BL sinew channel then become bilaterally weak (the gluteus maximus in the case of upper cervical fixations). In Sports Medicine Acupuncture, we treat upper cervical fixations by using vertebral mobilization techniques for the affected vertebrae, needling SP-4/P-6 (which affects the deep holding pattern) and needling the MP of the gluteus maximus. 

Fig. 4: Image from A Manual of Acupuncture by Peter Deadman

Sunday, August 14, 2016

Kunlun BL-60, the Urinary Bladder Sinew Channel, and Muscle Tension Headaches

“Kunlun BL-60 is the fire point of the taiyang Bladder channel and an important point to clear and descend excess wind, fire and yang from the upper part of the body.” So states Deadman in the commentary for this point in A Manual of Acupuncture. He goes on: “The principle 'for disease of the head select [points from] the feet' applies well to the point. Kunlun BL-60 is able to clear heat and lead down excess yang from the head in cases of headache, heat in the head, redness, pain and swelling of the eyes, bursting eye pain, nosebleed and toothache, and to extinguish wind from the head in cases of epilepsy and lockjaw.”

What I would like to consider in this post is the actions of this point on muscle tension headaches, specifically on reducing tension in a group of muscles that often become dysfunctional together as part of this pattern of tension headaches. These muscles individually refer pain to the posterior neck and occiput, the temple region, and the region of the orbit of the eye. Collectively, their referral patterns overlap and can create a composite pattern of pain that many of our patients describe when they come in for treatment. These muscles are the trapezius muscles (primarily the upper fibers but also the lower fibers can contribute to headaches), the suboccipital muscles, the sternocleidomastoid (SCM), and the temporalis muscle.

Fig. 1: TrP pain referrals of the upper trapezius, the suboccipital muscles, the SCM (sternal head), the temporalis, and the SCM (clavicular head). Image from Myofascial Pain and Dysfunction: The Trigger Point Manual by Janet Travell and David Simons.


Fig. 2: Urinary Bladder sinew channel image from
A Manual of Acupuncture, by Peter Deadman
What unifies these muscles from a channel theory perspective is the Urinary Bladder sinew channel. An uprising of Yang, and a flaring of Fire and stirring of Wind, often with disharmony in the Liver network, manifests as contraction in the muscles listed above. These muscles are all part of the Urinary Bladder sinew channel. This channel unites these muscles together in a type of disharmony that causes muscle tension headaches.

The sinew channel would indeed include the suboccipitals along with the chain of myofascial tissue, creating a myofascial meridian, and rising up the back of the body (Fig. 4). This is an obvious muscle to include in any channel description involving the trajectory of the Urinary Bladder channel. And this myofascial meridian also includes the thoracolumbar fascia, the thick aponeurotic structure in the lumbar region. But, other structures attaching to the thoracolumbar fascia explain several branches of this sinew channel. This includes the latissimus dorsi and the lower fibers of the trapezius (Fig. 3). The latissimus dorsi has obvious fascial connections to the pectoralis major which, in turn, connects with the SCM. The trapezius, accounting for the LI-15 and GB-21 binding regions depicted by Deadman and discussed in the Lingshu, blends in with the fascia of the scalp and connects to the temporalis muscle. Excess Yang rises up and all of these muscles become dysfunctional and contribute to the building pain many people feel throughout the day. It can also contribute to the typical guarding posture that is seen with increased stress which is referred to as upper cross syndrome (a posture with a forward head and protraction of the scapula).

Fig.3: Image modified from Netter's Atlas of Human Anatomy. Sinew Channel interpretations by the author, Brian Lau, AP, C.SMA

Fig. 4: A dissection of the Superficial Back Line from Anatomy Trains. This image includes, from left to right, the plantar fascia, the fascia of the periosteum of the calcaneus, the Achilles tendon, the gastrocnemius and soleus, the hamstrings, the sacrotuberous ligament and posterior sacral ligaments, the erector spinae and suboccipitals, and the galea aponeurotica or the fascia of the skull. This is very similar to the myofascial of the main branch of the the Urinary Bladder sinew channel.



According to A Manual of Acupuncture, actions of BL-60 include:
  • Clears heat and lowers yang
  • Pacifies wind and leads down excess
  • Activates the entire Bladder channel and alleviates pain
  • Relaxes the sinews and strengthens the lumbar spine
  • Promotes labor

This point, frequently combined with SI-3, serves as a great distal point to treat muscle tension headaches. This should be combined with proper needling of the motor points of the involved muscles and with treatment of the root of the disharmony (BL-60 treats the manifestation of Yang rising, so the practitioner should look to the pattern of excess and deficiency present with the patient, also). Many of the motor points of the muscles involved coincide with points that many acupuncturists already use, but the techniques and depth required to reach and affect muscle spindle relationships in the muscles is not always adequately preformed. The motor points are briefly described, but this type of information is best left to a classroom discussion. I will be teaching a foundation course in Sports Medicine Acupuncture for the neck and shoulder in Manhattan and in the Tampa Bay area in the new year (dates to be determined soon). For other classes and for Sports Medicine Acupuncture Certification (SMAC), you can look at the schedule on the SMA website.

  • Upper trapezius – motor point 2 is GB-21; the muscle can be grasped and held away from the rib cage, and it can be needled from SJ-15 with the needle pointed up (away from the pleura) towards GB-21. Motor point 1 is about halfway between SI-15 and -16 and is needled (with the patient supine) through the anterior edge of the muscle from anterior to posterior and with a slightly upward direction. This is through the fibers in the region where the muscle turns from being horizontal to more vertical as it ascends the neck.
  • Suboccipitals – accessed from GB-20. Deadman describes palpation with the finger angled towards the nose (this goes into the suboccipital triangle), the finger angled towards the contralateral eye (this accesses the rectus capitis posterior major), or the finger angled towards Yintang (this angles the needle towards the attachments of muscles such as the trapezius to the occiput). We discuss some other needle angles and depth in Sports Medicine Acupuncture classes, but there are safety issues with the vertebral artery that makes a classroom setting much better for this discussion. 
  • SCM – both heads can be needled from ST-9. However, it is imperative that the needle direction is lateral and that the needle ascends through the muscle of the SCM and does not travel medial to the muscle towards the carotid artery. Note: this is a different technique than ST-9 describe in A Manual of Acupuncture which discusses needling between the carotid and the thyroid cartilage. SJ-16, though not a motor point, is another reactive point that affects the clavicular head of the SCM. Palpate for the most reactive region and angle slightly anterior into the muscle.
  • Another motor point to consider is the piriformis motor point. This point is halfway between BL-54 and BL-53. It is an empirical motor point and it eases pain in the BL-10 region (describing the method of treating below to affect above). And it can also reduce tension in the pectoralis minor (a midday-midnight [zi wu liu zhu] relationship) and assist in opening the chest and correcting the typical upper cross syndrome seen).
  • Note: these motor points are listed in Motor Point Index - An Acupuncturist's Guide to Locating and Treating Motor Points.

It is worth noting that the sinew channels converge and that many of the muscles discussed are part of other channels and can be addressed via distal points on other channels. The trapezius, for instance, is a muscle where the Large Intestine, Sanjiao, and Gallbladder sinew channels also converge. There are many other instances where you would consider Shaoyang or Yangming point combinations for other type of disharmonies affecting this muscles; points such as GB-39 and LI-10 come to mind. The above discussion was specifically about a series of muscles related to muscle tension headaches and their dysfunction, which can be seen as a disharmony affecting the Urinary Bladder sinew channel.

Sunday, August 7, 2016

LI 15 (Jianyu) and Channel Relationships: A Point Reached by the Lung sinew channel and the Small Intestine Luo-Connecting Channel

"Jianyu L.I.-15, a meeting point of the Large Intestine channel with the Yang Motility vessel, is also reached by the Lung and Bladder sinew channels, the Large Intestine divergent channel and the Small Intestine luo-connecting channel. Jianyu L.I.-15 is considered the preeminent point for treating the shoulder, and clinically the majority of shoulder disorders affect this region."1 This is a quote from the commentary of LI 15 in A Manual of Acupuncture by Peter Deadman. There is a lot of information in this opening paragraph; a look at the anatomy will help to elucidate it. 
Fig. 1: Image from A Manual of Acupuncture,
by Peter Deadman. Illustrating the
The Lung sinew channel which
"enters the bottom of the armpit"
 but also "connects to the front 
of the shoulder joint"

In this post we will start with the Lung sinew channel and the Small Intestine luo-connecting channel. This will highlight the relationship of LI 15 to shoulder problems. The Lung sinew channel includes the biceps brachii. The Lung sinew channel is continuous, via myofascial connections, from the thenar muscles to the pectoralis minor, subclavius, and intercostal muscles. The biceps brachii are part of this sinew channel and it is specifically the short head of the biceps which blends with the pectoralis minor. However, as described classically and seen in the illustration from A Manual of Acupuncture, the long head of the biceps can be interpreted to be included. The long head has a fascial connection to the supraspinatus.2

Interestingly, the supraspinatus muscle is part of the Small Intestine sinew channel and its muscle belly is accessible at SI 12 (which is the motor point of the supraspinatus).3 However, its musculotendinous junction is reached by LI 16 and its humeral attachment is reached from LI 15.
Fig 2: Note the transverse ligament which is illustrated
as a separate structure. Compare it to Fig 3. where it
does not appear to be a separate structure. In a cadaver
specimen, it is observed to be a continuous sling as describe
in this post.
The long head of the biceps brachii (part of the Lung sinew channel) lies in the bicipital groove where it is held in place by a ligamentous structure called the transverse humeral ligament. While not described this way in anatomy texts, the transverse ligament is actually a fascia sling composed of the superficial fibers of the subscapularis tendon, a muscle of the Heart sinew channel, and longitudinal fibers of the supraspinatus tendon.4,5 Overactivity in the subscapularis muscle can contribute to pain in the long head of the biceps as the additional tension, transmitted through the transverse ligament, compresses the muscle and its tendon sheath and can be an aggravating factor for bicipital tenosynovitis (inflammation of the tendon sheath of the long head of the biceps).



So LI 15 is a fascial meeting point of the supraspinatus (SI sinew channel) and subscapularis (HE sinew channel), and this point is classically described as a meeting point of the Small Intestine luo-connecting channel, a point that would connect the Small Intestine channel with its internally related Heart channel.
Fig. 3: The anterior view of the scapula and humerus with the rib cage removed.  This image is modified from Atlas of Human Anatomy by Frank Netter.  LI 15 is on the anterolateral border of the acromion process of the scapula. When located this way, there is little space felt between the acromion process and the greater tubercle of the humerus. Anatomy illustrations are somewhat misleading and the above illustration seems to put LI 15 much farther inferior to the acromion. This is not the case. If the tip of your finger is on the point, it side should be in contact with the acromion process

Needling at LI 15 accesses the region where the supraspinatus tendon attaches and where the transverse ligament crossed over the biceps tendon. Therefore this point can be used when there is pain from supraspinatus tendinopathy and/or from bicipital tenosynovitis. These are two of the most frequent shoulder conditions, so it can be seen why LI 15 is so useful. Which other points are used in addition will be based on which pathology is being treated, which muscles are overactive and which are inhibited, and, based on this, how well the glenohumeral joint is functioning. Frequently used points include SI 12 (the motor point of the supraspinatus), SI 11 and the motor points of the infraspinatus, SI 9.5 (the motor point of the teres minor and half way between 9 and 10), and HE 1 (the motor point of the subscapularis).6 There are other direct techniques which can be used for specific conditions.

Many practitioners would agree that distal LI channel points are often used for shoulder problems such as supraspinatus tendinopathy and bicipital tenosynovitis. Obviously the LI channel flows through LI 15. But, as mentioned above, LI 16 accesses the myotendinous junction of the supraspinatus and the Large Intestine channel then intersects with SI 12 en route to LI 17.

A specific distal point commonly used for shoulder problems is LI 11. This point can be threaded to connect with HE 3 (or vice versa) which would help connect the Large Intestine channel (which intersects with SI 12 and the supraspinatus) with the Heart channel (which connects with the subscapularis) and helps balance the relationship of these to important shoulder joint muscles.

References:

1. Deadman, Peter, Mazin Al-Khafaji, and Kevin Baker. A Manual of Acupuncture. Hove, East Sussex, England: Journal of Chinese Medicine Publications, 2007. Print.

2, Myers, Thomas W. Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. 3rd ed. Edinburgh: Churchill Livingstone, 2014. Print.

3 Lau, Brian. "Anatomy of the Sinew Channels: Head, Neck and Upper Extremities." Sports Medicine Acupuncture Certification: Module 2 Anatomy/Palpation/Cadaver Lab. Pacific College of Oriental Medicine, Chicago. 24 Apr. 2016. Lecture

4, Gleason, P.D. "The Transverse Humeral Ligament: A Separate Anatomical Structure or a Continuation of the Osseus Attachment of the Rotator Cuff?" American Journal of Sports Medicine 34.1 (2005): 72-77. Web.

5, Stecco, Carla, and Warren I. Hammer. Functional Atlas of the Human Fascial System. Edinburgh: Elsevier, 2015. Print.

6. Callison, M. (2007). Motor Point Index: An Acupuncturist's Guide to Locating and Treating Motor Points. San Diego, CA: AcuSport Seminar Series LLC.






Wednesday, June 8, 2016

Tensegrity and Sinew Channel Relationships

I just submitted an article coauthored by Matt Callison to the Oriental Medical Newsletter, a publication of Pacific College of Natural Medicine. This article is the first of two parts and will discuss our research into the sinew channels (jingjin), secondary channels described in Chinese medicine. See Creating a Modern Model for the Assessment and Treatment of the Sinew Channels (Jingjin): Part 1 in the upcoming edition of the newsletter.

We have been exploring the sinew channels and building a more complete and comprehensive model of these using the original description in the Lingshu, but also fascial research, our own cadaver studies, and functional anatomy. With this information we have be building a model of these channels which is consistent with traditional channel theory while helping facilitate use of assessment based on orthopedic evaluation, postural assessment, and other functional tests. All of this information can be used then to build treatment protocol for these channels. We will be presenting this information at the Pacific Symposium in San Diego this Fall.

One of the concepts discussed in the article is tensegrity and this is used to help understand sinew channel relationships. Increasingly, many holistic health systems which work with posture (Rolfing/structural integration, osteopathy, chiropractic, etc.) use the principles of tensegrity when describing the human body and when describing how their inteventions improve alignment and reduce structural strain.

Tensegrity is a term coined by architect Buckminster Fuller and used in his design of the geodesic dome. Tensegrity is derived from tension integrity, and in tensegrity structures tension provides the integrity of the structures.

Fig. 1
Tensegrity structures, from the simple model in Fig. 1 to the human body, have several features. First of all, they have continuous tension and discontinuous compression. In Fig. 1, the continuous tension is created by the elastic bands, whereas in the body it is the myofascia. This myofascia consists of the muscles and the seamless fascia which connects one muscle to the surrounding muscles and the muscle to the bone via the tendons. The discontinuous compression consists of the wooden dowels in Fig. 1 and the bones in the body. These compression elements do not touch one another (there is a joint space in healthy joints), but are used by the tension elements to have something to pull on and create shape.

This is a simple concept, but for those who have studied anatomy and observed a model skeleton in a classroom, a perception can be created that the stacking of the bones is what determines the alignment of body. If a bone is out of place, then it needs to be reset and put back into place. The problem with this perception is that the skeleton is only standing because it is held up by a stand with a chain at the head. Without this and, more to the point, without the tension of the muscles and fascia pulling on the bones, this structure would fall to the ground. But, without the levers of the bones (or dowels in the Fig. 1), the myofascia would be a blob of useless muscle contraction.

So, the bones are not stacked one atop another like bricks are stacked in a wall, but, instead, float in a sea of tension comprised of the myofascia. What determines the shape of our structure, then, is the balanced, or possibly unbalanced, tension inherent in the myofascia. In a balanced structure, muscles pull on the bony framework; they have enough strength to perform their movement and supportive roles, but they are not overpowering other muscles (creating muscle imbalances) and their associated fascia is not too bound and restrictive.


Fig. 2
The sinew channels offer a way of assessing the tensional aspects of the body and how this tension produces or distorts shape. For instance, internally-externally (biao li) related sinew channels work together to create balance across major joint structures. In Fig. 2, the pull of the pectoralis minor (part of the Lung sinew channel and illustrated by the red arrow) coordinates with the pull of the middle and lower trapezius muscle (part of the Large Intestine sinew channel and illustrated by the blue arrow) to produce movements such as scapular protraction. Imbalances are frequently seen where the pectoralis minor (LU) is overactive and pulling excessively, whereas the middle and lower trapezius muscles (LI) are inhibited and failing to withstand the excessive pull of the pectoralis minor. This leads to a postural imbalance where the scapular position is held in protraction causing, among many other things, decrease in the volume of respiration. In addition to restriction in breathing, this imbalance can lead to many injuries (see the series of posts on Upper Cross Syndrome, a common postural imbalance resulting in scapular protraction and a head forward posture). Other sinew channel relationships exist, such as six divisions (liu jing bian zheng) and midday-midnight (zi wu liu zhu), that give insight into how the sinew channels interact to achieve overall balance in movement and position.

Fig. 4
Another feature of tensegrity structures is that they are very strong and come by this strength with little overall materials. They are strong because they disperse force that is put into them. If and when they do break, they often do so at a weak spot in the structure. For instance, if one of the elastic bands was already degraded or a slight cut was introduced and enough force was introduced, this area of damage would likely be where the structure would break. In our bodies, this is often in a region of a previous injury or damage from repetitive motion.



Clinically, these relationships can be used to build treatment protocols that balance overactive (excess) and inhibited (deficient) muscles, thereby balancing the sinew channels. Acupuncture to motor points and other ashi points, myofascial release, and corrective exercises are especially effective at treating the sinew channels. This approach is especially effective when combined with TCM to treat any Zangfu dysharmonies using acupuncture points (in combination with motor points), herbs and lifestyle recommendations.

Sunday, April 10, 2016

Acupuncture Treatment for the Spiral Line

A common treatment we utilize in Sports Medicine Acupuncture® when there is strain along a sinew channel involves the classical needle technique of multiple needles along a line (pai ci). This treatment can help release bound fascia and restore length and range of motion along this line. This post will discuss an acupuncture treatment for shortening along the upper portion of the spiral line (SPL) discussed in Anatomy Trains; it is a useful protocol for posterior neck pain (often unilateral) when there are shifts and rotations seen between the pelvis, ribcage, and neck.

The SPL is a myofascial structure that winds around the body. Posturally, it can be be associated with rotational distortions and shifts of major body structures. Often times, it is involved with more superficial counter rotations to deeper core rotational patterns, such as those caused by having one psoas shorter than the other.

First, a word about what the SPL is and how it relates to the sinew channels. The SPL is a myofascial meridian discussed in Thomas Myers' book Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. There are strong parallels between the sinew channels discussed in Chinese medicine and the Anatomy Trains (myofasical meridians) discussed by Myers. I have used this book, along with other sources, as one of my references as I determine which myofascial (muscles and fascia) structures belong in which channel. This sinew channel information is then taught in the Sports Medicine Acupuncture Certification program (which, for this certification cycle, is in Chicago).

While there are points in common, there are also key differences between which structures make up the sinew channels and which are discussed in Anatomy Trains. The spiral line, however, is not similar to any one sinew channel, and can be seen as a unique structure. Actually, it involves the interaction of multiple sinew channels, primarily the Urinary Bladder, Gall Bladder, and Stomach sinew channels.

The upper SPL travels from the ASIS of one ilium, crosses to the opposite ribcage, wraps around to the posterior torso and travels under the scapula, and crosses back around to the other side at the spine (on the same side as it started) to connect to the neck. For instance, if we started at the left ASIS, it would incorporate the left internal oblique muscle, the right external oblique to the right serratus anterior, and right rhomboids (see the last post on the rhombo-serratus sling), then crossing over to the left splenius cervicis and splenius capitis to attach at the left transverse processes of C1-C3 and head. There would be a parallel structure on the opposite side of the body starting at the right ASIS and ending on the right C1-C3 transverse processes.

When there is shortness in one SPL, the ASIS will be closer to the contralateral lower ribcage. This will be seen with a ribcage that is shifted left or right in relation to the pelvis (shifted towards the ASIS of the short SPL) and/or rotated in relation to the pelvis (rotated toward the ASIS of the short SPL). This will be caused by shortness in the fascial sling of one internal oblique and the contralateral external oblique and serratus anterior. In addition, the head will then be shifted in the opposite direction in relation to the ribcage and/or there will be lateral flexion of the cervical spine. This will be caused by shortness in the remaining portion of the sling, which includes the serratus anterior and rhomboids (rhombo-serratus sling) and the contralateral splenius cervicis and capitis. Assessment of this involves a visual observation of the patient's posture.


Once it is determined which side is short, the following acupuncture protocol can then be added to the treatment. This protocol will release the bound fascia and restore length to the shortened SPL. This shortened side will frequently correlate to the side of the neck pain that a patient comes in complaining about, and can include trigger points in the shortened splenius cervicis, trigger points in the levator scapula (which will also often be in a shortened position), facet joint pain on the side of the shortened splenius cervicis (and the side of lateral flexion compressing the cervical facets on that side, and many other cervical complaints.

The protocol includes the following points:
  • GB-26 (the motor point of the internal obliques) and the contralateral LIV-13 (the motor point of the external obliques).
  • Serratus anterior MP on the same side as LIV-13.
  • Rhomboid major and minor motor points on the same side as LIV-13.
  • Huatuojiaji points associated with attachments of the splenius cervicis and rhomboids (usually T2-T3 are reactive).
  • Bailao (the motor point of splenius cervicis) and splenius capitis motor point (close to GB-20), both on the same sides as GB-26.
This entire protocol can be performed with the patient prone as GB-26 and LIV-13 can both be reached with the patient in a prone position. Adding distal points creates a more balanced treatment. These can vary based on other findings, but a typical protocol is included in the figure to the right and these points are highlighted in red. This includes:

  • BL-62 and contralateral SI-3 (SI-3 on the side of cervical pain). This combination addresses the Yang Qiao and its paired Du mai. The Yang Qiao involves the coordinated interaction between the Urinary Bladder, Gallbladder and Stomach sinew channels.
  • GB-41 and contralateral SJ-5 (SJ-5 on the side of the short rhombo-serratus sling). GB-41 and SJ-5 address rotational aspects of the pattern.
  • LIV-5, Adductor longus motor point, Quadratus lumborum motor point (on the side of the elevated ilium). This combination addresses the deeper underlying core imbalance. This shortness in the Liver sinew channel on one side will often cause deeper rotations which will result in counter-rotations mediated by the SPL.








Monday, March 21, 2016

Shoulder Health and the Rhombo-Serratus Sling

The rhombo-serratus muscle sling is a fascially bound structure consisting of the serratus anterior and the rhomboid major.1 The serratus anterior travels anterior to the scapula to attach to the medial border of the scapula, just next to the attachment of the rhomboids. Fascial fibers are shared between these two structures and their continuity can be observed in dissection (Fig. 1).
Fig. 1


Fig. 2: From A Manual of Acupuncture
by Peter Deadman
This sling can be considered as part of the Pericardium sinew channel, though its function is more consistent with the Sanjiao sinew channel, and it plays an important role in scapular movement during overhead activities. The Pericardium sinew channel is described in the Lingshu as traveling from the arm and “ascends the yin side of the upper arm to connect with the bottom of the armpit, and spreads down to the front and the back by clasping ribs.2  Deadman, in A Manual of Acupuncture, describes it like this: “follows the antero-medial side of the upper arm to disperse over the anterior and posterior aspects of the ribs.3

Fig. 3
Functionally, this sling works synergistically both to move the scapula into upward rotation (primarily controlled by the serratus anterior) while also stabilizing against the lateral pull (primarily controlled by the rhomboids).4 In other words, the serratus anterior is the prime mover for upward rotation, while the rhomboids fire to a lesser degree to resist the lateral pull on the scapula produced by the serratus anterior.

This entire action takes place with abduction of the humerus at the shoulder joint and is an important movement as it prevents impingment of the rotator cuff, subacromial bursa, and biceps tendon. With abduction past 30o, there is 1o of upward rotation or the scapula for every 2o of abduction or flexion of the humerus. This 2:1 ration is known as scapulohumeral rhythm, and it keeps the subacromial space open, as can be seen in the animation below.



The serratus anterior often becomes inhibited and fails to take the scapula into upward rotation, therefore contributing to impingement. The upper trapezius also assists with this movement and it can be part of the problem, too. The upper trapezius is a muscle where the Sanjiao and Gallbladder sinew channels converge.

Fig. 4
So, the rhombo-serratus sling and the upper trapezius coordinate to produce upward rotation of the scapula. When these structures do not fire properly, they fail to bring the scapula into upward rotation with either humeral abduction or flexion. Although the rhombo-serratus sling is best attributed to the Pericardium sinew channel, SJ-5/GB-41 is a useful point combination to use distally to assist when there is inhibited action of these muscles. These points can be used with one of the motor points of the serratus anterior (SP-21 and GB-22, 23 are often reactive motor points) along with the motor point of the upper trapezius which is often needled by threading from SJ-15-GB-21.Proper training is required for all of these techniques so that the needle does not advance into the pleural space.



References

1. Myers, Thomas W. Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. 3rd ed. Edinburgh: Churchill Livingstone, 2014. Print.


2. Legge, David, and Karen Vance. Jingjin: Acupuncture Treatment of the Muscular System Using the Meridian Sinews. Sydney: Sydney College, 2010. Print.

3. Deadman, Peter, Mazin Al-Khafaji, and Kevin Baker. A Manual of Acupuncture. Hove, East Sussex, England: Journal of Chinese Medicine Publications, 2007. Print.


4. Phadke, V, PR Camargo, and PM Ludewig. “Scapular and Rotator Cuff Muscle Activity during Arm Elevation: A Review of Normal Function and Alterations with Shoulder Impingement.” Revista brasileira de fisioterapia (Sao Carlos (Sao Paulo, Brazil)) 13.1 (2009): 1–9. PMC. Web. 21 Mar. 2016.


5. Callison, M. (2007). Wrist and fingers. In Motor point index: An acupuncturist's guide to locating and treating motor points (p. 90). San Diego, CA: AcuSport Seminar Series LLC.

Monday, February 22, 2016

The Sinew Channels (Jingjin) and Vertebral Fixations

Below is a link for an article I wrote which will be featured in the Spring edition of the Illinois Association of Acupuncture and Oriental Medicine newsletter. It is currently posted on the Sports Medicine Acupuncture webpage. In addition to the link, I am including the full article below.

https://www.sportsmedicineacupuncture.com/wp-content/uploads/2016/02/The-sinew-channels-and-vertebral-fixations1.pdf

The Sinew Channels (Jingjin) and Vertebral Fixations
By Brian Lau, DOM, AP, C.SMA

This article will explore vertebral fixations and their relationships to both extraordinary vessels (Qi Jing Ba Mai) and the sinew channels (Jingjin). In Sports Medicine Acupuncture®, assessment of vertebral fixations is an important part of overall assessment and treatment when working with sports injuries and orthopedic conditions. Extraordinary vessel (EV) point pairs are used in conjunction with local needling at the M-BW-35 (Huatuojiaji) points, and with mobilization techniques, to free restrictions preventing proper vertebral movement. The Huatuojiaji needle technique and the mobilization are used to balance asymmetrical locking of the facet joints, where one side is locked in a closed position in relation to the other side. The EV point pairs regulate specific global strain patterns that stress the spine in specific regions. These strain patterns will be the focus of this article.

Vertebral fixations are assessed by motion tests and by manual muscle tests. Vertebral fixations at specific regions of the spine will cause bilateral weakness of specific muscles when testing with manual muscle tests.1 Interestingly, the muscles that become bilaterally weak are not innervated by the spinal nerves at the level of fixation. To gain insight into this phenomenon, it is useful to look at the sinew channels, note their connection to the spine, and understand how they can exert a negative influence on these spinal segments when dysfunction exists. Bilateral muscle weakness can then be seen through a channel relationship.

The Spleen Sinew Channel, The Penetrating Vessel (Chongmai), and Thoracic Vertebral Fixations

Fig 1: ©Brian Lau/drbrianlau.blogspot.com
The Spleen (Pi) and the Stomach (Wei) sinew channels are associated with the abdominal muscles and converge at the abdominal aponeurosis, a broad, flat connective tissue structure which attaches the internal and external obliques and the transverse abdominis at the rectus abdominis. The fascia of the external obliques travels anterior to the rectus abdominis muscle while the fascia of the internal obliques bifurcates; half of it travels anterior, half posterior. The transverse abdominis travels completely posterior to the rectus abdominis.2,3,4

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 while the posterior fascia comprises the abdominal portion of the Spleen sinew channel. This posterior abdominal fascia is continuous with the anterior portion of the diaphragm at the inner surface of the anterior ribcage.2,4 From here, one could follow the diaphragm around to its connection to the lumbar spine. This connection, called the crus of the diaphragm, attaches to the lumbar spine at L1 and L2.3 Restriction in this portion of the Spleen sinew channel can contribute to fixations at the T11-L2 vertebral levels.


Fig. 2: ©
Matt Callison/
Sports Medicine
Acupuncture
One could also follow the diaphragm up to the central tendon. The pericardium attaches to the central tendon on its superior surface, and is in the same fascial layer which comprises the hyoid muscles.2 This plane (posterior abdominal fascia-diaphragm-pericardium-hyoids) could be considered part of the sphere of influence described by the Penetrating Vessel. For all practical purposes, the Spleen sinew channel can be seen to follow this upward trajectory also. This portion of the channel can contribute to fixations from T3-T9.

When the Spleen sinew channel does not have adequate length, the abdomen becomes bowed and distended and the chest is depressed. This adds tension to the thoracic region and contributes to fixations in this region.

Vertebral fixations of these regions cause bilateral weakness of muscles that are part of the Urinary Bladder (Pangguang) sinew channel. These include the lower trapezius (for fixations of T11-L2), the teres major (for fixations of T3-T9), and the gluteus maximus (for fixations of C1-C3, which are not discussed in this article).1 This can be understood as a five element relationship involving the Earth and Water elements. These channels create a dynamic balance, as the Spleen and Stomach sinew channels consist of flexors of the legs and torso and converge at the abdominal aponeurosis while the Urinary Bladder sinew channel consists of extensors of the legs and torso and converges at the thoracolumbar aponeurosis, when looking at fascial connections, at least.2,4 When vertebral fixations are present, SP-4 (Gongsun) and P-6 (Neiguan) are added to the treatment.







The Liver and Kidney Sinew Channels, The Yin Motility Vessel (Yin Qiao), and Lumbar Vertebral Fixations

Fig. 3: © Brian Lau/drbrianlau.blogspot.com
The Liver (Gan) sinew channel travels up the medial leg and thigh and consists of the adductor longus, adductor brevis, pectineus, and the psoas major.5

The Kidney (
Shen) sinew channel includes the adductor magnus and the semimembranosus muscles. These structures link with the pelvic floor muscles which are then continuous with the anterior longitudinal ligament,2,5 which travels up the anterior portion of the spine.

The psoas major attaches to the lumbar transverse processes, the vertebral bodies, and even the intervertebral discs of the lumbar vertebrae.2,3 The psoas is more in a direct line with the Liver sinew channel, but since it attaches to the vertebral bodies and intervertebral discs and therefore links with the anterior longitudinal ligament, it also converges with the Kidney sinew channel.




Fig. 4: © Matt Callison/
Sports Medicine Acupuncture
When the psoas does not have adequate length, there is excessive lumbar lordosis and lack of freedom in the lumbar spine. This contributes to vertebral fixations of lumbar vertebrae.

Vertebral fixations of the lumbar vertebrae cause bilateral weakness of neck extensors.1 This can best be understood through the relationship of the Yin Motility Vessel (Yin Qiao) and Yang Motility Vessel (Yang Qiao). As one becomes short and tight, the other becomes flaccid. This is traditionally discussed in the context of their relationship to the muscles of the legs, but the relationship can continue throughout the entire channel.6 When vertebral fixations are present, KID-6 (Zhaohai) and LU-7 (Lieque) are added to the treatment.










The Urinary Bladder Sinew Channel, The Yang Motility Vessel (Yang Qiao), and Occiput-C1 Vertebral Fixations

Fig. 5: © Matt Callison/
Sports Medicine
Acupuncture
The Urinary Bladder (Pangguang) sinew channel traverses the posterior portion of the body and includes the muscles of the calves, the hamstrings, the sacral fascia, the erector spinae muscle group, and the suboccipital muscles which binds this channel to the occiput.5,7 These suboccipital muscles control the fine movements of the atlanto-occipital joints, and can contribute to fixations at this region.

When the suboccipital muscles do not have adequate length, there is capital extension and restriction in movement at the atlanto-occipital joint. This contributes to fixations of the occiput and C1.
Vertebral fixations of the occiput and C1 cause bilateral weakness of the psoas major.1 Again, this can be understood via the relationship of the Yin Motility Vessel and Yang Motility Vessel. When vertebral fixations are present, BL-62 (Shenmai) and SI-3 (Houxi) are added to the treatment.

Note: Vertebral fixations at C4-C6 and sacroiliac fixations, all treated with GB-41 (Zulinqi) and SJ-5 (Waiguan), are not discussed in this article. Also not discussed are fixations at C7-T2, which are treated with KID-6 (Zhaohai) and LU-7 (Lieque). These are left out to avoid excessively lengthy discussion.


References

1. Walther, David S. Applied Kinesiology: Synopsis. Pueblo, CO: Systems DC, 1988. Print.

2. Myers, Thomas W. Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. 3rd ed. Edinburgh: Churchill Livingstone, 2014. Print.

3. Netter, Frank H. Atlas of Human Anatomy. 6th ed. Philadelphia, PA: Saunders Elsevier, 2014. Print.

4. Stecco, Carla, and Warren I. Hammer. Functional Atlas of the Human Fascial System. Edinburgh: Elsevier, 2015. Print.

5. Legge, David, and Karen Vance. Jingjin: Acupuncture Treatment of the Muscular System Using the Meridian Sinews. Sydney: Sydney College, 2010. Print.

6. Wang, Ju-Yi, and Jason D. Robertson. Applied Channel Theory in Chinese Medicine: Wang Ju-Yi's Lectures on Channel Therapeutics. Seattle: Eastland, 2008. Print.
7. Wilke, Jan, Frieder Krause, Lutz Vogt, and Winfried Banzer. "What Is Evidence-Based About Myofascial Chains: A Systematic Review." Archives of Physical Medicine and Rehabilitation (2015). Web.