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.



Tuesday, February 16, 2016

Fascia Fiber Direction, Myofascial Release, and Acupuncture

Fig. 1: Electron microscope view showing
the endomysial layer1 
The image to the right (Fig. 1) shows the endomysium, the )fascial compartment that wraps individual muscle fibers. A simplified schematic is shown below (Fig. 2). The cross-linking fiber direction is particularly worth noting, as this can inform clinical strategies. These strategies are especially relevant to tuina (particularly myofascial release), but can also inform acupuncture needle manipulation.2

Beginning with myofascial release, it is important to note what happens to the fibers of the endomysium as a muscle is locked into a lengthened position (locked-long) versus locked into a shortened position (locked-short).3
Fig. 2

When locked-long, the endomysium cross-linked fibers are pulled horizontally, and they become increasingly more parallel to the muscle fiber length. A slow, sustained myofascial release stroke in the direction of the muscle fiber would further move these fascial fibers into this parallel arrangement, which could ultimately be counterproductive for long-term change of the patient.

However, this same slow, sustained myofascial release stroke perpendicular to the fiber direction would result in a positive re-balancing of the fascia, which would enhance the ability of the muscle to return to its normal resting length. So, in effect, this stroke against the muscle fiber direction could be considered a tonification technique.

Fig. 3
For the locked-long muscle to optimally return to its resting length, it is important to also address its antagonist. This frequently involves muscles that are on the internally-externally related sinew channel. For instance, someone with upper cross syndrome would have an overlengthened lower and middle trapezius and rhomboids. These are part of the Large Intestine sinew channel and, in this case, would benefit from the tonification technique described above.4

However, the pectoralis minor, part of the Lung sinew channel, would be in a shortened position (excess) and would benefit from an MFR stroke in a direction with the muscle fibers; a sedating technique.4 This directional stroke would reorganize the fascia and provide the most precise communication to the tissue.

How does acupuncture fit into this? First of all, proper needling to the motor points of both the locked-long and locked-short structures would help reset the dysfunctional muscle-spindle relationship of these muscles, and the myofascial release would help reset the fascia. 

Fig. 4 Image showing collagen fibers
wrapping around the needle6 
Acupuncture needle technique can also involve moving fascia. After needling acupuncture points, the needle can be turned in one direction (just like we were taught NOT to do in acupuncture school) until the needle can no longer turn. Now the needle has wound a considerable amount of collagen fibers around it. Then, the needle can be pulled in the appropriate direction to reroute the fascia. Over time, the fascia will loosen around the needle and the needle can be removed, though it is important that you remember which direction you turned it in case there is difficulty*.5

Imagine a patient with overpronation of the foot. The peroneals are now in an overlengthened position and are pulled up fascially, much like a shirt sleeve that is pulled up on the arm. Needling the motor points of peroneus longus and brevis, winding the needle, and them pulling downward, will help reset the dysfunctional muscle and fascia. Following this with a deep cross-fiber spreading of the tibialis anterior will balance the relationship of the tibialis anterior with the peroneals. This will balance Earth (tibialis anterior/Stomach sinew channel) with Water (peroneals/Urinary Bladder sinew channel).

*This technique is best taught in a classroom setting. Please do not attempt unless you have practiced under supervision first.

References:

1. Purslow, Peter P. "Muscle Fascia and Force Transmission." Journal of Bodywork and Movement Therapies 14.4 (2010): 411-17. Web. 

 2. Spina, Andreo A. "The 'Direction' of Fascia." Web log post. Functional Anatomy Blog. 10 Mar. 2011. Web. 16 Feb. 2016. 

3. Myers, Thomas. "Lengthening Fascial Tissue: Working with the Grain." Web log post. Anatomy Trains. 25 June 2014. Web. 16 Feb. 2016. 

4. Lau, Brian S. "Anatomy of the Sinew Channels Module 2: Head, Neck, and Upper Extremities." Sports Medicine Acupuncture Certification: Anatomy, Palpation, and Cadaver Lab. Pacific College of Oriental Medicine, San Diego. Lecture. 

5. Callison, Matt. "Assessment and Treatment of Lower Extremity Injuries." Sports Medicine Acupuncture Certification. Marina Village, San Diego. 17 Oct. 2015. Presentation.

6. Langevin, Helene M. "The Science of Stretch." The Scientist Magazine. 1 May 2013. Web. 16 Feb. 2016. 

Sunday, February 7, 2016

Osteoarthritis of the Hand and the Large Intestine Sinew Channel

 This post will discuss hand and finger pain, especially along the Large Intestine channel distribution. This will be relevant to pain associated with osteoarthritis and/or pain associated with myofascial trigger points referrals. We will also look at how certain muscle referral patterns can overlap and combine to increase the amount of pain in a particular region. In this case, we will examine pain in the LI-4 – LI-1 region, which can be associated with the first interosseous muscle, the extensor carpi radialis longus, the brachioradialis, the anterior scalenes, and often a combination of these muscles.

The dorsal interossei originate from the two adjacent metacarpal bones and insert at the proximal phalanx into the tendinous expansion, which is a fibrous branching of the extensor digitorum tendon.1,2 These intrinsic hand muscles flex the MCP joint, extend the interphalangeal joint, and abduct the phalanges. Heberden's nodules at the distal interphalangeal joint, often identified with osteoarthritis, may be associated with trigger points in the interossei muscles.3 The nodules are sometimes caused by contracture and enlargement of the soft tissue associated with the tendinous expansion on the posterior aspect of the phalanges.2 There are some indications that trigger point activity in the muscles attaching to this tendinous expansion, especially the dorsal interossei, contribute to the progression and pain associated with Heberden's nodules.3
Diagram of the finger tendons and ligaments
extracted from Alexander2

Regardless of whether Heberden's nodules are present, each dorsal interosseous muscle refers pain primarily to that side of the finger to which the interosseous muscle attaches.3 In particular, the first interosseous muscle can be a significant generator of pain, primarily to the radial side of the second phalanx, but also deeply into the dorsum and palm of the hand. This muscle is best accessed from its motor point location, which is located at the extrapoint M-UE-50 (Shangbaxie) approximately in the region of LI-3. All of the dorsal interossei motor points are located at the Shangbaxie.4

Needle technique for the first interosseous muscle involves locating the head of the second metacarpal and palpating along the bone in a proximal direction until a node is felt (this is fairly close to the head of the metatarsal). This node is the muscle belly of the first interosseous. The guide tube can be placed immediately distal to this node and the needle can be advanced in a proximal and medial direction into the belly of the first dorsal interosseus muscle. A strong da qi sensation will be felt, and often a muscle fasciculation will be illicited once the needle makes contact with the point. This is seen at the end of the video below as the finger suddenly abducts.



Fig. 3
Since the brachioradialis, extensor carpi radialis longus, and anterior scalenes refer pain to the hand in the region of LI-4 – LI1, these muscles should also be checked. The pain referral from these muscles can contribute to the overall pain of this region and can further aggravate the first dorsal interosseous muscle, causing a return of pain even if the local needling of the first dorsal interosseous is successful. All of these muscles are part of the Large Intestine sinew channel and can be accessed at their motor point locations at LI-11 and LU-6 (brachioradialis), LI-10 (extensor carpi radialis longus), and extrapoint jingbi (anterior scalenes)*. 4



* Jingbi should only be needled by those with appropriate clinical training and experience, due to its proximity to the pleural dome and the risk of a pneumothorax.

References:

1. Chaitow, L., DeLany, J., & Chaitow, L. (2008). Shoulder, arm, and hand. In Clinical application of neuromuscular techniques: Volume 1 (2nd ed., pp. 529-530). Philadelphia, PA: Churchill Livingstone Elsevier.

2. Alexander, C. J. (1999). Heberden's and Bouchard's nodes. Annals of the Rheumatic Diseases, 58(11), 675-678.

3. Simons, D. G., Travell, J. G., Simons, L. S., & Travell, J. G. (1999). Interosseous muscles of the hand, lumbricals, and abductor digiti minimi. In Travell & Simons' myofascial pain and dysfunction: The trigger point manual (2nd ed., pp. 786-793). Baltimore: Williams & Wilkins.


4. 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.