Monday, August 28, 2017

The 'Core' and Channel Relationships

One of the buzzwords in movement and posture-based therapies these days is the 'core.' The exact structures that make up this deep stabilizing region of the body vary depending on the system being studied, but there are some common themes that exist.

The muscles most frequently discussed as 'core muscles' are the deepest of the abdominal muscles. the transverse abdominis; the deep paraspinal muscle group, the multifidi; the pelvic floor muscles; and the diaphragm. These muscles coordinate to stabilize the low spine and pelvis before movement of the legs and arms occurs. This stabilization prevents degeneration of the spinal and pelvic joints. These muscles also work together to align the pelvis and ribcage and properly regulate the position of the spine.

Is there any allusion to these structures in Chinese channel theory? Many channels can be mentioned in this context, notably the extraordinary vessels such as the Daimai, Ren, Chong, and Du. However, it is the Kidney channel that links these structures and can serve as a model to describe this region in TCM terms.

To begin with, the Kidney sinew channel traverses the posteromedial thigh, the pelvic floor and  the spine. I interpret this sinew channel as including the adductor magnus and semimebranosus, which have connections into the pelvic floor muscles (such as the levator ani and obturator internus), which in turn connect to the anterior longitudinal ligament of the spine. The Kidney sinew channel includes some of the stabilizing muscles commonly associated with the core, specifically the pelvic floor.

Another secondary channel of the Kidney serves as a model to integrate function and structure of the core. This is the Kidney Luo connecting channel (Fig. 1). This is how Peter Deadman describes this channel in A Manual of Acupuncture:

  • begins at Dazhong KID-4 on the posterior aspect of the medial malleolus;
  • encircles the heel and enters internally to connect with the Bladder channel;
  • ascends along with the Kidney primary channel from Dazhong KID-4 to a point below the Pericardium where it travels posteriorly to and spreads into the lumbar vertebrae.

     
Fig. 2: Anterior abdominal wall seen from
the posterior view. This shows the
transversalis fascia blending into the
diaphragm. The pericardium would attach
to the central tendon on the superior surface.
Let's break this down and explore the anatomical structures. This secondary channel ascends along the Kidney primary channel. This would include the primary channel abdominal points from KID-11 to KID-22.  This then connects to 'a point below the Pericardium.' All of this can be interpreted to include the transverse abdominis. The fascia of this muscle (especially the transversalis fascia which is posterior to the muscle and anterior to the parietal peritoneum) does link with the diaphragm, and the pericardium of the heart attaches to the central tendon of the diaphragm (Fig. 2). So, there is a continuous plane running up the transverse abdominis to the central tendon just below the Pericardium. 

Fig. 3: Multifidi seen on L
at the Huatuojiaji points.
This channel then travels posteriorly to and spreads into the lumbar vertebrae. Like many of the Yin luo  channels, this channel includes a group of structures which would be on the trajectory of its Yang pair, but at a deeper region of the body. In this case, this would be the lumbar multifidi muscles (Fig. 3). 

I believe the Kidney Luo-connecting channel describes a functional relationship between the transverse abdominis, the lumbar multifidi, the diaphragm and the pelvic floor. These muscles function together to create core support to lift and stabilize the spine. When they are not working well together, there is a collapse that can be seen with a Kidney deficient posture, which overstresses the lumbar spine and contributes to degeneration (See images here, especially Kidney Qi and Jing deficiency). Besides this, when they are not stabilizing the spine and pelvis during activity, there is an increase in wear and tear of these joints. Furthermore, when they are not performing their job adequately, there would be signs and symptoms included in the indications for KID-4, notably, urinary and bowel issues (these muscles are essential to for the pushing type movements necessary for these actions); respiratory issues (tone in these structures regulates intra-abdominal pressure and influences respiration); and lumbar pain and stiffness.

You can work this important region with taiji and qigong exercises. In my own practice, I have been more aware how the timing of these gentle moves facilitates an expansion and contraction of these regions, which both improves tone and elasticity.


But as acupuncturists, we can also wake up this region with direct needling of motor points of these important structures in addition to using distal points such as KID-4. We can also reduce tension in the related Urinary Bladder sinew channel. When deep stabilization of the spine and pelvis is inadequately supported from the muscles associated with the Kidney network, more superficial stabilization occurs, notably from the latissimus dorsi (BL sinew channel) which blends in with the superficial layer of the thoracolumbar fascia (Fig. 4). The thoracolumbar fascia then becomes overly dense and rigid. Reducing tension here can help increase flexibility of the lumbar spine and pelvis and can then allow for adequate training of these deeper Yin muscle counterparts.

Fig. 4: Cross section at lumbar region.

Friday, July 21, 2017

SI 3 (Houxi), Du Mai, and the Small Intestine Sinew Channel

What is it about SI 3 (Houxi), a point along the Small Intestine channel, that makes it the master point for the Du Mai? I feel that the specific anatomy associated with the Small Intestine sinew channel, especially at the upper cervical region, helps give insight.

I interpret the Small Intestine sinew channel as containing the following myofascial structures:

  • Abductor digiti minimi
  • Flexor carpi ulnaris (ulnar head)
  • Triceps
  • Rotator cuff muscles (supraspinatus, infraspinatus, teres minor; subscapularis is not included in this channel)
  • Levator scapula
  • Atlantooccipital joint capsule
  • Digastric and styloid muscles
  • Hyoglossus
  • Buccinator
Image adapted from Gray's Anatomy
The levator scapula, in particular, helps link the Small Intestine sinew channel to the Du Mai. This muscle attaches to the posterior tubercles of C1-C4. From these attachments, there exist many fascial connections to the ligamentous structures of the superior vertebral column. These structures include the joint capsules, transverse ligament, and the midline ligaments (supraspinous, infraspinous, and posterior longitudinal ligament). 

Even tone of the levator scapula at these attachments helps produce balance at the upper reaches of the vertebral column, thus linking the SI channel network to the Du Mai. SI-3 is the Shu-stream point of the Small Intestine channel and "Augment the qi and warm the yang, and transform dampness". These actions would be useful when there is degeneration and inflammation of the ligaments of the spine. Adding BL-62 (Shenmai), the master point of the Yang Qiao, also addresses the suboccipital muscles, which are also integral to balance along the upper the spine. 

When these structures are out of balance, fixation of the atlanto-occipital joint can occur. This can have a local effect at the occiptal region, and can have effects further away, especially at the lumbar spine. In SMAC (Sports Medicine Acupuncture Certification) we teach a protocol to address this which was developed by program founder Matt Callison. Assessment of this is beyond the scope of this post, but treatment involves specific needling techniques at BL-10 and GB-20 to address the short and fibrotic (excess) side and to address the more lengthened (deficient) side. This is combined with the extraordinary vessel point pair SI-3/BL-62. The treatment also includes mobilization of the atlanto-occiptal joint to return proper function.


Thursday, April 20, 2017

The Fascial Slings of the Foot and the Balance of the Arches, Part 2

Part 1 of this post introduced the fascial sling which connects at the plantar portion of the medial arch. It includes the tibialis anterior and peroneus longus muscles. The tibialis posterior can also be included in this sling, and the last post looked at how the tibialis anterior (part of the Stomach sinew channel) and the tibialis posterior (part of the Spleen sinew channel) can function synergistically to lift the medial arch. It was discussed that the healthy T&T function of the Spleen-Stomach can help nourish these muscles and that a drop of the medial arch can be seen as part of the Spleen's holding or lifting function. See the previous post for this discussion.

This post will look at the main part of this fascial sling, the tibialis anterior - peroneus longus. This convergence of the Stomach and Urinary bladder sinew channels has a more agonist-antagonist relationship, and working to balance these muscles/channels is key to proper balance in the arches of the foot.


Fig. 1
The peroneus longus (aka the fibularis longus) attaches from the head and proximal portion of the fibula. It traverses the lateral portion of the fibula, passes posterior to the lateral malleolus, travels just superior to UB-62, and crosses under the cuboid bone in the peroneal canal which is created superiorly by the cuboid sulcus and inferiorly by the long plantar ligament. It reaches the medial cuneiform and base of the 1st metatarsal which is its distal attachment. This is the same attachment site as the tibialis anterior, and they connect to one another through the joint capsules of these bones. When it contracts, the peroneus longus creates plantar flexion at the ankle, which pulls on the lateral arch and everts the foot. When it is overactive, it can contribute to foot overpronation by pulling up on the lateral arch and dropping the medial arch.

Fig. 2: Note the lateral branch of the UB
sinew channel which travels behind the lateral
malleolus. Image is from Deadman's
A Manual of Acupuncture.
The peroneus longus is part of the lateral branch of the Urinary Bladder sinew channel (Fig. 2). This muscle has a very strong fascial connection into the biceps femoris (lateral hamstring). For more on this connection, see this past post. This muscle acts as an antagonist to the tibialis anterior muscle (part of the ST sinew channel), which performs dorsiflexion at the ankle and inverts the foot at the subtalar joint.

Fig. 3
Fig. 4
Many agonist-antagonist muscle imbalances are seen between the Stomach (Earth) and Urinary Bladder (Water) sinew channels. Examples include the quadriceps (ST) - hamstrings (UB) and rectus abdominis (ST) - erector spinae (UB). The relationship between the tibialis anterior (ST) and the peroneus longus (UB) is another example.

When the peroneus longus is locked-short and the tibialis anterior is locked long, the foot will be pulled into eversion (Fig.4). Alternately, when the tibialis anterior is locked-short and the peroneus longus is locked-long, the foot will be pulled into inversion.

Treatment can include needling the most reactive tibialis anterior motor point; ST-36 is often the most reactive, but the extra point lanweixue M-LE-13 is also a motor point. And the peroneus longus MP (approximately 1 cun inferior to the fibular head) can also be needled.

There are some more specific advanced techniques that Matt Callison and I will demonstrate at the Pacific Symposium this coming Fall 2017, involving an acupuncture fascial release that helps pull down the lifted UB sinew channel for foot overpronation. This is a bit tricky to discuss in a blog post, but stay tuned for more information in the future.

The next and final post in this series will follow the sinew channels up to the hip and explore how pelvic imbalances can influence foot overpronation.











Saturday, January 14, 2017

The Fascial Slings of the Foot and the Balance of the Arches, Part 1

Several authors have described a 'stirrup' or fascial sling of the foot which affects the balance of the arches.1,2 This sling comprises two or three muscles (depending on which author you're reading) which are linked through fascial connections at the medial arch of the foot. These are the tibialis anterior (which crosses the ankle to attach to the medial cuneiform and the base of the 1st metatarsal joint) and the peroneus longus (which crosses under the foot to attach to the same region). Sometimes, the tibialis posterior muscle is also included, as it has a large attachment area on the plantar region of the foot and interacts with the above two muscles.

In this post I will discuss the relationship of the tibialis anterior and tibialis posterior. These are part of the Stomach and Spleen sinew channels, respectively. They have a synergistic relationship, working together to lift the medial arch. In the next post I will follow up and discuss the relationship of the tibialis anterior and peroneus longus. These have an antagonist relationship, and balance between them is crucial for proper balance among the arches of the feet.

Fig.1

The tibialis anterior is part of the anterior crural (leg) compartment (Fig. 1). It attaches from the upper two thirds of the anterolateral tibia; crosses over the anterior ankle to the medial side and is held in place by the anterior ankle retinaculum; and then attaches to the medial cuneiform and base of the first metatarsal (Fig. 2). It performs dorsiflexion of the foot at the ankle, and it inverts the foot.

Fig. 2: Image from Gray's Anatomy
Fig. 3: Image from Atlas of Human Anatomy for Students and Physicians by Carl Toldt

The tibialis posterior is part of the deep posterior crural compartment (Fig. 1). It attaches to the inner border of the tibia, fibula and interosseus membrane. Initially, it is the middle muscle of the deep posterior compartment (Fig. 3), but it crosses under the flexor digitorum longus to become the most medial deep posterior compartment muscle at SP-6 (see this post about SP-6 three yin crossing). It is the most anterior tendon to pass behind the medial malleolus; it passes through the tarsal tunnel and then attaches to every tarsal bone except the talus, and it attaches to the 2nd, 3rd and 4th metatarsals (Fig.2)

Both of these muscles are important as they lift and support the medial arch. They can frequently become inhibited and fail to adequately support and lift the medial arch.

Fig. 4
Note the relationship of these two muscles in Fig. 4. The tibialis anterior is part of the Stomach sinew channel, whereas the tibialis posterior is part of the Spleen sinew channel.3 The muscles of these two sinew channels are much more synergistic than what is seen in more antagonist muscles found in other muscles of internal-external pairings.4,5

This synergistic nature is consistent with both the Spleen and Stomach primary channels and organs. Even the classical descriptions of these organs reflect this. It is worth remembering that in the description of the organs and their bureaucratic roles (which, for the classical physician, was a memory aid and a simple way to remember the functions of the organs), all of the organs had their own line in the Su Wen, with the exception of the Spleen and Stomach.

"The spleen-stomach holds the office of the granaries and issues the five flavors."6

The fact that these organs are discussed together reflects their synergistic nature in the body. I see that this is also reflected in the relationship between the sinew channels of these two networks. See the previous blog post about patellar balance of the Spleen and Stomach sinew channels for an exploration of how these channels work together to produce knee extension, but can be involved in imbalances which can affect patellar tracking.

For the foot, they work together to do what the Spleen and its related Stomach networks do; they lift. And, in this case, they lift the medial arch.3

Clinically, both of these muscles can fail to adequately lift and support the medial arch, especially in impact sports such as running. A certain amount of pronation is normal as weight is born by the foot; it acts as a shock absorber. This occurs with a medial rotation of the tibia and a drop of the navicular bone. Problems occur when there is foot overpronation, as the movement become excessive and added stress occurs in the soft tissue structures of the foot and leg, with biomechanical changes occurring in the the foot, ankle, knees, hips and throughout the body.7 Common injuries can include plantar fasciitis/fasciosis and anterior or medial shin splints (also referred to as tibialis anterior syndrome and tibialis posterior syndrome). But foot overpronation can also be a contributing factor for knee injuries and hip injuries, as this condition often correlates with excessive knee valgus (knees moving in with weight bearing) and excessive elevation of the ilium with weight bearing.

Local treatment involves specific local needling techniques to work with the fixed pain site .7,8 There will be different local techniques for plantar fasciitis, versus shin splints, versus something such as iliotibial band friction syndrome. Adjacent points can be selected to address the overactive and inhibited muscles; needling of the motor points can be used to address the foot overpronation or other imbalance of the foot.

There are cautions for needling the tibialis posterior. It can be accessed through the Spleen channel, but the depth it takes to reach the motor point takes the needle very close to the tibial artery, and instruction of this specific needle technique is best left to a classroom. SP-6, however, reaches and influences the tibialis posterior at the region that it crosses in front of the flexor digitorum longus and becomes the most medial (and most accessible) muscle of the deep posterior compartment.

Tibialis anterior, on the other hand, is simple, as its motor point is ST-36 (zusanli or leg three miles). Another motor point of tibialis anterior is the extrapoint lanweixue. The most reactive point can be selected for best results. I typically find ST-36 to be the most influential point to improve functionality of the tibialis anterior.

Additional treatment thoughts will be discussed in the next post after discussing the peroneal muscles and their role in injury.

References:

1. Myers, Thomas W. "The spiral line." Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. 3rd ed. Edinburgh: Churchill Livingstome, 2014. 132-149. Print.

2. Clemente, Carmine D. Anatomy: A Regional Atlas of the Human Body. Baltimore: Williams & Wilkins, 1997.

3. Lau, Brian. "Anatomy of the Sinew Channel: Lower Extremities." Module Four: The Lower Extremities Anatomy/Palpation/Cadaver Lab. Pacific College of Oriental Medicine, San Diego. 10 Sept. 2015. Lecture..

4. Lau, Brian, and Matt Callison. "Creating a Modern Model for the Assessment and Treatment of the Sinew Channels (Jingjin): Part 1." Oriental Medicine Newspaper (June 2016): 7; 33. Print.

5. Callison, Matt, and Brian Lau. "Anatomy of the Sinew Channels (Jingjin)." Pacific Symposium. Catamaran Resort Hotel, San Diego. 29 Oct. 2016. Lecture.

6. Wang, Ju-Yi, and Jason D. Robertson. "The tai yin (greater yin) system." Applied Channel Theory in Chinese Medicine: Wang Ju-Yi's Lectures on Channel Therapeutics. Seattle: Eastland Press, 2008. 64-76. Print.

7. Callison, Matt. An Acupuncturist's Guide to the Treatment and Assessment of Plantar Fasciitis and Excessive Foot PronationSports Medicine Acupuncture: Resources. Sports Medicine Acupuncture. Web.

8. Callison, Matt. "Acupuncture & Tibial Stress Syndrome (Shin Splints)." Journal of Chinese Medincine 70 (2002): n. pag. Web.

Sunday, January 8, 2017

The Great Luo-Connecting Channel of the Stomach and Heart Palpitations

All of the primary channels along with the Du and Ren vessels have luo-connecting points, which are where the luo-connecting channels branch off of the primary channels. In addition to these luo-connecting channels, the Stomach and the Spleen channels each also contain a great luo-connecting channel. The Spleen great luo-connecting channel is the more widely discussed in acupuncture texts, but is still a bit mysterious in its own right. I will discuss this in another post. The Stomach great luo-connecting channel (xu li) is infrequently discussed in acupuncture texts and, possibly has even more mystery associated with it.

Claudia Focks' Atlas of Acupuncture describes it thus: "The great luo-connecting channel of the Stomach begins in the Stomach, passes through the diaphragm, intersects with Ren-17, and spreads in the Lungs, trachea, and larynx. From the Lung, it travels to the Heart and emerges in the region of ST-18 where the heartbeat is visible."1

Pathology, like other luo-connecting channels, can be separated by full and empty conditions and are listed as thus:1,2,3

Great Luo of Stomach Full: Rapid, irregular breathing, chest congestion, congestive heart failure
Great Luo of Stomach Emptied: Palpitations, fibrillations, tachycardia.


Fig. 1: The heat and stomach in situ
Why would this secondary channel of the Stomach network cause palpitations of the heart? We can gain a more precise understanding by exploring the anatomy of the stomach and the heart, their topography in the body, and the way in which dysfunction of the upper portion of the stomach can contribute to the above symptoms.

Looking at the topography first, one sees that the upper portion of the stomach is in close proximity to the heart. In fact, the upper portion of the stomach is called the cardia due to its close proximity to the heart, as it is essentially just on the other side of the diaphragm (Fig. 1).

While many organs are close to each other, the research about to be published by an osteopath in Italy named A.J de Koning helps illustrate the link between these two organs. De Koning is coordinating with an Italian cardiologist, Dr. Stefano Bianchi, who regularly performs cardiac ablation for irregular heart beat due to atrial fibrillation (AFib).

A.J. de Koning is a visceral manipulation practitioner and teaches with the Barral Institute. Dr. Bianchi invited de Koning to work with him and has him evaluate the patients first using osteopathic 'listening' techniques to feel for dysfunction. When applicable, visceral manipulation techniques are performed, and the result has been a greatly reduced necessity for ablation procedures. In particular, visceral manipulation techniques for the stomach have been particularly beneficial. Many of these patients with atrial fibrillation who benefit from visceral manipulation applied to the stomach have a history of gastric problems such as gastritis.

De Koning theorizes that the effectiveness of this approach is due to the dual innervation of the heart and stomach by the vagus nerve. When the stomach is stimulated, the signal is sent to the CNS to a region in the brain which has an effect on the arrhythmia. Essentially, this is a viscero-visceral reflex between the stomach and the heart.4

Here is a summary of de Koning's research, which is available on the International Alliance of Healthcare Educators website.

Fig. 2: The Influence of the Chongmai
Now back to the channels. Can we have a similar effect working with acupuncture and the channel system? To regulate the great luo-connecting channel of the Stomach, an acupuncturist could treat the Chongmai via the command point SP-4 along with PC-6 (Fig. 2). SP-4, in addition to being the command point of Chongmai, is also the luo-connecting point of the Spleen channel. Wang Juyi, in his book Applied Channel Theory, discusses how this point has the ability to clear the collaterals of the paired yangming stomach channel to clear heat. Symptoms include nausea/vomiting, stomach pain, insomnia, and irritability, He explains that trapped yangming heat moves upward to affect the heart.5

In addition, Dr. Wang likens PC-6, a point that is frequently used for stomach conditions such as gastritis and stomach spasms in addition to heart conditions such as angina, to the parasympathetic nervous system. Jueyin closes inward and is the most yin aspect of the six divisions, describing a physiology that reflects the parasympathetic nervous system regulation. It is worth remembering that 90% of the parasympathetic nervous system is innervated by the vagus nerve.

So, in effect, this point combination can be viewed as having a regulatory effect similar to de Koning's description. It can be especially useful when this link occurs between dysfunction in the Stomach affecting the Heart (history of gastitis, ulcers, acid reflux, etc, might serve as clues) as opposed to dysfunction which comes from problems with the Heart directly and might better be treated with the Heart collateral point, HE-5.

In addition to this point pair, the acupuncturist can consider treating joint fixations in the thoracic spine using huatuojiaji points and tuina mobilizations.These fixations could manifest anywhere in the thoracic spine, and it would not be surprising to find them in the region of the back-shu of the heart, the stomach, or both.

Fig. 3: Convergence of the Heart and Stomach
sinew channels
Assessment and treatment of the sinew channels can also be useful for these types of arrythmias; especially assessing for dysfunction in the region of the convergence of the Stomach and Heart sinew channels (Fig. 3). Both of these channels include the rectus abdominis and rectus fascia. This would cover the region of the front-mu points of the Stomach and the Heart, but it would also include the area under the abdominal portion of the pectoralis major which extends all the way to rib 5. Myofascial release and/or motor point and trigger point work to this region allows more space and freedom on the outside and will reinforce any internal work performed with acupuncture, visceral manipulation, or other techniques that are addressing the zangfu.
Fig. 4: Cardiac arrythmia TrP
located on right side at the 5th
intercostal space. The vertical line
indicates the midpoint between the
sternal margin and nipple and the
horizontal line indicates the lower
border of the xiphoid process.

One final thought: Dr. Janet Travell, in her book Myofascial Pain and Dysfunction: The Trigger Point Manual, mentions a pectoralis major trigger point (TrP) which can develop on the right side in the 5th intercostal space and can contribute to arrhythmia of the heart (Fig. 4). Travell suggests that this TrP might be in the intercostals rather than the pectoralis major.7 I think it is also possible that this TrP is in the superior rectus abdominis attachments. Either way, it is at the area where the rectus abdominis meets the pectoralis major, or, to put it another way, where the Stomach and Heart sinew channels converge.

Dr. Travell discusses treatment of this TrP and its effect on heart rhythm as a somato-visceral reflex. Her colleague and co-author, Dr. David Simons, describes witnessing several occasions of conversion of atrial fibrillation to normal rhythm with the application of a vapo-coolant to deactivate this TrP and he states that pressure or needling could also be employed.


References:

1. Focks, Claudia, Ulrich März, Ingolf Hosbach, and Johanna Schuster. "Acupuncture points of the twelve primary channels." Atlas of Acupuncture. Edinburgh: Churchill Livingstone/Elsevier, 2008. 125. Print.

2. Maciocia, Giovanni. "Identification of patterns according to the 12 channels." The Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturists and Herbalists. Edinburgh: Elsevier Churchill Livingstone, 2005. 751-55. Print.

3. Cecil-Sterman, Ann, and Pat Didner. "The luo channels." Advanced Acupuncture: A Clinic Manual. New York: Classical Wellness Press, 2012. 49-128. Print.

4. "Atrila fibrillation, the stomach and visceral manipulation." International Alliance of Healthcare Educators. N.p., n.d. Web. 28 Dec. 2016. <http://www.iahe.com/images/pdf/Atrial_Fibrillation-AJ_de_Koning_Research.pdf>.

5. Wang, Ju-Yi, and Jason D. Robertson. "The source, cleft, and collateral points." Applied Channel Theory in Chinese Medicine: Wang Ju-Yi's lectures on channel therapeutics. Seattle: Eastland Press, 2008. 513-15. Print.

6. Lau, Brian. "The sinew channels & vertebral fixations." The Illinois Acupuncturist 1 (Mar. 2016): 24-27. Print.

7. Simons DG, Travell JG, Simons LS. Travell and Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 1, Upper Half of Body. 2nd ed. Baltimore: Williams & Wilkins; 1999. p.821-2, 829-30.

8. Simons, David G. “Cardiology and Myofascial Trigger Points: Janet G. Travell’s Contribution.” Texas Heart Institute Journal 30.1 (2003): 3–7. Print.