Tuesday, July 31, 2018

Assessment and Treatment of the Gallbladder Channel Sinew

This yoga pose (Parivrttha Janu Śirsāsana - revolved head of the knee pose) features rotation and movement of the ribcage, especially highlighting the lower ribcage and its ability to move in relationship to the pelvis. This movement is moderated by the Gallbladder sinew channel. Image of Tricia Amheiser used with permission, http://iy-sp.com/s-p

This will be the first in a series of posts looking at the channel sinews (jingjin) and their role in normal (and dysfunctional) movement of the pelvis, hip, and low back. This first post will explore the Gallbladder sinew channel and its role in both stability and movement between the pelvis and ribcage. These functions are necessary for balanced movement in the low back and hip region, and failure of this channel to perform these functions can be a cause, or at least a significant contributor, to pain of the low back and hip.

This post will specifically highlight the role of the movement between the ribcage and the pelvis, and also the pelvis and the sacroiliac joint. The reader is encouraged to visit a recent post on the Sports Medicine Acupuncture blog written by Matt Callison, L.Ac on the assessment and treatment of sacroiliac joint pain with acupuncture and Chinese medicine. For the most in-depth information on treating sacroiliac joint pain for the TCM practitioner, I recommend the upcoming Sports Medicine Acupuncture Certification classes which will cover this and other conditions affecting the low back and hip.

There is a video below which demonstrates a myofascial release technique for the Gallbladder sinew channel. This technique helps free the ribcage from the pelvis and can be used to round out a comprehensive treatment plan for sacroiliac joint pain, lumbar facet syndrome, and many other pain patterns of the low back and hip.

Fig 1:
Venus with the Apple, 1813-1816.
Contrapposto, or counterpoise, in visual arts refers to the pose of a figure with the weight on one leg and the various tilts, shifts and rotations of the pelvis, ribcage, shoulder girdle, neck and head that arise from it. While this is a bit of an exaggerated pose, many patients will exhibit some of these tilts, shifts and rotations. This will be evident in their normal standing posture and as they move, as an imbalance can be observed with the swaying, rocking and turning of the body.

Fig. 2
The myofascia of the Gallbladder sinew channel greatly influences this balance between the left and the right sides of the body, as it provides lateral stability to the body segments (such as the pelvis), but  also allows movement between body segments (such as between the ribcage and the pelvis). In Sports Medicine Acupuncture® we include the following myofascial structures in the Gallbladder sinew channel:

  • Iliotibial band
  • Tensor fascia lata
  • Gluteus medius, minimus, maximus
  • External obliques and internal oblique
  • Serratus anterior and pectoralis minor
  • Upper trapezius

Note: this is not a complete list, and some of these muscles are shared in other channels.

In particular, the hip abductors such as the gluteus medius and minimus need to stabilize the pelvis on the weight-bearing leg so that the ilium does not excessively rise and the pelvis does not excessively shift laterally. The weight of the body as it is supported on one leg would drive the ilium on that side superior and away from the midline (think of the 'sway' seen when a model walks on a runway). Look again at the statue in Fig. 1 and note the failure of the gluteus medius and minimus on the right to stabilize the lateral pelvis. The hip abductors would be locked-long and the femur is adducted.

Fig 3: Gluteus medius and minimus manual muscle test. The practitioner pushes the patient's hip into adduction while the patient engages the hip abductors to resist. The practitioner is looking for a locking of the hip indicating that the gluteus medius and minimus are strong. Image courtesy Matt Callison/Sports Medicine Acupuncture

This supportive function of the Gallbladder sinew channel can be assessed with a gluteus medius and minimus manual muscle test (Fig. 3), examining the portion of this channel which stabilizes the pelvis on the lateral side and prevents excessive upward and outward movement of the pelvis during weight bearing. This resistive muscle test assesses the ability of these muscles to respond to added force applied to them, which demonstrates how they respond as weight is transferred into the leg during the weight-bearing phase of gait. This and other MMTs are taught in Sports Medicine Acupuncture Certification; they are a valuable assessment for muscle function and, therefore, sinew channel function and health.

Fig. 4
While there needs to be stability in the Gallbladder sinew channel, it also needs to allow expansion so that the ribcage can move away from the pelvis. This occurs in movements such as walking, reaching, standing up from a seated position, and climbing stairs. The ability of the ribcage to move away from the pelvis is controlled and stabilized by the internal obliques; this allows for expansion without an excessive flaring of the ribs, You can observe the loss of this function when you see patients excessively bend the torso from side to side as they walk (not enough movement) or patients with excessively flared lower ribs (not enough stability). 

The ability of the pelvis to move away from the ribcage can be assessed as follows (Fig. 4): The patient stands with one leg forward and one back, with the weight initially on the back leg. As they stand up on the front leg, they reach forward and up with the opposite hand (shoulder flexion to 120 degrees). As they reach, you visually observe and/or feel whether the ribcage is able to move away from the pelvis without excessively leaning back (posteriorly tilting the ribcage) and compressing the lumbar region. You can also observe whether the scapula is able move away from the ribcage. In other words: is there expansion along the channel, allowing for differentiated movement?

It is not uncommon for one or both sides to have restrictions in this part of the Gallbladder sinew channel, binding the ribcage to the pelvis and/or binding the scapula to the ribcage. The abdominal obliques and the latissimus dorsi, part of the Gallbladder sinew channel, need to be supple and flexible to allow this independent, yet connected, movement of the body segments. See below for a myofascial release technique to free the ribcage from the pelvis. This can be done after acupuncture treatment.

Fig. 5: Cat Cow, image courtesy
Matt Callison/Sports Medicine Acupuncture
Observe as the ribcage moves with the pelvis: notice that it tends to move in a particular way. As the ilium goes into posterior tilt, the lower portion of the ribcage follows the inclination of the pelvis and moves posterior, causing the entire ribcage to tilt anterior (Fig. 5, top image). As the ilium goes into anterior tilt, the lower portion of the ribcage follows the inclination of the pelvis and moves anterior, causing the entire ribcage to tilt posterior (Fig. 5, bottom image).

This related movement of the ribs and ilium is normal, but fascial shortening and/or muscle inhibition can occur and prevent it from moving freely. Such restrictions might fix the lower ribcage in a position where it is held anterior or posterior. This could be a bilateral imbalance, or it might be different on the left and the right side. This twisting from side to side is frequently seen with sacroiliac joint pain. Why? The twisting in the lower ribcage (one side anterior, the other posterior) is a response to a twisting in the two ilia of the pelvis (one side anterior tilted, the other posterior tilted); the sacrum will also rotate in response to the twist between the two ilia. This means that there is a relationship between the holding patterns of the ilia, the sacroiliac joints, and the two sides of the ribcage. Unwinding one has an effect on the others.

Fig. 6
Let's state that again in a bit more detail, first highlighting the pelvic movement.The left and right ilia should be able to move in a contralateral motion, for example in walking and running. As one leg goes into hip flexion, the corresponding ilium rotates posteriorly. As the other leg goes into hip extension, the other ilium rotates anteriorly. This is vital for the health of the right and left sacroiliac joints, which move in conjunction with this contralateral motion of the ilia.

It is frequently the case that movement is easier in one direction than in the other. For instance, maybe the runner in Fig. 7 moves very easily as she swings her left leg back (left ilium rotates anterior as it follows the hip extension, right ilium rotates posterior as it follows the hip flexion), but less easily and with reduced range of motion as she swings her right leg back (right hip extension and left hip flexion). If this were the case, her left ilium would probably be anteriorly tilted and her right posteriorly tilted. This is sometimes referred to as pelvic torsion or a twisted pelvis. The sacroiliac joint is part of this twist and will often become painful on one side.
Fig. 7

The lower ribcage tends to follow the pelvis. The more anterior the ilium tilts, the more anterior the lower ribcage moves, and the more posterior the ilium tilts, the more posterior the lower ribcage moves. For the runner, it may be that the right lower ribcage moves back more easily (following the right arm swing) and the left lower ribcage moves forward more easily (following the left arm swing), but these sides do not move well when the position reverses.

Let's revisit the assessment illustrated in Fig. 4, which looks at the ability of the ribcage to move away from the pelvis. The left image below (Fig. 8) shows assessment of the ability of the ribcage to move away from the pelvis and the lower ribs to move forward. The one on the right shows assessment of whether the ribcage can roll back into line with the pelvis. Both are important movements.

With sacroiliac joint pain, the goal is often to balance the left and right sides. With acupuncture, corrective exercises and manual therapy, you would address the level of restriction at the sacroiliac joint, balance the pelvis (especially if there was a twist), and balance the ribcage (especially if there was a twist). The technique in the video below is just one part of this, and it would mobilize the ribcage away from the pelvis. To complete the treatment, one would work with any zangfu disharmony or other TCM patterns.

Fig. 8: The ribcage moves away and flares out on the left. The ribcage has difficulty rolling back on the right.
One last thought on the relationship of this channel to the organ network: as TCM practitioners know, the sinew channels do not attach to the zangfu. Nevertheless, there is a relationship of this sinew channel to the Gallbladder organ and its related yin organ, the Liver. Consider the movement we have been discussing regarding the lower ribcage movement. This forward and backward movement matches the mobility of the liver organ (and the gallbladder, which is structurally bound to the liver), which also rolls backward and forward as part of its movement (referred to as inspir and exspir). Freeing any stuck areas in the lower ribcage would allow these organs to have the freedom to move within their range of motion, something that is very important for their health. Conversely, if these organs are under duress, they will often become stuck and will limit the range of motion of the lower ribcage. Treating any signs of Liver or Gallbladder disharmony will help with the health of these organs; it will also make the manual technique below much easier to do and allow its effects to be longer lasting.