Mobility of the Lower Ribcage

The lower ribcage has a lot of movement potential, especially when compared to the rest of the ribcage. Part of the movement potential of this region is determined by the anatomy. The lowest two ribs, called the floating ribs, articulate with the lowest two thoracic vertebrae. This is the only place they articulate with bone. Ribs 8-10, called false ribs, articulate with the thoracic vertebrae and then indirectly connect to the sternum through a large bit of cartilage. The remaining ribs, referred to as true ribs, attach directly to the thoracic spine and the sternum. The direct connection to the sternum limits the movement of these ribs (1-7), but since ribs 8-12 do not have this direct attachment, they allow more rotation, compression, and expansion.

There are attachments of the respiratory diaphragm and the internal organs to the lower ribcage. Specifically, the liver, intestines, spleen, and stomach have strong attachments to the lower ribcage. Good movement in this region helps massage the internal organs and take the diaphragm through a good range of motion. This keeps these structures healthy and supple.

Much of the movement of this region is driven by the Liver and Gallbladder sinew channels, especially the rotational movements of the ribcage in relationship to the pelvis. The obliques are the driving force of this rotation. The internal obliques are most associated with the Gallbladder sinew channel. The Liver sinew channel involves the medial line of the body, but includes the external oblique which fascially connects with the contralateral adductor longus. Trunk and pelvic rotations are very tied to these channel sinews and imbalances are treated through these channel sinews.

Another movement of this region involves the ability of the left and right sides to flare (move away from each other) and to hold stability preventing excessive rib flare. This is largely controlled by the transverse abdominis and has more to do with the Kidney sinew channel. When the Kidney sinew channel does not properly support this region, the ribs excessively flare and the ribcage tilts posterior.

Check out the following videos for a simple qigong exercise to improve the mobility of this region, while massage the internal organs, mobilizing the diaphragm, and strengthening the core. This qigong pattern is derived from an internal martial art called liuhebafa and the movement is called 'Stop Cart and Ask Directions'. It is the first movement of this series.

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Treatment of the Kidney Sinew Channel for Injuries Associated with the Urinary Bladder Sinew Channel

Fig. 1: This myofascial release technique on the posterior intermuscular septum of the thigh (the fascial septum between the adductor magnus and the medial hamstings) is taught in the Assessment and Treatment of the Channel Sinews class in Sports Medicine Acupuncture Certification. It is a technique that could be used to treat the Kidney channel as discussed in this post.

I authored this month's SMA (Sports Medicine Acupuncture®) blog post, which is on assessment and treatment of the channel sinews for posterior and medial knee pain. It focuses common injuries associated with the Urinary Bladder and Kidney channel sinews (jingjin), including upper gastrocnemius strain, hamstring tenosynovitis (both of these are associated with the UB jingjin), and MCL injury (associated with the KID jingjin). Check it out.

At the end of the post, I discuss how treatment of the channel associated with the injury does not always yield lasting results. Obviously, acupuncturists know this. We have many channel relationships that help guide our clinical decision making. Sometimes we treat the channel that is associated with an injury; sometimes we treat the internal-external pair; sometimes we treat based on six divisions; sometimes we use midday-midnight correspondences; and sometimes our decision-making can be even more complex. The channel system is very interdependent and it is not always as simple as treatment including local, adjacent, and distal points where all of these are on the same channel.

In the SMA blog post, I gave an example of treatment of upper gastrocnemius strain and/or hamstring tenosynovitis (UB jingjin) when there is a loss of integrity of specific ligaments associated with the KID jingjin. In these cases, the gastrocnemius and hamstrings will need to make up for the loss of stability in the knee due to the loss of integrity of the ligaments. To get lasting results in this case, one must address the Kidney channel. There are many ways that one can accomplish this and I don't want to get into treatment in this post. Regardless of whether you are using acupuncture, regenerative injection techniques, manual therapy, or other tools, communicating with the Kidney channel will keep the UB structures from having to overwork as they attempt to stabilize the knee.

Fig. 2

There is another example that didn't get explored in the SMA blog post for space reasons. It has to do with the relationship of the UB and the KID jingjin and their associated myofascial structures, the hamstrings and the adductor magnus. The hamstrings are associated with the UB jingjin and the KID jingjin. The two superficial hamstrings (the biceps femoris long head and the semitendinosus) are part of the UB jingjin while the semimembranosus is part of the KID jingjin (Fig. 2). 

Fig. 3: The semimembranosus removed on the right
to reveal the '4th hamstring'.

There is also a '4th hamstring' which is comprised of the biceps femoris short head and the adductor magnus (Fig. 3). The adductor magnus is not technically a hamstring, but the middle fibers are fascially connected with the biceps femoris short head and this pair can be considered as a 4th hamstring. This '4th hamstring' is discussed both by Tom Myers in his book Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists, and by Janet Travell in her book Myofascial Pain and Dysfunction: The Trigger Point Manual.

To recap, there are two pairs of hamstrings; a superficial pair (biceps femoris long head and semitendinosus; both associated with the UB jingjin), and a deep pair (semimembranosus and biceps short head/adductor magnus; both associated with the KID jingjin). The video below explores the anatomy of these two channels in the foot, ankle, leg and thigh.

Back to the topic of this post; how one channel can influence another and how an injury associated with one channel might require treatment to a related channel. The hamstrings get their blood supply from perforating arteries which branch off of the deep femoral artery (femoral artery profunda), which itself is a branch off of the femoral artery. The name 'perforating arteries' implies that they perforate something, which they do. They perforate the adductor magnus on their way to the hamstrings (Fig. 4). If the adductor magnus is short and tight, this could definitely restrict blood flow to the hamstrings. If you have a patient that comes in with chronic hamstring problems, maybe it is worth assessing and treating the adductor magnus. You will be assessing and treating the KID jingjin to help with any work you do with the UB jingjin. The image at the top of this post shows a myofascial release technique which frees obstructions in the posterior intermuscular septum of the thigh (between the adductor magnus and the medial hamstrings)

Fig 4: Gray's Anatomy illustration showing perforating arteries perforating the adductor magnus on their way to the hamstrings. Hamstrings are not shown in this illustration so that the arteries can be seen.

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Assessment and Treatment of the Channel Sinews: Pes Planus

Fig. 1: A technique referenced below which can be used for pes planus 

Last Fall, Matt Callison and I put together a presentation for the Pacific Symposium in San Diego, CA. We presented on pes planus, a condition where the foot rolls into excessive pronation during weight bearing due to a collapse of the medial arch.

In the presentation, we discussed assessment and treatment of pes planus and discussed some common injuries associated with it. The role the channel sinews (jingjin) play in proper support of the medial arch and how imbalances can contribute to pes planus was emphasized. This month, Matt Callison will be expanding on this presentation for the keynote presentation at the Sports Acupuncture Alliance. I won't be able to make this event, but thought I would write a bit of an intro for those attending. You can consider this a study guide.

For those not able to attend, you can get a small flavor of the class and start to play with some of the information. If you are interested in expanding on this, it is taught in the Sports Medicine Acupuncture Certification starting in San Diego, June 19-24.

Fig. 2 Pronation includes dorsiflexion, eversion, and abduction;
supination includes plantarflexion, inversion, and adduction.

During gait, the foot is in supination at heel strike. After heel strike and as the weight travels into the foot, it transitions into pronation as it absorbs the body's weight (Fig. 2).

Normal pronation causes an increase in tension (a good thing, in this case) as the elastic myofascial structures in the foot are lengthened. The result of this is an elastic recoil which helps propel the weight off the foot and back into supination.

Fig. 3

In pes planus, the foot over-pronates and cannot recover into supination for adequate push-off from the big toe (Fig. 3).

Due to the altered mechanics in the foot and into the leg, pes planus sets a person up for a host of potential injuries such as plantar faciosis, Morton's neuroma, tibialis posterior tendinopathy, tarsal tunnel syndrome, Achilles tendinopathy, shin splints, medial knee injuries and injuries into the low back and hip. Clinicians working with these conditions will achieve far better results if they help correct pes planus, thus reducing the mechanical strain that led to the injury.

For the acupuncturist, it is important to understand the channel relationships associated with pes planus. This can be facilitated by looking at the muscles and other fascial structures which support the medial arch and understanding which channel sinew they are part of. The two main channel sinews which support the medial arch are the Spleen and the Kidney. The relevant anatomy is below:

Fig. 4: Yellow line is tibialis
posterior (medial side) &
anterior (lateral side) - SP&ST;
blue line is peroneus longus
and brevis - UB;
black line is soleus and
abductor hallucis - KID.

• Spleen jingjin - tibialis posterior, flexor hallucis brevis
• Kidney jingjin - soleus, plantar fascia (main portion), abductor hallucis

The Stomach jingjin is also involved. A relevant structure is the tibialis anterior which also helps support the medial arch.

In pes planus these structure fail to lift the medial arch, they are inhibited and become over-lengthened as the foot overpronates. The qi of these structures is dropped and needs to be lifted.

In pes planus as the Spleen and Kidney jingjin fails to lift and support the medial arch, other structures become excessively shortened. These structures are part of the Urinary Bladder jingjin and include:

• Urinary Bladder  jingjin - gastrocnemius, peroneus longus and peroneus brevis, adductor digiti minimi, plantar fascia (lateral band)

In pes planus the Urinary Bladder jingjin is locked-short and is pulling excessively up. The qi of these structures excessively lifts and needs to be dropped and lengthened.

A technique that we teach in SMAC and Matt will be teaching at the Sports Acupuncture Alliance involves needling motor points of the involved structure and lifting, dropping, or lengthening the channel sinew. This is an advanced technique and can best be taught in a class setting. There is a sample in the image at the top of this blog post which involves lengthening the lateral band of the plantar fascia, a myofascial structure which becomes short and tight in pes planus.

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KID 10 (yingu) and the Posterior Knee

KID 10 (yingu) is a very interesting point in relationship to the knee and knee injury and pain. It contains some fascinating anatomy that might not be apparent on first glance. 

Peter Deadman, in A Manual of Acupuncture, describes the location thus: “At the medial end of the popliteal crease, between the semitendinosus and semimebranosus tendons.” Claudia Focks, author of Atlas of Acupuncture, has a similar description: “At the medial end of the popliteal crease, between the tendons of the semimembranosus and semitendinosus muscles, on the level of the knee joint space.”

I find these descriptions a bit confusing, as they don't completely match what we find in palpation. In a way, it might be more accurate to say that KID 10 is between the semimembranosus and another part of the semimembranosus. If you press into the space between the semitendinosus and the semimebranosus tendon, you might be able to feel a very thin, but palpable band. This band will definitely contract when the knee is flexed, verifying that it is a hamstring.

In this illustration, the semitendinosus tendon has been
removed. It would be lateral (to the right of)
semimebranosus (SM). I think KID 10 is about
where the label for 'Coronary attachment' is in
the above illustration.

What hamstring muscle is between the semimembranosus and semitendinosus tendon, you might ask? Look at most anatomy books and you won't find one. The answer is that this band is a fibrous expansion of the semimembranosus tendon which blends into the oblique popliteal ligament (a major structure of the posterior joint capsule). I think KID 10 is between the main body of the semimembranosus and this lateral expansion. If you advance into this space, you will affect the fascia of the fibrous expansions of the semimembranosus.

Press slowly and gently into this space and you will frequently elicit a referral deep into the knee joint and into the medial tibia. Needling into this would contact this proprioceptive rich fascia which blends with the posterior capsule of the knee. These expansions also have connections to the medial meniscus and the medial collateral ligament (see 'anterior arm' in the image to the left).

If you press or needle lateral to this expansion, in other words, between it and the semitendinosus, you miss this fascia altogether. 

This is a somewhat challenging area to palpate. When palpating, stay very close to the lateral border of the main tendon of the semimembranosus and you will slide between it and this fascial expansion. Having the knee flexed helps with palpation.

In addition to KID 10, and when presented with medial knee pain and/or problems with the posterior knee capsule, you might consider treating the motor points of two muscles of the Kidney sinew channel: semimembranosus and popliteus. As can be seen in the image above, these muscles are very connected to this important fascia that stabilizes and supports the posterior and medial knee. Obviously, there is a lot more assessment that would be required to build a treatment plan, but these suggestions would frequently be applicable for MCL injury, medial meniscus injury, weakness of the posterior joint capsule, and medial knee pain referred from semimembranosus.

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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.

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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. The full article below.

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.

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