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Occiput-C1 Fixations and Imbalances in the Channels

 

 

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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Hello everyone. Thank you very much for coming to our presentation. Thank you very much to the American Acupuncture Council for having us. My name is Matt Callison. I’m here with my dear friend and colleague Brian Lau. Thanks for having us. Brian. And I were talking the other day and we were discussing our topic for this particular presentation.

We’ve got the module one presentation coming up for the smack program and it has a lot to do with the T-bar fixations and sacral fixation. How they can contribute to patient’s pain. And this particular one with the occiput and the Atlas is a very important one for acupuncturist to know.

So we wanted to be able to shed some light on this particular fixation and how it can contribute to a number of different injuries. So with without further ado, we’ve got quite a bit to get through. So why don’t we go to the next slide there?

All right. So in the certification program, sports medicine, acupuncture certification program in module one, we look at the role that fatigue and sacral fixations play in the patient’s complaints, including musculoskeletal conditions, but also food. When there’s a table fixations in the thoracic region in this particular presentation.

As I mentioned before, we’re going to introduce the occiput and see one fixation. That’s going to be taking place at the Atlanta occipital. Now this fixation could cause many patient complaints, such as cervicogenic, headaches, muddled, or cloudy thinking neck pain. And, for that matter also it can contribute to job pain, low back pain, and a very interesting so as strain because of the association that this fixation has with bilateral.

So as is that we’re going to touch upon here and just a little bit. So why don’t we get started about what is of the tibial fixation with the next slide? So if a fixation complex is going to be the compression and torquing of one vertebra on top of the other and the locking of the vertebrae together, creating creates a hype boat, mobile, it just fixate those two vertebraes or even three vertebraes that lock together.

Have a lack of mobility within that segment of the spine, which is going to be further restricted with Maya. And also ligamentous adaptations, holding that fixation in place. Now the Fossette choice can be locked into a compression into rotation. It can be tilted to the left and right sides in the sports medicine acupuncture program.

We also discuss how the thoracic vertebrae can be stuck in flat. And also into extension. So if you can take a look here is as if the vertebrae, when it has a compression and torquing, it just locks one on top of the other. And it may not actually look like it’s out of alignment. Many times the vertebraes actually feel like they’re in place, but they end up.

Moving very well. They get stuck with one another that causes a barren motion within the region. And the more chronic that fixation is going to be in place, it starts to then affect the spinal nerves itself. So acupuncture, manual techniques work extremely well to be able to open up these fixations and get more energy to the Zong Fu and also the innervated tissue.

So skeletal system. So what’s on, then let’s go right into that Oxford C1 here. All right. So we’re going to focus on this particular fixation. We’re going to call it the joint from now on just cause it’s a lot easier than saying atlanto occipital joint from the entire presentation. So the skull or the head, it sits right on the superior articular Fossette via the occipital condyles.

Brian, would you be able to show. Where those condos are on the skull and the image on the right. You can see those blue images there that’s on that skull. So then those particular articular areas are going to then fit right into the articulate areas of the Atlas. And you can see there in the cost services, superior articular surface of the lateral mass.

So it’s really quite interesting. The headsets, basically balancing on this very small area on that Atlas. So let’s go to the next slide then.

Now this joint is a small range of motion. That’s going to be approximately 10 to 15 degrees of flection and extension. So that’s going to be the movement of basically nodding. Yes. So it’s the very small movement of 10 to 15 degrees of flection and extension of nodding. Yes. Which is a difference between.

Full cervical flection and full cervical extension. It’s just that small little movement of nodding. Yes. Now some research researchers are going to agree that there’s also a little bit of movement in lateral flection or a lateral tilt of the occiput on the Atlas. And we’re going to discuss that a little bit there too.

When you start to, when we get into the assessment. Now the suboccipital muscles that are located deep to gallbladder 20, and also the semispinalis capitis muscle, especially the superior fibers. They’re going to be primarily responsible for this action. So those are going to be two muscles that we’re going to be definitely treating and linking that with their senior channels.

Let’s go to the next slide. I want to discuss a little bit about how the angle of post. So on the left, you see an image of the four suboccipital muscles that surround Cobb that are 20. So you can see the angle or the line of pull of the suboccipital muscles. They’re going to go ahead and. Tilt the cap or tilt the occiput into extension now on the right, you can see those upper fibers of the semispinalis capitas.

Those will also be tilting the cap or the occiput into extension. So let’s go through that language again. You’ve got cervical extension. But then with that small little movement in the AAO joint, it is capital extension or a little bit of a tilt. If you take your fingers and put them rod over gallbladder 20 on yourself.

And once you’re there, just look to the ceiling, you’re going to have a small little movement of capital extension. So what you’re feeling then is these upper fibers starting to contract. And holding that area in place. So therefore, if you have a posture, let’s go to the next slide there. Brian, we could, if you have a posture where the person’s going to be stuck in capital extension, for example, this image on the far right.

Where the head is basically stuck in the end range of yes or capital extension. Many of our patients who have cervicogenic headaches are clouded thinking low back pain, neck pain, have this particular posture, which on the upper right, that had, is stuck in capital extension. So therefore the AOJ.

Is locked has, and then the soft tissue around that AOL joint actually starts to become adhered and locking that position. But you also have people that we have the end range of. Yes. So you can see on the lower right. That person is going to be more into a flection of that capital. Now that can also be a fixation of the joint and also have muscle and soft tissue balances as well.

So let’s talk about those soft tissue balances, because we’re going to be looking at that for treating with acupuncture. Now, all the tipo fixations, including the fixation of this AOL. It’s going to happen, have the mild fascia imbalances between left and right sides of this, especially apparent with the suboccipital and the semispinalis spinoffs muscles.

So often there’s going to be a lock short muscles, which we can be able to label and treat as an excess on one side of the joint, which is really holding on locking that joint. And then on the opposite side, there’ll be locked long muscles, which we can categorize. As deficient and they’re inhibited their weekend, which is going to predicate needle technique that we’re going to be talking about here in just a little bit.

And that’d be on the opposite side of the choice. Now, this image on the right, this is going to be of the thoracic spine. So you can see there’s going to be locked short Xs on one side and lengthened and deficient on the. For this particular conversation, we’re going to be looking at the upper fibers of the semispinalis capitas and also the suboccipital muscles that we can treat with and also specific needle technique for gallbladder 21 side will be excess and the other side will be deficient.

And this is something that you can often feel just with palpation. And we’ve got a video of this. We can be able to show you here in just a little. So not only are these a local needles that we’re going to be using the extra earn near vessels of small intestine three, and you’ll be 60 to work exception.

To build a help with releasing that occiput and Atlas fixation as well, there’s going to be other muscles that we honestly want to look at and associated channels that we want to look at. That could be actually fixing. The a O joint. And I think we can hand it right over to Brian. So you can get into that.

Brian, are you ready?

Okay I don’t know, Matt, did you mention that inclusion of ? Yeah. At the very end, the extra investors can do my job. Yeah. So we’ll come back to that in a second. Looking at the primary channels associated with it. We have really a combination between the urinary bladder and the small intestine that channel sinew channels.

We’ll go with this new channels. Just to get a quick overview, we’re not going to go through the whole channel for this lecture, but I have it listed here in terms of the myofascial structures that are part of the UV new channel. It’s primarily what you’d expect, running up the posterior part of the body, following the urinary bladder.

But let’s take note of these little branches that sometimes we forget about, if we don’t look at this, the new channels that branch from the primary channel going up and down the back and then wrap around the front and then wrap up to the shoulder. So we’ll get this anatomy in a second, but we can just briefly see this Leticia, this door sigh wrapping around to the PEX and then linking for this lecture.

What’s really important is the Sternocleido mask. And then we have another branch that comes off of this region also and links with the upper trapezius. So that’s one thing. And then the last thing to look at is this binding region that we’ve already discussed at this suboccipital region. So let’s start with the suboccipitals Matt’s already talked about them.

This image is nice because we have a slightly different angle and we can get an appreciation, not only for. The rectus capitis posterior major and minor and the angle they take, but how sharp of an angle. Then we miss out on, when we look at those images that are going straight from the back, we lose track of how much of angle these oblique capitus muscles have.

So that’s nice to see from a slightly different. But collectively, these are going to have a really big influence over the balance of the suboccipital joint and seeing the angle, these muscles take, you can see how imbalances between one side and the next might not just have that extension aspect that Matt’s talking about, but also that ability to sorta have the head not sit on quite straight.

Really key muscles to suboccipitals for the balance of the, of this Atlanta occipital. But also really the balance of the whole urinary bladder send channel. And the tone of that whole urinary bladder send you a channel included also would be the cervical extensors semispinalis capitas.

But then if we go to the the branches that were discussed off the urinary bladder channel, oh, we have the lats into the pecs and then creating a myofascial plane with the sternocleidomastoid is an interesting muscle it’s part of multiple sinew channels. Definitely part of the stomach.

But it has this linkage with the urinary bladder channel. And I’ll give you one indication where you might’ve seen something related to this is when you’ve learned about points and learned about urinary bladder 60. That, that is a common point for headaches. But the description, if you go back and just read the commentary saying Deadman, the description of that often talks about young rising, excess, young, rising up the.

Urinary bladder channel. And the way I interpret that is that tension that rises up to back when people have a lot of St Liberty’s stagnation, a lot of rising liver, young, rising, but it often rises up that urinary bladder channel and everything tenses up, SCM, upper traps, the cervical muscles, the back muscles.

It’s that raising of the shoulders that happens in that scrunching of the neck that happens. So it’s a very typical stress response and these muscles are very involved with. But they’re also because of their mechanical attachments at the mastoid process for the SCM and then the upper traps going all the way up to the EOP, they can also contribute to that capital extension and that discrepancy from left to right.

So their accessory muscles, their muscles, we can also consider as part of a treatment when we’re working with fixations at this region and things that are associated with that. Cervicogenic, headache, cervicogenic. Okay, quickly going through the small intestine, send your channel. We have multiple structures.

We’re not going to get into them all today, but levator scapula is a big one. And that binding region that happens at the upper cervical region, look at an anatomy image of that. Levator scapula actually attaches to C1 through C4 transfers processes. So it has an influence on much of that upper cervical spine, but especially that C1 transverse process.

Be a big contributor to that tilting of the head from side to side, some of the discrepancy in terms of how that’s going to balance, not just a position from a capital extension, but that maybe shortening and raising the shoulders or on one side. And that discrepancy from side to side. So levator scapula is another one that can be a player in this and can be And accessory muscle treating the suboccipitals important.

We’re going to be looking at a technique at gallbladder 20 and semispinalis capitas. Did you be 10, but don’t forget about levator. Scapulae it’s a good one to consider in this whole list. So collectively these two channels are going to meet and have a binding region at that upper cervical spine Atlanta occipital joint region, the suboccipital region.

And collectively are going to be a part of that whole balance of the AAO joint. So here’s a nice image showing that upper fibers of the levator scapula meeting at the transfers per process, and then sharing, communicating mechanical information with the oblique capitus superior and inferior muscles, which are two of the muscles of the suboccipital.

Triangle two of the suboccipital muscles. So they can really work together in terms of balancing, but also become dysfunctional together. All right.

Kind of piety to look at some images. Okay. Yeah, Brian. So let’s get into these and talk about these. I think this is a nice segue into that discussion of the upper trapezius and levator scap as well. So the image on the left, you can see that she’s got a bit of a lateral tilt of her head onto the AOL joint.

You can see how that left ear is slightly lower than right. And this is something also that you see with patients, let’s say, for example, that you’re sitting on a stool and the patient’s sitting on the table right in front of you. Have you ever noticed that it looks like their head’s just not quite on straight.

So there has slightly, just slightly tilted. This is something that you would see on the left and I’ll guarantee you 99 out of a hundred. If you go back and you palpated the gallbladder 20 and the bladder 10. Once I will feel very access and the other side will feel very deficient. Hence something that we’re going to discuss here next is that person will also have bilateral.

So as weakness. So we’ll talk about that here on the next slide, but for right now that image on the left, you can see that they’ve got a little bit that lateral tilt, same thing with the image on the right, this gentleman. You can see his tilt on the right to the levator scapula is going to be in a locked, short position on that right-hand side.

And he most likely has an Oxford C1 fixation as well. So these people could have cervicogenic headaches or any of those aforementioned signs and symptoms that we had. Brian, do you want to talk about the capital extension there on the remaining two? Yeah, I would agree that, the big structures to consider on these ones that Matt talked about would be the suboccipital muscles are so influential on the tone, but it seems to me without having any other information on these patients, you know what they’re coming in with, et cetera, it seems to me like levator scapula would be indicated for those.

Whereas these pictures on the right, I might change my tune if I saw them from the back, but at least from the view, from the side and the success of capitalization, The suboccipitals are going to be involved with that, but I would also be looking at the SCM for both of these these patients.

And it could, it’s going to be the case at one side, it’s going to be shorter and that’s going to contribute to that tilting of the head not being quite on straight. So it would be an accessory muscle to consider along with the suboccipitals and semispinalis capitas, especially if they’re coming in with headaches and it seemed like the SCM was a component of that.

Maybe referring into the frontal region or deep into the occiput STM would likely be involved with that. Maybe even upper traps, all upper traps are in a position where they’re pulled forward. So we’ll be including in this discussion, after looking at some local needle technique, we’ll be including a myofascial technique that you can refer back to those two, right images when we’re talking about that myofascial technique.

And that would be the type of patient that, that the technique we’re going to show with. Yeah, that’s a good point. I would suspect the image on the far left that her left upper fibers of the SCM would also be really quite locked short. The same with the gentlemen on the money. I would think that his SCM on the right.

Yeah, that’s great. Holding this fixation in place. Now you guys, we are zeroing in on the AAO joint for those people that might be looking at the posture on the left images there. Yeah, of course, the elevated ilium and the side bands at the spine and such all of that would have to be addressed.

Which we do in the different modules in the smack program. But right now we’re just zeroing in. Joy joint, how important it is to observe and treat it for different types of signs and symptoms and pain patterns. All right. So the next slide is one is an assessment from applied kinesiology.

So this is George Goodheart’s work, but I’m not exactly sure if it came from him or maybe John PHY in touch for health. I’m not exactly sure which one, but yet with an occiput Atlas fixation at the joint, it will create bilateral. So as weakness. So therefore, if somebody has this muscle that’s in hidden.

And therefore they’re going out and doing extra curricular activity, hiking, doing something above and beyond. You could see how that muscle would be struggling and eventually could actually strengthen. So when somebody has a hip flexor strain, it’s affecting that. So as it’s always a good idea to go up and look at the joint now, since the so as is not going to be stabilizing that lumbar spine as well, being inhibited from a fixation at that AOA joint, it can also create low back.

This is a really great assessment looking at the so as, and then once you correct the AOL joint with acupuncture, and also we’re going to be showing you a little bit of a manual technique that you can use, and also a mild fascia release technique on the upper trapezius that’s affected. You would then go back and check the so as for strength and if it is not bilateral, so as weakness anymore.

So then therefore you’ve done your job with some patients. It might be, then you need lateral weakness, meaning it’s just one. So as that’s weak, that means that the AAO joint is still corrected. Remember with the fixation it’s bilateral. If bilateral weakness turns into unilateral weakness, it then becomes more of a segmental problem or just a localized problem, which we could go ahead and treat the Watteau GS of the high T 12 down to about as well as GB 27 on that particular side in order to be able to turn that.

So as right back on. Cool. All right. So what do we got next here? I will say one quick thing about that. It seems odd, right? The, so as in the occiput C1, there’s not a direct innovation. It’s not like the so has, is getting its innovation from C1. But if you wanted to just look up something called the ocular pelvic reflex it talks about the relationship between the eyes, which have a strong relationship with the suboccipital muscles in terms of turning the head and following eye movement and the pelvic position and really the lower spine position.

So it’s probably a regional. Component that’s communicating between eye movement and stabilization of the spine. And maybe that gets turned off when there’s an occupancy one fixation theory, but it’s really more clinical observation than it is a direct anatomy thing. But that’s what I think it works according to those principles, but that’s something that you teach and demonstrate in the senior channel class.

And it’s really quite interesting. So as fire, when the eyes left or right with that. So that relationship, thanks for bringing that, Brian. That’s good. That’s where it’s like, if there’s somebody seated and you press into the abdomen and you can touch the, so as you often feel that firing slightly, when people look up to the coroner, which suboccipitals will start the fire and you can feel that tone change, like I got my eyes closed and be like, okay, you’re moved.

You moved sometimes you don’t feel it. Maybe those people, you don’t feel it as well. Or you only feel that. Sometimes it’s quite prominent sometimes not so prominent. Maybe the people it’s not really prominent on are the ones with the occiput C1, fixation but you can definitely feel this how, as I’m communicating with that small little eye movement, that’s happening in this small head movement that occurs from that.

All right. Cool. Next.

All right. So when you’re feeling the gallbladder 20 suboccipital region and bladder 10 left versus right. When someone does have an AOL fixation, one side definitely feels more pliable, more deficient. The other side is harder tissue. It’s more dense tissue. It’s usually a bit more painful to palpate.

So with the excess side, what you could do is to go ahead and palpate gallbladder 20, but in three different directions. So from gallbladder 20, if you angle it toward the contralateral gallbladder one, you’re going to be affecting the rectus. Capitis posterior minor and major. If you take your finger from gallbladder 20 and you angle it toward the ipsilateral gall bladder, one is going to be affecting the oblique capita superior.

And then from gallbladder 20, if you angle toward rent 24, you’re putting pressure into the Oakley capitus inferior. So whichever one is actually the most tender or Maven creates a headache is the angle that you want to actually needle from gallbladder 20. If you need a one to 1.1, five inches in any of these directions, it’s going to be totally.

It’s, it is safe to be able to do that. The only one that you want to make sure that you’re definitely kneeling toward the ipsilateral gallbladder. One from gallbladder 22 effectively. Capita superior is one inch to one to 1.5 inches. That’s not an inch and a half. It’s one-to-one. Five suggestible over an inch.

Needling that direction will be very safe. If you do go towards maybe the ear, maybe you’re going too fast. You’re going to be very close to the table, ardor in it’s unprotected region. So we want to make sure that we’re not angling towards or also the ear in that particular case. And then bladder 10, if we can go to the next slide there, which I think it just continues to discuss as go to the next slide.

Yeah, I try to maybe it’s try it again. It’s just stop. Okay. Nope. Here we go. All right. So there we go. So then bladder 10 is going to be the key point for the semispinalis capitas. Now, as we know the way that we were taught as bladder 10 is going to be level with do 15 and gallbladder 20 is level with do 16.

For the last this, so this particular image is from the motor point index that was published and 2000, the year 2000 news I believe was published. And so the information has changed. We have found the actual motor entry point for the semispinalis capitas, the upper fibers at least to be level with deuce 16.

So that means that we’re putting bladder. Level with gallbladder 20 and frankly from my own clinical experience, I think Brian can agree with this as well. Is that treating the upper or the modified bladder 10 level with do 16 and also level with cobbler 20, you get a lot more cheese sensation than you do.

When it’s level with the do 15, but don’t believe me, try that yourself. You guys make sure that you’re needling one soon perpendicular to the table or to the floor going in level with popular 20 and do 16 compared to level with do 15. I think you’ll find, you’ll get a lot more cheese sensation at that particular point.

So the next side is actually showing another view. Semispinalis capitas. You can see how it’s just 20. We’ve modified this and we’re putting it level with gallbladder 20. Everybody got a lot more cheat that way. All right. So the video you’re about to see is going to be needling bladder 10, one inch perpendicular to the floor on one side will be the excess side.

And then on the other side, we’ll end up. Gallbladder 20. So it’s not necessarily going into the three different directions. We’re just needle gallbladder 20 on this particular time, which you can do. But a good idea on the excess side is to palpate those three directions affect that suboccipital triangle.

I think you’ll get better success rate for releasing the AAO joint. This particular video, the audio didn’t turn out very well. So I’m going to go ahead and narrate this as it goes. So Brian, whenever you’re ready, I’m ready.

all right. So we’re going to be looking at, there’s do 16 right there. This is going to be for your a oh, joint fixation do 16. So I’m going to go ahead and palpate on the right-hand side and that feels. Really quite dense there at bladder 10, which we know is going to be about 1.3 soon lateral, that’s going to be the upper trapezius that I’m working my finger through to get to the deeper layer, which is sound mispronounced.

Moving lateral going into gallbladder 20 and feeling the density of gallbladder 20. Now going over to the left-hand side, bladder, 10 more pliable, softer tissue, easier to get in gallbladder 20 more pliable, soft tissue. So there’ll be excess on the right perpendicular to the table of floor going in at bladder.

One inch, you could even go in 1.2, five inches here. I do recommend a deeper needle technique at this particular point to get into that semispinalis capitas and a gallbladder 20 on the right. We’re going to needle just toward the tip of the nose in this case at gallbladder 20. But this would be the area that we could go ahead and pop it to three different directions for the suboccipital triangle in this particular video.

no, on the left-hand side, we want to reinforce this. So this is going to be a shallow needle technique going right into that upper trapezius going in just about a quarter of an inch. No more than a half an inch in that area. A very light CISA station compared to the opposite side, and then a gallbladder 20, the same thing going toward the tip of the nose.

Very light needle sensation here. More of a reinforcing needle technique from clinical experience going in and really wailing on these areas are getting a lot of cheat on areas that are deficient will actually make the person a little bit worse.

So deeper on the right-hand side, more of a reducing needle technique, more superficial on the left hand side, more of a reinforcing needle technique.

This is a video is on our YouTube channel. By the way, I know sometimes streaming the, you can get a little choppy, but if you want it to go back and look at it again, that’s on our channel sports medicine, acute.

All right. This was a really great muscle energy technique for the Suboxone suboccipital triangle muscles. I believe it was developed from Phillip Greenman in the 1940s. He’s a very famous osteopath that has quite a few different books out. It’s a great technique to build. Right after the needling and after the mile fascia work as well you can even use this type of a myofascial technique.

When there isn’t an a O fixation, it just helps to really relax the patient quite a bit. So this is a step-by-step you can see there’s these different slides. That’ll be in your notes here or in this recording here that you guys can be able to check out. It’s basically gently pulling the person’s head into tracks.

And they’re going to look back at you to help to stimulate those suboccipital muscles. And then once they relax, you’re then going to go ahead and just eat a long gait, the head and traction a little bit further. So it is a muscle energy technique where they contract against you. You prevent any kind of movement for about the count of six.

They relax, and then you pull the head chest. Farther. So you’re helping to realign the occiput onto the Atlas. This again, it’s just a, it’s a fantastic mobilization technique.

Here’s the other rest of the instructions. So like Matt said, if you go back and access this recording and you’ll have this, we also have this, I believe in module. Is it module one? Senior channel class or is that going to be module four? It might be module four senior channel class we actually have. Oh yeah.

On a, not a knowledge. Yeah, that’s correct. It’s module four. Okay. All right. So one more technique. And this one will highlight that branch of the urinary bladder send new channel, that’s connecting with the upper traps and the SCM many ways it’s working with the foster. Of that that, that surrounds both the upper traps and the SCM, which are embryologically one muscle, but splits.

So they really have the same fascial compartment, same fascial bag. And this is just taking the fascia and bringing it back. This video has a lot of different steps. We’re going to not watch the whole thing. We’re going to watch just a portion of it. That’s relevant to this discussion. So I’m gonna kinda go a little ways into the video.

Let’s see, that might not be able to, yeah, there we go. Okay.

And same thing. I’m going to be narrating this just for sound aspects. So we’re going to use it as a loose fist and that loose Fest is going to place right on the upper trapezius on that border of the upper trapezius. So we want to put a lot of pressure so much. It’s just enough to get a hook into the two.

And then we’re going to bring the tissue down towards the table back, really bringing the tissue back while the patient rotates their head to the opposite side. It’s like when I learned this technique, I think we use the description of a velvet glove, which kind of is a nice way to think about it.

Do you want a soft pressure? Doesn’t mean it’s not deep. It’s just not pushing into the tissue deep. The next step we can follow up that same fascial compartment up through the. But I’m highlighting is I don’t want to go in front of the SCM with my fist. I want it to be on the SCM. I don’t want to go in front of that border.

Same thing I put in just enough pressure to get ahold of the fascia. If PHP patients are hyperextended like that, I want to use that pull down towards the table to help straighten and elongate the back of the neck. I might even have them bring the chin and a little. And then they rotate while I’m bringing that whole fascial layer back to the almost to the spine as processes as far back as I can reach it while they’re rotating.

So it’s not a lot of pressure into the neck. It’s more about hooking that superficial layer of the cervical fascia and bringing it back. And then I can have them do it again with another pass. When I’m showing there is when they turn, I want them to rotate on an axis and not bend the head to the side.

It’s almost like they have an access or a pole going through the spine that stays straight. So it’s just a very, they should almost feel their hair scraping along the table as they do it. And I’m bringing that whole superficial cervical fascia. So it’s a nice technique to help decompress the back of the neck and elongate that fascia that’s associated with many things, but the occiput C1 area for this lecture let’s create.

So Brian, we’ve got the proverbial hook coming to pull us off the stage right now. We have. Let’s get through this within the next 30 seconds or so. So the new Nepro is forced Mestinon department certification program starting in San Diego here in July. There is the QR code. We’re happy to answer any questions that you guys may have.

And then also in March, end of March of next year, we have a, so as events, the Pacific sports and orthopedic or acupuncture symposium, that is the acronym. So as. And this is going to be based on myofascial pain. We’ve got incredible speakers that are coming, including Dr. Antonio Stecco Dr. Roberta Pratt Rebecca Pratt, our Nielsen, Brian Lau.

I will be there and Bensky, we’ve got a whole, a great list of people that are coming to present. There’s the QR code for? We’ve got a lot of online recordings as well, that we can be able to further your continuing education. That’s going to be through Lhasa OMS here in the United States, Eastern currency in Canada.

And there’s also distributors international for that. You can also follow us. We’ve got YouTube and Facebook and Instagram and Brian, you want to give a shout out for your movement therapy? We’ve been putting together a lot of description of movement associated with the channel sinews. So it’s a not evaluate calisthenics and Qigong Tai Chi, various things, but it’s not about what the exercises are.

It’s really looking at it more from a channel perspective, how you train those channels, wake up those channels and incorporate like really efficient movement, but those channels, and then you can start strengthening. So Jim gen channel sinews movement training a QR code, or you can just do a search for Jim gen movement training, all the other stuff.

We mentioned the sports medicine acupuncture. If you go on YouTube and you don’t have to code with you, just do a search for sports medicine, acupuncture for any of those are fantastic. That’s it. Yeah. Hopefully this was a useful for you. There was some pearls for you guys to be able to crab and help out some patients.

Cause that really is the bottom line. We want to be able to help other people. If you have any questions whatsoever, please reach out to us. We’re happy to be able to answer those questions. Next week. Cholon Moya, who’s going to be coming. I was really happy to be able to hear that she’s actually going to be presenting chose a fantastic speaker and an incredible practitioner.

She’s one of Kiko, Kiku Matsumoto is top students. She took the sports medicine, acupuncture certification. Twice and she’s blending the two things together and she’s just a ball to listen to. She is just a walking dictionary, amazing Tsao-Lin Moy for next week. Thank you very much, everybody. Thank you so much for the American Acupuncture Council.

Happiness. Brian’s always great to hang out with you, buddy, and we’ll see you again soon.

 

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A Proprioceptive Acupuncture Technique at Extrapoint Chonggu

 

 

Click here to download the transcript.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Hello, everyone. Thank you very much for attending our American Acupuncture Council webinar presentation. My name is Matt Callison. I am here with my esteem colleague, Brian Lau. I thank you. That. We’ve got a really fun topic today. It’s a proprioception at Extra Point Chonggu. Brian, can we go ahead and go to that first hetero slide?

Let’s get this slide.

So we’re going to be discussing is a needle technique for Extra Point, Chonggu, which is actually just one portion of a treatment for a upper cross syndrome posture. The upper cross syndrome posture, which we’re going to be elaborating here in just a little bit can lead to a multitude of different injuries.

And today is very short presentation. We’re gonna be. We’re going to be lecturing about how to actually needle this particular point and stimulate these lower cervical area that usually has a proprioceptive deficiency from this particular posture of a Ford, had an upper cross syndrome. So let’s go ahead and I think jump right into upper cross syndrome so we can discuss that.

So this term upper cross syndrome was coined by Vladimir Yonda close to 40 years ago. He is an osteopath in specializing in rehabilitative medicine, and he coined this term basically from looking at his patients that have a very unique type of posture that we actually see in our practice. And you as well, commonly, I would say every single.

It is looking at a forward head posture of a plumb line, increased thoracic kyphosis. So you can see that upper back really starting to curve without forward head. That’s going to lead to a number of different postural imbalances and agonist antagonist. So Bladimir, Yonda when he saw this, he actually coined this term is looking at it as a cross.

So you can see that the pectorals in purple here, the pectorals are going to be in a locked short position. Pulling on that humerus, making the humerus internally, rotate, collapsing the chest. Now going through that, you can see the next purple would be the neck extensors. Now those neck extensors are locked short, but they’re actually with through evolution, looking at portions of these neck, extension extensors are going to be locked short, and some of them will actually be locked long.

The longer part let’s say the lower cervical aspect of. That posture you’ll see that the neck extensors would be more in a lengthened position because of the forward head. Then the upper cervical region, the neck extensors actually be in a shortened position. So a little bit more on that with the next slide and just a little.

So that’s the purple aspect. Those are your locked short muscles. Now you’re locked long muscles will be, if you can see where the increase thoracic kyphosis would be your rhomboids, your middle trapezius, your lower trapezius, those muscles be very weak, allowing scapular, protraction, as well as that increased thoracic kyphosis.

Now, if we look on the Antar aspect of the body, you see the neck flexors. So it’s the deep neck flexors in particular that are going to be. Locked long or inhibited posture. If we look at the sternocleidomastoid, which will also be a neck flexor, that’d be more in a locked short position. So you have your general upper cross syndrome, but there’s also going to be just some variabilities within those muscle groups that will be locked long and locked.

So the point, the takeaway here is to look at as today’s presentation is that lower cervical region will be usually proprioceptive deficient in that forward head posture. It’s a lengthened area. So we’re going to use an acupuncture needle to try to reestablish some of that proprioception combined with an exercise to bring that forward, head back to neutral position.

Let’s look at a couple of models here. Let’s go to the next slide. There’ll be. So zeroing in on this upper cross syndrome or a common posture that lengthens the lower cervical region. So you can see how the head is really quite forward, but then it’s going to compress the tissues of the upper cervical region.

So if you could take two fingers and just put them right there at gallbladder 20, and once you have that, just simply start to look toward the ceiling. You might tilt the head back just a little bit. That’s called Qapital extension. So that’s different than cervical extension. Cervical extension is when you have all of the cervicals moving capital extension.

When you had your fingers there, gallbladder 20, you might have flipped those muscles. Just move just a little bit. When you’re looking up, that’s going to be looking at the upper neck extensors, especially the suboccipital triangle. And when those muscles get really quite taut that can lead to a number of different types of headaches, nerve and syndrome.

So the third occipital nerve, the greater occipital nerve, the suboccipital. Lots of different injuries that can occur from this particular posture. So you can see what the, both these models, if they got increased thoracic kyphosis, the head goes forward as a compensation for that forward head. The person’s just going to tilt their heads slightly upwards so they can see the horizon.

And that’s going to cause that capital extension and a number of different injuries. Now Brian’s going to go ahead and show a video that he did of himself to explain this a little bit more. Brian, do you want to take that away?

Yeah, sure. Videos just showing the relationship between the shoulder girdle movement, the scapular movement and the.

So there’s a ton of sinew channels that act on the position of the scapula and the movement of the scapula, not a ton, but there’s several. And we can go through them, but really, I just wanted to highlight in this video, how the spinal movement links with those scapular movements and the tie into what we’re seeing in these images here, before we go into the video, these models, as you see, have increased thoracic.

So their spine in that thoracic region and the upper, or excuse me, lower cervical region. The spine is stuck in flection. So we’re going to look at the relationship between the flection and extension components of the spine and how that relates to the scapular movement. Pretty short video. It’s an Instagram video.

It’s going to be on our Instagram channel or Instagram page. So it’s a minute long Instagram. Doesn’t give you a lot of time for these things, but it’s very brief. So let’s give it a look at. Okay there. We’re going to look at the relationship of the spine to the shoulder blade movement using this resistance band.

So as I go from protraction retraction, that movement likes to occur. As the spine comes out of flection, the cervical spine starts drying back and pact traction. That the spine will want to go into election retract. Buying comes out of flection, cervical spine throughout the back. Many people have a forward head posture.

So the spinal movements not coordinating with the entire movement of the body that sets them up for injury in the cervical spine angle, her girdle potential job problems, headaches. So they need to learn how to get rod, that surgical site back to encourage the entire.

all right. I’m gonna go back here for a second, a fun thing about filming things is you notice aspects that you wouldn’t notice otherwise. I had my mic here on the shirt. So when my head goes forward, of course, I go a little ways away from the. But I was acutely aware of how different my voice was and I was strained.

My voice became when I went into that forward head posture. So that was quite interesting, but yeah, just also noticing the the difference tension in the extensor suboccipital reason and how that sets you up for a whole host of different potential problems. But with that video you might notice the scapular movement and how much activity there, there occurs in the rhomboids lower trap.

It was mentioning those structures that are pulling the scapula back and retraction. So that can get us thinking about ways of treating this beyond just the technique we’re going to be highlighting. And I think Matt’s going to get into that on the next slide here. Okay. Okay. Thanks, Brian. That was good.

So just as an overview, what we’re looking at is just a portion of that upper cross syndrome, the increase thoracic kyphosis, which are going to, it’s going to have a lock long and weakened and. Rhomboids middle trapezius, lower trapezius. The head is going to be forward, which is going to be a lengthening of those lower cervical vertebra.

Then you have a shortening of the upper cervical tissues. So in this image, the head is neutral. Now, if we look at, if we can be able to take that head and just move it forward, we can start to see a little bit more of how. Lower cervical vertebrae going forward and how it would be great if there was a way for us to actually pull that lower segment of the cervical vertebra and all of the tissues that are highly appropriate, receptive your deep paraspinal muscles, your supraspinous ligament, your interspinous ligament, and encourage that to be able to come back while the person’s.

He is trying to strengthen the rhomboids, the lower trapezius, the middle trapezius, and add proprioception add sheet to that particular part of the. So I would say probably about 15 years ago. So I started playing around with this needle technique with the exercise and the combination is pretty profound.

And this is the reason why we wanted to share that with you today. Again, the takeaway here is this is one portion of the needle techniques or the points that we’d be using and the exercises that we’ll be using for upper cross syndrome. And Ford had an increased thoracic hypothesis, but it is a Pearl.

This is a big point. This is a great technique to be able to use. So it’s underneath the C6 vertebra. You’re inserting the needle through the skin, through the superficial fascia, the adipose tissue, and then the first tissue of resistance that you’ll feel would be the supraspinous ligament. Now, once you go through that, supraspinous ligament than the.

Long and wide interspinous ligament is going to be the next issue of resistance that you’ll feel with that acupuncture needle on most people, it’d be probably about, just about a one inch needle insertion, which is completely safe. You’re very far away from the spinal cord. Some patients when they’re laying on the table prone, it’s difficult to get to that C6 area because maybe they have a lot of tissue in the area or are just increase extension for some patients.

Some practitioners like to lower the head. To be able to open up that neck personally, as a patient. I don’t care for that very much. Having my head drop down a little bit. Doesn’t feel very good to me. Usually what I’ll do for patients is just to put a pillow underneath the chest and that’ll open up the neck.

So as a practitioner, just take your finger or two fingers and start feeling underneath that C6 vertebra separating the tissue so you can get an idea. On how to be able to put that needle up underneath the spinus process of C6 and get through those a formation, a four mentioned tissues. Once you get into that interspinous ligament, which is about, like I said, about an inch deep propagate Xi, and it may take a while actually for that patient to get to you because of the lack of appropriate.

Now, remember this is also going to be combined with other points for example, the wrong point motor point, the middle trapezius rotor point, the lower trapezius motor point you could use GB 20. There’s a number of different points that we can use depending on the patient’s case. So once you’re able to get an established Che at Extra Point Chonggu, then what we’ll do.

We’ll wrap the tissue around the needle by twisting the needle in one direction until the needle starts to get stuck. Once it’s stuck, then we’re gently going to start to pull that tissue back posterior where alongs. So we want that tissue to go back it’s lengthened because of the forward head position.

We want that tissue to go back at the same time as the. Doing an exercise, the prone and neck protraction exercise. So let’s go to the next slide there. Be

all right. So as that person is elongating that lower aspect of the cervical spine, bringing him back into extension, you’re pulling up with the needle so they can start to get an understanding of raising that lower cervical part of their body up toward the. They’re going to slowly just start to tuck their chin a little bit.

So that starts to get rid of some of that capital extension. And they set up this exercise by lowering and squeezing the scapulas together. Then engaging the middle trapezius, the rhomboids and the lower trapezius. So this is an exercise that you would do after all of the needles have been taken out with the exception of Extra Point, Chonggu.

Brian, is there anything that you wanted to add to that before we jump right into the video to show them. Yeah, you’ll you’ll see this a little bit on the video coming up that the tendency for the people who really need this technique in particular, the tendency, when people start to lift their chest by engaging the rhomboids middle lower traps they’re really tied into the idea, not even consciously, but just their body’s kind of stuck in it in a particular position to where they want to arch their neck.

And exaggerate the neck position that we’re trying to get them out of. It’s just something that’s very difficult for people who really need this technique. It’s difficult for them to find that movement where they both retract the scapula and bring the, draw the cervical spine back and lengthen that posterior portion of the cervical spine, especially the upper cervicals.

And now of course, the technique is designed to help with that, to help give them a signal and encourage them. But you have to look at the. And make sure that they’re not going further into capital extension, like trying to lift a lift up and going further into capital extension. So you have to coach them.

Now, the good news is the technique helps give a little cue and coach them at the same time, but sometimes verbally coaching is necessary. And you’ll see an example of that coming up. Yeah, that’s a really good point. A lot of people will go into that capital extension just because they’re used to doing that.

So thanks for saying that, Brian, by coaching the person, just to tuck their chin a little bit, that helps with it. Now, this technique also is useful. If you didn’t want to needle it by just pinching the tissue of Chong GU and lifting that. But it’s not as successful in my own opinion as actually using a stainless steel needle, going into the interspinous ligament propagating sheet.

To me, that’s the changing proprioception far better than just actually just lifting up that skin. Cool. All right. So let’s, and again, you’re in the blue channel, right? With the needle you’re in the do channel, you’re in the ligamentous tissue and you have a lot more sway on it. So you’re ready for the video.

Yes.

super supplies.

Squeeze caplets together, race together and relax everything. So bring these guys to be a backbone because you put this together

for me and agree this.

all right. That video is up on our YouTube channel by the way. So if I noticed the birds are a little aggressive, they’re mad in your background, they’re making some noise and it might not have heard anything. This sounds a little put out by that, but we do have that up on our YouTube channel. If you wanted to check that out sports medicine acupuncture, and you can do that.

Oh, sorry, Brian, are you finished? Can I go? Okay. This was a recording that we just did in New Jersey to finish the 2019 2022 smack program. It was three years because of the smack of sorry for him because of the COVID. So we just finished this. This was a module for neck, shoulder, and upper extremity. This is one of the techniques that we’re using now.

Remember, we’re also going to be needling the other points as well, and that helps with proprioception. So the person gets an idea on how to be able to lower and squeeze the scapulas together. So that’s great. That’s, this is a really wonderful technique to be able to use. We’re going to be teaching this class again here in San Diego and that’s coming up in June four days and that will be wrapping up completely of the 2022.

So also what we’re going to be teaching with this is a wonderful myofascial technique that Brian has introduced into the program that works extremely well for that particular posture and opens up the tissue. Great mile fast, mild fascial technique to use after all the needling. Brian do want to take it away.

Yeah, sure. So this is a seated technique. It’s a interactive between you and the patient. So first and foremost, you want the patients sitting in a position that is going to help facilitate change in the body. So you don’t want to just slouching though. I am starting a little slouch. So if you look at the picture, there’s three images, the one in the left most image once you have the person stacked on their sit bones, you’re going to take your Louis kind of knuckles.

I usually use just the flat kind of inner phalanx of two fingers. And you’re going to place that approximately I’m not being really exact on any location, really, whatever real estate you can get in that upper cervical spine. And you want to allow the patient to drop their chest and go into the Capitol extension.

Why am I doing that? I’m doing that so that the tissue shortens and I can get a good investment of the tissue. I can hook, I can engage the fascia. I can sink into the fascia and then you’re coaching the patient to start a lift. The sternum, descend the scapula by engaging the rhomboids lower. And drawing the cervical spine back.

So they’re a long gating, the the posterior part of the cervical region, especially those lower cervical structures that we’re trying to to engage. So they’re doing that while you’re descending and gliding through the tissue. So again, just initial setup, they drop the, they exaggerate the posture, so you can get a hook on the tissue.

And then as you’re drawing that tissue down, And elongating, they’re doing the movement, bringing the cervical spine back and opening the chest. So you’ll see that in the technique, these just give you the kind of rundown and the instructions for that. But let’s look at the video.

this technique is a combination between the manual work that you’re doing and also the movement of the patient. So you want to coach them with the movement, first of all, so have them drop the chest. And serve a call extension. So that’s going to be the starting position, starting them with bad posture.

And then they lift the chest and the length and the posterior cervical spine. So they start an extension with the chest dropped and then lift the sternum, like in the back of the neck, the chin comes in. Many times patients will have a difficult time doing that. When they go to lift the sternum, the loss of go more into extensions and some patients you have to coach them to the movement of this technique is really a big part of it to starting them.

And this position is it let’s come back to neutral. I’m going to gently place my fingers up towards the occiput. Just any area of the cervical spine that I have access to. I’m going to take them into the starting point. That will shorten the tissue. It allow me to get a purchase of the tissue and now it’s a pin and they start to come out of that and I’m stretching the tissue in the posterior cervical spine associated with urinary bladder.

Edgington.

and another pass maybe slightly lateral or slightly medial is again, place your fingers on the deck. Take them into the starting position. That allows me to get a hook last meeting the hold of the tissue, because it’s in a short position now, as I bring the tissue to known where they come out of that position, lifting the sternum, bringing the chin, like the need of the posterior part of the neck.

And I can take it all the way down through the upper part of the thoracic spine.

all right. So this is a supine version. I guess time to the seated extensor technique. So in this one, we had the patients who I’m limited the ability for them to be as involved in it, by dropping the chest, by lifting the head. So it takes away a little bit of the re-education aspect, but at the same time, there are next, a little bit more relaxed or they’re in a more neutral position that way.

I can still take them into capital extension with them in capital extension. I can sink into the tissue pretty close to the occiput. And as I bring the tissue down and start spreading downward, I can bring their neck back into a neutral position. So it’s a little more passive on the patient’s arm and the seated.

so it might be appropriate if there was currently neck pain, that they were having a harder time in the seated position, or if you just don’t have time to put them into a seated position or to use the time of their place,

the two movements. With the hand where you’re bringing them in to flection

lengthening the posterior part of the neck. The other one with the other hand, simultaneous where you’re spreading downward descending, the aging.

So a question about how many times, or how long would you do this technique? It’s a short technique, two passes, three passes. You don’t need to do it really more than three passes. If I were to doing multiple passes, I would probably move slightly lateral or slightly medial and cover the same region but tissue that’s slightly medial to the first pass or silent lateral to the first.

These are short techniques. There are supplement to the acupuncture. They don’t need to be something you spend a lot of time with something else, especially with the seated technique that might not be apparent is when I was following the person, as they went into a kind of exaggerated drop chest capital, a extension I’m not cramped.

I’m not digging my hand in as deep as I can. I’m really just following it’s more of a pivot point is you’re guiding them and following you’re not trying to force them into that position. So I’m not using a lot of pressure. By doing that, I get a hook on the tissue and the pressure really comes from when they start coming out of that position.

So you don’t need to use a whole, a strong ton of pressure with it. It’s a pretty gentle. There’s four, so they’ll feel it, but it’s not anything that you’re driving them in or trying to sorta mobilize the spine by doing it. So it’s more just following, Hey, Brian. I also saw that same question about the needle techniques.

So I think I’ll go ahead and address that as well. Do you want to go to the next slide? Just so people can see that information?

There we go. It’s just has our information that you do, but general, we have a lot of these videos up there. We also post them on our Instagram account and Facebook page. So all sports medicine acupuncture. If you searched for that, you’ll find it. And then our webpages there. So to address the question about how often are you using the Chung goo lifting technique?

Until the patient actually has a really good command of the movement of going into prone, neck retraction. Once they have that, then you can go ahead and stop now. So we addressed this needling technique as basically for that forward head, but you can also use. This 0.4 disc problems, cervical disc problems.

Also, if there’s going to be tenderness to just in that local area, there’s an Oscher point. You can also just go ahead and needle that without actually the lifting technique is for when you see that forward head posture. But again, this point could be used for a number of different types of local injuries.

Brian, is there anything else that you want to add before we had. Just as the bounce off what you said. Yeah. It’s used when they’re, when they have that forward head posture. It might also be used when you say use that neck extension exercise that we highlighted and the person’s really struggling and they can’t figure out how to coordinate that movement to bring that portion of the spine back.

It’s very difficult. And actually I was teaching, I teach some online Teagan classes that was covering this today because there are people that do that very thing when they go to open the chest. Arched the neck up and you try to coach them and they have a very difficult time finding that region.

So it’s appropriate aseptic technique. It gives that a pointer to this tissue bring this back, without using words, they can feel that the noodle kind of pulling that region is oh, that’s what you’re asking me to do. You’re asking me to bring that back. It’s just, it becomes very clear.

It’s like a spotlight on that region. So yeah. Just use it, use the technique, but you might use it when you’re seeing people struggle with particular instruction that.

The guys that wraps it all up. If you have any questions whatsoever for Brian or myself, or you’re interested in the program or any of our classes and information, there’s our contact information that was there in those notes. Thank you so much for attending. Really appreciate it. I remember next week also, Sam Collins is going to end up being here.

I thank you again for the American Acupuncture council. And we’ll see again next, next month. Yes. Thanks everyone. Thanks everybody.

 

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Huatuojiaji Points and Spinal Fixations: A Zang Fu Perspective

 

 

So we extend the Huatuojiaji points all the way up to C1 on all the way down to alpha. All right. So I think let’s just go right into this video, which is showing the anatomy of the Huatuojiaji points.

Click here to download the transcript.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Hello everyone. Thank you so much for coming to our webinar. My name is Matt Callison. I’m here with my colleague and friend Brian Lau. We’re going to be just, oh, there you go. Huatuojiaji points and spinal fixations. An emphasis of this will be on the middle jaw actually. This is something that is such an important technique that I want to share with acupuncturist.

This is over the last 30 years of clinical practice, just one of the go-to treatments when somebody is having any kind of Zong food type of injuries or Zong food patterns that we want to have a little extra emphasis in that treatment to help out that organ. So we’re going to emphasize the middle job in this particular discussion.

So before we get rolling Brian, is there anything you want to add or should we just go right into it? I will jump in. I will add that. I’m going to be working on some re streaming aspects that we’re doing just so we can get it stream live to our YouTube channel for future webinars, our Facebook page multiple platforms.

So I’m experimenting with some new software. So I’ll probably have a little bit of a backseat today. I might, I’ve been a little. But but I’ll mostly be in the background today. Thanks for handling. It’s exciting that we’re having that live broadcast. So thanks for handling that. All right. Let’s jump into the cadaver warning here.

If we could. So you guys, we are going to have a couple of different cadaver videos just to be able to show some of the dorsal primary, primary nerves and the depth of the Huatuojiaji, the anatomy of the Huatuojiaji points. So in the future, if somebody is watching this recording, you might happen to be at a coffee shop or something for that.

He just wanted to be really mindful of the surroundings that some people may actually end up seeing these cadaver images and it can really be quite upsetting to people. So let’s be really careful of this place. I want to make sure that we don’t offend anyone. But also they are here for you to be able to learn from so you can be able to help your patients.

All right. So let’s jump right in. It’s go to the next slide, if we would. And it’s talk about the definition of the . I believe most of us know that the Huatuojiaji points are 0.5 to one soon. Lateral from the lower border of the spot is process of that particular vertebra. In many texts, you’ll see that the Huatuojiaji points stop at T one.

I’m not exactly sure why that is. However, we’re gonna, we agree with Dan Bensky and John O’Connor in their text acupuncture, a comprehensive. That was first written in the 1980s. And they bring the points all the way up into C1, which makes a lot of sense, because if you have a dorsal Ramiah nerve, which goes all the way up to C one and all the way down to L five, then you’re going to have a walk toe jig point.

And the effect without points can be the same. So we extend the Huatuojiaji points all the way up to C1 on all the way down to alpha. All right. So I think let’s just go right into this video, which is showing the anatomy of the Huatuojiaji points. This will be a cadaver video, and we’re going to be cutting the video a little bit short.

It’s a long video, seven minutes and 46 seconds. It’s a great educational tool, but we’re going to stop about five minutes in so we can save time for the rest of this presentation. Yeah.

So this video is on our YouTube channel too. This one you might want to have access to. It’s really a great resource for looking at down the road.

Yeah. Excellent. So let’s go to video one, please.

Before getting to the cadaver video, let’s take a moment to review the relevant anatomy.

The Huatuojiaji points are located 0.5 to one son from the midline on the posterior aspect of the. For the thoracic region, it is imperative for safety. That the 0.57 measurement is used as a greater distance from the midline increases the risk of causing a pneumothorax, especially with deeper perpendicular needling.

The Huatuojiaji points are also motor points, depending on the depth motor points of different muscles. The most superficial motor points reached or that of the spin Alice, which is the most medial of the erectors being a muscle group, the deeper motor points reached are the part of the transversospinalis muscle group.

This group is frequently referred to as the deep pair of spinals. This video specifically examines the Huatuojiaji point at the level of T nine, starting with the skin and progressing layer by layer through the subcutaneous fat, the lower trapezius, the spinalis thoracic, the deep pair of spinals and ending at the laminate.

The video shows the layers and succession and potential safe needling depth for patients. However we do not advocate deep needling for every condition and assessment of the points and the patients must be considered for safety and efficacy. In some situations, a more superficial needle. Insertion is suggested and other situations, a deeper insertion is desirable palpating for excess and deficiency along with other findings will inform needle technique.

And then. At Accu sport education, we teach proper needling technique and depth for the Huatuojiaji points based on clinical efficacy, patient safety and patient comfort. A thorough understanding of the various layers is vital for proper needling. Let’s now look at these layers on a non chemically treated cadaver specimen.

All right. So with a deeper needling of Watson Georgie point at T nine, let’s look at the layers that we’ll be penetrating. Okay. So we’ve already gone over subcutaneous. There’s the skin subcutaneous fat.

And we have posterior aspect here at T nine. This would be the lower trapezius tissue here would be the participants’ door size. We’ve pulled that back, retracted back

then the next tissue that the needle will be going through at the Watchers yards, you will be the erector spinae. So we take the erector spinae. We retract that back. We go through the erector spinae, the need would then with deeper penetration, go into the deep of spinal muscles, which lie directly on top of the Lamanna.

So the deep needle of walk to a jig point, if it did go to the bone, it would go to the laminate. So this, now this take these deep paraspinal muscles off so we can show the bone.

So continuing with the anatomy, with the walkthroughs, Georgie, as we’ve discussed, we’ve got the skin, we’ve got the subcutaneous tissue. We’ve got the lower trapezius peeling that away the Leticia store side, we peel that away. The needle of the Watchers, as you pointed Tina, it’s not going to affect Leticia store.

So I was moving out of the way so we can see now the deeper layer we’ve got the erector spinae. So the needle would be going through the erector spine as well. We were tracking that back. Okay. So then now you can see here’s the deep pair of spinal muscles. That covers the Lamanna, the deed pair of spinals.

And if we were tracking this back, track that back now is great tissue that you can see

right there. That’s going to be the vertebra. So this would be the last. So the acupuncture needle would be hitting the laminate with a deep insertion. So 0.5 spoons. Okay, great. Thank you. All right. So that gives you a nice in-depth look of what’s happening with the Huatuojiaji points in the safety of the, as you point when you are 0.5 stone away from the lower border, that spine is processed.

It is protected by that laminate. Now what we didn’t see in that video, we’re going to be at the very. Very thin as a hair, the dorsal line. Now this dorsal rabbi nerve is a collateral branch that extends posteriorly from the spinal nerve root, the medial aspect of that dorsal around my intervates, the tissue of the deep pair of spinal muscles and travels all the way up in interface, the skin, all of the watchOS Yashi point.

There’s a lateral branch of this door, ceramide that then intervates the erector spinae at the outer bladder line. So your back shoe points are motor points of that particular level. And then we have a further lateral branch of that same nerve. It’s a collateral branch going into the outer bladder line.

So the dorsal primary is innervating the tissues of the Wachovia. Which would be motor points of the deep paraspinal muscles, the inner flatter line, the back shoot points. And then also the outer bladder line. Let’s take a look at another cadaver dissection that we’ve done so that you can appreciate the innervation of the dorsal primary rabbi at UVA 18, 19 and 20 and special note look at where the innovation site is going to actually be underneath that long, just in this muscle.

Brian, did you want to say something? Yeah. Before the video, maybe just the quick. Summary. So the next one we have what the setup for this cadaver video was, is we took a lot of time. This is a kind of a meticulous process to open up the layer between the erector spinae and the deep para spinal muscles, so that you can start to reflect back the erector spinae.

So in, before all that process, the, that fascia covers everything. It all looks one layer. So you have. Systematically go and tease it away and make it a model basically that you can learn from, instead of it being all intertwined. The fact that the fascia holds everything together and encompasses everything is informative and it gives you information to see how everything’s interconnected, but it’s a little hard to see the different layers.

So that’s the setup for the the video is, as we did take that time to tease away those individual layers. And you’ll see that when you see the video, so context for those who haven’t done. Good. You ready for that? Yep. Let’s do a video too, please.

As we’ve been discussing in the smack program, the Huatuojiaji point, the back shoe points, and also the outer bladder line are innervated by the dorsal primary route. The medial branch of the dorsal primary rabbi, which is a stem that comes right off of the spinal nerve root interface, the tissues of the Huatuojiaji point.

Then there’s a lateral branch that will then Intervate the long dismiss muscle. And there’s a lateral branch that then intervates the tissue on the other low-cost Alice and the outer bladder line. We can use back shoe points when we’re treating the Depot vexations. In addition to Huatuojiaji points to reinforce a stronger signaling system.

When we’re de fixating fatigue, fixations, let’s take a look at urinary bladder 18, 19, and 20. Lift the tissue up. Let me take a look here.

Here we go. Let’s take a look here. We can see a lateral branch right here. We’re right into the, longissimus innovating at you. You’re near bladder 18 coming right down here. Here’s another branch lateral branch. Now coming from going right into the long dismiss innervating urinary bladder 19. The longest-serving.

Back down here now we’ve got T 11, 2 11 coming up, innovating right into the long, just miss urinary bladder 20.

Okay. So I hope you can really be able to appreciate the depth of actually when you’re needling the back shoe points going in a perpetrator. Needle insertion is something that we teach in the smack program. So we can take advantage of as much of that dorsal primary nerve as possible in the innovation, because innovation is going to be on the underside of that long, just a mess.

We want to get into that long dismissal in order to be able to help stimulate the back shoot points, which will also in addition to end up stimulating the sympathetic ganglion. So let’s go ahead and talk about that actually. So from that dorsal primary Ram, I wish we were talking about late, earlier. It was a posterior branch.

Let’s now talk about the intercostal nerve, which is going to be an anterior branch of that spinal nerve root. So in the thoracic region, obviously the anterior branch going, becoming an intercostal nerve, going all the way to the anterior aspect, interface, the tissues of that front. This is the reason why that we find our front move points and the back shoe points on the same level line is because of that thoracic nerve.

Now, if we take a look at the sympathetic ganglion, or if we can go back to that spinal nerve root, so the spinal nerve root then goes into. Just basically telling Newport location of it. So just anterior of the fatigue column, your sympathetic ganglion about sympathetic gangling on then has our branches that are going into most of the organs.

But this is where, what you can see there in your notes as being that young innervation so that the sympathetic nervous system being more than young aspect of it and the of the Vegas nerve actually being more of the UN. Of intervening in those organs. So let’s take a look at the connections between the dorsal primary nerve, the back shoot point, the front move point.

We can see how it’s all the same nerve. And so by stimulating these points, you are affecting the particular organ through the sympathetic ganglion, because it’s all connected classic treatment would be your therapy, which is discussed as your front moon, your back Shu point. But if we add the . In addition to that, we’ll be discussing here in just a tick, the do might as well.

All of that tissue, we use neural signaling because it’s communicating to that particular Oregon as well. Let’s go to the next slide so we can be able to look at a couple of different images. You have described this. So on the image to the left, this is a nice view from Clemente’s book. As you can see the dorsal primary nerve on that image to the left, the dorsal primary.

And then you have that the intercostal nerve then going scrounge to the anterior aspect to the front moot point. So you got a really good appreciation of the continuity of this particular nerve and how it can be able to stimulate with a highly conductive stainless steel needle. The acupuncture. And to be able to propagate Xi and a signal of our intent, then you can see that sympathetic ganglion also within that image of the lab, how it’s an extension and anterior extension of that thoracic nerve in the spinal nerve, this image on the right, you can be able to see also where your Backstreet points are, your Huatuojiaji, your outer bladder line and front crawling along those intercostal nerves between the.

All right. So let’s, now let’s talk about why we want to actually include the Duma with particular cases. So let’s go to the next slide

here. It’s really quite interesting to me is that the different branches? So the different pathways of the Dumas. So we know actually from school that the two miles is going to be traveling along the spot is processed. But there’s also different collateral branches in second branch and third branch of these different pathways for the do mine.

I found it really quite interesting. How, for example, here on the image on the far left the pathway, there is of the third branch of the doom eye and in the drawings of how similar the drawing is to the form. It’s the, being a deep pair of spinal. Innervated by the dorsal rabbi and how interesting that is, how it looks like it could be multiple.

So when our founding fathers are discovering and looking at the the do my through cadaver dissections, I can’t help, but think that when they’re looking at these deep paraspinal muscles and they can see this as being associated as part of the Dumas and not just the points of the doom, my the underneath the spinus processes, but how to do my, can be able to expand laterally to include the wok doji points, which makes a lot of sense, because the super spot is.

And the interest bondage ligaments, which attach from spinus process to spawns process are innovated by the same nerve, the dorsal around that interface, the Huatuojiaji points. So it makes sense to be able to add, do my points to particular areas where you want to be able to have a stronger sensation to at Oregon.

And you look at the image on the right, this is your low collateral. Look how the line of the going extending up from the kidneys themselves, that kind of looks like it could be the same type of fiber direction of the semispinalis, which is going to be part of the deep paraspinal muscles innervated by the dorsal ceramide.

So the similarities are really uncanning in my mind. All right. So why don’t we now talk about when there’s a fixation? So the next slide, please, the VTB fixations are commonly found at the same intervening, stagment of a chronic Zong who? Oregon pattern. For example, if somebody is having, let’s say digestive disturbances, like GERD or any kind of hyperacidity anything like that as effecting that middle jaw, it’s really quite interesting to find a, the Teebo fixation in the same level, that interface, those particular Oregon’s level with the back Shu point.

So what is a sativa fixation? So just to be able to put it really quite simply, it’s going to be where one vertebra we’ll go ahead and tighten on the vertebra above or below. It’s a fixation of the Fossette joints. Normally. Vertebrae we’ll go ahead and move into interdependently. They have motion when they get stuck or fixated, they become actually as one unit.

So in that particular case that can cause wear and tear within the deep paraspinal muscles innervated by the dorsal primary rabbi, and also lead to decreased signaling going into the organ systems themselves, especially with chronic material fixations. So if have the deeper fixation, it’s a stuck area.

It can decrease the amount of she going to the walk doji points to the back point to the front moot point. In addition to the organ itself, we want to be able to make sure that we can try to get rid of this fixation and open up the movement of the chief through the doom. I, what you’ll find with the VTB fixation with palpation is that one side will end up being excess and the opposite side will end up being.

You’ll know this through your palpation, by palpating, the side of the shortened deep pear spinal muscles. That’s holding that vertebra into that locked position. It will feel excess. It will be tight. It’ll be really quite tender. It’ll have some rigidity to it. And then on the opposite side, when you’re palpating, the Huatuojiaji point becomes more pliable.

It’s more open, it’s more deficient. So in my mind, this actually is going to be predicating, a different needle. I’ve been doing this for close to 25 years. So I’ve had a really good eye DM practice of how to be able to needle these particular Beattyville fixations through trial and error and by making patients really quite sore.

So what I did learn is that when you’re on the deficient side is to needle quite a bit, shallower more of a reinforcing needle technique. And we’ll talk about that here in just a little. Let’s go to the next slide and figure out how to be able to actually de rotate or de fixate these particular vertebra.

And Matt, quick question. Can you touch on the role if any, of needling into or stimulating the fascia and these needling techniques? That’s the question on.

Sure which level of the fascia, that’s like for once you get past the skin, you’ve got your superficial fascia and then you’ve got your deep fascia and then you’ve got the fascia that’s separating each one of these muscle layers and because the fashion intertwines into the different muscles themselves I guess I need a little bit more understanding of the question.

Can you answer that, Brian? Yeah, I would maybe need a little up question on it, but I think just to simplify it basically the fascia is going to have the same innovation aspects. So the needles even touching the superficial fascia, it’s going to have an effect on that. If you’re at the lotto level on the medial branch of the dorsal, Rami, if you’re at the back Shu point on the lateral bands on the outer back, Even just in the superficial fascia, it’s going to have an effect on that innovation.

Now, the musculature is going to start to become taught and ropey and irritated, and that’s going to start to become part of the pattern made. Maybe it starts with the food. Maybe . Yeah, digestive disturbance or whatever example we’re looking at. And then those musculature starts getting ropey and knotty.

So I think there’s added value in going deeper than the superficial fascia and going into the level of the myofascia, which is fascia, but also the muscle tissue and effecting the the deep holding patterns in those structures. And of course, if we’re needling the Dumas we’re needling ligaments, which are.

So it’s all part of that innovation aspect. I think something to note on that fascia is that with research that has come out over this last decade is that the refining that the fascia itself is a lot more proprioceptively innervated than muscles themselves. And so that’s part of what the needle technique, how important that is of lifting and thrusting and rotating and getting the mild fascial tissues to wrap around the needle.

Cause that really starts to signal product that hopefully that answered your question. All right.

All right. So just a very simple way of assessing and also mobilizing the thoracic vertebrae is when one thumb is going to end up being on the vertebra above. You just mobilize in a frontal plane and just see if there’s play to the Verdun broad. Does it move or does it stuck for example, like you’re just pressing your thumbs into a brick wall when it doesn’t move and it’s stuck, that’s going to end up being fixated.

That’s going to be the side that you’re going to have a deep needle on. That will be your excess side. So then on the opposite side, we want to make sure that we’re needling more superficial, more of a reinforcing needle to attack. And I think we have a video that actually shows this mobilization right now on TA and Tina and Brian, do I say anything before we show the video?

Yeah, sure. You’ll notice that the videos in portrait mode this video will be up on our Instagram page. If you want to check it out later, we’ll put it up on YouTube too. It’s nice to have reference for it, but it’ll be on our Instagram page for sports medicine, acupuncture. You can check that out.

If you want to watch it later. Of course, it’ll be in the recording of this webinar to all right. So let’s have that video. This video is assessing for a TA T nine Mightybell fixation. I locate the spinus process of TA palpating, the superior and inferior borders so that my thumb placement is in the middle of the spinus process.

Once the location is obtained, I applied the same method to the T nine. Motion palpation is then applied to the spinus process of these vertebrae in the frontal plane. The same method is applied to the vertebrae in the opposite direction, examining for freedom of motion, a lock sensation, or lack of motion indicates of a tibial fixation.

Okay.

Common, you’ll find for TiVo fixations in sets of two and three. So it’s a good idea to needle at also mobilized. And this is what I was discussing earlier, how it’s amazing how well this actually helps your zone food treatment. Alright. So it is very important in my mind, just from creating a lot of soreness with patients, with kneeling deep on both sides and how obvious it is that one side is going to end up being deficient.

So a lighter needle technique for sure. On the deficient side, only a half inch to three quarters of the. It can even be shallower than that if you’d like. And then on the excess side, we do want to get it down to the the deep para spinal muscles. Absolutely. Because that’s going to be the muscle that’s really locking on and holding that burden right into a locked.

So we want an excess or a reducing needle technique at the on the excess side and a reinforcing needle technique on the deficient side. Now let’s discuss needling into the Duma as well to help to reinforce this treatment. So then the next slide. Yeah, wait a minute. Quick thing, just to add to that, Matt.

The deep side, I think you can see the cursor going through. Maybe you get cheap, not so deep. And you can always then put the other needles in and that’s going to start to soften that area and then come back, maybe just before you, you leave the room and let the needle set. Maybe after you put the last needle in and then go a little deeper, cause the tissue or relaxed.

So it doesn’t have to just barrel in right from the start all the way to the deep tissue. Oftentimes it’s not an issue, but sometimes you want to do it in stages. So just to have that heads up.

All right. So what you’re seeing is from that same cadaver dissection that bride did with the videos earlier, how this is a lateral view, the rector spot has been taken off. And this is the deepest view. I’m not sure if you can see that copper handled acupuncture needs. That’s going to be chest underneath the spot is process.

So the needle is going to be inserted into the supraspinous ligament. So we have passed the skin past the subcutaneous tissue, which should have been removed from this particular specimen. And then you have the supraspinous ligament, which is attaching the tops of each one of the spinus processes. Then deep to that is your entire spine is.

That’s a large, broad ligament. So my finger there, the pinky is actually showing the depth of that interest by this ligament in my mind, this is where you’re actually starting to really propagate, do my cheese in this interspinous ligament. So once you start using needle technique at this depth, the patient will often feel the sensation either traveled up or down the spine.

So therefore in my mind, this is really the depth of the Dumas or to be able to see. At do my cheek moving now, importantly, like I said earlier is that these ligaments are highly proprioceptive and they’re innovative also by that dorsal primary nerve. So it’s just another point to be able to increase the signal for your Zog, Oregon patterns, as long for Oregon.

All right. So then what we’ve talked about really is just needling the Huatuojiaji point, the back Shu point, the front move point. Also the doom eye using a potato fixation mobilization. This is really a quick and easy way of getting pretty profound results. There’s a lot more to this. Obviously it’s we have six days discussing actually how to be able to do all of this coming up, module one in the sports medicine acupuncture certification program, that’s going to be starting in July in San Diego.

So this is going to be discuss really quite thoroughly a number of different aspects of it. In addition to look and help your patients go to the next. Is examining their posture and seeing where the Viterbo fixations usually occur. And it’s really quite curious with a lot of patients with organ disharmonies that they’ll have spinal beds, the spinal bed.

And you can see on this image on the left this particular patient was coming in with middle job disharmony lots of different signs of symptoms of acid regurgitation. And and you can see how the elevated ilium. And then you’ve got a spinal then of that lumbar spine and going into the lower to mid thoracic region.

That is usually where you’ll get a BTB. Fixation is where the spinal band then comes back to the do my, now this is going to be the posture of this particular patient. This is the initial office. After the acupuncture treatment. And then also with mild fascia release and reeducation techniques that we teach in this module.

One, in addition to emphasizing different exercises that will help to continue to stimulate your treatment. I may keep mobilizing that spine for the patient to do at home. So these are all things that we’re teaching. Now let’s take a look at the next slide. This is before and after. The first treatment.

So we did the acupuncture treatment as discussed before I did some artifactual work, had to perform some exercises and you can see how the elevated alien from the left of poor treatment is now neutralized. That helps to straighten up the spine. And you can see that his do channels now much straighter.

So that’s going to start taking stress off that middle jaw and on the road to healing for this particular patient. Brian, is there anything that you wanted to say with that? Yeah, just a quick something on this previous slide that both the myofascial and the corrective exercises you notice are movements more in the sagittal plane.

So going flection and extension. So without getting into spinal mechanics, moving in that way, we’ll help D rotate and take the side, bend, soften the side, bends in the spine. So you’d think, just the viewer to look at it without knowing spinal mechanics necessarily, you would think that. You would want to have them do a lot of side bending because of its side bent one way maybe you could sign better the other way, which would help, which would do something.

But this is just another strategy. We get a lot more into it and classes, but that’s why you might notice that it’s a movement in those different planes to balance is fine from a different perspective. Okay. All right. Okay. All right. So we have some contact information on the next slide there.

If you guys have any questions at all, feel free to reach out to us. And I think Brian, if that’s anything else for you, we can give thanks to the American Acupuncture Council so much. This is really fantastic. Thank you. And make sure that you come on back next week cause Sam Collins is going to be back talking about insurance and billing and such.

He’s a real cool. A fun lecture to listen to. Yeah. Sam’s full of energy. Brian, always nice hanging out with you and thank you very much, counsel, and we’ll see you again. Bye.

 

Callison-LauHD02232022 Thumb

Quadratus Lumborum: Structure and Function and Treatment

 

Click here to download the transcript.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Hello, everyone. Thank you so much for coming to our discussion on the quadratus lumborum structure, function and treatment. My name is Matt Callison. I’m here with Brian Lau and we’re here to shortly discuss this. Amazing muscle that we use quite a bit in acupuncture. That’s also very popular in massage therapy, as well as functional medicine.

It’s a muscle that has been discussed for four decades as being a primary pain generator. But with the advancements within mile faster research and also with biomechanics and functional medicine, the quadratus lumborum is actually evolving into a muscle that is different than from when I first learned about it in sports medicine in 19, late 1986.

Early 1980s, actually. So it has evolved quite a bit with its actual functionality. So Brian and I here to be able to discuss a little bit about this muscle give some quick assessment and some quick treatment techniques with us. And Brian, is there anything that you want to go for as an overview before we jump right into

slide two now I think we can jump on in the presentation up.

Yep. All right.

All right. So the quadratus lumborum is a complex muscle with a various fiber directions. Okay, this is, what’s so interesting about this muscle is that it’s just not one pancake of a muscle. That’s going to elevate the ilium or lower the the 12th rib, which is the way that I was actually taught in the early 1980s, late 1980s is that it was an elevator of the ilium, which we’d really don’t see that very much at all anymore.

What we’ll be discussing is looking at these different fiber arrangements and how this muscle is seen more of a, like a cross-link between. At other muscles acting on the spine or the ileum. So it’s really quite interesting that its role as more of a, synergist or an assistant to a lot of other muscles in different movement patterns.

So we’re going to start to talk about that here in just a little bit. Let’s look and see where it is actually oriented. You can see that the muscles part of the post, your abdominal wall, looking at this cross section of as directly connected to the transverse of dominant. So Brian, can you get the cursor in there?

And maybe we can see that the quadratus lumborum has a direct line along that core line, right into the transverse of dominance. Now that’s via the lateral Rafa tissue. And because it’s got such a strong connection to the transverse abdominis, that is the quadratus lumborum. If there are dysfunctions or increased tensions or lack of.

Tension actually in the transverse of dominance in the Antar aspect, it will directly affect the quadratus lumborum and the poster aspect, and also vice versa. Common commonly you’ll see this with certain fascial distortions as well. Let’s get into the latter Rafa just a little bit more here and the next slide.

So let’s look at the quadratus lumborum and how it’s sandwiched between the anterior and middle layer of the thoracolumbar fat. As we know, the thoracolumbar fascia has three different layers. It has an anterior later layer. It has a middle layer and it has a

post to your person

noticing you’re actually doing a really dumb job plus, cause that’s not easy to do right now.

All right. So we’ve got the quadratus lumborum and the three layers of thoracolumbar fascia. Increased tension, lack of tension to the quadratus. Lumborum how it’s going to affect the transverse abdominis, how it’s also going to affect all layers of the thoracolumbar. So that poster layer, the thoracolumbar fascia is what we commonly see in the anatomy artwork or anatomy charts, where you can see on the backside, the white tissue, that’s connecting the store side down to the glute Maximus bilaterally.

So that would be your post to your thoracolumbar fascia. And we just need to remember that there are two other layers and the quadratus lumborum is sandwiched between those two layer. Very important. And let’s see what’s next.

All right. So looking now from an anterior view, you can see that post to your abdominal wall. You see the quadratus lumborum from there. And also the psoas. The psoas is something that Brian and I spoke about for, gosh, it was a three hour conversation on the structure, a tree, a function and treatment.

Which was great. It was a lot of fun because there were so many things to discuss on the psoas. And that was in January or was that Brian? He did that.

Yeah, we it was early, earlier in January, maybe mid January. I think it’s a loss of now recorded the week we had the live class still online live class in January 10th.

It sounds like. I think it seems about right.

That was the first of the acupuncture anatomy series that Brian and I. Intending to do quite a few videos. Within this realm or the folder of acupuncture anatomy. And this is the second one actually, but it’s coming up soon. So what this presentation today is actually going to be able to give you a couple of pearls that you can be able to really use with the quadratus lumborum and some knowledge about some possibly new knowledge about it.

And then if you wanted to actually go a little bit deeper with it, we’re going to talk for about two hours or just over two hours. I’m just the quadratus lumborum and it’s connection. And it’s connections. Like I was saying before the quieter, some borrowers is seeing more of a crossroad now, like an assistant or a synergist to a lot of other functional movements.

So it’s a lot of fun. It’s a lot of fun to be able to discover that and how it can actually be able to change a needle technique and also treatment protocols or extra points that you can be able to use in addition to the quadratus lumborum so not just local, but also adjacent and dystonia. So looking here at the view, you can see the quadratus lumborum there, that Brian has his cursor on I’m gracefully placed.

I might add. And where are the quadratus lumborum inserts? You can see how it has a direct connection to the diaphragm there at the RQ at ligament. So that would be the lateral arcuate ligament. Okay. Going over the, so ads would be your medial, Q it ligaments. So they act as like a sleeve where it is part of the function of the diaphragm, which is an important thing to remember when you are treating low back.

So then also take a look inferior where that quadratus lumborum attaches to the iliac crest. It interdigitates, it becomes as one with the Illy axis. And it’s really quite fascinating to see on a cadaver because the fibers do actually come together. So if we were to tease away the fibers underneath the iliacus and the quadratus lumborum with a scalpel, just riding along the periosteum, you could lift that up and it would just become one to.

And all the way to the diaphragm, if you continued up that way.

Yeah. True. True. All right. So Brian, I think, are you

taking it away now? Yep, I believe so. Okay. All right. So this is a from research with six cadaver specimens, really looking at the physical arrangement of the quadratus. Lumborum not keep in mind.

This is six specimens. So it’s not a hundred or 200 or 300 spins. But at least it gives a, it starts to give an idea of the complex arrangement of the quadratus lumborum. And when looking at these specimens in this research, there’s three layers to the quadratus. Lumborum, we’re looking at the back through the the, posterior part of the body right now.

So we’re looking at the posterior layer, but then there’d be a middle layer and there’d be an anterior layer. So there’s really three layers to this complex muscle of the quadriceps. And this particular research then compared the six specimens and looked at the various fascicle arrangement. And this is something we might expand upon when we do the the longer two hour class.

But just to give a quick overview of this now there’s first of all, there’s a lot of variability from specimen to specimen, variability, and size or place. Really number of assets, musicals all those types of things. But generally there was mostly at least half of the physicals acted on the 12th rib and there were Leo costal fast tickles.

So that’s what outlined in green from ilium to the 12th rib, there was Leo lumbar facet. That’s what in that more yellow line from the alien to the lumbar spine. Actually, there were some Elliot thoracic basketballs that went all the way up to the body of the 12th thoracic vertebra, but by and large, these are the bulk of the, vascular disease.

Leo costal, Emilia lumbar. The middle layer is the one that has the lumbo costal from the transverse processes to the 12th. You can’t see those from this image, but that would be sandwiched in that middle lane here. So do you have to memorize all of these different farcical arrangements? Not necessarily but, to understand the role or at least to understand the complexity of this muscle, it’s important to remember that there are these various layers, some going from alien to rib, some going from ilium to the lumbar spine, some going from lumbar spine to the 12th rib.

So very complex. And it’s a classical arrangement in size. And. So because of this complexity, the muscle fiber and physical orientation of the QL, it’s difficult really to identify the actions when you’re looking at the quadratus lumborum and this line of pulse the one thing, if it went from ilium to 12 three, that was just like a straight shot from the ilium to the 12th.

Speculate much more easily of what these this role would be because it would be acting from the hip to the rib. And it would be a little more of a straight shot, but because of the fact that there’s these various forces, various vectors acting on it, there’s a lot of uncertainty on the role, the action of the quadratus lumborum.

So let’s go over the general actions. Notice that all of these, at least the first two bullet points on the actions have an asterisk. So let’s talk about the asterick first. So these actions are really placed under question right now by researchers because of just what we said because of this complex arrangement.

So it seems that maybe the quadratus lumborum has not so much to do with a particular action. Let’s say lateral flection of the trunk Obliques are in a much better mechanical advantage to do lateral flection of the trunk, but the quadratus lumborum is there to help out with the, to assist with that, to be a helping aid at same time, it can stabilize the spine.

So there’s a lot of stabilization roles of it probably in potentially. And that’s what the research seems to show extension some sources say extension. It doesn’t really have a good leverage to do extension, but it has leveraged to help with extension help with directors. You can see a lot of different rotational aspects based on the fiber direction.

So really what it seems is that like, when Matt mentioned is really more of this cross link where it’s helping in assisting more functional units of, structures that are moving together. But the traditional roles of the quadratus lumborum is that there’s a unilateral contraction or when there’s a unilateral contraction that does lateral flection of the vertebral column of the lumbar spine.

And whereas the opposite side then would be stabilizing. So we were looking at this right QL that could laterally flex the the lumbar spine. So it’d be come. The lumbar spine would become concave to that side. Bilateral contraction is where it’s usually talked about as a extension, but it seems like it’s pretty minimal and extension and more about assisting if it doesn’t mean.

And then it does seem to have a role in assisting with inspiration because of it’s a poll on the 12th rib as the diaphragm contracts, it would want to lift the 12th rib. So the QL is under there to stabilize the 12th rib and, aid in countering the, diaphragm’s pole. So this would be important, but things like speech anything where you’re getting up there and really projecting your voice in particular, you can picture that QLD in there to assist with that.

So complex muscle.

Yeah. So those, oh, Hey Brian, can I add something to that? Sure, absolutely. So the first two bullets, you guys with those asterix. That research. They actually did some EMG studies on that and they had the patients go, or the models go into extension of the lumbar spine as well as lateral flection into a number of the D into the muscles that actually act on the spine.

And what they found was that the erector spinae was actually like 90% involved in the extension of the lumbar spine. Whereas the quadratus lumborum only 10%, which truly is very interesting. And they basically had the same results with the unilateral contraction. The quadratus lumborum as well. How is wasn’t really actually a primary mover.

It’s just, again, it’s like more of a cross-link across road, a synergist and assistant a stabilizer. So it’s really quite fascinating with that. And I think

we were discussing this recently about myself and I feel like working on the muscle, which is jumping ahead and I don’t want to get into too much on that now, but if the lumbar spine isn’t hyperextension.

To me. I’d never really think that I really want to lengthen the QL so much because it does have, it seems like it has a minimal role in extension, but to be able to get that free gliding of the QL and the erector speed and to be able to decompress the tissue. So you can almost try to lift the tissue out from, being buried deep into the lumbar spine.

To me, that’s how I think about it more. And its role of extension is more postural and less dynamic.

Yeah, the QL being more of a posture muscle, like for example, in single lady, single leg weight bearing in order to have the stability of the lumbar spine than the lateral sling comes into play. So you’ve got the glute medius and minimus and the tensor fascia Lata on one side, and then you’ve got the quadratus lumborum on the opposite.

With that sling, being able to keep the balance in the frontal plane when somebody is standing on one leg and how important that actually is, this is something that we’re going to discuss quite a bit further in the law. And discussion of the quadratus lumborum is coming up in a couple of months. It’s important gives you a lot of great treatment protocols and ideas about what senior channels to be able to treat locally, adjacent and distal as well as mild work and addition exercises to prescribe as well.

That’s going to be very important with that frontal plane. Cool boy, we talked about that slide for a long time.

Okay. A you’re on stuff. Yeah. The quadratus lumborum has a, relationship in terms of at least the topography of it with the lumbar plexus, but it’s really a little bit more complex than just that. So first of all, just a review of the lumbar plexus. This is coming from the ventral Rami of L one through L four, but if you look at this top image the subcostal nerve, the T 12 intercostal nerve, which is called the subcostal.

Share some fibers down into L one. So really the subcostal nerve five contributes to the lumbar plexus. Why are we focusing on the lumbar plexus, these specially, this upper portion, the subcostal nerve, the Elio hypogastric nerve which I don’t know. I can see this on the screen, but subcostal nerve would be right under that 12th rib.

Then the next one to come out would be the ilial hypogastric and then the ilioinguinal. Those travel right on that anterior surface of the quadratus. Lumborum okay. Interesting. But th those are also the primary innovation sources, which especially the subcostal nerve, which is map it’s going to get into in just a moment.

But something to bear in mind as we get a little farther in the lecturer, we’ll come back to this and talk about it is if we follow these these nerves that wrap around the posterior part of the abdominal wall and start to become anti. Because they have cutaneous sensory branches that create sensation that, that supplied the skin and then the sensory aspect for the posterior lateral gluteal region.

I think that says thigh, but that’s really say the gluteal region. Posterial lateral gluteal region. The greater trocanter region, the suprapubic region and the proximal medial thigh. So hold that thought, we’ll remind you about it. But just keep that in mind that, the nerves that are kind of part of the innovation of the quadratus lumborum that have us a structural relationship into, in terms of where they are have the sensory distributions to the lateral.

Greater trocanter grind and I’m up in the superpubic region. So we’ll come back and look at that and how that applies in just a bit. Anything you wanted to add to this map before jumping into the,

no, it was a good setup for what’s to come

fix some interest on it. All

right. So we’re staying within the motor nerve innervation. So this isn’t some research that I gathered. It’s really quite interesting. I found this to be true is that varying research articles and textbooks. There’s not agreement on which nerves actually innovate the quadratus lumborum, but the most important one will end up being the subcostal mainly with the research that’s below because of its large Dianne.

It’s measurement of being so large diameter, therefore you’re going to have more neurons and motor neurons it within that motor nerve, that’s going to be entering the quadratus lumborum and then it also discussed the ill hypogastric nerves that were also innervating the quadratus lumborum. But with those nerves, actually having less contribution to it.

So there are, what we know of is three primary. Motor entry points with the biggest one or the go-to one in my mind will be the one that the subcostal nerve is actually going to be intervening. So let’s go to the next slide because it does show some research on here and you can see, so here a you’ve got the T 11 intercostal nerve, and then you’ve got the subcostal nerve will be B.

You can see that it’s has a larger scale. And innovations to that. Now what they did is actually they opened up that subcostal nerve so that you can actually start to be able to see the different branches then see, is going to be your

So see what ended up being, I believe part of the hill in Greenville and possibly part of the ilial hypogastric so you can see how that subcostal nerve in B is going pretty close to. Brian, can you show on the far upper left corner that the iliac crest, the ilium there? Yeah. There you go. So you can see how that subcostal nerve is going toward the muscle valley of the quadratus lumborum.

So we’ll discuss the subcostal innervation coming up in the treatment section. All right, Brian.

All right. Some of the work we teach quite a bit and work with in the, sports medicine acupuncture program is the Sydney channels. So we’ve really been working for probably 10 years now coming up on 10 years now on really building a comprehensive model for the channel, send news DJing, gen 10 new channels, whatever translation you’re using for the.

And really highlighting the specific anatomical structures that are associated with each channel sinew, how they relate functionally to seeing things like their external internal relationships. In this case, the gallbladder send you a channel or other, correspondences to have they function together.

But for today, just looking straight at the myofascial plane that makes up the liver Sindu channel is quite interesting. Cause this one. A little diverges a little bit from the classical description. The classical description has the liver sinew channel terminating or ending at their groin at the genitals, I think specifically is what it says.

But if you look at the the myofascial plane and it has a much more interesting relationship in that, Line that’s coming up from the foot through the medial thigh, up through the ad doctors doctor longest brevis pectineus Priscilla’s adductor. Magnus is a different one. That’s more in the kidney sinew channel, but this more anterior line of the abductors longest brevis and tineas, that would be then very continuous with that fascial plane all the way up into the iliac.

And as Matt mentioned where the iliac has shares fascial fibers, interdigitates in with the quadratus lumborum. And then up into the tall throne, that would be the liver send you a channel. So if you follow that plane deep into the pelvic structure for the LA axis, it would come out into the QL.

And I know a lot of people might be thinking QL, it’s a back muscle. It seems like that would be urinary bladder maybe, or maybe even. Send you a channel, but if you think about it as being less of a back muscle, which it really isn’t, but more of an abdominal muscle it’s in the abdominal wall, it’s it’s much more of a yin much muscle, much more of a core stabilizing deep structure.

And it starts to make more sense, especially then when you look at that, continuous fascial plane through the abductor line, up into the iliac is QL and The would be a part of that also, especially the distal fibers. , it’s a little more complex than, we can get into today, but we covered this quite a bit in our so as a three hour class and different sort of relationships with the cell ads, but that this, the portion in particular would be part of deliver, send new channel also.

Yeah, Brian was sold me on this one was. Okay. When you gave me a call and you said, Hey, try this liver five points. And I, my practice on every person that day, I palpated their quieter to some warm and then needled liver five. And it was remarkable how well liver five, we will point at the liver channel, soften the quadratus lumborum on not couple, but every single.

And in particular, what we’ve been teaching this for Yon syndrome or the deep layer, which we’re going to actually be talking about just a little bit that y’all, don’t send him, but he was pretty magnificent to be able to feel how liver five and in combination of liver three. And I think I might be jumping ahead with information time.

Yeah, it is. It’s remarkable how well that does work. So I think we’re going into assessment now.

Yep. That is the case. So when I go ahead, no, go ahead.

Okay. So with elevated ilium, this is one thing that we can be able to look for, that we know that the quadratus lumborum, the myofilaments, the actin, and the mind.

Are going to be in a locked short position. It’s not because it’s pulling on the alien pulling upward, but it’s because the glute medius and the amendments have weakened on are allowing that ilium to actually rise up the opposite side. Glute medius and minimus are then shortened and pulling that side down the opposite side.

So it’s it’s the opportunity for this muscle then to become shortened. Now, commonly what we’ll see with this as well is a lateral tilt of the rib cage on the same side, which want to go to the next slide.

All right. So when you get that elevated ilium, what the body wants to do is to compensate. They start to lean to the same size, so it can start to balance itself. So that would be another sign that we can address. I’m looking from the post, your review, an elevated alium always go ahead and measure it with your fingers as well.

Just to confirm your visual findings and then look at the lateral tilt of the rib cage. Usually with the love handles, so to speak, you’ll see a difference between. And left sides and more of an accumulation of tissue when there’s an elevated ilium and a lateral tilt of the rib cage. So in that case, you’ve got the this 12th rib is now going to be actually coming down.

And which means shortening of pretty much all of the fibers of the quadratus from quadratus lumborum I would think making people. Tender to palpation and also Yon tender to palpation, as well as the motor entry point. Let’s go to the next slide. Brian, you want to chime

in on this? Yeah. And this particular image.

It looks like really more just lateral tilt without so much of a elevated ilium, a little tricky to tell. We’d have to almost get in there and get our fingers on. And make sure that what we’re seeing on the exterior surface matches, but just glancing at it. I don’t see a whole lot of elevation of the helium this particular person, but more about the lateral tilt more about that 12th rib being pulled, down.

So you don’t always have to see an elevated ilium with it, but frequently you’ll see these two go together, elevated ilium and lateral tilts with routine. This particular person is a massage therapist. So she leans a lot with her right arm in terms of using a pressure with her right arm quite a bit.

So you can see how that would have a propensity to shorten that right side.

Oh, do you want to say before we move on Matt, that these distal point recommendations are just go-tos that are frequently. Helpful for this condition. There’s ways we apply these in our program and really make determinations of which points to use, but you can just try them out and experiment with them in terms of the part of the full, comprehensive treatment.

In addition to the local points, which we’re going to be getting into, this is just a portion of the treatment, right? This isn’t like a whole treatment is treat the QL out the door. You go in the person. And it might temporarily help, but but you need to be much more comprehensive to get lasting results and, looking again at the fact that the QL across links.

So we need to treat multiple structures and look at his role of communicating between multiple, structures instead of just QL, maybe put a little electrical stem on it, out the door next patient comes in.

Yeah. Yeah. I forgot because we grabbed these slides from the senior channel class, which we have.

So the acupuncture distill those points we’re using as acupuncture is in assessment. We’ve discussed this a few times before, basically trying to be able to change an orthopedic exam and manual muscle test a certain particular posture by using different acupuncture points that will change that myofascial sin, U2.

Before and after and using acupuncture and assessment, it’s just basically seeing, can you make a change in that body using these acupuncture points? And once you can see it and retest it, then you pull those needles out. But you remember to be able to plug those needles back in during the comprehensive treatment of acupuncture, because you saw how it actually makes a difference.

And I think that’s where that’s where this is coming from. Good. I’m glad you explained

that Brian. Yeah. Maybe this is not a great time. I think there was some, a question on the QL and the diaphragm. I see some references to it, but I don’t see the actual question. So we’ll catch that at the end.

If if that hasn’t been answered already,

there it is. We do believe the QL Motorpoint help with help in effect with the diaphragm. Yeah, I would say that I, used the QL personally and I’ll see what Matt has to say. But personally, when I’m working with respiratory issues, I don’t even want to say respiratory issues cause that’s a broader category.

Restricted breathing when breathing seems like it’s a component of the back pain, maybe the person is more of a chest breather and that deep diaphragmatic breath is, and it isn’t filling the low back and massaging the, spinal joints and expanding. And that elastic aspect of the inhale, exhale, expanding the lumbar spine and expanding the soft tissue structures in that lower part.

I definitely go to QL as part of the treatment. It’s

absolutely also the, so as cause we teach we’d be able to see if the low back pain is actually could be. Weakening or an inhibited. So as it’s been constricted in the diaphragm, there’s a manual muscle test that you can use with that. Yeah, for sure.

So add also GB 20 stabbing, you’ll be 17 UV 23 for the kidneys. So as, and also quadratus lumborum I think would be a good idea.

I’ll say one other thing about it then maybe move on unless you have anything else to add. And Matt to it as is, I also think about what’s at the other side of the rib cage. So you have the QL attachment to the total.

And then you have the scalings attaching to the first two ribs. And I find that, especially with people who are more of these chest breathers, who are overusing the scalings is that relationship can be very important as it is speaking to scaling. Especially the anterior scaling is a little hard to needle unless you’ve had specific training on it, but at least some some myofascial work or some, softening manual work to help free some of that excess tension in the scalings.

And. Speaking to the tension at the QL, you’re working on both sides of the ribcage. That can be really useful.

All right, this is great. But how far should we go on this? We’ll start talking about forward head posture and

we got to get going. I can never get. All right. So yes, let’s now talk about needling. These points. And the upper left image, you can see pop patient, the extra point P guns. We know that P guns going to be located at 3.5, some lateral food lower court spot. The process of hell one. Really what I’m going for in this particular case is that the corner pocket I call it, it’s where the Elliot cost Alice also the quadratus.

Lumborum where they attach to that 12th rib. Just palpating along the 12th rib from the lateral aspect up into that corner, you can see a bit of a crease there. So the needle then would be inserted the same direction as my middle. And making sure that it’s not going to go anterior to the 12th rib. So it’s a really good idea to palpate that 12th rib and the topography of that all three, because you don’t want it to go and tear that could cause a pneumothorax.

So you don’t want to insert that and go Antar to the 12th rib caution is advised. Then you can look at the motor point, which is going to be approximately halfway between P gun and Yon. It’s not on every. The directions for finding this motor point, or it’s gonna be just lateral to you be 52 on some people you could find that just slightly more superior from the midpoint being between extra point Pentagon and Yon.

So that’s one aspect that you can get it, or you go slightly higher. If you get, if you can find you be 52, that’s going to put you in the ballpark of that subcostal innervation. So insert the needle, make sure it’s going to end up being parallel to the T. With the quadratus lumborum, I’m sure all of us have gone ahead and needle that quite a bit.

Being an educator and seeing a lot of people that are needing needling, the quadratus lumborum palpation is everything here, and you need to be able to make sure you are actually on that QL and on the deeper. I see a lot of students actually needling the ilial cost Dallas, which is going to get results.

Absolutely. But it’s not dealing the quadratus lumborum so it’s going to be different intent there. And we have in the upper right-hand corner, we have Jaan. This is going to be the deep layer of yang, which would be the quadri Islam. Attachment on that lateral aspect of the pelvis. And it’s amazing how far the lab, the quadratus lumborum actually attaches to the pelvis.

So this particular needle technique is, not going to be on the edge of it, but it is going to be going through the quadratus lumborum in across fiber direction. So you’re influenced in influencing quite a bit of appropriate sectors there, the golgi, tendon, organs, and such Brian, anything to add, or you want to jump to the next.

I know let’s go ahead. And I think the next one just shows some images of the the needling placement.

All right. So we just described that pretty well. I think you guys can be able to that in the images, these images are from the sports medicine, acupuncture, textbook, and now.

Yeah. So we’ve already discussed the liver five.

So when I was talking about the lumbar plexus and there’s nerves that wrap around some of which intervates the QL, the subcostal ilial hypogastric Leland. We know Matt, do you know if it’s the, I was here, it’s the L and L to a anterior division, anterior. For for QL or at least I’ve seen you indicate that, is that branches off the Leo hypogastric Amelia.

We know. Cause I know those are one L region or are they like before the lumbar plexus ranches off?

I didn’t understand your question because it is the illegal hypogastric Ilian wino. And I do agree that it’s the ventral Rami. That’s how it’s talked about, but what is, okay. What was the question?

My question is sometimes I’m just seeing reference to L one and L two and I wasn’t sure if it was before.

If it was the, ventral Ray mine, Aramco Ramey, before they get to the lumbar plexus. And there’s like a motor nerve that branches off before intermingling with the lumbar plexus, or is it post lumbar plexus? gastric then it’s, definitely post lumbar plexus. I don’t know. It’s gonna be one more thing for us to be able to go research.

Anyways, those have an intimate relationship with the QL and it is intriguing. The re pain referral, the trigger point referrals. Many folks here are probably work with trigger points, or maybe use them as, a part of the assessment. I use them. That’s not the air, the only thing that can refer and cause pain.

But I think it’s a a useful thing to look for. Especially QL is so frequently involved with a lot of low back pain patterns. And when you look at the the QL referral pattern pretty much goes to where those sensory divisions of the nerves. To the lateral posterial lateral gluteal region to the greater trocanter region, wrapping around to the suprapubic region and then wrapping around to the groin.

There’s also some divisions that go really more posterior deep into the gluteal SSI joint or into the, kind of deep buttock region. But to me that. It doesn’t really talk about it this way and literature, when you talk about trigger points. But to me, that sort of emphasizes that segment has become irritated.

The QL has maybe the QLC irritating factor. Maybe the QL is part of the irritation of that segment, but the sensory division of that complex, so to speak has, been irritated. Maybe that’s, open to debate. And I haven’t seen it quite some depth that way and discussion of trigger point sensitization, but it would make sense to me because there’s such a neurologically intimate relationship between those nerves and the quadratus lumborum.

But to me that also speaks to the the possibility or at least a possible mechanism of how liver five it’s so effective for the QL is that. Working with that collateral circulation being the the low connecting point, it’s working with that collateral circulation that is referring pain, both to the gallbladder channel distribution and the liver channel distribution.

It’s has a referral that’s between these two internally externally related channels. And it’s interesting that it’s the low connecting point that would have. It’s such a, strong relationship in terms of removing pain from the quadratus lumborum and helping with that pain referrals, sensitization.

And then this is something that I’ve been working with in that I started adding liver three, and that seems to really increase the effectiveness on liver five by itself is quite effective, but liver three, yet the low point on that channel is just even a stronger treatment. So this is a really great disciplined.

Combination that you can use in combination with the local noodling. Let me just covered for that side where the TQL is really a pain generator. Yeah. For something like that.

It’s interesting to see the image, the trigger point image that’s on top there on the upper. You can see where the X’s are at Yan and pagan and that reasonable.

These points have been needled for thousands of years or have been known to be a referring type of point a trigger. And then the points lower. Let’s see the deep ones. Is that around you be 23 regions, that upper one. Cause the other one looks like it’s close to almost. Yeah. So

This, is what first of all, let me give a quick statement that this is the old edition of travails book, because I think that, I think it’s the third edition, the newest.

Addition, they’ve taken out these exes because trigger points can inform anywhere in the muscle. I kinda like the, I kinda the Xs, but it’s around for Lark. Chevelles passed, on now. So the decision was made after the fact that I guess they’re basing it on ongoing research and such, but they made the decision on the third one, which is I understand the decision to take out the Xs.

So I think the X’s aren’t. That this is where the trigger point is going to be in this referral, but it’s just tendencies. It’s if there’s a tendency for that upper, especially more lateral fibers to have this that’s marked one to have this referral, which I find is pretty commonly the case that it refers pain that’s, where that trigger points.

So it lives in more of that lateral edge of Yon tends to have more of that number two district. Then, if you go deeper, you advance the needle deeper. And your question, Matt, I wonder the same thing. Are you actually hitting those medial fibers of the QL? Are you starting to get into attachments of the multi-fit eye?

Cause they blend so much together. We’ve seen that a lot on cadaver specimens, but those are the ones that tend to refer deeper down. And I wonder that same aspect. QL or if it’s the relationship of the QL to the , which are on the same layer that I think that

Be really interesting the next time that we get an opportunity to dissect this, Brian is to follow the subcostal nerve into the motor entry point.

And then if we have time to do this would be great is to see if, and then do intramuscular dissection and just follow where it starts to buy for Kate. Is that smaller, small branch traveling intramuscular going to. Yeah, Yon and P going to be fascinating to see if we could follow it up there. Got you. In our system.

We’re really geeky. That’s why, by the way, that’s why I liked the Xs. Cause I think that’s what the X is. That tendency is probably more intramuscular sort of international

sites. Dr. Trevell is probably rolling in her grave because if they’re going to take those exits, I don’t know.

All right. An interesting that channel discussion, but it’s a really effective treatment.

Pate QL. We’ll give it a try. Yeah. Before you actually needle QL, especially Yon seems to be really highly effective. This way is palpated to get a pain scale from your patient. Let’s say, oh that’s, a seven. When you really get on that, that really gets to the source of the pain needle liver five liver three, and then go back and palpated and see what happens.

And I think you’ll find that if you get a really good cheap response to those disappoints, that in and of itself reduces pain by 50% or more. And then the rest you’re getting the the, local needs. It’s a really big part of the full treatment.

It’s good.

All right. We teach a lot of myofascial release techniques in the program especially like targeted ones that really supplement the treatment. And this is a a myofascial release technique for the quadratus. Lumborum especially getting to that lateral edge. If you try to reach the QL through the erector spinae, good luck.

That’s a really. Layer, especially in the lumbar region of tissues. So it’s maybe you can touch it. But you’re going to have minimal influence on it with your fingers. It’s you can needle in there, but it’s hard to determine the depth, cause you don’t know exactly where you are when you’re just going perpendicular.

That’s why the needle technique matchup is going more from lateral to medial, almost the same way my finger is there, but he was showing it with the person in a prone position. So this will be very much like the the needle technique as well. Anterior to the , I’m pretty much at Yon rubbed up right against the iliac crest.

You can angle your finger. Once you get a really deep contact there and engage the tissue, you can angle that pressure up towards the 12th rib and have the person reach their leg down to bring the hip down. So their thigh, you can’t see it fully in this image, but their thigh is in line with their.

So as they reached their foot, say, let the towards the back wall or something straight in line with the torso downward, that’ll start to pull the hip down while you’re spreading and moving that tissue towards the 12th room. So you’re elongating one direction is there, their forest is going the other direction.

And you can take that up to the tall throne. Then you could change directions because of those different fiber orientations. You can change the orientation then down towards the iliac crest and have them reach their. Upward to pull the rib cage up. So you’re decompressing the tissue away from the 12th rent on, and then bring the tissue down towards the Lem.

Is there having a force in the opposite direction, really effective technique after a needle lane and it can help return that tissue to a really good resting length.

Yeah. There’s a lot of good techniques in that class. Yeah. A lot of good ones to use. Same thing with my techniques and same thing with needle techniques is there’s a lot of good exercise techniques as well, trying to be able to accomplish on reinforce your treatment.

I’m thinking about it still as excess and deficiency is when you have a locked short muscle, it will act like it’s excess, but it will be an underlying deficiency when you have a lock long-term. It acts as a deficiency. So it’s a good idea to once you reestablish the channels and the CIM blood and the axle plasmic flow, and we discuss in the actual muscles and the channels themselves.

It’s a great idea to go ahead and strengthen the. It’s long muscles and then try to be able to stretch those lock short muscles. This is one particular stretch is one of our favorites as well. That’s a patient favorite as well. The figure for spinal rotation, where you have the ability to eat long gate, the quadratus lumborum, you can see on the lower photo that she has crossed over that figure for a position.

So her right foot is on the floor and the lateral aspect of her leg, and also thigh is going to be on the floor. So for her to be able to bring her right knee into hip AB duction that helps to lock down and pull down that ilium that could be elevated and causing a shortening of the quadratus.

Lumborum so great exercise to be able to use, like I said, it’s a patient favorite. It helps to release the quadratus lumborum as well as to activate that glute medius, which is going to end up being part of that lateral sling that we briefly talked about. And we’ll talk about it quite a bit more. Yeah. A two hour lecture coming up in just a couple of months on the quadratus.

Lumborum Brian, I think that’s it, man. We went way over time. I hope that. Okay. We have references as well. You guys, we also have something in the notes that you can buy. You guys can go ahead and take a look. We have a number of different recordings. About 75% of our smack program is now. And also on loss at OMS, which is great.

Also the psoas class, the three-hour class that Brian and I did just this last January, that’s available as well as part of the acupuncture anatomy series. LASA OMS also carries a sports medicine, acupuncture textbook, which is the next slide. And so I think we’re probably good to go.

Brian, anything else that you want to be able to quick?

This has classes is great on a Lhasa and it’s much more comprehensive because we have more. But there was no, we did do a, C a. So as if you want to get a little taste for that class that wasn’t, I knew you remembered November. So if you go on a C’s page, you can search back for the the, so as webinars we did there also, so that’s a give you a sort of a sample of that, class, and then you can see it through AAC’s page,

which we always appreciate them having us on and, a

thank you to both an Acupuncture Council. Yeah, absolutely big, huge. Thank you for having us and supporting us. Thank you so much for that, Brian. That was a good call to be able to bring that back in. So that’s good. Anything else, Brian? Ah, Lauren Brown.

Yes. He’s going to be here next week. Make sure you check him out. He’s. A big professional in our field, a wonderful academic and an amazing practitioner. So check him out. He always has really interesting things to be able to say, thank you very much. American Acupuncture Council Brian, always nice hanging out with you.

I’ll talk to you again soon. All right. Bye everybody.

 

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Working with the Psoas Major and its Respective Sinew Channels

 

 

This is  a particular muscle that a lot of people have interest in. It’s a very prominent structure. You could consider it part of the core of the body depending on how people define core.

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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Hello, welcome. And thanks for having us. Thanks to the American Acupuncture Council for welcoming us back. Uh, always great to do these webinars. Um, very frequently I do these with Matt Callison who had something to attend to today, so he wasn’t able to be here. Uh, we’ve kind of put this presentation together, uh, between the two of us, but in some ways, uh, sometimes one of us does a little bit more work on one particular one or the other. So this one, I actually did a little bit more of the setup with, so if he’s going to be out for a particular event, this one was probably as good as any, but it’s always nice to have them here and do this together. But anyways, um, that is why I’m doing this one by myself, but let’s go ahead and jump into the presentation. So what we’re going to be presenting on is the psoas major muscle.

This is, uh, a particular muscle that a lot of people have interest in. It’s a very prominent structure. Uh, you could consider it part of the core of the body depending on how people define core. Um, it can be one of the core structures. That definitely is a very core structure in terms of its stabilizing role on the spine. So we’ll go over all of this in the presentation, but it is such a central muscle that we decided to focus on it. Um, this particular timing, uh, we, we are focusing on it in this presentation because we’re getting ready to put together a, um, a little bit longer of a class, maybe like a three hour class, really much more of a deep dive into the, so as that that’ll probably be out for, um, available, uh, on a webinar for, uh, um, see use later in the, either the year, probably more likely, uh, closer to the new year in January.

So, uh, be on the lookout for that. It’ll be available on our webpage. It’ll be available through net of knowledge. Uh, so this is kind of the preparation for that. It’s a little shorter version of it. And we’re going to go into a little bit of depth in here and give you some ideas of how to work with this really important structure. So let’s go ahead and jump in. So first of all, let’s look at the anatomy. The, so as some ways has two heads on the axial spine there’s attachments, uh, on the vertebral bodies and actually right into the intervertebral discs of L four through T 12. So that tells you something right away that this is going to be involved in a lot of spinal problems in terms of its centrality and how it’s right up against those vertebral bodies with attachments right into the desks.

But that’s one of the heads L four through T 12, but then that one’s available in this image here. But if we were to kind of think, uh, posterior to this, if we were to kind of remove a vital little clicker and could remove the front surface of that. So as we’d see, it’s more posterior head, which is on the lesser trow canter, uh, excuse me, on the transverse processes of L five through T 12. Uh, so we have those two heads, which will be important in a, in a second, when we look at some of the neurology of this structure. Um, but for now just understanding that it really has attachments all the way up from L five to T 12, all the way on the lumbar spine, including lumbar discs for Debo bodies and that, um, the transverse processes, then it sort of descends down.

It crosses over the Elio pectineal Ridge, sort of over the junction between the pubic bone and the ilium, and then crosses and dives down towards the lesser trochanter of the femur. So that’s the territory we’re looking at in the grayed out sort of portion of this structure. We have the iliacus and as you see, and as many of you I’m sure know that the iliac is, has a common attachment on the lesser trow canter with the SOA. So sometimes people refer to as the iliopsoas, including that iliac Cassandra. So as I personally like separating those muscles, even though they have a common attachment on the femur, for reasons that we’ll get into a little bit later, both, uh, something we can see right now. And so as has actions on the spine where the ELA Acus doesn’t, but when we started looking at the channel sinews and some of those relationships, it’s nice to, in some ways have those muscles and separate mental compartments so that we can look at the sort of channel relationships to them. But yes, a lot of times people were referred to the iliopsoas because of that common attachment on the femur. Uh, so that’s the anatomy and that’s the territory that we’re looking at.

So one thing to know, right from the get go with the solo ads is it’s intimately related with the lumbar plexus. Uh, and, and particularly with the nerves that come from the lumbar plexus. So let’s look at this Netter image for a moment and kind of get our orientation straight. First of all, on the right side, we have the so as intact. So if you look at it by right side, I mean the illustrations, right. You know, the, the specimens right on the right side of the size is intact. And if you look at the left, so as not only is it cut as you get a little bit towards L five, you know, imagine you’re doing dissection and never was painting this image, I’m sure he was going by a dissection model. Um, so maybe they had already cut the so as, and, and so we can see the iliac is deep to that.

Um, but more than that on the left side, you can see that some of that more anterior head that attaches to the vertebral bodies and discs have also been cut away and we can see right into the body of the psoas and see that the lumbar plexus is actually situated right in top or right inside the, so as between those two heads between yeah, right there between those two heads of the, so as, uh, is the lumbar plexus and the nerves that come from the lumbar plexus, uh, and this particular study, uh, I’m quoting here, looked at the, um, dissections for 63 specimens and dissection and 61 of those, that was the case. So there’s variability like everything in human body, but in the majority, the vast majority of the cases that whole lumbar plexus is going to be situated inside the so ads. And then all the nerves that are coming from the lumbar plexus are going to penetrate through the solo ads.

So we can kind of look at that here. If we go back to the right side, we can look at the top most nerve that doesn’t actually penetrate through the, so as cause it’s not part of the lumbar plexus, that’s the subcostal nerve. It does share with the lumbar plexus, but then it wraps around the body, uh, innovate some of the abdominal muscles and the skin kind of, of the, the abdomen then below that we have the Iliad hypogastric and the ilioinguinal nerves, those do actually penetrate right through the psoas cause they’re coming from that lumbar plexus. So then they exit the, so as in those upper portion, uh, upper kind of proximal fibers of the, so as if we continue down from there, we have the lateral femoral cutaneous nerve. So it exits, so as a little bit more distal, a little bit more on the inferior portion of the fibers.

If we go a little bit, medial, you can see penetrating right through the psoas is a genital femoral nerve. And then if we go actually immediate to the, so as in that area, we’d have to kind of pick it out, but there’s the opterator nerve. So all of those have a relationship with the psoas in the sense that they’re all coming from the lumbar plexus, they all, you know, Pierce the, so as, uh, an exit, the, so as, um, and they have, you know, again, this intimate relationship with the psoas muscle. So we’ll get into that later in the importance of that. There’s a lot of importance just thinking about the anatomy. I’m sure you can think of many cases and pain patterns, trigger point referral patterns, how all of that is tied together and makes the, so as such a prominent structure and creating its own pain in the body, but also contributing to, um, various pain syndromes, like maybe back a lumbar junction syndrome, uh, involvement with clean Neal nerves, which are also coming from this lumbar plexus, but they’re on the posterior part, not visible from this image.

There’s a whole bunch of pain patterns. Um, a brief sidestep on this. This is not directly about the solo ads, but for those who are really into channel relationships, my interpretation of the dye, my, uh, is really these nerves that wrap around like those subcostal nerves, dealio hypogastric Leo and wean all lateral framework, cutaneous nerves, there’s nerves that are wrapping around from the back lumbar plaques, plexus and wrapping around the abdomen. I think that that speaks a little bit to the dynamite. I don’t know if I would say that the dynamite equals those nerves, but those nerves are part of the physiology of the dynamite because those nerves also innovate the abdominal muscles, like the transverse abdominis and the mobile leaks. Um, those nerves are influenced, as we know, by gallbladder 41, the oblique muscles are part of the gallbladder send you a channel. So I think somehow regulating tension through gallbladder 41 has an effect on those nerves that really wrap around following the trajectory of the diamond.

One other little thing about this it’s quite interesting is that the, you might have to go back and look this up if you haven’t looked at it for awhile, but the kidney divergent channel links intersects with the, my, uh, at L two, that’s just how it’s classically described intersects at the dynamite. And if you look at the trajectory of the opterator nerve, this other nerve of the lumbar plexus that opterator nerve goes right down and has sensory fibers right down to almost like the kidney 10 region. And that’s where the, um, kidney divergent channel takes off come kind of from that popliteal region comes up the thigh and then meets and intersects at the dynamite at L two region. So I think when we’re looking at the, my we’re looking somewhat at the physiology of the, uh, um, the lumbar plexus and the psoas is as kind of part of that relationship, but little bit more of a different subject, maybe in another day, we can hash that out a little bit more, but since we’re looking at this anatomy, it’s worth taking a moment to kind of, uh, compare and look at that kind of comparative anatomy between Western and Eastern.

All right. So some other, uh, ways that the, so as, um, interacts with the anatomy around it again, let’s get our orientation straight from this Netter image on the right of the specimen. The so as has been cut. So if you look closely, you’ll see the proximal fibers where it’s cut, and if you follow it down, you might even see the distal fibers. That’s kind of right over the [inaudible]. Yeah, they’re right there. So again, that’s so we can see what steep to that. We can see the quadratus lumborum. So the psoas and the quadratus lumborum have a pretty close relationship. The quadratus lumborum being a little bit more posterior takes off from the iliac crest and then goes up to the 12th rib. So there we have the quadratus, lumborum a really important muscle. We could do a class on the quadratus. Lumborum, it’s, it’s also really a, a quite a, um, important structure.

And maybe someday that’ll be a subject of one of these webinars. Um, I do want to highlight that anatomy because we have a dissection video coming up that is on the, so as, and that’s why I put it on here, but it does also cover the QL because if you look just distal to the quadratus, lumborum on the right. You can see how it shares fibers into the iliacus muscle, which isn’t that kind of pelvic bowl. And then that iliac is muscle. Like we looked at that common attachment on the lesser Cho canter, really farms, a continuous myofascial plane, all the way down to the ad doctors. You’ll see this in another image coming up and I’ll highlight it again. Um, but that in our interpretation and sports medicine, acupuncture is part of the liver send you a channel. You wouldn’t think of the quadratus lumborum as being part of the liver channel because in some ways we have to needle it from the back, but it’s not really a back muscle.

It’s a core, it’s a central muscle. It’s really a yin muscle on the inside of the body. Um, none of the medial thigh from the ad doctors, but then it blends in at the spinal attachments that we looked at and it really then becomes part of the kidney send new channel, which is interesting because not only is it part of the kidney send a channel, but we can see that the kidney organ is right up against that. So as, and in visceral osteopathy, they talk about how that, so as moves along the rails of the, so as you know, that if you kind of picture the psoas as being a rails of a train track, you know, that the kidney moves along the, so as the fascia is really intimately related with the, so as the renal fascia, and so as muscle, um, and by moves, what I mean is every time you take a breath that, so as moves about two centimeters down as the, as the diaphragm descends, it pushes the dominal contents, including the kidneys, all of the organs, liver, all of that.

But in this case, the kidney itself, it moves along. It kind of follows along that rail of the solo ads. So if you think about how many breaths you take every day, I don’t have the exact figure. This is something that when Matt was here, because he does know this Lennox, I heard him say it recently, but, um, but it’s quite a large amount of distance that, that kidney travels two centimeters isn’t that far, but two centimeters, every several seconds, all day that’s, that’s a lot of territory. So what happens now, if the renal fascia and the kid in the psoas, fascia are all adhered to each other and there’s limited capacity for that kidney to descend, well, then we’re going to have, you know, maybe restrictions in the psoas restrictions in the, in the hip flection. Uh, we’re going to have inability for the diaphragm to descend, you know, it’s going to cause some kind of obstruction, some kind of congestion that’s going to cause some health issues.

So when you’re working with the psoas, I think what I would take home from that relationship is when you’re working with the psoas, to some degree, you’re working with the kidney, if there’s more movement and more movement potential. And so as there’s more movement potential in the kidneys, and one of the ways that the kidneys become ill, and I don’t mean like kidney disease, um, in Western Sant standpoint, but in terms of lack of function is that they start to lose that mobility and motility of the Oregon kind of moving along the, um, the, so as, and then that can maybe descend a little bit. It can put pressure on those nerves we were looking at and it can cause their own symptomology. So being able to free up this region can really, um, both include improve function in the hip muscles. But, um, but also in the internal organs, the other thing that we can highlight, if you go back to the right side, we can see that proximal part of the, so as it’s cut, we can see how intimately related that is with the Dyer for him.

So that’s the cut portion yet right there. So in this nice, clean, better image where they take off all the fascia, you can see that it touches it, but in a real dissection with the fascia intact, you can see how integrated those fascial components are. And they become really one in the same, those sort of feed the crew of the diaphragm, the extensions and attachments of the diaphragm with the proximal. So as, so when you get people who are posterior tilt of the rib cage, maybe their pelvis slides forward and the rib cage tilts back. And it compresses that region of the diaphragm on the, so as that can have implications in breathing, I’m already thinking of kidney, not, um, grasping lung Chi is one way that I see it manifest. Um, so it’s gonna, it’s gonna decrease the ability of the diaphragm to descend, but it also can actually turn off the, so as, and cause problems with SOS its ability to stabilize the spine.

So when you start getting patients who maybe have back pain after starting to run, or they’re out dancing, moving in the back, pain comes on maybe five minutes as they start to tax their breathing. That’s one to start thinking of that relationship. And we have ways that we work on that in sports medicine, acupuncture. Unfortunately it won’t be in this webinar, but we’ll look at some ways that would affect it. Um, also, so kidney, so as QL, those are all and diaphragm. Those are all pretty intimately related. So let’s go into the next image, the next slide.

So here’s the, uh, image I put together for the send new channel relationships. So we’ve already talked about them. I don’t think I need to spend a whole ton of time saying it again, but, but we can see it from a different capacity now. So we have that medial thigh with the ad doctors, especially at Dr. Longest brevis and Peck tineas Priscilla’s could also be included in that these are part of the liver, send you a channel for those who know anatomy pretty well. The posterior muscle of this ad doctor group adductor Magnus attaches to a different portion on the back of the femur. It’s in a little bit different that, um, region that’s a little more posterior than this group that would be part of the kidney send new channel. So we’re looking at the thigh portion. We’re looking at the liver, send you a channel as it comes up to medial thigh, and you can see both the iliac is in the, so as the Eylea.

So as is part of that, liver send you a channel coming from distal, going up into the body. Uh, we talked about the iliacus and the QL. You can kind of find that in this image that it’s marked on the right [inaudible], that’s following that liver sinew channel all the way to the 12th rib. And then the, so as starts to attach more into the bodies of the vertebra blends in with the anterior longitudinal ligament, and it becomes part of the kidney sinew channels. So the SOA has this kind of a crossover. It takes off this delay from the liver sinew channel, and it ties into, um, the kidney send new channel. So which isn’t, well, we talk about it a couple different ways when you’re working with the distal ileus. So as for like grind strains, then more often than not there’s direct needle and you can do of course, but if you’re using disappoints, it’s going to be liver channel points that are going to have more of an effect on it.

Liver for liver five, those types of points are going to have a stronger effect on that liver. Five’s going to have a really strong effect on the quadratus lumborum through that, that QL iliacus relationship, but it would also have an effect on the distal Lilya. So as, so really when you’re talking about that distal portion, as it comes over the alien pectineal Ridge, and then God goes down to attached to the femur, you can kind of think of that as, as liver territory, liver sinew, channel territory, as it dives deep into the body. And we’re talking more about stabilization of the lumbar spine. We’re talking about how that stabilizes and moves and supports the lumbar spine. Then I’m going to put on my kidneys and new channel hat and think about its role more from the kidney sinew channel and how that’s going to affect it.

We will look in this webinar at a way of affecting that relationship when it’s not stabilizing the spine. And if the, um, so as this sort of testing week, um, but if I were going to use distal points, I might start thinking more kidney points, give me seven, the tone of vacation point on the kidney channel, uh, can sometimes wake up that ability for the SOS to support the lumbar spine. Uh, so if you’re thinking more body of the size, I guess you could say kidney, if you’re thinking more distal iliopsoas, you can think liver’s a new channel. I can say it a different way that if I’m thinking excess, I tend to see more of a relationship with the liver sinew channel, uh, excess meaning hypertonic restrictive. When I start seeing situations where it’s more about stability and support, then I see more of a relationship with the kidney channel kidney, send new channel a kidney channel points, distally.

So that’s a way of kind of making sense of its roles in terms of these two channels and it connects with all right. So actions of the SOS, the, so as does hip and trunk flection, hip flection, of course, we think about that with walking trunk flection. I want to come back to and a couple of slides. So just kind of put a little asterisk by that one that does lateral rotation of the hip, unless you see a source that says it does medial rotation of the hip. Um, lateral rotation is the bigger consensus, but I think gets rotation on the hip is negligible. I don’t really think about it so much personally, unless I’m doing a manual muscle test and you’ll see in the image coming up for that, that, um, there is a slight, uh, lateral rotation, but I don’t think it has a real large role in terms of lateral or medial rotation of the hip. Um, and sources say different things about it. So maybe it varies depending on the person’s position and how their body’s structure is hip flection, definitely trunk flection, definitely. Um, this third bullet point also definitely lateral flection of the spine and contralateral rotation. So if you can kind of picture that. So as contracting on one side, it’s gonna side them, that’s fine until a lateral flection to that side and rotated away.

Okay. So let’s think then about that. The, so as could be shortened, it could contract and shorten can contract and shorten and movement have flection and all that. But if it’s chronically hypertonic, it’s going to Paul on the lumbar spine it’s going to, and this is the consensus it’s going to pull it into more of a excessive lordotic curve. It doesn’t attach directly to the pelvis, but in the process of that spine being pulled into a lordotic curve and exaggerating that hyperextension of the spine, as it pulls the spine closer to the lesser trow canter, it’s going to pull the pelvis into an anterior tilt. So that top image is showing a neutral pelvis. Matt has a measurement at the ASI S and then I’m in the front and then a PSIS in the back. And there’s about a quarter inch. We’ve got about a finger width between that.

So that’s, uh, the, the measurement for a normal kind of a neutral pelvis. It’s about a quarter of an inch higher on the back, that’s normal. Um, but in the lower picture, you can see now that, uh, that quarter of an inch that is greater than a quarter of inch, that ASI S is situated, uh, much lower than what you see in the top image. So that’s what you had started seeing with bilateral shortness or unilateral if we’re just looking at it from one side, but let’s imagine that the, so that the pelvis bilaterally in that anterior tilt that same measurement and he’s doing on the right would look very similar on the left, this measurement, you know, it takes a little practice. You have to be right at the center of the PSIS. You have to find the upper border. You have to find the lower border, kind of find the lateral medial border and get right in the center of it.

And then the highest part also of the ASI S and that’s going to give you the measurement, cause you can kind of picture if I’m at the top border of the, um, uh, geez, it looks like I’m a mirror image here. I’m going to change my Android phone. See if, I don’t know if you guys are seeing the same thing I am. Um, if I’m, if I’m at the top border of the PSIS and the lower border of the ASI S it’s going to give me a false read, I need to be in a very consistent place. And that would be at the peak, you know, the central aspect of the PSIS and DSIS, um, and that’s gonna give me a sort of a more accurate measurement, but, um, that’s how you would measure it. But, you know, just looking at it, if you just look at that lower image, you can see that there’s a greater inclination forward, uh, anterior tilt of that bottom image.

So that was that way on both sides. And I would be thinking that the so as is in a locked short position, bilaterally polling, that’s fine into an excessive lordotic curve, taking the pelvis with it into an anterior tilt. Sometimes it looks like the person can’t fully stand up, picture them, seated, their hips flex. They go to stand up. And it’s like, as if they, that last few degrees of hip hip extension isn’t there, and they’re kind of held into hip flection and their spine tends to be a little bit more arch. This is the consensus with a shortening of the, so as at least bilaterally, uh, Tom Myers has an interesting perspective on it that I do kind of think there’s some merit to this, and he looks at the upper fibers versus the lower fibers. So when you remember back to those images were talking about the anatomy.

There is, it’s almost like six muscles, right from, from L five all the way to T 12. I did it as dissection at university of Tampa with a physician assistant group, um, where they’re there for the students, for the physician assistants. And I was helping lead this dice, the kind of group of dissections, and one of the specimens had really severe scoliosis in the spine and the lumbar spine almost became horizontal. And you could really see on that side, there’s six individual slips of the muscle as they were kind of widen that whole aspect of the psoas. And you’d see those each of those little slips going and attaching to the various side, um, attachment sites on the, on the spine. And with that spine orientation change to kind of widen the whole. So as, and, and almost gave that appearance of the six muscles.

So if you think of that, that way, those upper fibers, the ones that are accessible more laterally are the ones that go up higher, uh, on the, uh, on the, on the T 12 L one region, if those are shortened, like in that upper picture on the right, that might actually pull the spine more into a, uh, straighten kind of curve as if the person is on the floor doing trunk flection, like a curl, which the so as would be involved with, I would say that, that in that case, it’s more of the upper fibers, whereas the lower fibers in that bottom right image and kind of drawing, that’s really showing more of the lower fibers, pulling the spine into a hyperlordotic curve. I think this plays out quite a bit, especially when you get people whose pelvis has shifted forward and the rib cage has shifted back.

Sometimes those upper fibers are the more involved ones. So you can almost see the, so as, as being, uh, an antagonist of itself, you know, upper fibers versus lower fibers, this is not the norm, a normal view. This is not the consensus. This is an alternate view, but I kinda liked this view. And it kind of does give me some suggestions of how I work, especially with manual therapy, unilateral shortening, like we mentioned, is going to pull the spine into lateral flection to that side and contralateral rotation. When you’re looking at somebody, the umbilicus will look like it’s pointing away from the, the short. So as, so it’d be, that’s a, that’s a simple way of looking at it. You can kind of see the, uh, the umbilicus saying, you know, I’m pointing away from it that said the direction is pointing to would be more of the length.

And so as the, the direction is pointing away from would be the short. And so as there’s a lot of things that can involve that can affect the iliac. I mean, the umbilicus a position there could be scar tissue there. So I don’t take that too literally. That’s, um, it’s not an way, but you can sometimes come over the person and look down the spine and you can see that lumbar spine rotating one way or the other. So the side that’s more posterior is going to be the length and side. Um, in the side, that’s more anterior is going to be the shortened side. We’ll look at another way to, uh, to address this in a second.

All right. So we have a cadaver video coming up. I just want to remind people, who’ve seen some webinars where we have cadaver videos that these are, um, you know, it, shouldn’t be kind of viewed in public if you’re at Starbucks right now, and there’s somebody who can see your screen, maybe it’d be good to, to not watch this. Now, come back and watch it later. Just be mindful of your surroundings. This one, no faces are shown, but this one is pretty internal. And I think it could be disturbing for people who aren’t medical professionals of yourself. Do you find this stuff kind of disturbing, maybe don’t watch, but especially be mindful of your surroundings. Don’t take screenshots, don’t share these don’t record and share these videos. You know, we have to be really respectful for the donors. This is for medical professionals. Um, so just have that caveat when you’re watching it. And let’s go ahead and look at this. It’s going to show the, so as it’s going to show that QL and iliac is relationship and some movement.

So one last that aspect with the solo ads is we can look at the different fibers medial versus lateral, and how that relates to the lumbar spine. So if I look at these medial fibers, the medial fibers are going to be attaching to L five and L four and the lower portion, but the more lateral I go, the higher up the fibers become. So the fibers that are going up to T 12 L one upper portion are going to be the lateral fibers. And the ones that are going into the lower lumbar spine are going to be the medial fibers. So there’s some indications and some viewpoints on this that the medial fibers would be more involved with an anterior tilt and with lordosis, as they would be pulling the lumbar spine into a hyperlordosis hyperlordotic position, pulling the a L five L four L three lower portions into lordosis versus a posterior tilt where maybe the T 12 L one portion could be putting the, uh, lateral fibers and more upper fibers into a shortened position.

It’s not the common view, it’s just an alternate view, but interesting to think since the muscle is multiple slips, that this could be both involved in an anterior and posterior tilt, depending on which fibers you’re looking at, especially relevant for manual work, um, because we’re, we could highlight the different fibers. Last thing we can look at since we’ve talked about the quadratus lumborum is we get a good view of the quadratus. Lumborum now coming to the medial portion of the iliac crest and joining facially, at least the fascia has been taken off, but you can see the same fascial plane in through the iliacus. And then of course, down into the liver channel, as it travels and meets with the, uh, fascia of the abductors, as I go up from there, the diaphragm has been removed during the evisceration process, or at least disturbed, but we can appreciate that that same fascial plane then would blend into the cruise or the feed of the diaphragm from the upper fibers of the QL. And of course the so as itself would be a very, uh, integrated with the upper fibers of the diaphragm.

Actually, Alan, I think there was a, a little bit more of that video. I wonder if we can go back and slide forward a little bit, if we can’t do this, it’s no big deal instead of watching the whole thing. I don’t know if this can be a jumped up at the middle,

Unfortunately.

Okay. Yeah, no worries. No worries. Yeah, no worries. Okay. So let’s go to the next side that this one just shows some of the, like, kind of move the rib cage and you can see the, so as like side bending the spine, but I think we got a pretty good, pretty clear idea with that. Um, just by description. Uh, so this, uh, test here is, uh, lumbopelvic rhythm. This, we look more at for the urinary bladder, uh, channel relationships and new channel. It’s looking at the normal position where the lumbar spine moves in a one-to-one relationship with the nominate bone in the middle one. It’s showing that the innominate bone, um, is not moving so that you’re getting all, all movement in the lumbar spine, showing a restriction in the hamstrings, in the farthest, right. One, the nomina bone is moving, but the lumbar spine, not some more of that restriction in the urinary bladder sinew channel at the level of the lumbars.

Why am I showing it here? Because after we do this test, we can go to the next slide and we can have the person, uh, facing away from us and we can look at them from the back. And if you look at that image and I’ll let you look at it for a minute, um, from the back, can you see that one side is up higher? And by one side, I mean, the lumbar spine is up higher than the other side. So going back to that information of what the unilateral imbalance does at the, so as that Ray’s side is going to show us, show us the likely locked long inhibited. So as whereas the lock short, so as it’s going to be on this case, on the right side, which is pulling that accessibly into rotate rotation, or the left side is failing to support the spine, which is it, is this excess or deficient excess on the right deficient on the left, in relationship to each other, but on any given person, then we have to figure out, is this more about that excess more about the deficiency or both, but at least it’s telling us there’s an imbalance there.

So this lumbopelvic rhythm, great test for the urinary bladder, you a channel, but we can, uh, look at it from the back and get a window into the kidney sinew channel. So we have that left side showing that a relative length and position compared to the right side. And we can take that right into a manual muscle test manual muscle test of the psoas is having the hip and about 35 to 40 degrees. Fluxion that image is showing a little bit more than that. I think I put the wrong image in that. I noticed this just before we went live. Uh, this looks like the iliacus manual muscle test. So imagine that same position, but a little less hip flection. Yeah, yeah. About that angle of hip flection. So they look alike and I just grabbed the wrong one. But, um, so as manual muscle tests, everything else would be approximately the same, but it’s more of that 35 to 40 degrees of abduction flection, and then abduction to about 35 degrees driving UV 58 back towards the table.

So you’re taking them and slight AB duction, but really focusing on the extension and the so as it’s called onto to support that. So that is a manual muscle test of the so as you can do that immediately after the, um, seeing that, that sign, that, so as signed in the previous task store, you might do this on its own, but this is going to give you a window into how the so as is, are supporting the body. You have the person, you kind of give an initial load and as you over pressure, the, so as you’re seeing of that, so as fibers has enough cheese to lock on, we’ll talk about GB 27 in a second at top, probably we’ll close with, but you could also try even just putting a point in something like kidney seven and seeing if that wakes up, you might have to draw the needle back before you test and then retest and see if there’s a little bit more strength than the, so as kidney 27, we’ll definitely do it.

But, um, but you can also look for other points like kidney seven, kidney, three, kidney, six other channel points that might affect it. I’m not going to talk about 62 and [inaudible], that is a little bit longer of a discussion. Um, let’s go then to the next slide. So that goes into treatment. We have motor points that lie deep to UV 24 and UV 25. I’m not going to go in and into the needle technique for these because they involve a pretty deep needle technique that really takes some time to, to talk about, um, and we’ll allude to it, but it’s really something that needs to be spent a lot more time, uh, for safety reasons, but you can needle the, so as directly from the back, um, there’s these two motor points, they lied deep to a U B 24 and UV 25 physician is going into the next slide is through the back.

There’s a needle technique that kind of follows the edge of the, um, Leo Castelli’s lumborum muscle and goes along the lateral Rapha, right to the, the, so as, um, it’s safe if it’s done properly, but to go through all the details in such a quick, uh, class, like this would be a little bit irresponsible cause this one can cause damage. Cause it’s a fairly deep technique and there’s some, some complications, first thing going to reflect some spasm. You just have to be aware of some things before doing it. Um, this could be though useful for the excess side, particularly. So it is one of the, to consider learning at some point. Um, but the next one is going to affect the psoas actually quite well, especially for the, the locked long inhibited. So as, um, this is a technique that Matt, uh, came up with years, uh, years and years ago and as used and taught and a lot of people have used it quite successfully for a long time.

And this is using, uh, gallbladder 27. So with gallbladder 27, you’re angling it slightly lateral. And with like a slow sort of in and out, um, green turtle searching for the point, uh, noodle technique until you get either one of the following sensations, either wrapping back around the diamond, uh, wrapping down towards the liver channel towards the groin or following the stomach channel down the side of the leg, effecting either the lateral femoral cutaneous nerve down the stomach channel, the Elio hypergraph gastric nerve going towards the groin or the ilioinguinal nerve wrapping around. Um, maybe I think I have that back rail hypogastric wrapping around the DMI ilioinguinal wrapping to the groin, but it’s affecting one of those nerves from the lumbar plexus then, which is going to reflexively turn back the, so as on kind of stimulate that same neurology, cause it’s also in an innervated by that lumbar plexus and turn that so as back on, so it doesn’t have to be a strong sensation, but you need one of those three sensations and that will turn kind of calm down.

We’ll lock short. So as, but this technique really shines for the lock long inhibited size. Right. And I think I was wasn’t sure timing if we’d have time to show a manual technique, but, um, I think we have a little bit of time. It’s not real long, so let’s go ahead and go into that because I think this will bring it together. This is from a blog post. We just came out in October. Um, so it’s not sports medicine acupuncture. If you’re looking at this, um, webinar later on, um, it’s the October post. You don’t need to know that you can just find it, do a search warrant or find it, but it’s called working with SOS. Um, and it goes into this technique a little bit of setup, but then into this technique a little bit more in depth, uh, this technique is also on our YouTube channel, this video you’re about to see so you can access it there.

And if you wanted to review it later, um, or of course it’ll be in the recording for this class. So quick set up and then we’ll look at the video I’m working on both sides at the same time. It’s a very integrated technique. I’m going to do a movement that simulates walking. And then as simply I could say, I’m pinning down the cell ads and just letting that kind of free up each side, but really I can do more than that. I can kind of nudge, you know, maybe so as it’s really narrow and pulled medial, I can nudge it more wider. I can kind of work on those medial fibers and nudge it out a little bit. I can nudge the lighter side more, even more medial and kind of even that out that way. So, um, depending on which fibers are short, I can kind of affect it.

I can feel when I’m in there, that one, so is going to be much more medial and that’s going to be probably the last kind of short side and the way it kind of changes the orientation of that. So as the, um, other thing is when the person presses their foot move into, you’re going to see in a second and lifts the other foot, there’s sort of a down on the foot, they press, there’s sort of a downward movement and an upward movement on the foot they lift. And you can feel if those are even, and I can nudge it down or nudge it up. So I can kind of look for an even movement of the psoas. But what I’m really doing is using the SOA as its puppet strings to sort of mobilize and get an easement, even rotational movement in the lumbar spine and all the way through the pelvis. So simply I can just hold it down and kind of free, or I can influence movement. I can kind of mobilize in various directions. I kind of say this in the video, but I don’t think I go quite in as much detail. So let’s go and look at the video.

So we’re going to do it. So as technique, this one is going to be, um, working on both sides left and right at the same time, it’s very much of an integrative technique because we’re trying to sort of get an even tone between the two sides, but also an even movement. So let’s look at the movement aspect. First, the patient is going to slowly lift one foot up. At least they’re going to lift the weight up. They might not actually lift the foot off the table, but they’re going to start to bring the weight off that foot while they push the weight into the other foot. It’s like a walking motion. There you go. You don’t have to actually lift the foot up. It’s more about the pushing, but than it is about the, um, lifting foot. So they don’t have to literally lift it off the table.

There you go. Now decrease that movement by about 60, 50%. There you go. Yeah. So it’s a small movement. So she’s starting to do a movement. That’s very much like walking. So when I’m in working on the SOA, as at the time, I’ll be able to feel the movement that’s happening associated with the so as I’ll be able to feel the tone of the size, but also the rotation aspect that’s happening in the spine and through that area to the sacrum. So go ahead and relax. I’m going to find the ASI S going to start following the slope of the iliacus muscle, and we’ll be able to, to get down to the depth of the solo ads. So it’s like, you’re kind of going into a, um, a slope going medial, which will take you right to the iliopsoas. I can move a little bit, medial moving, any visceral or neurovascular tissue off to the side.

And now I feel like I’m at the depth of the size before she does the movement. I want her to lift and lift your left foot. Relax. I can just fine tune where I want my pressure and lift the left foot again. Here we go. Good. Now I’m right. The psoas on the left. And I go ahead and lift the right side, right side already feels like there’s a little bit more tone. Okay. So now I’m on the sides on either side. So start slowly doing that movement. It doesn’t have to be a big movement. It’s just about encouraging an alternating contraction with the as, and I can do two things. I can soften the right side, but I can also follow that rotation and help try to get an even movement to where it kind of sinks more easily on the left side, right side feels like it doesn’t want to go, but I can follow it into that movement And just wait for the tissue to sort of normalize and feel a little bit more similar between the two sides. There we go. Now it’s starting to move, starting to soften a little bit too. Okay. Definitely want to work respectfully with SOS because it’s very sensitive and you want to take your time and not bully through the tissue.

You might also, with this one, find that you work a little bit more on the medial aspect of the psoas and one side and the lateral aspect on the other, which I’m doing on the right side. I’m hooking into that medial aspect and helping bring it lateral.

[inaudible]

One more time. That’s good. Okay. Now I’m just going to hold and just have her just do that movement a little bit. I’m not going to do so much this time just to let the body function normalized a little bit. Okay.

[inaudible]

All right. So that is ed. Here are some references. If you want to go back and look at any of, of those, um, just from the presentation, but I think that is, uh, the presentation for today. If you wanted to look at that blog post, it goes into that last technique a little bit more in depth. Um, and like I said, hopefully by new year, we’ll have a three hour class, so we’ll be able to go through a little bit more of the needling and more, um, comprehensive. But I think hopefully this is something you can use right from the get-go. So, uh, Lorne Brown is going to be here next week. So tune in for that and thanks again to the American Acupuncture Council for having us and look forward to seeing you guys next time.

 

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Cluneal Nerve Entrapments: An Often Overlooked Cause of Low Back Pain

 

 

We’re discussing actually some case studies in low back pain and how routinely it is so important to check for cluneal nerve entrapments that could be contributing to the patient’s low back pain, or even mimicking it being 100% of the low back pain.

Click here to download the transcript.

The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Hello everyone. And thank you very much for coming to the American Acupuncture Council, our sports acupuncture webinar. We’d like to thank the American Acupuncture Council for sponsoring us with this. I’m here with my friend, colleague and partner in the sports medicine acupuncture certification program. Brian Lau.

Hi, nice to be here again,

Brian and I were discussing just the other day about the upcoming module two low back hip and groin webinar that we’re having in the anatomy pop patient cadaver lab. We’re discussing actually some case studies in low back pain and how routinely it is so important to check for cluneal nerve entrapments that could be contributing to the patient’s low back pain, or even mimicking it being 100% of the low back pain. For example, the superior cluneal nerve entrapment can mimic yarn syndrome pain at the iliac crest, or it could be maybe 30% or 40% of that con contribution to the pain. So something just to routinely check in your cases of low back pain to see if an attraction is contributing to part of it. So I think we could probably just start bouncing right into it. So, Brian, do you want to go ahead and take it away and we’ll just go to the next slide.

Yeah, sure. So, uh, we’ll go, um, pass the title slide here. So into the next slide, and we’re going to start by, um, just giving a quick overview of the clinical nerves. So you have three circles that you see there. Uh, we have the superior cluneal nerve, so that’s that upper circle, uh, that I’m going to cover quite a bit in just a moment. So just for now, yeah. There’s the highlight, uh, showing the superior cluneal nerves now there’s multiple ones. Um, and we’ll, we’ll talk about that in just a moment, but then below that, in that middle circle, we have the middle cluneal nerves. Uh, those mats going to go into a little bit more, we’re both going to discuss some, but, um, he’s going to take that primarily. We’re not going to be discussing the inferior cluneal nerves, that bottom circle, uh, in this particular webinar, just because, um, this one is a little bit more on causes of low back pain and fluid inferior cluneal nerves, or are important.

Maybe another day we’ll cover those, but we’ll focus more superior and middle. Uh, so these nerves are cutaneous. Nerves are sensory nerves. Um, they, uh, then that means they’re going to be primarily innervating the skin. So they’re traveling in the subcutaneous tissue and innovating the skin. Uh, so let’s go ahead and move on and we’ll go right into superior cluneal nerves. So the superior cluneal nerves, uh, come from, they stem from [inaudible] the dorsal ramus. They travel posterior, uh, as they get more inferior penetrate through fibrous tunnels within the thoracolumbar fascia, uh, then they branch over the iliac crest to become subcutaneous where they, uh, innovate the skin and the subcutaneous tissue. Uh, so these are a common site of entrapment. Uh, so this, uh, superior cluneal nerves can becoming trapped in the superficial layer of the thoracolumbar fascia and can contribute to low back and leg pain.

Uh, just the note is that’s a little bit of a shorthand. So when it says that they, they, uh, stem from L one through L three travel posterior, there’s a whole lot of territory, you know, they’re not traveling through empty space at that time period. They’re actually traveling through structures like the, so as they’re traveling sometimes through the quadratus lumborum, but usually between the psoas and the QL, they travel through the para spinal muscles. So there’s a lot of territory, uh, in that region that we might be able to come back to later on in the, in the webinar to differentiate between various types of injuries. Our focus though is going to be on that, uh, area where they Pierce the thoracolumbar fascia, just at the iliac crest region, and then drape over the iliac crest. So maybe more on the other, other areas later, but let’s go with the entrapment site that we’re talking about in this webinar. So that’s the superior cluneal nerves and their site of entrapment.

So in, in terms of, uh, entrapment, there’s a, these are all the superior cluneal nerves, but there’s a middle or medial. Uh, one of those though, you know, the one that’s most medial, uh, then there is a middle or intermediate and then a lateral, uh, superior cluneal nerve. So these are all superior cleaning, the nerves that we’re talking about now, but we’re looking at the multiple nerves. So the medial most the middle and the lateral one, and it’s usually the medial branch that is commonly affected, uh, in terms of, um, becoming and trapped. So they all can be contributors, but this, this medial branch is the one that we’re really, um, gonna focus on, uh, in terms of where it’s, it’s going to become trapped. So, uh, these traveled through a fibrous tunnel, uh, then they go over the iliac crest so they can get in trapped in that fibrous trunk tunnel of the thoracolumbar fascia, or they can get trapped between that and kind of adhering to the iliac crest. So there’s a lot of research out there. You can look into it if you want it to, to check more information about it, but this image really kind of highlights that fibrous tunnel that you can see that those medial branches of the superior cluneal nerves travel through. So it’s just a, just a sort of a fibrous tunnel through the thoracolumbar fascia. All right, so let’s move on next one.

So in a cadaver studies, the researchers found that this medial branch of the superior cluneal nerve was frequently adhered between the fibers tunnel and the thoracolumbar fascia and where the medial branch travels over the iliac crest located just lateral to the PSIS. So there’s a lot of studies on this. Um, why it’s studied in Western literature, uh, is twofold. Uh, they study it of course, because it’s an entrapment site and it can be a pain generator. It’s considered not super common of a pain generator, but it is a pain generator and it’s worth knowing about, uh, that’s one reason that it’s a study. The other reason that it’s studied is when they harvest bone from the iliac crest to use for, um, fusion for lumbar fusions, uh, they want to know, you know, it’s really important that they know where these, uh, cluneal nerves are, so that they don’t damage the cluneal nerves in the process of process of harvesting bone from the iliac crest.

So because of that, there’s a lot of really good research that that kind of gives an average of where these cluneal nerves exit, um, both, you know, the, the medial ones, the intermediate and the lateral ones. So they have it all charted out on various different cadaver studies, measured from the PSIS are measured from the midline. And if we look at this, um, medial branch of the superior cluneal nerve, it’s approximately in the region of Yan, you know, of course they’re measuring it from different criteria. They’re usually usually measuring in millimeters, but the measurement kind of comes to about that same measurement, uh, as Yan, which is three and a half sun from the lower border of L four, just over the iliac crest. So this being a common site of entrapment means that it’s also a contributing factor, or sometimes the factor for Yan syndrome, which is pain at this particular region.

Um, again, we can come back and differentiate this type of pain that’s caused from an entrapment of the superior cluneal nerve versus other things that are in this region. Like the Leo Castelli’s lumborum, which attaches to the iliac crest in that region, or deeper to that, the quadratus lumborum, which attaches to the iliac crest in that region. So being able to differentiate what’s the, the pain generator is important, but in that process of determining what’s the pain generator, we want to make sure that we take into consideration the, uh, the superior cluneal nerves. So those cause pain Ayanna, that pain might radiate down into the buttock region, and you could follow those nerves and see how they drape over the glute medius. And even over the glute Maximus. Matt, do you want to add anything to that kind of just jumped in and covering it, but

That was great. Yeah, that was really good. So, uh, just to reiterate the, the, on, we just published a, an article as well on the sports medicine acupuncture website, and it’s talking about the superior superior cluneal nerve entrapment at the extra point Yon, and also in the Yon region, just something to, for practitioners to consider that there is a cadaver dissection that we did. And we were able to find one of the superior cluneal nerves, which is a difficult dissection to tease out these cutaneous nerves. Um, it’s not just us, that it’s actually in some of the articles, um, that are in the references. Um, they talk about the difficulty of actually trying to tease them out and try to be able to dissect them, to see if they are entrapped or not. Um, Yon syndrome that we call it is also in Western science called iliac crest syndrome is basically the, um, the strain of the soft tissues within that area like Brian was talking about, could be the thoracolumbar fashion, the illiocostalis or the thoracolumbar fascia and the quadratus lumborum.

And this has been treated for thousands of years by acupuncturist, but yet the entrapment side also could be a contributing factor to that. So the patient is complaining of that low back pain. They may also talk about a mild parasthesia you’ll have to dig that out of them. Most people are not going to consider that as a chief complaint. Um, it’s just more of the low back pain in that Yon region. So the entrapment side is something definitely to assess which we’re going to be talking about. The very simple assessment coming up in just a little bit, Brian, should I jump into the next entrapment? Uh, yeah. Yeah.

There’s some other things that we can come back to later on. That’ll be more differentiation. Um, but, uh, just to highlight one real quickly, what you said about why these are so difficult to dissect is that they live in the, at least the process that we’re the part of them that we’re looking for, uh, in terms of where they drape over the iliac crest, those live in the adipose tissue, and you know, this dissection, I mean, this, uh, this image from Netter, they they’re so clear looking. It’s so easy to see, but in dissection and it all looks alike, it’s all the same color. These are little over a millimeter in diameter, so they’re super thin. And just finding them in that adipose can be very challenging and take time to look for. But, um, one highlight from the video that Matt referenced on the blog, um, that in the processing of this video, it’s funny how you listen to things over and over, and you never noticed something. I just noticed today, actually, when I was listening to it, that I say superficial cluneal nerve over and over again, instead of superior cluneal nerve. Um, so, uh, if you listened to that video, if you go to the blog post and you look at that, that dissection video, don’t be confused. It is superficial because we’re looking at it, look, our we’re highlighting and showing it where it would be in the adipose tissue. But I meant to say superior cluneal nerve and not superficial clinical.

Yeah, that’s good. Brian, I think, I think it’s important for people to understand that this is really quite superficial. So if we have the low back, you’ve got the skin, then you’ve got your layer of your subcutaneous tissue. Then it’s just underneath that. So people have been treating the superior and middle cluneal nerve entrapment for a long, long time with techniques with cupping. And guash on with acupuncture. All of those actually have a strong effect on this superficial tissue, which we’ll talk little bit more about Sue

And Matt. It sounds like your chickens are laying eggs in case people are wondering.

Yeah. They just, they, they, they love to interrupt these webinars. They do. All right. I was wondering if you could hear it. All right. So let’s go to the next slide. Thank you. All right. So the middle cluneal nerves, so let’s separate, let’s differentiate this from what Brian was just talking about. The superior cluneal nerves are further broken down to medial, intermediate and lateral. You can see those three nerves as the superior, right? That’s not circled in this particular image. So now, now we’re going to be talking about the middle cluneal nerves that are branches from the [inaudible] dorsal. Ramiah now like the superior cluneal nerves. They also exit through the thoracolumbar fascia. And then the cutaneous area for them to innovate is going to be the lower part of the PSIS medial, buttock and OXA also the coccsyx region. So a patient may be complaining of pain in that area. It could, it could be planning of pain in the SSI joint that at first glance, you’re thinking that it could be a sake really actually problem. Um, but then you further differentiate that possibly the middle cluneal nerves are part of this. And we’ll talk about that. And just a little bit, when we get into our assessment and treatment, let’s just break down the anatomy of it for, for us right now. So let’s go ahead and go to the next slide.

So anatomically here’s an image from Grey’s anatomy, the course of the middle cluneal nerve stems from the sacral nerve roots. So we talked about S one through S3, then it travels posteriorly either under or through the long posterior sacroiliac ligament. Now there’s a number of different references for you guys to be able to check out and through the different anatomy from human to human, the course of the medial cluneal nerve, um, does vary. So sometimes it’s going to be underneath this long posterior sacral ligament, and other times it goes through it. And other times it goes above it with patients that have had the medial cluneal nerve entrapment with the surgeons. What they’re, what they’re saying. And their research is that when the long posterior sacral ligament becomes two tense in certain conditions, it will entrap the medial corneal nerve as it exits from the [inaudible] underneath that ligament, or in some humans, it’ll actually go through that ligament.

So that would be the entrapment site in the ligamentous tissue. However, like we saw in the slide before we saw that, that medial cluneal nerve, as it exits deep in this ligament and then comes superficial cause it’s a cutaneous nerve and it goes through thoracolumbar fascia. So in one of the articles that are in the references, they actually talk about that as being one of the entrapment sites it’s strong and Divya in 1957, they actually talk about how difficult it was to go to find the medial corneal nerves, but they felt that the entrapment side was through that thoracolumbar fascia. And then with further research, I think a decade later is when they actually started seeing the possible trap this side of the long posterior sacral ligament. So there’s two and Travis’ sites for us to be able to consider with the middle cluneal nerves that can mimic or contribute to pain in the SIB joint region. So let’s remember that one.

Hey Matt, can I add something to this, uh, later on, uh, when we talk a little bit more about treatment, it’s worth that noticing the connection between the, um, long posterior sacral, uh, sacroiliac ligament and the sacred tuberous, like a mint, cause that’s all kind of one chain of, of continuous tissue. So the sacred tuberous ligament ligament goes from the issue of tuberosity on the kind of bottom of that image as starting right there and then travels up at an angle towards the sacrum. Um, so we might come back and mention that later. So just, this is a good image to see that. All right, thank you. Um, next slide,

We talked about the neuro travels through the superficial fibers and exits a slightly lateral to you be 32 and 34. So that would be our landmarks. So the entrapment site couldn’t be through that long posterior sacral ligament. That’ll be deep to that region and also through the thoracolumbar fascia as a possibility. All right. So in this very interesting study from, uh, Kono and atta, the middle cluneal nerve is associated with pain involving lower back and buttocks. It can mimic sake, really act joint pain. It creates sciatica likes sensations, which is really quite fascinating. Now, according to our research, the trapping of the middle cluneal nerves is underdiagnosed cause of low back and or lakes symptoms. And if you refer to this research, uh, what they found was in 13% of the cadavers that they dissected, they found that the, uh, middle, middle cluneal nerve was adhered and trapped underneath the long poster sacral ligament.

In fact, they teased out the middle corneal nerves in the middle colonial nerves. If we look at this pin had normal density on one side normal density on the other side, when the attract it was, it was really, really very, very thin. So that patient most likely had low back pain, which was an attribute from the middle cluneal nerve as fascinating. So 13% of the population. So think about how many people are coming into your office with low back pain, like said it’s a good routine thing to check for superior cranial, nerve entrapment, and middle cluneal nerve entrapment on this image. You’ll see, there’s an a, and then there’s a B. And what they did is they measured from the lower border of the PSIS and the posterior, um, the long posterior sacral ligament, which is a mouthful to say where approximately where that attracted is from the lower border of the PSIS. And on average, it was about one centimeter. It was about one centimeter, so that you can see why that entrapment would mimic sacroiliac joint pain because you’re right next door to the lower aspect of the sacroiliac joint. [inaudible]

All right. So Brian, we’ll go ahead and jump into this one together. I’ll start it off. So the Cardinal symptom of chronic low back pain with, or without legs symptoms, you guys, so this remember that it doesn’t always have to be a chief complaint of parasthesia, but it’s a good thing to ask if somebody talks about a little bit of numbness or tingling and they may not even be aware of it because it can be so subtle, um, into the butt off region or maybe down the leg. I’ve of course, if it’s going down the leg, we have to rule out a disc problem with the many different nerve tension test for sciatica. Um, common aggravating activities are going to be walking rising from sitting, standing flection and extension. So a lot of functional examinations are going to be important with this. Uh, patients often find that pushing above the iliac crest with their hand relieves symptoms of the superior cluneal entrapment. So that kind of body language you want to watch for, you can ask the person if they find that if they put pressure on their low back and they push down a little bit, if that helps, that would be a sign as a possible nerve entrapment.

Yeah. They’re kind of decompressing it themselves, right? Yeah,

Exactly, exactly. They’re decompressing and try to open up the, uh, Travis’ side. I mean, people can have this for years because it may be just low back pain of a two or a three, and then sometimes it gets really bad to a four or five. And how many people do you know that just don’t get treated with their low back pain thinking that it’s just an aging thing. So this is something for us to consider when that patient comes in. They’ve had it for chronic low back pain for years, definitely check for these nerve Travis’ sites. In addition to the other things that could be occurring, it could be sacroiliac joint problem. It could end up being a Yon syndrome where there’s a strain within that soft tissues. And we’ll talk about that a little bit more when we get into posture, which I think is in a few more slides, Brian, you want to take it from here?

Let me just, uh, dimension the, uh, leg pain aspects. And, and you can tell me if I’m correct on this map. And my understanding with that, first of all, the cluneal nerves, if you go back to those images, do travel through the gluteal region. Uh, they’re superficial at that point, but they’re traveling in the adipose to, in route to the skin, uh, over glute max glute medius, depending on which, uh, which ones we’re looking at. Um, but the leg symptoms, uh, from my understanding, I think is more of a sensitization and, and a common innervation for other nerves that are traveling peripheral nerves that are traveling down to the legs. So if it’s very, um, severe entrapment, then that can start to irritate the other, other structures in that same innovation zone and, and cause pain in the legs. That’s my understanding of it. Does that match, match your, your, um, understanding of that, the leg symptom, uh, component of it?

Yeah. Cause it makes sense. I mean, it shares the same sciatic nerve distribution of being L four down to S3. Yeah.

Yeah. And especially the middle cluneal nerves, which have a lot of, uh, innovation of the legs. Yeah. So, um, looking at, uh, uh, pelvic imbalances, if there’s an elevated ilium, uh, anterior tilt, uh, is, is often associated too with it because of the shortening that can happen in the thoracolumbar fascia with that, of course a posterior tilt is going to kind of overstretch that, um, that same structure. So it wouldn’t be unheard of to have a posterior tilt of the pelvis, but those are the things to really note and notice with, um, with, uh, uh, cluneal nerve entrapment, regardless if we’re talking about the superior or the middle colonial nerves, just because those, uh, postural imbalances and we’ll look at an image for this to kind of highlight it. Those are gonna put extra tension on, on the ligaments, the, the, uh, posterior, uh, sacred iliac ligament that we’re talking about, the long posterior sacral ligament, um, but also the thoracolumbar fascia and how that tension patterns are then going to relate to a propensity to entrap the nerve.

So when we get to an image on that, we can highlight some of those aspects. Uh, as we both mentioned, this could be the cause, you know, this could be what, uh, is the, the, the main pain generator for a patient. Um, it could be like number one, but you know, it also can be just a component of a series of things that are kind of coalescing in the same area, and that can cause pain. So it doesn’t have to be an all or none type of type of thing. Like Matt mentioned, I think 20 or 30% of it might be coming from the clinical nerve irritation and entrapment. So it’s worth checking for, uh, do you want to talk about assessment mat

With it? I think the next slide we can jump into and kind of get into a little bit more. Yeah, there we go.

Yeah. So here we have that image of somebody with an elevated ilium. So you can look at and see that the person has an elevation on the left. So sometimes we call it a left, elevated ilium. Sometimes we refer to that as a right tilt of the pelvis because the whole pelvic structure is tilting to the right. The top of it’s kind of pointing to the right, but the left side is high. And that’s the main thing to notice. So with that, there’s going to be a lot of shortening and things like the quadratus lumborum iliacus Talis lumborum, those are all, uh, kind of intimately associated with the thoracolumbar fascia. Um, so that’s gonna, uh, tend to, uh, correlate with more of a propensity for entrapment of the, um, cluneal nerves. I would tend to see it more often, see it on the side of the elevation, but again, just those changes are going to change the tension patterns on both sides. Really. So the fact that that, that the tension patterns are changed and disrupting the, uh, the, uh, uh, normal sort of, uh, even balance, uh, in the pelvic and low back region that, that elevation of the Lem could really be a big factor for, for people. Um, of course it’s not the only one.

Yeah. So at the takeaway with this, I believe is to make sure that you are addressing the pelvic imbalances, which will then help with the soft tissue imbalances that are in trapping the cluneal nerves, as well as causing a sick really act joint problems or Yon syndrome, or the other many other causes of low back pain, something of which that we spent a heck of a lot of time in module, two, trying to be able to teach people how to be able to balance these. Because when you think about it, you want to balance that dantien your center of gravity. And then by balancing that pelvic curdle that changes the balance above, and it changes the balance. Yeah.

Now this particular patient, uh, I can’t tell looking at them, especially from the back, uh, if there’s an anterior or posterior tilt, um, sometimes visually you can see that it’s a little easier to get in and palpate, uh, to, to, um, feel landmarks like the PSA. I S N a S I S and look, we have a particular protocol we teach to measure that that’s a little bit more accurate than just glancing. Same with pelvic rotation. That’s a somewhat of a visual assessment, but it’s all, it’s really more of a palpatory assessment, but this particular model, you can definitely see the elevation of the Lem. Cool.

All right. So then now the second to last bullet, did we cover? Yes. So, so the third to last bullet where it says cluneal nerve and trauma can be a contributing factor along with other causes of low back and leg pain. Absolutely. So when you’re diagnosing what is causing that person’s low back and leg pain simply, and this is the assessment. One of the assessments is simply taking your index finger or your middle finger, and just tap firmly, firmly, right over the area of Jalya where the superior cluneal nerves could be in tract. It’s like a tunnel sign. Alright, just tap very thoroughly all around that region, even onto the PSIS, where the traffic could happen, then move down level with you be 32 and you’d be 34, do the same type of tapping. What you’re looking for is the patient have any pain with that is a reproducing, the pain that they’re complaining about, is it reproducing any of the parasthesia that they know about, or maybe they don’t about it? Like if you’re, if you are tapping on there and it’s causing that, parasthesia consider that the nerves are entrapped and they are contributing to part of the clinical picture here. Brian was anything.

Yeah. Even before that, you might not have gotten to the point where you, you think about doing a tunnel sign there, but you’re just palpating. You’re kind of going through the process of figuring out where the cause of the low back pain is and trying to diagnose what the, what the condition is. And you go to palpate, maybe you think it’s an SSI joint, um, uh, it’s SSI, joint pain, and you go to palpate that PSIS region. And even with superficial pressure, you know, you barely, you’re definitely not pressing past the subcutaneous tissue into the deeper muscular structures, but when you start getting that superficial, uh, pain, that’s a little bit more pain than you’d expect at such a superficial level. That’s if I haven’t already been considering cluneal nerve entrapment, that’s a, that’s a point at which I’m definitely starting to think about it because it’s, uh, it’s, they’re, they’re cutaneous nerves. So you don’t have to press particularly hard to elicit pain if they’re irritated and then going from there to the tapping for a Tinel sign might be a consideration that’s, especially the case with the superior ones, you know, with the, the middle ones, the, the entrapment can be a little deeper if it’s at that, uh, ligaments. So that may or may not be quite the case, but if it’s irritated, uh, uh, at a periphery from that entrapment site, you still might get that elicit that, uh, very superficial pain.

All right. Should we go into a couple of needle techniques we could use? Yeah. So these are some images from the sports medicine acupuncture textbook on the left-hand side, you’ll see four arrows. Those are different vectors angles that we’ll use to palpate to affect the, um, iliac joint region. So the needle is going to actually be going into ligamentous tissue and the deep [inaudible], but let’s talk about the arrow that’s on the very bottom. Now that particular direction there, if you remember that direction is going to be very, very close to where the entrapment site of the middle cluneal nerve in the long post of your sacral ligament would be. So you could take your finger underneath that. PSIS approximately one centimeter go directly anterior, and then push upward toward that PSIS but deep angle it toward the sacroiliac joint. Now that’s really very, very tender and maybe even causes some parasthesia again.

Then you could be able to consider an entrapment site, and that would be a needle angle that we could choose. So going in with a three inch needle, or maybe a two-inch needle going into that Oscher point that we just diagnosed through palpation stimulating. Now, what you can do as well is to rotate the tissue around the needle. So turn the needle 180 degrees, 300 6720 degrees in one direction, as long as the patient’s. Okay. And then gently just pull up to loosen up that tissue with the idea, the intention of opening the area of the entrapment site. Of course, always to patient comfort. Uh, patients usually really liked that area because a deep, deep massage really doesn’t get to it, but that acupuncture needle can get to that region. So that’s one needle technique that you can use, but remember, that’s just one spot and this area is associated with the urinary bladder primary channel, and also the sinew channel.

So remember to link points that will address this region. So your adjacent and your distal points as well. Now you’ve got the images on the middle here on this slide and also in the lower right. That’s going to be looking at Yon. So the finger, you can see the middle fingers pointing right toward where that superior cluneal nerve can be entrapped. So that’s really quite tender. You can kneel that with your three inch needle. Um, the lower right-hand side is going to be kneeling in that level. And then as we discussed in the smack program, and this was Brian’s finding that this particular level is going to be more about the urinary bladder, send your channel, and if it would happen to be deeper, it’d be more about deliver channel Brian. You want to take it away? Uh,

Yeah. So this is another one that that needle technique by itself, uh, is great. And, um, I think what Matt was alluding to was if we’re at superficial, uh, pressing into Yon, we might, we’d be pressing into the iliacus Dallas, uh, muscle, which is also a potential, uh, site of pain in and of itself. But, uh, that could be putting excess tension into the thoracolumbar fascia. Um, and that would be more online with this new channel associated with the urinary bladder. So we might link it with, I don’t know, biceps, remoras, motor point, maybe beat channel points. We could try distal points and then go back and palpate that area and see if it reduces pain. If we go a little bit lateral sink in and go deep back to that same point. And we were at the quadratus lumborum attachment quadratus lumborum is on the myofascial plane that is continuous with the iliacus and into the abductors.

So it’s part of the liver send your channel. Uh, liver five would be my go-to point for that, but again, you can try different points and see if, uh, if that helps reduce pain at that site. Um, those, those are, those could potentially be vectors for the muscle pain, but those would also be associated with tension in that region. Um, when I, when I think that there’s, um, cluneal nerve entrapment, sometimes I do one vector like that, uh, just as being shown and I’ll do another vector above and trying to actually touch the iliac crest, kind of like two needles meeting at the same point and do it just what Matt mentioned with the middle Glendale nerve, where I’ll, I’ll, I’ll twist the needle to comfort to get the needle stuck purposely. You know, if you let it sit for awhile, it’ll, it’ll be able to come out, but you want to be able to get it a little bit, uh, wrapped around the tissue so that I can pull both of those needles in opposite directions. You know, one superior the other lateral to help decompress and open that area up. Maybe even a couple needles in, in that, uh, that region might be useful that way, but that would be by patient comfort. And you have to keep in communication with your patient.

Chinese needles are usually the best for that. Some of the, um, the Japanese or Korean Neil’s needles that are coded doesn’t wrap the tissue as well. So, um, our favorite needles for that is watchtowers. And you get the, watch us from LASA RMS. That’s good. Um, we’re about to show you. We’ll be,

Uh, Matt, since I let’s go back just for a second, since we’re mentioning, we both mentioned that, uh, usually you let the needle sit for 10 minutes or however long you’re going to have the treatment. They come right out after that time, but it’s always good to note which way you’re rotating the needle in case there is an issue and you have to D rotate it. Do you want to remember, oh, I did a clockwise. I needed to D rotate a counter-clockwise. So just, uh, to make a note of that is, is useful.

One more thing for me now is that after that needle technique, now this is not just an allopathic needle technique. This is going to be a needle technique for decompressing, that nerve entrapment in the region that you leave with that we’ll be communicating with all of the rest of the needles that you’re using during that treatment. So just to be clear, we’re not going in and doing the different needle techniques and then taking the needles out. That’s actually part of the treatment it’s going to be communicating with the channel systems. Just want to make sure that that was clear, uh, before we go to the next one. So we’re going to have two videos right now. These are some myofascial release techniques that are really very useful to use after the needle techniques. These techniques are going to be taught in the assessment of treatment of the channel sinews module two coming up in September. So these are just two of the, uh, mini techniques that we’re going to be teaching in that weekend class. Um, very useful for, uh, low back pain. And also in particular, these nerve entrapments. Brian, can we just go for it? Yeah, sure.

So this is a very simple technique just to spread and, and descend the tissue or the erector spinae as part of the urinary bladder sinew channel. A couple of considerations though, is as we’re spreading down the urinary bladder line, when we get to the iliac crest, we have a couple options. If the patient has an elevated ilium, may hike your Liam up. We might work a long, the iliac crest to be able to descend that tissue, but also to help, uh, push the helium down. In addition to that, a posterior tilt moving from medial to lateral will help sort of put the tissue back into a place. That’ll take them into an anterior tilt. So either posterior tilt or ilium elevation, I can take that tissue then to, from a medial to lateral position, they have an anterior tilt. I might gently come over the ilium, just being sure not to push into the bone and then descend down through the fascia over the sacrum. We’re going to find a good starting place somewhere around the inferior angle of the scapula. I want to be careful not to dig my elbow into the spine, but I’m going to be pretty close to the Lima, but the bulk of the pressure is going to be along the urinary bladder line sink in, and then slowly spreading downward [inaudible]

Patient movement. They can just gently take a nice deep breath and breathe in to the pressure

And exhale [inaudible].

And again, when I get closer to the OEM, that’s when I need to make a decision based on my assessment to either spread along the top of the iliac crest, going medial to lateral or in this case, I think I’m going to be careful not to dig my elbow into the bone. And I’m just going to continue downward to take the pelvis or influence the pelvis into a posterior tilt. Yeah. I can have the patients slowly talk to the pelvis under and relax one more time and track the glitch. Just try to slowly, just a little bit tuck under. Yeah, there you go. And that feels like a good place to exit.

Okay. It’s a very nice technique, especially after Neely needling in that area and helps reduce any kind of needle soreness. And then we have another one coming up, which is in particular really great for the sacrum and middle cluneal nerve. Brian, do I say anything before we jump into it? Nope. I

Think it’s about to start anyways. Or maybe that’s that play? Yeah, I think the video will describe it pretty well.

So it will be well working on the attachments of the glute Maximus, especially the sacral attachments and just that spreading and moving kind of softening the attachments along the sacrum. Very nice technique. Uh, we can adapt the technique to somebody who has a posterior and anterior tilt. This model. We have an anterior tilt, but I’m an exaggerate. The anterior tilt. You can imagine with that, that it’s going to be much more effective if I move that tissue away from the sacrum. Yes. But also downward to help encourage more. Posteriority tip the pelvis. Conversely, if somebody has posterior telecon tuck your pelvis under. Yeah. And in that case, you know, if you were working in that same direction, it’s going to encourage them more into a posterior tilt in the RDR. So it would make more sense to come from a different angle and help lift the tissue to help encourage more anteriority to the pelvis.

So we can adapt that general direction. But in both cases, you’re moving the tissue away from the sacrum, either away and down kind of lateral and down or lateral and up. So we’ll start with lateral and downward. I’m going to set a little bit out at the edge of the table. My side is towards her, so I can gently let my body sink into the tissue, using the elbow. Also a little bit of the proximal, although I’m going to go right to the sacral attachments, think perpendicular and then spread slightly lateral just to distract the tissue away from the sacrum, an inferior. I might have the patient gently and slowly tuck the pelvis under just the small movements, adequate good and relax, move slightly downward, get another area of the tissue sink in, talk under and move. That movement that you’re doing is going to help them talk the pelvis under relax [inaudible] and slowly, gently talk under

[inaudible].

So in some instances you might, especially with an anterior tilt, you might add to the technique I put in the patient into sort of a crawl position. And you can see in this position, that’s going to encourage even more of a posterior tilt of the pelvis. So I can do similar technique here. Again, similar technique with them in this position. And the position itself is going to encourage more of a posterior tilt

[inaudible]

And I might hold a little longer in this particular position.

[inaudible]

Okay. That was great. So with that crawl position, you could see that the long posterior sacral ligament will then be slackened because the attachment sites were brought together closer. The PSIS went into a posterior tilt and his Brian’s elbow was right there. Pretty much level with S two S3 S four region. So what a great technique for sacred iliac joint problems, as well as if you are suspecting any kind of, of middle cluneal nerve entrapment, Brian, anything you want to say before we do our conclusions?

No, I think, uh, I think we’re, we’re good. Um, just the fall assessment really to differentiate what’s causing the pain. Is this a contributor or is this really a sacred iliac joint problem or is this a facet joint problem? Um, thoracolumbar junction syndrome for me is one that’s really tricky to differentiate between just because of those nerves can also be involved in thoracolumbar junction syndrome, but they’re involved, uh, not as they exit the thoracolumbar fascia, but they’re involved, uh, in route to, to that region. So those are, those are a little trickier to differentiate, but looking at all, differentiation for all of those really ruled out which one is, or, you know, figure out which one is really the pain generator is important.

Yeah. A thorough differential diagnosis. Yeah. With through sports medicine assessment, and also through TCM, which is something that we do in sports medicine, acupuncture certification program. So you guys, if you like our education, please come join us at www.sportsmedicineacupuncture.com. You can also reach out to Patricia, which is, uh, through email AQI sport info@gmail.com. Um, I believe that’s going to be wrapping it up for us. You guys thank you so much for staying the extra time. I know that these are only supposed to be a half an hour, so thanks for the extra time and also come back next week. Cause we have Chen Yen coming in. Who’s going to be discussing a lot of great things. So, uh, Brian, it’s always a pleasure. Thank you so much. We want to thank the American Acupuncture Council for having us. Thanks for much you guys. And we’ll see you again soon. Yeah. Have a great day, everyone. All right. Bye