Reflections from the Cadaver Lab: Week 1 Day 3

Reflecting on my third day teaching this year's Cadaver Lab.

Things really get moving on day three. The specimens are turned back to supine and we are now differentiating structures so that we can view the musculature and expose neurovascular structures such as those in the femoral triangle, anterior neck, axillary region and down into the extremities. Here are some thoughts from today.

1. Possibly the biggest roadblock people doing dissection for the first time (really, the first several times) is that, after successfully reflecting the skin and subcutaneous layer, they stop at the hands, feet, pubic area and groin, and the face. This is because these areas are more difficult to dissect and they have a complex anatomy. The problem is that, as you progress deeper, you can't follow the structures fully. For instance, if you don't reflect the skin and adipose at the groin region, you can follow the adductors to their attachments which makes it more difficult to differentiate them. Or, if you don't reflect the skin and subcutaneous tissue on the hands, you can't follow the wrist and finger flexors in the arms to their attachments, This then makes it harder to differentiate the structures which becomes more and more difficult the deep you go.

   This problem becomes apparent on day three. It is always a problem, but I have to say that the class did pretty well with this. I prepared them for the problem with a simple example. I had several shirts on and a hoody. I first took the hoody off, but kept the hood on my head and the sleeve on my right arm. In other words, I didn't completely take it off. Then I proceeded to take of the next shirt. Obviously, since the hoody wasn't removed fully, I couldn't take off the second shirt all the way. Each successive shirt become more problematic.

   I feel a similar problem can occur when working with patients. There can be a tendency to use a needle to release tension in a deep structure. But sometimes we need to unwind tension in the outer, overlying areas to allow the deep structure more room to release.

2. When differentiating structures, you start to use the scalpel to introduce more movement in the natural planes of movement. This means that you are cutting fascial crosslink between muscles along the natural sliding surfaces. One thing you immediately see is that the muscle becomes loose and floppy which causes it to sag and loose the relationship with other structures. Freeing the crosslinks between the sartorius and underlying quadriceps, for instance, cause it to sag and allows you to move it to see underneath. Seeing this over and over has changed how I work. While we don't want our patients structures to loose integrity and the need these crosslinks between muscles, I do find that I work much more in these fascial spaces, especially with manual work. Encouraging movement in these fascial spaces can have a significant impact on the movement potential of the muscles connected by these crosslinks.

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Reflections from the Cadaver Lab: Week 1 Day 2

Reflecting on my second day teaching this year's Cadaver Lab.

For description of this series and reflections from Day 1, Click here.

On day two, we flip the donors into a prone position and reflect down to the layer of the deep fascia. For this particular five-day lab, the PA students spend the first half of the day on surface landmarks and suturing. So we only have a half day in the lab doing dissection. Here are some reflections from this day.

1. I got to practice suturing on the cadaver. This is something that is in the scope for PAs and the dissection lab is a good place from them to start the transition from suture kits to eventually a live person. Obviously, suturing uses a specialized needle. It seems like acupuncturists should be able to do this under our scope. I think as more acupuncturists work in hospitals, this would be a good skill to have and would put them more in demand.

2. When I show students how to uncover the medial plantar fascia, I describe using the scalpel to cut from the posterior calcaneus and have the blade skim the plantar surface of the calcaneus. The blade then continues directly over the plantar fascia as it removes the skin and adipose. You can use a similar method with palpation of the plantar fascia. You can palpate from the medial side of the foot and feel where the plantar surface of the calcaneus is. As you move more distal past the calcaneus, you would then be just inferior to the depth of the plantar fascia. This gives the depth of where to palpate for plantar fasciitis. However, I often find pain much deeper than this and feel that many times our patients presenting with plantar fasciitis, often are coming in with pain at the quadratus plantae muscle.

3. The scalpel and the dissection process directly relate to palpation skills. This is not just due to being able to see the structures we work with in dissection, but how you use the blade to uncover layers. One obvious aspect is that, when removing tissue over a muscle, it is best to sweep the blade perpendicular to the muscle fibers. If you sweep the blade parallel to the fibers, it is much more likely that the blade can find the grove between muscle fascicles and go too deep. You can try an experiment yourself that demonstrates this. Sweep your fingers pads of one hand perpendicular across the fingers of your other and notice how the finger pads glide over the fingers. Then do the same in a parallel direction and notice how the pads find the space between fingers and can easily go deep. This is one reason why it is so much easier to feel a muscle when you palpate across the fiber direction. However, when using a blade, you can direct the pressure too deep and start to cut into a muscle or you can come out too superficial and loose the fascial plane. The same can be said with palpation, You have to find the depth and then keep a consistent pressure or you will go too deep or retreat back too superficial and loose the structure you are palpating.

   There is something else that the blade teaches you that expands on this idea of depth. I am going to use an example from day one. When you are reflecting the subcutaneous tissue of the thigh and following from the anterior thigh to the medial thigh, the blade follows the contours of the thigh over the quadriceps. However, you have to anticipate the sartorius muscle or the blade can easily follow this contour and go under the sartorius and cut into it. When you start to see the sartorius, you need to direct the pressure more superficial and over it. This is the same for palpation and I find practitioners struggle with palpating this muscle for the same reason. As you follow the contour of the thigh going in a medial direct, you need to anticipate this muscle and not push your fingers under and deep to it.

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Reflections from the Cadaver Lab: Week 1 Day 1

Reflecting on my first day teaching this year's Cadaver Lab.

The first two weeks of every December, I teach two back-to-back five-day dissection labs with the Physician Assistant program at the University of Tampa. When I teach this class each December, I attempt to share some thoughts at the end of each day, but this does not always happen. Dissection takes concentration, and when you are in a teaching role for 24 students, you are tired at the end of the day. This year I will follow through and will keep it simple to make sure I stay on task.

Day one involves some identification of surface anatomy and some time with use of instruments, so it is a shorter day of dissection. We start with reflection of the skin on the anterior portion of the body. At some point, we proceed to a slightly deeper level and reflect the superficial fascia and reach the level of the deep fascia or fascia profunda. Below are some thoughts for the day:

1. When looking at surface anatomy and noting surgical scars, many students become curious and potentially excited about seeing surgical procedures, especially joint replacements. This is perfectly understandable, especially for healthcare providers. However, I am always struck by how much more complicated and sophisticated the human body is compared to manufactured hip or shoulder. These devices have become much more sophisticated over the years, but they are nothing near the original. Even in a pathological joint, the evidence of the intelligence of the body is on display in the attempt to adapt to injury. I think that the real thing is so complex it can be a bit overwhelming, and when we are new to dissection, we can potentially miss so much that we can't fully appreciate it. You need to see many, many dissections to start to understand the tissue. Having said this, I find it very interesting to see replacements and the effects of other surgical procedures. But, I am more interested in seeing how the body has adapted to this new device or procedure.

2. At any level of dissection, you are studying movement. I don't need to state the obvious that the donors do not have an intact nervous system, so what can one learn about movement from this process? The answer lies in the fascial sliding surface in the body. Muscles, nerves, blood vessels, lymph vessels, organs, and really all of the body surfaces are connected to one another through fascial crosslinks. When you are introducing your scalpel into these fascial spaces between structures, you are assessing the movement potential between these sliding surfaces and how easily they move in relationship to one another. On day one, when you are removing the skin, you see a difference immediately between different donor bodies. However, there are regions where the skin is much more adhered across the board. The knee, for instance, is like this, especially the medial knee. The adipose is much thinner, and the skin is much more tightly bound to the underlying tissues. While we have ligaments to support the knee and the muscles also play a role, the skin seems to have a supportive role, much like a knee brace.

3. The adipose varies quite a lot in color, ranging from almost a whitish-pale color to yellow to bright orange. Generally, the paler color is on donors who have much more fluid in the tissue space, whereas the dark orange tends to be on leaner bodies with dryer tissue. For the next two weeks, I am teaching Physician Assistant students, and I have a far easier time discussing these color variations with practitioners of Chinese medicine since we have a system to understand things such as Yin deficiency with deficient heat and Yang deficiency with water overflowing.

4. The platysma is such a cool muscle!

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The Dai Mai and the Lumbar Plexus

What is it about the dai mai that would make a gallbladder channel point (GB 41 zulinqi) have such an influence on it? Or, stated another way, what is it anatomically that connects these? I feel there is a relationship when you look at the neuromyofascial anatomy. 

Dai Mai: Channel Images from A Manual of Acupuncture, by Peter Deadman

KID Luo

I hear many people say that the transverse abdominis (TrA) is the dai mai I think this is not too far off, but it is not technically correct. Interestingly, the TrA is one of the girdling structures of the core and is, in my opinion, a muscle associated with the kidney channel. For ease. I teach that it is part of the kidney sinew channel but actually the kidney luo-connecting channel describes this anatomy the best. The luo channel follows the primary channel in the abdomen. The depth is not described, but it is likely at the depth of the TrA which is the deepest abdominal muscle. The channel then follows as the TrA connects to the diaphragm. which takes it all the way to the central tendon of the diaphragm. The central tendon is a point just below the pericardium, as the pericardium attaches here from above.

The TrA also wraps around and connects with the lateral raphe. This fascial layer then separates into layers of the thoracolumbar fascia and connects with the lumbar multifidi. This is posterior to the spinal column and accessible at the huatuojiaji points. The TrA works with the lumbar multifidi to decompress and stabilize the spine. 

If I have convinced you that the kidney channel relates to the TrA, now we have three things that need to be connected. 1) the dai mai, 2) GB 41, and 3) the kidney channel. Fortunately, there is a really notable link to all of these and this is the lumbar plexus.

The lumbar plexus runs from L1-L4 and has contributions from T12 via the subcostal nerve. The subcostal, iliohypogastric, and ilioinguinal nerves all exit the lumbar plexus, wrap around the abdominal wall, pierce and innervate the lower portions of the abdominals such as the TrA, and obliques. and then become cutaneous.  To me, these nerves are a better representation of the dai mai. 

KID Divergent

Another link of the dai mai and lumbar plexus can be observed. The kidney divergent channel is said to intersect with the dai mai at L2. This channel traverses from the KID 10 region and travels cranially. The pathway, at least, the lower half, follows another nerve of the lumbar plexus which does come from L2. This is the obturator nerve. So, if the kidney divergent channel does have something to do with the obturator nerve (which I think it does) and the dai mai does have something to do with other nerves from the lumbar plexus (which, again, I think it does), then they literally do connect and intersect at L2. 

The final link is that the gallbladder sinew channel is a myofascial plane that runs up the lateral side of the body. It includes the obliques, which are muscles that are innervated from the nerves listed in the lumbar plexus. I think that it is a very plausible that acupuncture to the distal portion of this myofascial plane at GB 41 would communicate mechanical information in the channel, affecting the tone and tension in the obliques, thereby stimulating the nerve coming from the lumbar plexus and innervating these muscles at points such as GB 26 (the motor entry point of the internal obliques) and GB 27 (possibly also a motor entry point of the abdominals). 

I have taught this material at two conferences in 2022. The first was at the Neuroscience Acupuncture Conference and the recording is available through the Neuroscience Acupuncture Conference website.

I also taught a version of this class at the Pacific Symposium, but it was not recorded. 

Finally, the video below looks at activating and strengthening the gallbladder sinew channel, including the obliques. This is to improve the stabilization role of this channel, and balance the left and the right sides and, also the lateral and medial portions of the body. I will be recording another series for this channel soon that has more to do with the rotational role of this channel. While one series will focus more on stabilization and the other on rotation, They each have elements of both stabilization and rotation, You will see some rotation as I get my body into position to activate the channel. When you look at the biomechanics of the pelvic and spinal joints, you see how integrated these to movements are and this helps understand the role of the gallbladder sinew channel for both stabilization and rotation. This starts to highlight the dai mai and its coordinating role for these movements. 

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Scapular Training for the UB and the GB Jingjin

Scapular training is an essential component of bodyweight calisthenics training and qigong training. Not only do you want proper scapular stabilization when you are hanging or reaching overhead, but the scapulae need to have controlled movement to increase power with things like pulling exercises. The scapular movement also needs to coordinate with other muscles for efficient whole body movement. Let's look at this coordinated movement in relationship to the the Urinary Bladder and the Gallbladder channel sinews (jingjin).

UB Jingjin: Superficial Branch.
Deep Branch includes
spinal erectors.

A simple pull up serves as an example of the movement pattern of the UB jingjin. The lower trapezius and the latissimus dorsi both depress the scapulae and this motion occurs with other muscles of the back such as the erector spinae. If you are bringing the chest to the bar, this is especially apparent. Another example would be taiji when in mountain climbers stance. The chest would be up and there is a coordinated activation of the Urinary Bladder jingjin which activates the scapular depressors, spinal erectors and gluteus maximus.

GB Jingjin

Other pulling exercises would highlight the movement pattern of the GB jingjin. The same scapular muscles would be activated, but they would coordinate this activity along with the obliques and the hip abductors. The human flag would be a great example (see video below for an example). Also movements that would involve rotation such as swinging from monkey bars would require pulling motions engaging the scapular depressors along with trunk rotation activating the obliques. 

So these same muscles can be part of a global movement pattern of different channels. And injury of these muscles could be associated with different channels. Local treatment may involve motor entry points (MEP) and/or myofascial trigger points (MTrP) of these same muscles, but how you link this local treatment can change depending on the channel involvement. Check out the video I did to explore this dynamic.

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Mobility of the Lower Ribcage

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

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

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

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

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

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