Acupuncture and Traditional Chinese Medicine (TCM) theory can seem like a complete mystery to our Western-conditioned minds and often feels like a complete departure from what we know and are accustomed to. In this blog, I aim to use one particular acupuncture point to give some context to this mysterious topic and provide an understanding of how acupuncture functions both in the context of Traditional Chinese Medicine and modern health science.
What is Gallbladder 21?
There are a handful of acupuncture points that I use in my acupuncture clinic in York every day and JianJing, also known as Gallbladder (GB) 21 is one of them. It's a multipurpose point that I use for a variety of issues and conditions. Its uses are so wide-ranging that it can be difficult to comprehend how one small area of the body can be responsible for influencing such an array of issues.
Where is GB21?
This acupuncture point is located between the neck and shoulders, on top of the muscle. More specifically it is midway between the spinous processes and the acromium process, at the crest of the trapezius. Less specifically it's roughly the area that feels good to squeeze if we are stressed or have been working at a desk for a long period. The needle is generally inserted from the front or back of this point and angled to the opposite side. Needling straight down is generally avoided as it aims the needles towards the top of the lungs and although there is plenty of space between, it's better to be safe.
What Does GB21 Do?
GB21 has a long list of indications for treatment. Peter Deadman's 'A Manual of Acupuncture' states it's used for:
Neck stiffness
Neck pain
Shoulder Pain
Difficulty raising arm
Cough or dysponoea (shortness of breath)
Redness of the face
Difficult or prolonged labour
Breast Pain, failure of breast milk to flow
I can also add high blood pressure and headaches to this list, and its links to other aspects of the Chinese Medicine framework create a whole host of other issues, symptoms and conditions it can be used for, some of which will be discussed throughout this blog.
The Chinese Medicine Perspective
GB21 acupuncture Theory
Channels, Flow & The Exterior
As the uses of GB21 stated in A Manual of Acupuncture are based in Traditional Chinese Medicine (TCM) theory, the Chinese Medical perspective seems a good place to start. There are crossovers with Western anatomy and physiology which I will explore later in the post.
TCM theory is a fascinating and rich framework that would take lifetime to understand fully. There are however some basic concepts that may help you to understand the principles behind this acupuncture point's actions. One of the most simple yet important diagnostic tools is determining if the patient's issue is external or internal. If external, we are talking about muscles, bones, skin and soft tissue; if internal we are looking at emotional, digestive, endocrine or nervous system disorders to name but a few. You can of course have one influencing the other. When thinking externally, we use the TCM channel system to locate, track, explore and treat an issue.
The channel related to the Gallbladder starts at the outer point of the eye, moves up the forehead then zigzags across the side of the head before moving down onto the top of the shoulders where GB21 is located. From there it continues down the side of the torso to the waist and follows the outer aspect of the hip, leg, and foot before ending on the outer aspect of the fourth toe.
Why Gallbladder? Well, that's because each external channel is named after and connected to one of our internal organs, and acupuncture points on each channel are related to the functions of that organ. It's worth noting that the TCM internal organ doesn't always match the functions and purpose of what we know the organ does from our Western biomedical knowledge, but if you can forgive thousands of years of translation through several different languages, plus a bit of metaphorical language thrown in, then it all does make sense once you have all the framework together.
There are 12 primary channels in total, and it's through these pathways that Chinese Medicine states we have a flow of energy or qi. If it's a difficult concept to get your head around then just think of this flow of qi as a metaphor for our blood circulating around our body, our lymphatic system destroying old and abnormal cells, the peristalsis of our digestive system, or how our thoughts flow throughout the mind and affect our mental health.
An ancient Chinese proverb states "If there is pain, there is no free flow; if there is free flow, there is no pain". No flow is also known as the TCM diagnostic term - stagnation. Using the previous examples, this could lead to constipation and/or pain in that area if there is no flow in the digestive system, whereas if our thoughts get stuck or stagnated it can lead to overthinking or obsessive thoughts that give us mental anguish.
In the context of the Gallbladder channel on the exterior of the body, we most often view stagnation as pain in muscles or soft tissue, or an imbalance between different structures of the body. If we think about it, when we bash our leg we can break the tiny capillaries in that area which then bleed under the skin and cause a painful bruise. That bruise is physical, visible stagnation, and the flow of blood through the area of the capillary network is interrupted. Similarly, when our muscle fibers get shortened and taut, a knot forms. This muscular knot is a stuck-ness of this portion of the muscle, and prevents the blood flowing through the area as easily and the muscle moving freely.
Where GB21 lies is an area where muscular tension often sits. Whether it be from sitting at a desk, a stressful period or painting a wall, this is often the area we reach to and squeeze when we feel we have overused or underused it, or feel particularly stressed. That squeeze is moving stagnation and creating flow, and it usually feels great. Inserting a needle into GB21 is doing the same, but in a deeper, more targeted way.
Put simply, every needle that is inserted creates flow and moves the qi in the channel. Given the pathway of the channel, it makes sense that the first uses stated for this acupuncture point are related to pain and lack of movement in the neck and shoulder area. GB21 is also related to the area the trapezius muscle spans which we will look at a little later.
In true TCM tradition, things don't stay simple for long. By following the primary channel we can track pain and 'stagnation' in that area, however as the acupuncture system is a holistic practice, everything is connected. This means that the primary channels have connections to other TCM channels and organs.
In the case of the Gallbladder, it is primarily linked to the Liver organ (remember that for later), but more significantly for this section, Gallbladder 21 is a crossing or intersecting point for itself and two other channels, the San Jiao (Triple Heater) and the Stomach channel. It is also a crossing point for the Yang Wei Mai, an Extraordinary channel. The Extraordinary channels have their own set of functions and properties that differ from the primary channels and aren't directly related to an internal organ, more to broader functions or concepts in the TCM framework. The meeting of all these channels at this point means that in certain instances GB21 has an influence on the full pathways of all these channels and functions of their corresponding organ, adding symptoms such as ear-ache, hearing loss, breast pain, colds and flu, and certain types of headaches to our list of potential issues GB21 can be used in conjection with other acupuncture points..
As already alluded to, the primary channels are not the only channels. There are numerous versions of each channel that either operate at different depths, with different functions or provide as a connection between its organ or a paired channel. One of these additional channel networks is the Sinew channels. These channels are related to muscles and connective tissue, as well as being the first line of defense against pathogens. On this basis, one might argue that painful conditions linked to muscles and soft tissue such as shoulder pain and neck stiffness should be linked to the sinew channels rather than the primary channels, and I'd have a tendency to agree. These pathways are broader and more superficial, so work very well when analysing painful issues and integrating Western anatomy into the diagnosis. Notably, the Gallbladder's Sinew channel transcends the neck and shoulder area, but also diverts through the chest. Along with the crossing of the Stomach channel which also passes through this area, Stagnation in the Sinew channel explains why breast pain and difficulty expressing breast milk are included on the list of symptoms GB21 can treat.
Why is internal pathology so different in Acupuncture Theory?
While the notion of the exterior channel pathways, and how they relate to muscles and soft tissue is a relatively easy concept to visualise, the TCM ideas of interior pathology are a bit more of a departure from the Western biological knowledge of how our body functions. Sadly, the 'master-and-apprentice' transition of knowledge has left big holes in understanding why certain acupuncture points were chosen for particular functions when acupuncture theory was developed thousands of years ago. Also, unsurprisingly the seminal Chinese Medicine texts do not speak about ideology in the context of modern Western medicine and anatomy due to culture, technology and comprehension simply not facilitating it.
A little bit of history
Chinese culture deemed the body to be sacred and therefore forbade dissection. On this basis, it's widely thought that the early principles of TCM were developed without direct knowledge of the internal human body. The oldest known anatomy text was discovered in China and is dated around 300BCE. Entitled Mawangdui, it maps the body as having 11 divisions, each of which relates to specific patterns of disease and matches the pathways of 11 of the 12 primary channels. It also contained some depictions of the human body which would have been impossible to know without opening a body up, and further investigation reveals that criminals of the era were not seen as quite so sacred, often being subjected to mutilation for the benefit of science.
The 11 divisions curated in Mawangdui, with the addition of a twelfth, were then published in the Neijing - a text that holds huge significance in Chinese culture and history and is the basis from which TCM is derived. While this mapping of the body differs largely from modern anatomy, parallels between this system and muscular, fascial and nerve pathways are present, albeit not always precise. Furthermore, the theoretical connections between these divisions and our bodily systems, disease, and illness are staggeringly accurate in many cases.
The rationale behind the depictions and theories in the Mawangdui and Neijing are still somewhat of a mystery. Perhaps years of trial, and error and experimental treatments, or perhaps some lost knowledge that was never preserved. Whatever the case, as an acupuncturist you have to throw a bit of faith into the mix when utilising these theories, but when you see patients benefiting from your treatments, that faith is repaid.
One such theory is the descending function of GB21. As previously discussed, we want a nice flow around the body whether that be externally around our channels, or internally around our internal organs. One important thing to consider is that we want that flow to be travelling in the correct direction. To explore this idea further, we need to delve into a little more Chinese Medicine theory...
Yin & Yang: The only metaphor you'll ever need.
Even though TCM theory can get complicated, Yin and Yang is the reductionist ideology that underpins the whole TCM system. The symbol of Yin and Yang (pictured below) shows two opposite colours taking up 50% of a circle. Each colour encroaches on the other's half, symbolising a spectrum and balance between all things - for every action, there is an equal and opposite reaction. Sound familiar?
Newton's third law is a perfect example of how we cannot have one thing without another, there is always a cause and effect. A more classic example is how we have night (yin) and day (yang), but we also have dusk and dawn, the transitions between the two - we even have the odd eclipse, which turns day into night! The examples go on: movement is yang and stillness is yin, hot is yang and yin is cold, up is yang and down is yin, male stereotypical characteristics are yang and females are yin; and there is a spectrum between each of these examples. TCM theory is all about finding that balance between two opposites and making sure our bodily systems are not working too much or too little, working harmoniously in conjunction with other systems, and flowing smoothly at the right speed in the right direction.
So, to bring this back around to GB21 and its descending function: Up is Yang, so if we have a symptom that we assess is ascending in nature and we want to encourage descension, we would use a point such as GB21, dependent on where that ascending symptoms is affecting. We would also use other points to create a better balance between Yin and Yang. It may be that there is too much Yang in the system and we need to get rid of it, or it may be that there isn't enough Yin in the system to provide enough downwards force.
With this idea, you may have to take one of the little leaps of faith as we can't physically see the descending action of GB21, just like we can't see qi or the channels neatly napped out of the body. However, we can see the effect of this descending action in the improvements of our patients so we use it as a metaphor for the physiological effects this acupuncture point has. It's a bit like the theory of gravity vs dark energy. Gravity is pulling objects together, whereas dark energy drives things apart and is responsible for the constant expansion of the universe - opposites. We can measure the results of gravity, but we can't see it, and we know very little about dark energy other than it is the opposing force to gravity, and there's a lot of it. Yet most believe that it exists and that it is fundamental to the existence of our universe.
If we use the metaphor of a descending function we can explain some more uses for GB21:
Red Face: We would associate redness on the body as heat - heat is yang, and heat rises upward.
Shortness of Breath: Air should move downwards into the lungs. If we are unable to breath deeply we can encourage the descension of the air with GB21.
Cough: Coughing is our reflexes sharply expelling air upwards - it's quirkily known as 'rebellious qi' which we want to keep descended.
Difficult Labour: A baby needs to move smoothly down the birth canal, we can aid this with GB21's descending function. It's also why this point is contraindicated in the early stages of pregnancy as we do not want the descending action at that point.
There is also a lot of discussion about using GB21 for people who hold a lot of frustration and/or anger. When we feel these emotions, we can feel them bubbling upwards or like a pressure wanting to escape, both very Yang in nature. The descending action can help with this, but also has another connection with these emotions. As mentioned earlier, the Gallbladder is paired with the Liver in TCM theory. The Liver is responsible for the smooth flow of emotion (especially anger and frustration), and without the flow, the emotions can become stagnated or stuck. If our internal TCM organ is dealing with something, it can often display symptoms on the paired external channel. In this case, the internal anger and frustration (hosted by the Liver) is manifesting in the Gallbladder channel. It manifests particularly at GB21 as it is the meeting point of the Stomach, Gallbladder, San Jiao and Yang Wei channels, which are all Yang channels in nature, and it is the point where excess Yang collects. As a result, having GB21 needled can often feel like a release of pressure across the whole body.
The final symptom from Deadman's list of symptoms is loss of speech. The mechanism for this point once again has some extra theory needed to explain fully, but for the sake of brevity I'll keep it short. The Liver we know is responsible for smooth flow, and if the flow isn't smooth stagnation can occur. If we think of this in the context of body fluids, this lack of movement coupled with some heat causes the fluids to dry out and become more viscous. This is another metaphorical idea that causes stagnation in the body, and depending on how much we consider fluids to have dried out, TCM refers to it as either damp or phlegm. How this links to GB21 and a loss of voice would take a bit longer to explain but just know that this damp or phlegm can lodge in the throat and cause stagnation of the voice. I'll be honest, if someone came for treatment for a lost voice, this theory and GB21 wouldn't be the first that came to mind but the holistic nature of TCM means there are numerous ways of interpreting the same symptoms depending on what other signs and symptoms are present. This is why thorough questioning is paramount when determining which acupuncture points to use. It's also worth noting at this point that GB21 alone may provide some relief of symptoms, but the likelihood is that a range of points will need to be used to support the treatment and deal with all aspects of a patient's imbalance; whether that be energetic imbalance or musculo-skeletal imbalance.
How Does GB21 Fit Into Modern Medical Knowledge?
The acupuncture TCM theory we have looked at is a different way of looking at health. I see it as a way to describe and explain our body's anatomy and function figuratively, the only way they could thousands of years ago when these theories were developed. We now have a much more advanced map of the body and its functions and have been able to analyse and dissect each part at a micro level. That doesn't mean the TCM theory is obsolete, just a different perspective. There are some modern models and theories that sit very closely to TCM theory, and there are some aspects that seem far apart. We shall briefly explore some of these theories and look at how the fit alongside GB21.
Muscles & Channels
GB21 is on the upper crest of the trapezius muscle. This is a kite-shaped muscle that spans the upper back and neck and tapers down to the 12th vertebrae. It attaches to numerous points of anatomy to create movement when contracted, the bit we are interested in is the upper aspects of the trapezius. This portion attaches from the acromium process of the shoulder to the base of the skull, and allows us to shrug our shoulders when used. It is also the exact pathway of the section of the Gallbladder channel where GB21 is found.
We use this shrugging action all the time, and hold it in position during many common activities. For instance, when we get cold, when we work on a computer or drive - everytime we raise our arms. The more we assume these positions, the more our muscle fibers retain a shorter length, form knots, and ultimately we become stiff and sore. This is essentially the same description as the TCM term stagnation in the Gallbladder channel.
Trigger Points
We can take this comparison further by introducing Trigger Points, a model developed in the 1940's by Dr Janet Travell. This theory takes the idea of treating knots and tender areas of muscle tension but extends it by relating these points to pathways of referred pain. For example, if you have a trigger point in the middle of your upper trapezius, it can cause pain up the neck and into the side of the head (see image below). This pathway follows the Gallbladder channel from GB21 to GB1.
Much like acupuncture, there is speculative rationale given for trigger point theory, but no hard evidence for how or why these trigger points and pain referral pathways relate and respond to treatment. Theories include how nerves interact with the muscle at motor points, and how the the chemistry of muscle use effects pain and movement, though there is little discussion around how and why the pain referral patterns relate anatomically to the trigger point.
Notable parallels to trigger points, acupuncture theory, and GB21 are:
Stagnation describing muscle tension
The trigger point for upper trapezius is in the same area of GB21
The motor point for the upper trapezius is in the same area as GB21
The pain referral pathway for the upper trapezius matches the pathway of the Gallbladder channel
Stress & Tension
We have discussed how emotions can create tension or stagnation from the TCM viewpoint, and there is also a simple explanation from a biomedical standpoint called Neuromuscular Hypertension.
When we are angry or stressed we release stress hormones. These stress hormones stimulate the nervous system and we enter fight or flight mode where we need to be ready for action at any given moment. We can liken this to a runner on a start line, they would be at a severe disadvantage if they were totally relaxed as the start pistol fired. So for our bodies to be prepared to flee or fight we contract our muscles slightly. If that period of stress passes quickly our muscles return to a relaxed state, however, if the stress is prolonged our muscle fibers get used to being in a contracted state, much like when we adopt bad posture regularly. If we only had one period of prolonged stress in our lives, we could probably get away with any pain or discomfort, but thats not how the world works. Each time we have a period of stress these areas of tension grow and increase, until in the end we have pain, tension and lack of movement. The upper trapezius is the area that most commonly gets contracted under stress as we can feel our shoulders raising as our stress levels rise. Acupuncture and massage are great ways to release the stuck contracted muscle fibres and encourage a nice fresh blood supply full of oxygen and nutrients.
Anatomy Trains
Anatomy Trains is a book written by Thomas Myers where he maps the body using planes of connective tissue called fascia. Our fascia spans long continuous pathways across our bodies and wraps and contains our muscles and internal organs. Issues along these planes can have effects at other points of the body and how our muscles function. While there is not a direct plane that encompasses the trapezius muscle and the whole Gallbladder channel, parallels still exist with an intrinsic relationship between different areas of the body. Fascia also conducts nerve signals which again is likened to the flow of qi though the channels.
Internal Acupuncture Theories and Biomedicine
There a many connections between muscles, soft tissue and the TCM channel network, however, parallels between TCM and the inner workings of the body are sparse in the context of GB21. We know that acupuncture lessens our brain's pain response which I have discussed in this blog post - https://www.benelliot.co.uk/post/what-happens-in-your-brain-when-you-have-acupuncture - but I feel a lot more expensive research is needed into acupuncture to understand how and why specific acupuncture points have specific effects on our bodily systems. For now, I'm happy to accept that I see it work on a daily basis and that it is not just a placebo - another topic I have written about - https://www.benelliot.co.uk/post/placebo-the-dirtiest-word-in-healthcare-or-a-fresh-perspective-on-recovery.
GB21 as a weapon
As a final reminder of the power of GB21 I wanted to draw your attention to the Vulcan Death Grip. It's a special shoulder grip located at GB21 used to disable baddies by Spock in the sci-fi Star Trek series. There has been more research into the practicalities of this than I had anticipated and the general conclusion is that while you may be able to render someone unconscious due to the nerve being compressed, you are not able to kill someone by using the Vulcan Death Grip.
Further Reading & References:
P Deadman, M Al Kafaji. A Manual of Acupuncture
Anatomy Trains - Thomas Myers
Correlation Between the Sinew Channels with the Myofascial System, Pathology, and Treatment https://www.journal-jams.org/journal/view.html?uid=1094&vmd=Full
Hiding in Plain Sight-ancient Chinese anatomy
Yin and Yang: the Nature of Scientific Explanation in a Culture
What is Dark Energy?
David G. Simons, Janet Travell, Lois S. Simons, Travell & Simmons’ Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body: Second Edition,
Trigger Point Injection