Qiological Community

Extreme Muscle Tension & Excess Phlegm Case

Hi Fellow Sa’amsters!

I haven’t participated in the forum for a while, but I’m looking for suggestions on this case. I feel like I’ve thrown the kitchen sink at it without much progress. Thanks in advance for any comments. I’ve been using Sa’am since Toby’s Seattle seminar in January 2019 but haven’t used it exclusively so I could use guidance (and most likely a refresher webinar sometimes soon); I think I’ve missed some more advanced signs & symptom education (like pointy index finger for GB)!?! Please also give me feedback on formatting if it is not correct.

Case: 32 year old slender & timid male with pale to normal complexion (is a red head and can get rosy when flushed).

Chief Complaint: extreme chronic (several years) muscle tension & spasms on the L side of the body (all channels affected); muscle weakness on the R side of the body that feels like muscles aren’t engaging; and extreme bilateral hip, low back, & jaw tightness

Secondary Complaints: clear copious phlegm in the sinuses that drains when his muscle tension improves, L sided throat obstruction (that may or may not be phlegm related), one big loud sneeze a day with a funny smell & subsequent salivation, tinnitus worse when muscles relax (when meditating)

Appearance: thin tight body (+8), small frame, wears all black clothing, quiet, shy & reserved (+8) but can be friendly & engaging with nervous laughter, very intelligent (+9)

Lifestyle: IT guy with plenty of financial resources, plays guitar in a heavy metal band but has recently discovered meditation, qi gong, spiritual awakening, etc.

Body & flesh: underweight (+3), moist skin (+5), minimal red pustular acne on face & back, sweaty hands & feet, flat spinal curves esp. in neck (+5), jumpy spastic muscles (+10) – some areas are too painful to palpate & he has even come in with multiple bruises on his calf muscles where his calves went into spasm & burst blood vessels

Body Temp: warm body (comes underdressed in winter) with cold feet

GI/Urinary: no complaints, regular BMs, some lack of appetite (+1) that manifests as general ambivalence towards food, eats the same thing daily, some thirst (+3), urination normal

Respiratory: lungs are clear, all phlegm issues are in the sinuses (+7) & throat (see above)

Emotions: seems somewhat repressed emotionally (+8) but not depressed or lacking energy

Tongue: pale body, puffy front with slight toothmarks, purple dip in center, white coat – thicker in back, red tip, distended sublingual veins

Excesses (not sure I’m doing this part right):

SJ: polite & hyperaware

PC: quite & intelligent

ST: thin body, moist skin, acne

Grossest Thing in the Room: muscle pain & phlegm in sinuses

I’ve tried tonifying LR, GB, SI, & LU at different times without much change. So far the most profound treatment has been to needle all acupuncture points on the L side that affect the vagus nerve. Stimulating these points at the neck area seem to cause a domino effect in his body & his muscles relax & open up temporarily.

His muscles are so taut and his body is thin but he has all this phlegm in his head with a big puffy tongue. I’m not sure where to go from here…

Thanks for your help!

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Hi @joyblais
Well, this is a tough isn’t it? So many contradictory signs.

Thin, but with clear signs of interior dampness and phlegm.
Sensitive and with signs of TB excess and plays in a heavy metal band
One of his body is tight, the other is slack

The thing that stands out to me is the contradictions he presents with.

I’ll start with something that is not Saam, but it might lead us back there.

You mention you’ve done needles that affect the vagus nerve, by using points in the neck. What points are you using? And how do you know these affect the vagus nerve?
I know that the poly-vagal hypothesis is getting lots of play these days, and I’ve seen some interesting changes in my clinic when I do treatment (it’s unrelated to Saam) with an eye toward changing the tone of the ventral vagus nerve.

So maybe that is a discuss we could have off forum.

But back to Saam. One of the things that I’ve found, and there are quotes for this in the classics, is that phlegm can cause all kinds of oddball symptom presentations and even can throw off treatments as it is an obstructive influence. But not obstructive in a consistent way like blood stasis. My herb teachers in particular would say that if you have oddball symptoms and presentations that don’t make a lot of sense and you see phlegm— then first clear that.

So maybe double down on that dampness aspect, and then see what is the most notable aspect of his presentation.

Keep us posted!

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Thanks Michael Max! @michaelmax

Would you suggest LI+ on the right to dry phlegm? I hesitated to try it because of all the tight muscles, but the patient is really open & willing to try anything (and at least I know the antidote if things go sideways). Currently, I am giving him herbs to clear phlegm in the head, support his SP, & also tonify Blood & relax muscles (with Bai Shao/Gan Cao/Ge Gen), but it’s still too early to tell I think…

As far as the polyvagal theory goes, I have thoroughly nerded out on the work of Stephen Porges for the last 6 or 7 years. Thankfully others have taken his theories and adapted them for clinical use in easy form. I find Porges’ books very academic and dense, although brilliant.

My patient has been to multiple specialists & been either misdiagnosed or given no diagnosis at all so we’ve been really digging for causes to his issue, which are so unusual for a healthy man of his age. To me, he has clear vagal dysfunction signs (offset uvula, some facial tone flatness/reduced expression, & abnormalities in hearing, etc.) & responded positively to the vagal exercises I gave him to do at home. One thing that really stood out for me was how flat his cervical curve was and how changes in his head & neck would immediately cause a domino effect down his L side along the vagus pathway (face, ear, throat, chest, diaphragm, etc.) causing relaxation of his muscles. Then lots of phlegm would drain from his head.

I wondered if the phlegm obstruction could be causing pressure on the vagus nerve as well. I tried many treatments & herbs for tonifying blood & relaxing sinews but I never really focused on addressing the phlegm primarily, so that’s where I’m at in my process with him.

The points I referred to as affecting the vagus nerve were:
LEFT FRONT: GB12, SJ17, ST12, LU2, ST9, LI18, SI16 (plus LI4)
Auricular Points: Vagus, parasympathetic cranial nerves

And additional points for the flattened cervical curve:
LEFT BACK: BL10, GB20, Huatoujiaji C1-C6, DU14, KD1

I did all these points on the L side only. It was kind of radical (not my usual style) but he said it was by far the most helpful treatment he’d had & feels he is slowly improving. To answer your question of how I knew these points affected the vagus nerve, well I just sort of looked at anatomy charts and followed the pathway of the nerve, then looked at all the acupuncture points that overlapped & were accessible (aka: I was winging it).

So, to bring this back around to Sa’am, I am thinking I should do a R sided treatment to address the phlegm, but I get confused about what is considered inside vs outside dampness. Would you think that this kind of phlegm is inside (the sinuses) and outside (the damp hands & feet), or is this outside damp (sinuses & sweaty hands & feet) with inside dryness (tight muscles)?

Thanks so much for your feedback!

I’d start with tonifying the LI on the left. Because “left for male” and because I’m associating the flaccid muscles with dampness.

I’ve trying getting through some of the more technical books on PV as well, without much success. I’m more clinically oriented. I like the one that Stanley Rosenberg did.

Is he really a healthy man for this age?
He has some very odd issues going on, I’m not sure I’d characterize him as healthy.

So this curveball treatment you did that was not your “usual style,” I’m curious to know what you were seeing and paying attention to, which in turn lead to trying something “new” for you. Sounds like the results were good (love the Saam idea of treating one side to affect the other).
Given that treatment was seen as positive by the patient. What exactly changed for the better? Perhaps that will help you to better understand the dysfunction of the right side.

Again, I’d treat the left side to address the dampness, as I see the flaccid muscles as an expression of dampness (my current working hypothesis)

As to what is “inside” and what “outside,” that always depends. Sometimes it is cut and dried (no pun intended). But often and certainly in this case, the “line” is not clear. And with this patient there are aspects of dampness being both what I’d call interior (what I’m seeing with the tongue" and exterior (damp hands and feet) and to some extend the sinuses, which I see having the possibility of being interior or exterior. Sinuses often being easy affected by wind and pollens, which I see as leaning toward exterior.

With this guy it seems there is not only interior/exterior aspect, but right/left as well.

Hope this helps

Some Thoughts Joyblais . . . .

In my experience, when the ‘congestion’ is ONLY in the sinuses, but not in the lungs at all - all very very upper body . . . I have almost never found it to be a primary issue around getting rid of dampness . . . in my experience this is much more often - almost always an issue of phlegm getting trapped in the very upper reaches of the body for some reason (you’ve even confirmed that by noting that when his muscles relax, he drains).

He is thin. His body type is dry. that’s big for me . . . and he seems pretty active and industrious . . . IT guy, works, earns money, plays in a band, etc . . . I’d ask more questions to bring out where he sits on the couch potato - active spectrum, but I would seriously consider a Spleen plus treatment. I’ve had patients like this respond miraculously to that treatment.

walking around scantily dressed in the winter with cold feet . . . thats big for me . . . he is very warm but also has circulatory issues. And I get the sense from what you have written, that in spite of appearing ‘timid’, ‘quiet’, etc . . . repression and suppression are key here . . . and while you did do GB+ without much response, I would consider PC+ (what is his sleep like? does he have SOB with mild exertion, can you detect repressed rage? ask him a LOT more about patience and frustration, I would . . . I have found so often, high levels of repression and suppression need the Mike Tyson antidote!)

How is he around intimacy, intimate contact, warmth towards you, social warmth, personal relationships?

What is his relationship with himself vis a vis self-esteem, self- confidence, self-doubt?

Digestion? appetite? he is thin, does he eat a lot and not put on weight or does he eat very little? bowel movements?

from what you have presented, the two things I would try are Sp+ and PC+

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Hi Michael,

I would love to know how you inserted my text in little chunks to reply to. That’s a cool & useful feature! Since I don’t know how to do that though, I will address a few of your comments piecemeal:

I had not thought about the flaccid muscles as dampness. That’s interesting & I will ponder that. Sometimes he has said that the R side only feels dysfunctional compared to the L side which is the real trouble maker. I do think both sides are tight in general, it’s just that the L side is uber tight and the right sided muscles don’t engage. I will dig deeper with some questions & explorations to see if “flaccid” is an appropriate description.

Stanley Rosenberg’s book on the polyvagal theory is good but a bit incomplete I think, certainly easier to digest though. I would definitely recommend some of Stephen Porges’ interviews on Youtube. Here are a couple suggestions but there are so many more that are quite interesting:

You bring up an interesting point about the state of his health. It sounds odd, but he does seem healthy to me in the sense that he is young and had no issues before this problem began. He still gets on with life despite being in a lot of pain. It’s as if once this thing gets addressed, he could rebound back into this young energetic guy again. Maybe I need to look from a different perspective on this…

What made me try this new style was how unsatisfactory all other treatments had been. He always says that he feels better after acupuncture but then he is right back to the starting point when I see him next. He thinks he is slowly getting better. I think it’s going snail paced as I have been treating him for years. Busting out the vagus treatment was an attempt to stimulate the nerve to see what kind of response I could get. I only did it on the L side because the L side is the crux of the problem.

I really appreciate all your suggestions and comments. It’s always helpful to see what others have thought about that I may have missed :slight_smile:

Daniel thank you for your thoughts!

Yes, you are right about phlegm being trapped. That seems clear. And of course, since pathological fluids can’t act on the body physiologically, this is a real problem for him. Something is making these fluids collect while the rest of him is dry & tight. A SP+ treatment seem logical when I look at it this way.

He is not really a couch potato (he’s even been running a few times a week for short periods of time) but he does sit at a desk for long hours at work. He definitely has elements of repression & suppression of emotions but at the same time we have had very deep and beautiful conversations about spirituality and life purpose. He is really such a sweet thoughtful guy and is easy to be with. I suggested a therapist who he has been working with to explore the origins of some repressive tendencies. He has rare moments of frustration but it’s not really a big problem. At the same time, he does play in a heavy metal band (an outlet for feelings of rage perhaps!). I think of his emotional state more as protection for a very kind & vulnerable interior - not so much repressed rage, as a cue for others to leave him alone. There may be some self-confidence issues, but he is extremely smart and capable in life, has a loving wife, generally likes his life & acknowledges he is very lucky to have so much (wife, house, pets, lots of money, etc.). Maybe the Mike Tyson treatment is something to revisit to bust him out of his shell a little. We have not discussed sexual intimacy issues, so I can’t comment there. You said at the end of your post to try PC+, but I assume you meant GB+, right?

I have asked him about digestion, urination, and bowel movements so many times and he assures me that everything is normal & like clockwork. The only obvious earth deficiency I can see is his indifference towards food. He eats the same things at the same times every day. He is thin but at the same time I have questioned whether I put him in the “thin” category just because he is physically small. He is only in his early 30s and claims that his father is also small and never even got a little pot belly or anything as he aged. So, I don’t know…maybe he is just genetically a smaller person with a normal body (not thin).

Thank you for taking the time to respond. You have given me some things to think about & I appreciate your suggestions!


Hi Joy

Yes, that is a clinical tough one - to assess ‘thinness’ (dryness) on a short person . . . are they just appropriately ‘thick’ for their height or not??
I actually did mean PC+ . . . but you know, it is so hard without the patient in front of you.
I have found in my own experience that the PC-GB pair can be tricky in cases with significant repression and suppression of frustration . . . when they are not so much ‘punching out’ at the world, but they are punching up and out at themselves . . . . bruxism, shoulder tension, some headaches, sinus . . . sometimes GB+ moves it all out and sometimes its PC+ that settles it all.

just some thoughts


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Thank you for the clarification Daniel. I see what you mean…it’s about assessing if there is an “inner Mike Tyson” beating ones self up vs an “outer Mike Tyson” taking it out on the world. Thanks again for your thoughts!

@Daniel thanks for pointing this out. I see that wet phlegmy tongue and I get rather transfixed on “some serious internal dampness” but you are right, there are all these other signs of dryness, and LI+ type activity. So even though it seems contradictory, the SP tonficiation can help as most of his system is dry. And a dry system will hold on to impure fluids and phlegm if that is the only fluid it has to work with.

Thanks for the reminder!

Hi @joyblais
Yes! These little insert text blocks are cool, and helpful.

To insert a text block from a previous comment, simply select it and press the Blue Reply button, It will pull that text and pop it into a new response.

Thanks for the links for Steven Porges. I’d like to reach out by email as I’ve got some more questions, but they are not relevant to the Saam discussion. Can you send me a message to michael@qiological.com, so I’ll have your email and we can then continue the discussion?

Yes, will do! I want to be respectful to the Sa’am forum :slight_smile:

Thank you guys for a thoughtful discussion on a difficult case with so many contradictions.
I see this forum as sort of a Sa’am wiki with its easy search function. For the sake of new comers I am going to step in as a Sa’am grammar police as sometimes we get loose with how we phrase excess and treatment.

Should have been …LI Excess activity…the SP+ supplementation.

I feel we should save the “+” and “-” for Supplement/Drain of the channel and use the words excess when we are talking about the paired channel we are considering. Thoughts?

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Thanks George! Yes, I think it’s always helpful to be as clear as possible and standardizing the grammar does help us all get on the same page. I appreciate you jumping in :policeman:t4: :police_car:

yes!! + and - should be reserved for supplement and drain
XS for Excess