LI Han (李晗), ZHENG Han (鄭涵), ZHANG Jianming (張建明), ZHANG Jianbin (張建斌)

1 Affiliated Hospital of Nanjing University of Chinese Medicine/Changzhou Hospital of Traditional Chinese Medicine, Jiangsu 213000,China

2 The Second Affiliated Hospital of Nanjing University of Chinese Medicine/Jiangsu Province the Second Hospital of Chinese Medicine,Jiangsu 210000, China

Abstract

Keywords: Acupuncture Therapy; Belt Vessel; Intervertebral Disc Displacement; Low Back Pain; Point, Mingmen (GV4); Point,Wushu (GB27); Points, Ashi

Low back pain (LBP) is one of the clinical indications of acupuncture and moxibustion. At present, the acupoints of the Governor Vessel (GV), Bladder Meridian (BL), and Gallbladder Meridian (GB) are usually selected for treating LBP by acupuncture and moxibustion[1]. By analyzing ancient acupuncture literature, we have found that the BV is closely related to LBP. Therefore, selecting acupoints along the pathway of the BV to treat LBP is worthy of discussion[2].

1 Understanding of BV and LBP in Ancient Literature

The term BV initially appeared in theLing Shu(Spiritual Pivot). The main manifestations of BV-related LBP described in theMai Jing(Pulse Classic) are pain around the umbilicus that radiates to the groin.According to theQi Jing Ba Mai Kao(Studies of the Eight Extraordinary Meridians), the BV starts from Zhangmen(LR13) on the hypochondrium, intersects with the GB and encircles the waist like a belt. The literature suggests that the BV is indeed closely related to LBP.

2 Features of BV-related LBP

2.1 Sagging distention in the low back

The earliest record about the relationship between the BV and LBP is found in theNan Jing(Classic of Difficult Issues). According to the relevant records in this book, we can speculate that patients with BV-related LBP will experience obvious sagging distention in the low back, which is also emphasized by modern reports on needling the BV for treating LBP[3]. The BV is closely related to the rise and fall of the Qi movement. Doctor SHEN Jin’ao in the Qing Dynasty put forward in theZa Bing Yuan Liu Xi Zhu(Wondrous Lantern for Peering into the Origin and Development of Miscellaneous Diseases)that, the BV governs the rise and fall of Qi, and thus Qi will sink if the BV is damaged. A similar record can also be found in theQi Jing Ba Mai Kao, which holds that the BV restricts all meridians[4]. In clinical settings, we also find that many patients with LBP complain of sagging distension in the low back. Doctor YANG Xuancao in the Tang Dynasty mentioned in his annotations of theNan Jingthat the key to treating BV-related diseases lies in softening the BV via adjustment. The BV is closely related to the other seven extraordinary meridians as well as the twelve regular meridians. The disharmony of Qi and blood in the BV may cause Qi disorder of other meridians,thus leading to abnormal rise and fall of the Qi movement. Some acupuncturists also find that patients with LBP who are effectively treated by needling the BV often experience low back discomfort and sagging distention in the lower abdomen before treatment[5].

2.2 Enlarged and flabby abdomen

In clinical settings, by observing the abdomen of patients with BV-related LBP, we have discovered that when the patient stands, his abdomen drops; when he lies flat, his abdomen is flat, and the waist muscles flabby.Such abdominal state can be considered as the failure of the BV in restraint[6]. Modern medicine has already found a correlation between abdominal muscles and LBP.The abdominal muscles, together with the diaphragm and pelvic floor muscles, form a closed abdominal cavity in front of the spine. The tension of abdominal muscles can maintain a certain intraperitoneal pressure. The abdominal muscles contract during movements, and the pressure in the abdominal cavity increases, which can reduce the pressure on the spine and protect it. Clinically,patients with scoliosis often experience recurrent LBP.Modern rehabilitation medicine recommends adjusting the abdominal muscle functions of such patients to reduce the onset frequency and severity of scoliosis[7-9].

2.3 Pain radiating to the groin

LBP radiating to the groin can be treated by targeting the BV no matter the segment of lumbar disc herniation is in T12-L2or not. Upper lumbar disc herniation is more suitable to be treated in this way.

3 Understanding of BV and LBP in Modern Medicine

3.1 Upper lumbar disc herniation

Acupuncture treatment emphasizes acupoint selection along the pathways of meridians and local acupoint selection. The location of the lesion is highly coincident with the starting area of the BV[10]. At present,it is considered that T12-L2intervertebral disc herniation falls under the category of upper lumbar disc herniation.The nerves from these segments are mainly distributed in the lower abdomen and the anteromedial thigh.Patients with such lumbar disc herniation often complain of groin pain[11]. We often treat patients with this complaint by needling the BV, and the efficacy is confirmed.

3.2 Lower lumbar disc herniation accompanied by groin symptoms

Lumbar disc herniation in the segments below L3falls under the category of lower lumbar disc herniation.According to the area dominated by the ganglion segment, the pain is generally distributed around the lateral or posterior edge of the lower limbs[11]. However,we once observed that some patients with lower lumbar disc herniation also experienced groin symptoms.Studies have found that L4and L5intervertebral disc herniation may stimulate the sinuvertebral nerves,resulting in groin pain. The pain area is consistent with L1and L2upper lumbar disc herniation, and belongs to the pathway of the BV[12].

3.3 Scoliosis

There have been relevant reports on needling the BV for treating LBP caused by lumbar disc herniation[11], but adopting this method for treating scoliosis is still blank.Scoliosis patients often experience recurrent LBP with a long disease duration. The goal of treatment for such patients is to reduce the frequency and severity of LBP.In clinical settings, the acupoints of the GV, BL, and GB are often selected for treatment.

Some scholars point out that the BV encircling the waist is actually not one line, but four horizontal lines from Zhangmen (LR13) and Daimai (GB26), three horizontal lines from Wushu (GB27) and one horizontal line from Weidao (GB28), forming up a total of 12 horizontal lines going up to the diaphragm and down to the perineum[13]. Coincidentally, modern rehabilitation medicine holds that all kinds of muscles in the abdominal cavity, from the diaphragm to the pelvis,constitute the core muscle group. The strength of this muscle group is closely related to LBP. Among them,psoas major muscle, iliac muscle, and psoas minor muscle constitute iliopsoas muscle. The strength of these muscles is of significance for maintaining the stability of the lumbar spine[14]. Generally, patients with scoliosis may suffer from instability of the core muscle group.Regulating the functions of the core muscle group can reduce the frequency of LBP. Consequently, we often treat scoliosis via needling the BV.

3.4 Modern research on needling BV for treating LBP

Some doctors have conducted some research on the BV and LBP. LIU H Y[15]employed needling and cupping the BV to treat LBP due to wind-cold and dampness, and found that the effect was better compared with acupuncture alone in terms of analgesia and improving the quality of life. ZHUANG X J[16]found that needling the BL, as well as Daimai (GB26) and Weidao (GB28) for treating lumbar disc herniation had a better effect than conventionally needling the BL in terms of analgesia and lumbar function improvement. Based on needling the BL,DENG Y,et al[17]deeply needled Daimai (GB26) on the affected side and found that both the analgesic effect and improvement of LBP score were more significant compared with conventionally needling the BL. LI Y J[18]found that needling Daimai (GB26) and Zulinqi (GB41)can significantly relieve the symptoms of LBP within one week. CAI K Z[19]adopted needling the BV or Zulinqi(GB 41) to treat LBP, and confirmed the analgesic effect of this method. ZHANG D Y[20]once treated a patient with LBP. ZHANG conventionally needled the BL, but it was ineffective. Then ZHANG needled Daimai (GB26) and Mingmen (GV4), which quickly alleviated the LBP.

4 Pattern of Acupoint Selection in Treating BV-related LBP

4.1 Starting acupoint of the BV

According to the pathway of the BV, Mingmen (GV4),Daimai (GB26), Wushu (GB27), Weidao (GB28), and Zhangmen (LR13) can be regarded as the BV acupoints.Mingmen (GV4) and Zhangmen (LR13) are located below the 14th vertebral body and at the hypochondrium,respectively. Some researchers believe that the superior lumbar triangle composes of the 12th costal edge, the lateral edge of the erector spinae muscle, and the internal oblique muscle, which should be the main stimulation position of Daimai (GB6)[21].

4.2 Tender points near the transverse process of L3

At present, the literature on BV-related LBP points out that the L3transverse process syndrome falls under the category of BV-related LBP[22]. L3is located at the midpoint of the physiological lordosis of the lumbar spine, with the longest transverse process and the largest traction force. Therefore, the ligament, muscle, fascia and aponeurosis attached to it have the highest risk for injury. The core muscles that maintain the stability of the lumbar spine (such as psoas major, psoas quadratus,erector spinalis, and psoas minor) are attached to the transverse process of L3. Through clinical observation, we have found that the patients with LBP are more likely to have tender points here.

4.3 Tender points near Wushu (GB27) and Weidao (GB28)

In clinical practice, we find that 95% of the patients with LBP have tender points near Wushu (GB27) and Weidao (GB28). Deeply needling these tender points can stimulate iliopsoas muscle, and the patient may experience obvious heavy and sore sensations radiating to the thigh. Clinical practice also shows that the clinical effect is better when such sensations are present.

5 Case Report A 31-year-old male.

Chief complaints: Recurrent LBP for two years,aggravated for one month.

History of present illness: LBP located in the thoracolumbar region, with obvious local tenderness radiating to the groin, enlarged abdomen, and difficulty bending forward and backward. The score of visual analog scale (VAS) was 8 points.

Past medical history: LBP for two years with insignificant effects after treatment. MRI examination of lumbar spine a month ago showed T12-L1and L1-L2disc herniation; endplate inflammation of L1lower edge and L2upper edge; L4hemangioma.

Traditional Chinese medicine (TCM) diagnosis: LBP.

Western medicine diagnosis: Upper lumbar disc herniation.

TCM treatment principle: Unblocking the BV to relieve pain.

Methods:The patient took a supine position. Bilateral Hegu (LI4), Wushu (GB27), Zusanli (ST36), and Taichong(LR3) were selected. A filiform needle of 75 mm in length was used to perpendicularly puncture Wushu (GB 27) for 2.5 Cun, and filiform needles of 40 mm in length were adopted to perpendicularly puncture the other acupoints for 1.0 Cun. After the arrival of Qi (Deqi), even reinforcing-reducing manipulation was employed, and the needles were retained for 30 min during which the patient experienced heavy sensations in the legs. Then the patient took a prone position. Mingmen (GV4), Jiaji(EX-B2), and the tender points in the affected segment and near the transverse process of L3on both sides were selected. Filiform needles of 40 mm in length were adopted to perpendicularly puncture the acupoints for 1.0 Cun. Even reinforcing-reducing manipulation was employed and the needles were retained for 30 min. The treatment was given once every other day, a total of four times. After two times of treatment, the VAS score decreased to 3 points, and the symptoms were significantly relieved. After four times of treatment, the VAS score decreased to 1 point. We followed up the patient three months after discharge. The patient selfreported that the LBP occurred occasionally and mildly.

6 Clinical Experience

The existing studies hold that the BV can store Qi and strength, regulate vessels, and consolidate the body. BV deficiency may cause failure of the BV in storing Qi and strength as well as disorder of the Qi movement,subsequently impairing the information regulation function of the body and leading to the disorder of immune function[23]. The BV is related to many meridians,and its pathway connects multiple organs, including the liver, gallbladder, spleen, stomach, kidney, intestine, and uterus. Therefore, the BV can regulate the Qi movement of various forms.

LBP is a kind of BV-related disease. LBP patients with abdominal sagging distension, enlarged and flabby abdomen, and groin symptoms can be treated by targeting the BV, significant effect can often be achieved.Mingmen (GV4), Daimai (GB26), and Wushu (GB27) can be selected for this disorder. We hold that Wushu (GB27)needs to be deeply needled by long needles in order to obtain strong needling sensations (Deqi). Via clinical practice, we have found that not only the LBP caused by lumbar disc herniation can be treated by needling the BV,but also scoliosis and lumbar surgery failure syndrome.With long-term health management, generally, patients can obtain a better quality of life.

Conflict of Interest

The authors declare that there is no potential conflict of interest in this article.

Acknowledgments

This work was supported by Youth Project of National Natural Science Foundation of China (國家自然科學(xué)基金青年項(xiàng)目, No. 820044531); Jiangsu Province Chinese Medicine Science and Technology Development Program(江蘇省中醫(yī)藥局科技項(xiàng)目, No. YB201951); Changzhou Sci & Tech Program (常州市科技技術(shù)局應(yīng)用基礎(chǔ)研究計(jì)劃, No. CJ20190070); Changzhou Municipal Health Commission Science and Technology Program (常州市衛(wèi)生健康委員會(huì)青年人才科技項(xiàng)目, No. QN201939);Changzhou Municipal Health Qing Miao Talent Training Program (常州市衛(wèi)生健康委員會(huì)常州市衛(wèi)生健康青苗人才培養(yǎng)工程, No. CZQM2020083); Changzhou Municipal Health Key R&D Program (常州市衛(wèi)生健康委員會(huì)重大科技項(xiàng)目, No. ZD201813); Natural Science Foundation of Nanjing University of Chinese Medicine (南京中醫(yī)藥大學(xué)自然科學(xué)基金項(xiàng)目, No. XZR2020043).

Received: 14 September 2020/Accepted: 21 April 2021