Note: This lecture on low back pain treatment is founded in the Sports Medicine Acupuncture Certification (SMAC) Program and will be further elaborated on in the Pacific Sports and Orthopedic Acupuncture Symposium (PSOAS)
Click here to check out this American Acupuncture Council Video on DU 1 by Matt Callison.
“Through a scientific review and a comparison of anatomy texts a ‘fascial continuum’ exists between abdominal wall, pelvis and lumbar wall and such knowledge could improve the understanding of referred pain pathophysiology and mechanisms. Research has shown that the deep fasciae are well innervated and capable of transmitting mechanical forces from a distance (Langevin, 2002). This concept of a fascial anatomical continuity may have important clinical implications for treatment of pelvic pain, such as from abdominal (e.g. caesarean section, abdominal surgery) or even lumbar injuries.”
“Lower back symptoms might find their origin and explanation from pelvic floor disorders. This new concept could improve the treatment of chronic pain and could lead to an important enhancement of current anatomical knowledge and therapies.” (Ramin, A., 2016).
The anococcygeal ligament (ACL) is also referred to as postanal septum, anococcygeal raphe and anococcygeal body. The ACL can be described as a myofibrous, thick connective tissue located in the midline of the body in the floor of the pelvis. This tissue directly connects to various fascial layers including the posterior layer of the thoracolumbar fascia and internally to the endopelvic fascia that envelops the regional organs. The ACL connects as a raphe tissue with bilateral slings of the levator ani i.e. iliococcygeus and pubococcygeal muscles. The puborectalis muscle fibers also interdigitates into the ACL. (Luong D, 2022, Kinugasa Y, 2011).
The anococcygeal ligament consists of two distinct layers:
- A superficial fibrous band originating from the fibers of external anal sphincter (EAS) and running upwards to the coccyx with fascial and ligamentous attachments on the posterior aspect (superficial ACL). (Luong D, 2022). This superficial ACL joins the sacrotuberous ligament and continues into the gluteus maximus and posterior layer of the thoracolumbar fascia. (Moszkowicz D,. 2012)
- A deep fibrous band, thicker than its superficial counterpart, originates from the periosteum of the coccyx, merging with the sacrospinous ligament and the dense presacral fascia (directly connects to the endopelvic fascia). Its anterior attachment is external anal sphincter muscle (deep ACL). This deep layer directly connects to the endopelvic fascia and to the bilateral slings of the levator ani i.e. iliococcygeus and pubococcygeal muscles. The puborectalis muscle also interdigitates its fibers into the deep ACL. (Luong D, 2022, Kinugasa Y, 2011)
The ACL measures approximately 1-2 cm in length and 2-5 mm in width. Its average thickness was measured to be on average 2.7 mm; with a range of 1.5-4.5 mm. The anococcygeal ligament was abundant in smooth muscles and elastin fibers. (Kinugasa Y, 2012)
During activity, the anococcygeal ligament will involuntarily shorten and tighten and is responsible for absorbing and transmitting forces generated during movement. (Catania, V. 2022).
It also functions to support the pelvic viscera and when the levator ani contracts, the AL pulls the vagina and rectum forward to maintain urinary and fecal continence. Weakness of the levator ani causes sagging of the anococcygeal ligament, which therefore decreases the ACL support of the pelvic floor. This sagging increases the probability of urinary incontinence and constitutes a predisposition to pelvic organ prolapse. (Gowda, S. 2021).
Its integrity is vital in defecation and maintains continence and sexual function. The anococcygeal ligament is of clinical significance as it contributes to maintaining the integrity of the pelvic floor muscles as a dynamic anchor for stabilization. (Muro S, 2013, Jin, Z. 2015).
“Because the structure and composition of fascial connective tissue is responsive to mechanical stimuli, we propose that acupuncture plays a key role in mechanotransduction signaling and the integration of several physiological functions. The mechanical stimulation of connective tissue generated by acupuncture needle manipulation could transmit a mechanical signal to sensory nerves” (Langevin, 2002).
Acupuncture needle stimulation that results in the spreading of collagenous matrix deformation and cell activation along fascial connective tissue planes may mediate acupuncture effects remote from the acupuncture needle site (Langevin, 2002).
DU 1 (Changqiang)
Long strength, strong
Halfway between the tip of the coccyx and the anus.
Diarrhea, bloody stools, hemorrhoids, prolapse of the rectum, constipation, pain in the lower back, epilepsy, manic disorders.
- Regulates Du Mai and Ren Mai, resolves damp-heat, calms the mind
- Luo-Connecting point of the Du Mai
- Crossing point of the Du Mai, Ren Mai and the Kidney and Spleen channels.
Using pelvic blocks or a pillow under the pelvis allows for easier needle insertion. Because of it’s potential to communicate with many pertinent structures of the low back, Du 1 is an excellent point to combine with other low back, groin, thigh and abdominal acupuncture point prescriptions.
Locate and treat in the prone position. Cross-fiber the ACL from left to right to feel for the center of the tissue.
Perpendicular needle insertion 0.75-1.25 inches directed superiorly. Needle stimulation can affect the layers of the ACL and seemingly help to signal left and right sides of the pelvic floor musculature that translates to the low back and abdominal fascial layers.
Caution is advised—Do not needle past the ACL or in an anterior direction due to the close proximity of the rectum.
DU 1 can be combined with many different points and is dependent on the pattern. The following are some common point combinations to choose from.
- Piriformis MEP: The piriformis is considered a posterior support for the pelvic floor
- Coccygeus MEP: Connects DU 1 to the presacral fascia and supports the pelvic floor
- Extra Point Yaoyan: Connects DU 1 with the thoracolumbar fascia at Yaoyan
- Sacrotuberous ligament: Connects to DU 1
- GB 29 is the MEP for the tensor fascia latae and has a direct connection to the pelvic floor fascia
- Abdominal MEP’s: Connects to pelvic floor fascia via Camper’s fascia and Scarpa’s fascia
Catania, V. D., Randi, B., Di Salvo, N., & Lima, M. (2022). Functional anatomy of the pelvic floor and the anorectum. In Ano-Rectal Endosonography and Manometry in Paediatrics (pp. 11-23). Springer, Cham.
Gowda, S. N., & Bordoni, B. (2021). Anatomy, abdomen and pelvis, levator ani muscle. In StatPearls [Internet]. StatPearls Publishing.
Jin, Z. W., Hata, F., Jin, Y., Murakami, G., Kinugasa, Y., & Abe, S. I. (2015). The anococcygeal ligaments: cadaveric study with application to our understanding of incontinence in the elderly. Clinical Anatomy, 28(8), 1039-1047.
Kinugasa Y, Arakawa T, Abe H et al. Anococcygeal Raphe Revisited: A Histological Study Using Mid-Term Human Fetuses and Elderly Cadavers. Yonsei Med J. 2012;53(4):849-55.
Langevin, H.M., Yandow J.A., “Relationship of acupuncture points and meridians to connective tissue planes,” Anat Rec, 269:257-65, 2002.
Lemos, N. L., Sermer, C., Cancelliere, L., Li, A., Kumar, K., & Roncatti, V. C. (2020). Neurophysiology of the Pelvic Floor. In Anorectal Physiology (pp. 155-164). Springer, Cham.
Luong D, Sharma R, Bell D, et al. Anococcygeal raphe. Reference article, Radiopaedia.org (Accessed on 28 Nov 2022) This superficial layer continues into the gluteus maximus and posterior layer of the thoracolumbar fascia.
Moszkowicz D, Peschaud F, Bessede T, Benoit G, Alsaid B. Internal anal sphincter parasympathetic- nitrergic and sympathetic-adrenergic innervation: a 3-dimensional morphological and functional analysis. Dis Colon Rectum. 2012;55(4):473–81.
Muro S, Yamaguchi K, Nakajima Y et al. Dynamic Intersection of the Longitudinal Muscle and External Anal Sphincter in the Layered Structure of the Anal Canal Posterior Wall. Surg Radiol Anat. 2013;36(6):551-9
Ramin, A., Macchi, V., PORZIONATO, A., De Caro, R., & STECCO, C. (2016). Fascial continuity of the pelvic floor with the abdominal and lumbar region. Pelviperineology, 35(1), 3.