THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 15, Number 12, 2009, pp. 1285–1291

ª Mary Ann Liebert, Inc.
DOI: 10.1089=acm.2007.7118-O

Localization of Acupuncture Points BL25

and BL26 Using Computed Tomography

Dietrich H.W. Groenemeyer, M.D., Ph.D.,1,2 Lei Zhang, M.D.,1

Sven Schirp, M.A.,1,2 and Jürgen Baier, M.D., Ph.D.1

Abstract

Objectives: The aim of this study was to provide a metric description of acupuncture points BL25 and BL26, to
investigate their relation to individual anatomical landmarks and structures, and to identify anatomical struc-
tures that are involved in needle manipulation during de qi.
Design: Fifty-eight (58) white patients with low-back pain received 107 needlings that were documented using
computed tomography (CT).
Outcome measures: For each patient, the body–mass index (BMI) and the interscapular distance were measured.
Using the CT scan, the following parameters were assessed: thickness of the soft tissue layer, distance of the
puncture site and the needle tip to the vertebral line, distance of the needle tip to the body surface and the
intermuscular space, and the needle depth in muscle tissue.
Results: The mean distance from the puncture site to the vertebral line was 3.5
0.5 cm for BL25 and 3.4
0.4 cm
for BL26. The distance of the needle tip to the vertebral line was similar (3.4
0.5 cm for BL25 and 3.2
0.4 cm for
BL26). The mean distance of the needle tip to the body surface was 4.1
0.9 cm at BL25 and 3.9
0.8 cm at BL26.
The majority of the needle tips were located in the intermuscular region between the erector spinae and the
transversospinal muscles. There was a significant correlation between the interscapular distance and the
thickness of the soft tissue layer with the BMI at both acupuncture points. Nearly all parameters correlated with
the BMI. At BL26, correlations between the distance of needle to the vertebral line and the BMI were not
statistically significant but the scatter plots indicate a positive dependency.
Conclusions: The results of this study show an association between de qi and needle location within the inter-
muscular septa. BL25 and BL26 are located as clusters in and around the intermuscular region of the erector
spinae and the transversospinal muscles, with a distance to the vertebral line of 3.49
0.58 cm and
3.32
0.53 cm, respectively. Using proportional methods is relevant for the success of acupuncture therapy.

Introduction
A cupuncture points are known as specific locations of
the body that are needled during acupuncture treatment.
Acupuncture points are located along ‘‘meridians’’ that run
longitudinally along the surface of the body and have been
defined for several thousand years.1
Traditionally, acupuncture points are localized using cun as
proportional measurement. In addition, acupuncture guide-
lines refer to anatomical landmarks to help localize the exact
position of needle insertion. The individual interscapular
distance, for example, measures 6 cun. After needle inser-
tion, the needles are manipulated by the therapist in order to
achieve a sensation known as de qi that is often elicited to
enhance the effect of acupuncture treatment.2,3 Considerable
efforts have been made to examine the anatomy and physi-
ology of acupuncture points in order to understand the
therapeutic mechanism of acupuncture4–9; however, the
mechanism by which acupuncture works remains contro-
versial. The majority of these studies have been of an experi-
mental nature or in vitro cadaver studies.
Despite rapid advances in medical imaging techniques,
modern imaging has rarely been used to investigate acu-
puncture points in vivo.10,11
Among others, Dachangshu, or Bladder 25 (BL25) and Gua-
nyuangshu, or Bladder 26 (BL26) are acupuncture points that
are of relevance for the treatment of low-back pain. They are
located along the medial segment of the Urinary Bladder me-
ridian and belong to the acupuncture points associated with
the posterior cutaneous branches of the lumbar spinal nerves.12

1
Groenemeyer Institute of Microtherapy, Bochum, Germany.
2
Department of Radiology and Microtherapy, University of Witten Herdecke, Witten, Germany.

1285
1286 GROENEMEYER ET AL.

The anatomical structures involved and the exact loca-
tion of the needle tip during de qi have not yet been de-
scribed. We hypothesize that de qi sensation and acupuncture
point location can be related to distinct anatomical structures
using computed tomography (CT) imaging.
The objectives of this study were

to provide a metric description of acupuncture points
BL25 and BL26,

to investigate their relation to individual anatomical
landmarks and structures, and

to identify anatomical structures that are involved in the
manipulation of the needle during de qi.
Materials and Methods
This study was performed at the Groenemeyer Institute of
Microtherapy in Bochum, Germany. The study protocol was
approved by the University of Witten=Herdecke Ethics
Committee in Witten, Germany.
Subjects
A total of 58 white patients (26 male, 32 female) with low-
back pain were enrolled in this study after informed consent
was obtained from each patient. Subjects were patients who
received treatment for low-back pain at our clinic and
volunteered for the study from March 2002 to January 2003.
The back pain duration ranged from 6 weeks to several
years. Only patients without a history of severe internal
organ disease or psychiatric disorders and with radicular
and=or nonradicular low-back pain were included in this
study. Exclusion criteria were spinal deformation (e.g., se-
vere scoliosis), spinal tumors, systemic diseases, current use
of antibiotics, immunosuppressants or anticoagulants, and
obviously deviating stature.
The mean age of patients treated at BL25 was 62
14 years
(range 35–86 years). The mean age of patients treated at BL26
was 65
11 years (range 31–82 years).
Further patient data are summarized in Table 1. Demo-
graphic data were similar across groups.
Protocol
Routine CT examinations that were scheduled as part of
the patient’s back pain therapy were used to perform acu-
puncture for this study.
The position of BL25 and BL26 was determined tradition-
ally by 2 experienced acupuncture therapists. All needling
procedures were performed by a single, experienced thera-
pist (L.Z., 18 years of acupuncture experience). Acupuncture
was performed using 0.350-mm needles (Seirin Kasei & Co.
Deutschland GmbH, Dreieich, Germany) and 0.3575-mm
needles (Suzhou Medical Appliance Factory, Suzhou, China).
During the procedure, patients were positioned prone in a CT
device (Tomoscan M=EG, Philips Medical Systems, Eintho-
ven, Netherlands). Needles were inserted vertically and the
needle was manually manipulated until both patient and
therapist confirmed de qi. De qi was confirmed when the pa-
tient reported a feeling of heaviness, paresthesias or tingling, a
sensation of cold or heat in the needling area, or an aching
sensation in the area surrounding the needle. On the therapist
side, a ‘‘tug’’ on the needle or ascending needle rigidity was
considered a positive de qi. The therapist’s de qi sensation was
relevant for the de qi confirmation (i.e., if the patient did not
have any sensation but the therapist did, de qi was considered
positive. No metric was employed for the de qi assessment).
The patient was then asked not to move and a CT scan
was performed (Fig. 1). At first, a lateral 250-mm routine
topogram was made followed by three 3-mm axial slices
(one center slice focused on needle entry point, one cranial,
one caudal slice) for image reconstruction. Only axial images
were used for the analysis.
After a radiologist had confirmed the position of the
needle tip on the CT image, the needle was removed, the
patient’s interscapular distance was measured in an upright
position, and the patient was released.
Using the CT scan, the following parameters were as-
sessed:
 Thickness of the soft tissue layer (distance between body
surface and muscle tissue measured from the needle
entry point)
 Distance of the puncture site to the vertebral line
 Distance of the needle tip to the vertebral line
 Distance of the needle tip to the body surface
 Needle depth in muscle tissue
 Distance of the needle tip to the intermuscular space.
The distance between the acupuncture point and the ver-
tebral line was described as ‘‘theoretical distance’’ (i.e., 1.5 cun
based on an interscapular distance of 6 cun), and as ‘‘actual
distance’’ (i.e., from the puncture site to the vertebral line).
Statistical analysis
The statistical analysis was done using SPSS Version 11.0
(SPSS Inc., Chicago, IL). Continuous variables are shown as
means
standard deviation and range. Normal distribution

Table 1. Patient Parameters

Acupuncture point

BL25 (n ¼ 28) BL26 (n ¼ 36)

Parameter Mean
SD, range

BMI 26.5
3.5, 18.9–33.3 26.4
3.9, 18.0–37.7

Interscapular distance (cm) 14.1
1.2, 11.0–16.5 13.6
1.5, 11.0–16.5
Soft tissue layera (cm) 2.0
1.0, 0.5–4.8 2.3
1.4, 0.6–7.9
a
Distance between body surface and muscle tissue measured from the needle entry point.
n ¼ number of patients; SD, standard deviation; BMI, body–mass index.
TOMOGRAPHIC LOCALIZATION OF ACUPUNCTURE POINTS 1287

FIG. 1. Localization of the acupuncture needle in the computed tomography image (left: BL25, right: BL 26).

was tested using the Shapiro-Wilk test. Normal distribution
was concluded from a p value  0.1. To test correlations be-
tween variables, the Spearman and the Pearson (for normal
distribution) correlation coefficient were used. Median and
mean values of dependent samples were compared using the
Wilcoxon signed rank test and the paired Student’s t-test (for
normal distribution), respectively.
The following correlations were evaluated:
 Interscapular distance and thickness of the soft tissue
layer with body–mass index (BMI)
 Distance of the puncture site to the vertebral line, dis-
tance of the needle tip to the vertebral line, distance of
the needle tip to the body surface with BMI
 Distance of the puncture site to the vertebral line, distance
of the needle tip to the vertebral line, distance of the
needle tip to the body surface with interscapular distance.
Results
Overall, 107 acupuncture needlings were performed: 49
(46%) needlings at BL25 in 28 patients and 58 (54%) nee-
dlings at BL26 in 36 patients. De qi was confirmed in 43 (88%)
of the needlings performed at BL25 and in 47 (81%) of the
needlings at BL26. In the remaining 6 (12%) needlings at
BL25 and 11 (19%) needlings at BL26, de qi could not be
confirmed by the therapist or the treated patient.
Needle localization
Descriptive data on needle localization for BL25 and BL26
are summarized in Table 2.
For both acupuncture points, the difference between the-
oretical and actual distance of the acupuncture point to the
vertebral line was not statistically significant ( p ¼ 0.527 for
BL25, p ¼ 0.105 for BL26). In general, the mean distances
from the puncture site to the vertebral line and the needle tip
to the vertebral line were similar, indicating vertical needle
placement in most cases.
Conversion of the metric data into the proportional ‘‘cun’’
system resulted in the data shown in Table 3.
Overall, there was no statistically significant difference
between the positive and negative de qi groups ( p > 1.0) for
any of the parameters shown above.

Table 2. Metric Description of Acupuncture Point Location

Acupuncture point (mean
SD)

BL25 (N ¼ 49) BL26 (N ¼ 58)

Positive Negative Positive Negative

Parameter (cm) de qi (n ¼ 43) de qi (n ¼ 6) de qi (n ¼ 47) de qi (n ¼ 11)

Theoretical distance of the acupuncture 3.5
0.3 3.5
0.2 3.4
0.4 3.6
0.4
point to the vertebral line
Actual distance of the puncture site 3.5
0.5 3.2
1.1 3.3
0.4 3.6
0.8
to the vertebral line
Theoretical versus actual distance 0.04
0.39 0.44
0.89 0.09
38 0.08
0.95
of the acupuncture point to the
vertebral line
Distance of the needle tip to the 3.4
0.5 3.2
1.3 3.2
0.4 3.6
0.9
vertebral line
Distance of the needle tip to the 4.1
0.9 3.6
1.1 3.9
0.8 4.5
1.4
body surface
Needle depth in muscle tissue 2.2
0.6 1.7
0.7 1.9
0.6 1.1
1.1

n, number of needlings; SD, standard deviation.

1288
Table 3. Proportional Description of Acupuncture Point Location
BL25 (N ¼ 49)
Positive
Parameter (cun) de qi (n ¼ 43)
Distance of the puncture site 1.52
0.2
to the vertebral line
Distance of the needle tip 1.47
0.2
to the vertebral line
Distance of the needle tip 1.78
0.4
to the body surface
n, number of needlings; SD, standard deviation.
Location of the needle tip
In the group of needlings with confirmed de qi, the CT
evaluation showed that the majority of needle tips were
located in a cluster in the intermuscular region between
the erector spinae and the transversospinal muscles (72%
for BL25 and 60% for BL26). Of these, 58% (BL25) and
50% (BL26) were located in the superficial third of the in-
termuscular region, 26% (BL25) and 32% (BL26) were lo-
cated in the median third, and 16% (BL25) and 18% (BL26)
were found in the profound third of the intermuscular
region.
Sixteen percent (16%) (BL25) and 17% (BL26) of the needle
tips were located in the erector spinae muscle, and 12%
(BL25) and 17% (BL26) of the needle tips were located in the
transversospinal muscle. Of these, 61% (BL25) and 62%
(BL26) were found in the median third of the muscle, 33%
(BL25) and 28% (BL26) were located in the profound third,
and 5% (BL25) and 9% (BL26) were located in the superficial
third of the muscle. At each acupuncture point, 1 needle (2%)
had perforated the muscle.
In addition, 6% of the needle tips at BL26 were located in
the proximity of the facet joints.
FIG. 2. Distance of the needle tip to the intermuscular region.
GROENEMEYER ET AL.
Acupuncture point (mean
SD)
BL26 (N ¼ 58)
Negative Positive Negative
de qi (n ¼ 6) de qi (n ¼ 47) de qi (n ¼ 11)
1.34
0.4 1.47
0.2 1.55
0.4
1.35
0.5 1.44
0.2 1.57
0.5
1.54
0.4 1.77
0.4 1.91
0.5
In patients where de qi was not confirmed (n ¼ 6 for BL25,
n ¼ 11 for BL26), none of the needle tips were located in the
intermuscular region. They were found in the erector spinae
muscle, the transversospinal muscle, the soft tissue layer, or
in the proximity of the facet joints.
The evaluation of the distance of the needle tip to the
intermuscular region resulted in a clear difference between
the group that confirmed de qi and the group that did not
confirm de qi sensation. The needle tip tended to significantly
be closer ( p < 0.005) to the intermuscular region when de qi
was confirmed (Fig. 2).
Correlation between measured parameters
and the BMI in needlings with confirmed de qi
Pearson’s correlation between the interscapular distance,
the thickness of the soft tissue layer and the BMI was r ¼ 0.59
(BL25), 0.44 (BL26) ( p < 0.05), and r ¼ 0.63 (BL25), 0.58 (BL25)
( p < 0.05), respectively. This result shows a linear correlation
between both the interscapular distance as well as the
thickness of the soft tissue layer and the BMI.
Consequently, the correlation of needle locations with the
BMI were evaluated and the results are shown in Figures 3–5.
TOMOGRAPHIC LOCALIZATION OF ACUPUNCTURE POINTS
FIG. 3. Correlation between the distance of the puncture site to the vertebral line and the body–mass index.
The scatter plots show trends of positive dependency be-
tween all parameters and the BMI. At acupuncture point
BL26, correlations between the distance of the puncture site
to the vertebral line and the BMI, and between the distance
of the needle tip to the vertebral line and the BMI were
not statistically significant, although the scatter plots (Figs. 3
and 4) indicate a positive dependency.
Discussion
To localize and evaluate acupuncture points BL25 and
BL26, 107 needlings were performed in 58 patients and
documented using CT. Using this imaging modality, the
needle position could be accurately described. The majority
of needle tips were located in a cluster in the intermuscular
region between the erector spinae and the transversospinal
muscles.
FIG. 4. Correlation between the distance of the needle tip to the vertebral line and the body–mass index.
1289
The results of this study confirm classic and current de-
scriptions of the localization of acupuncture points.13–15 To
date, several studies have been performed to investigate the
anatomical structures involved in de qi to find an explanation
for the mechanisms and the physiology responsible for this
sensation.6,16–18 These studies were mostly experimental in
nature, including animal studies and studies in human ca-
davers. Although many of them have contributed to the
understanding of de qi, many studies lack standards in the
localization of acupuncture points or needle manipulation.
The results of our study support the hypothesis suggested by
Langevin et al. that the network of acupuncture points
and meridians is a signal transduction network formed by
interstitial connective tissue.7 In their study, mapping of
acupuncture points on the human arm showed an 80% cor-
respondence between the sites of acupuncture points and the
location of intermuscular or intramuscular connective tissue
1290
FIG. 5. Correlation between the distance of the needle tip to the body surface and the body–mass index.
planes in postmortem tissue sections. The intermuscular
septa, related to the de qi response in our investigation, are
sites of fascial and connective tissue planes. This association
between de qi and needle location within the intermuscular
septa suggests that acupuncture needle manipulation pro-
duces cellular changes that disperse along connective tissue
planes.
The important role of the nervous system in the effect of
acupuncture has also been well described.12,19 The CT eval-
uation in our study showed that during de qi, the majority of
the needle tips were located in a cluster in the intermuscular
region between the erector spinae and the transversospinal
muscles (72% for BL25 and 60% for BL26) and in the median
third of these two muscles. The relevant nerves that can be
found in the intermuscular region are the ramus cutaneus
dorsalis medialis L 4 (BL25) and the ramus cutaneus dorsalis
medialis L 5 (BL26). It is likely that this nerve is provoked
during needle manipulation in this region and it is important
to note that this nerve is a target of multiple types of invasive
and ablative procedures for the treatment of back pain.
Several studies in considerably larger populations have
shown that acupuncture can effectively reduce pain in pa-
tients with back pain.20,21 If acupuncture stimulates relevant
nervous structures, its value in the treatment of back pain
may at least partially be explained.
The interscapular distance is a central landmark for the
localization of acupuncture points on the back. This study
showed a significant correlation between the interscapular
distance and the thickness of the soft tissue layer with the
BMI at both acupuncture points, supporting the use of pro-
portional measurements for the localization of BL25 and
BL26. Overall, the needle locations in this study correlated
with the BMI, indicating that metric measures alone are in-
sufficient to locate acupuncture points. The results suggest
that proportional methods should be used to effectively
target acupuncture needles and that specific anatomical
structures must be provoked in order to achieve de qi.
The authors are aware of only one report on the use of CT
for the evaluation of acupuncture points. In 2006, Huang
GROENEMEYER ET AL.
et al. evaluated acupuncture point Yao Tu to define needling
depth and a safety depth.22 The evaluation included one
needling; thus, no statistical analysis was done. Yao Tu is an
empirical acupuncture point that is not listed on China’s
official standard (GB=T12346-1990).
A limitation of this study is the lack of a control group and
the fact that the treatment effect of acupuncture was not in-
vestigated. This study did not evaluate the efficacy of acu-
puncture treatment for low-back pain but rather aimed at a
description of the location of acupuncture points relevant for
this treatment. Since an association between needle position
and relevant anatomical structures could be shown, it would
be important to investigate whether the results can be asso-
ciated with any treatment effect. No conclusive data on
the treatment effect could have been obtained from patients
enrolled in this study, because the large majority received
acupuncture in addition to other back pain therapies such
as injections or ablative interventions. CT was shown to be
suitable for this investigation but does have limitations in the
detailed evaluation of tissue. Magnetic resonance imaging
(MRI) should be used to obtain more detailed images of an-
atomical structures surrounding the acupuncture needle, al-
though nonmagnetic needles are required for MRI evaluation.
Moncayo et al. have been able to demonstrate the relation of
acupuncture points to musculoskeletal structures in vivo us-
ing three-dimensional rendering of MRI data and have sug-
gested a close relation of acupuncture points of the Yang and
Yin motility vessels as well as of the Dai mai to tendinomus-
cular structures.23 Similar studies should be performed com-
paring groups with positive and negative treatment effects to
further investigate the role of anatomical structures involved
in acupuncture.
Conclusions
The results of this study show an association between de qi
and needle location within the intermuscular septa. Acu-
puncture points BL25 and BL26 are located as clusters in or
close to the intermuscular region of the erector spinae and
TOMOGRAPHIC LOCALIZATION OF ACUPUNCTURE POINTS
the transversospinal muscles, with a distance to the vertebral
line of 3.49
0.58 cm and 3.32
0.53 cm, respectively. The
needle position correlates with individual anatomical land-
marks, suggesting that the use of proportional methods is
relevant for the success of acupuncture therapy.
Disclosure Statement
No competing financial conflicts exist.
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Address correspondence to:
Dietrich H.W. Groenemeyer, M.D., Ph.D.
Grönemeyer Institute of Microtherapy
Universitätsstrabe 142
D 44799 Bochum
Germany
E-mail: krueger@groenemeyer.com