Is direct moxibustion justified on clinical grounds in ethical practice?

March 24, 2008

Hi All,

Direct (scarring / suppurative) moxibustion does harm (admittedly minor

harm) in most cases.

IMO, practitioners who to the ethic of " First Do No Harm " , must

question the use direct moxibustion, or at least reserve its use to cases that

have not responded to gentler methods.

Are there any well designed trials that compared the clinical outcomes of

indirect (non-scarring) versus direct moxibustion?

Do those trials produce sound evidence of a significantly better outcome

from scarring / suppurative moxibustion over the milder form?

A of Medline search produced only 2 hits for the profile:

moxibustion AND (indirect OR non-scarring) AND (direct OR scarring OR

suppurative) AND ( " comparison of " OR compare*)

As one might expect, those hits confirmed that moxibustion increases skin

temperature and permeability. One study concluded: " Direct moxibustion

with a traditional moxa stick may produce its potent therapeutic effects by

thermal action, while traditional indirect moxibustion may act by producing

modest thermal action and a sympathetic vibration at the skin surface. Non-

traditional thermal materials and media may not be suitable substitutes for

traditional materials. The data provide a scientific, biophysical rationale for

traditional moxibustion " . NEITHER study compared the clinical outcomes of

the two methods (direct versus indirect).

Tatiana cited an article from Blue Poppy [ " Clinical Use of Suppurative

Moxibustion " by Li Ming-zhi, Shang Hai Zhen Jiu Za Zhi (Shanghai Journal

of Acupuncture & Moxibustion), #3, 1992, p. 33-34

www.bluepoppy.com/press/download/articles/acup_tuina_rr.cfm ], which

said:

" Following administration of suppurative moxibustion, one may often

observe the immediate resolution of lingering illness. The *Zi Sheng Jing

(The Classic of Nourishing Life)* states that, " All moxa should must produce

a sore in order for the patient to recover. " As a result of this, it would

seem that suppurative moxibustion has a distinctive therapeutic effect.

Without citing evidence, http://www.jcrows.com/moxaarticles.html said:

" Because of the difference of quality and processing of moxa between

Japan and China, Japanese acupuncturists in general prefer direct

moxibustion while Chinese therapists do indirect moxibustion, especially

stick moxa. It requires a great deal of training for a therapist to master the

direct moxibustion techniques, but it is much more effective than indirect

moxibustion. "

In a very detailed review, " MOXIBUSTION: Practical Considerations for

Modern Use of an Ancient Technique " [ www.itmonline.org/arts/moxibustion

], Subhuti Dharmananda said:

" [scarring / suppurative] moxa therapy is not discussed in any detail as part

of Western acupuncture training because it is not allowable in Western

practice. "

He cites a Chinese study:

" The authors suggested that indirect moxibustion was preferred by patients

over acupuncture because of lack of pain & discomfort (needling in Chinese

clinics is far more vigorous than in Western clinics). This is in contrast to

the

situation w direct moxibustion, which can be more painful than acupuncture;

the painful nature of usual direct moxibustion being mentioned in several

texts. "

Subhuti concludes his review as follows:

" It is difficult to know, based on the literature review, whether moxibustion is

more effective than acupuncture or other stimulus methods administered for

the same condition. In the absence of more detailed studies, moxa is

applied primarily on the basis of the Chinese traditional medical descriptions,

such as treating syndromes associated with cold, retention of food, spasms,

immune deficiency, and local stagnation of fluids with formation of masses.

Moxa may be utilized in some cases of heat syndromes. "

So, taking the data above into consideration, and apart from local / state

legislation on the topic, where does the profession stand on the justification

(or otherwise) of using direct moxibustion in clinical practice?

Best regards,

March 29, 2008

Dear ,

Your inquiry about direct moxibustion (DM) raised some excellent

questions.

Some thirty years ago I received training from Dr. James Tin Yau So,

who was a real master of DM. I went on to use DM in my acupuncture

practice, and the clinical results certainly appeared to justify its

use. (For example, in one case, a chest wall tumor the size of half a

grapefruit shrank away to nothing after several DM treatments.) My

patients accepted DM quite well. DM was within my legal scope of

practice, and was not prohibited by my state acupuncture association.

Nonetheless, it became clear to me that DM would soon become a lost

art in the US. This may be due in part to a widespread lack of good

training, exclusion from coverage by professional liability insurance

policies, and prohibition by integrative clinics. While far more

harmful interventions are accepted in biomedicine, DM remains

distanced due in some measure to its unfamiliarity. And a lack of

controlled research certainly sustains that unfamiliarity.

It is ironic to consider that DM may become so unfamiliar within our

own profession as to be considered for banishment. Particularly in a

profession that has not yet, at the national level, banned the re-use

of acupuncture needles. There are traditional techniques of imbedding

needles or metallic wires that also should be banned (as the fragments

don't stay put, and can cause serious medical harm). The harm of DM

scars is cosmetic, while the procedure itself is somewhat painful. DM

has indications and contraindications. DM requires skill, and can be

done well or poorly.

Is it ethical to use clinical techniques that lack formal research

justification? Sometimes, and yet not always, and certainly not

without discretion. Clinical advancements often push the envelope of

the known, and produce new questions for researchers. When I first

began learning traditional Oriental medicine, there were very few good

clinical studies of acupuncture available. But there was a tradition

(or more correctly, multiple traditions) that pointed out when and how

to proceed, and how not to proceed.

Is it ethical to use a clinical technique without adequate training in it?

Is it ethical to use a clinical technique without full informed

consent by the patient?

Is it ethical to use a clinical technique not within your legal scope

of practice?

Is it ethical to use a clinical technique prohibited by your

professional peers?

In ordinary circumstances, the answer is NO to each of these four

questions.

I would surmise that the mechanisms of action of DM are dissimilar to

indirect moxa, and dissimilar to acupuncture. The body seems to

respond disproportionately to a small third degree burn. The body also

seems to respond disproportionately (though in different ways) to the

stimulus of an acupuncture needle.

Best regards,

David Kailin, Ph.D., M.P.H., L.Ac.

Author, Quality in Complementary & Alternative Medicine

http://www.convergentmedical.com

March 30, 2008