Moxa sticks: thermal properties and possible implications for clinical trials

Moxibustion treatment for Parkinson's disease: study protocol for a randomized controlled trial

BACKGROUND

Parkinson's disease (PD) is the second most common neurodegenerative disorder and seriously affects quality of life globally. Moxibustion is widely used to treat neurodegenerative diseases in the clinic and has achieved a beneficial clinical effect. However, strict control and high-quality randomized controlled trials are still lacking. Therefore, this trial aims to evaluate the clinical efficacy and safety of moxibustion in patients with PD and preliminarily explore the underlying mechanism.

METHODS

This is a randomized, single-blind and placebo-controlled trial design in which 70 eligible participants will be randomly divided into a moxibustion group and a sham moxibustion group. Baihui (DU20) and Sishenchong (EX-HN1) are selected for both groups. The treatment will be performed for 30 min per session, two sessions a week for 8 weeks. The mean change in MDS-UPDRS scores (including MDS-UPDRS II, III subscale scores and total scores) from baseline to the observation points will be the primary outcome. The secondary outcomes will include scores on the Parkinson's Disease Questionnaire-39 (PDQ-39), Fatigue Severity Scale (FSS), Parkinson Disease Sleep Scale (PDSS), Montreal Cognitive Assessment (MoCA), and Self-Rating Depression Scale (SDS) as well as the Wexner constipation score. All the above outcomes will be assessed at 4 and 8 weeks. Laboratory blood biochemical analysis and functional magnetic resonance imaging (fMRI) will be conducted at baseline and at the end of treatment to explore the potential mechanisms of moxibustion in regulating PD.

DISCUSSION

In conclusion, the results of this trial will reveal whether moxibustion is effective for treating motor and nonmotor symptoms in PD. This trial will also preliminarily explore the underlying mechanism of the regulatory effect of moxibustion in PD, which will contribute to providing a theoretical basis for the treatment of PD.

TRIAL REGISTRATION

ClinicalTrials.gov ChiCTR2000029745. Registered on 9 August 2021.

Cephalic version by moxibustion for breech presentation

BACKGROUND

Breech presentation at term can cause complications during birth and increase the chance of caesarean section. Moxibustion (a type of Chinese medicine which involves burning a herb close to the skin) at the acupuncture point Bladder 67 (BL67) (Chinese name Zhiyin), located at the tip of the fifth toe, has been proposed as a way of changing breech presentation to cephalic presentation. This is an update of a review first published in 2005 and last published in 2012.

OBJECTIVES

To examine the effectiveness and safety of moxibustion on changing the presentation of an unborn baby in the breech position, the need for external cephalic version (ECV), mode of birth, and perinatal morbidity and mortality.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, and conference proceedings), ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (4 November 2021). We also searched MEDLINE, CINAHL, AMED, Embase and MIDIRS (inception to 3 November 2021), and the reference lists of retrieved studies.

SELECTION CRITERIA

The inclusion criteria were published and unpublished randomised or quasi-randomised controlled trials comparing moxibustion either alone or in combination with other techniques (e.g. acupuncture or postural techniques) with a control group (no moxibustion) or other methods (e.g. acupuncture, postural techniques) in women with a singleton breech presentation.

DATA COLLECTION AND ANALYSIS

Two review authors independently determined trial eligibility, assessed trial quality, and extracted data. Outcome measures were baby's presentation at birth, need for ECV, mode of birth, perinatal morbidity and mortality, maternal complications and maternal satisfaction, and adverse events. We assessed the certainty of the evidence using the GRADE approach.   MAIN RESULTS: This updated review includes 13 studies (2181 women), of which six trials are new. Most studies used adequate methods for random sequence generation and allocation concealment. Blinding of participants and personnel is challenging with a manual therapy intervention; however, the use of objective outcomes meant that the lack of blinding was unlikely to affect the results. Most studies reported little or no loss to follow-up, and few trial protocols were available. One study that was terminated early was judged as high risk for other sources of bias. Meta-analysis showed that compared to usual care alone, the combination of moxibustion plus usual care probably reduces the chance of non-cephalic presentation at birth (7 trials, 1152 women; risk ratio (RR) 0.87, 95% confidence interval (CI) 0.78 to 0.99, I2 = 38%; moderate-certainty evidence), but the evidence is very uncertain about the effect of moxibustion plus usual care on the need for ECV (4 trials, 692 women; RR 0.62, 95% CI 0.32 to 1.21, I2 = 78%; low-certainty evidence) because the CIs included both appreciable benefit and moderate harm. Adding moxibustion to usual care probably has little to no effect on the chance of caesarean section (6 trials, 1030 women; RR 0.94, 95% CI 0.83 to 1.05, I2 = 0%; moderate-certainty evidence). The evidence is very uncertain about the effect of moxibustion plus usual care on the the chance of premature rupture of membranes (3 trials, 402 women; RR 1.31, 95% CI 0.17 to 10.21, I2 = 59%; low-certainty evidence) because there were very few data. Moxibustion plus usual care probably reduces the use of oxytocin (1 trial, 260 women; RR 0.28, 95% CI 0.13 to 0.60; moderate-certainty evidence). The evidence is very uncertain about the chance of cord blood pH less than 7.1 (1 trial, 212 women; RR 3.00, 95% CI 0.32 to 28.38; low-certainty evidence) because there were very few data. We are very uncertain whether the combination of moxibustion plus usual care increases the chance of adverse events (including nausea, unpleasant odour, abdominal pain and uterine contractions; intervention: 27/65, control: 0/57), as only one study presented data in a way that could be reanalysed (122 women; RR 48.33, 95% CI 3.01 to 774.86; very low-certainty evidence). When moxibustion plus usual care was compared with sham moxibustion plus usual care, we found that moxibustion probably reduces the chance of non-cephalic presentation at birth (1 trial, 272 women; RR 0.74, 95% CI 0.58 to 0.95; moderate-certainty evidence) and probably results in little to no effect on the rate of caesarean section (1 trial, 272 women; RR 0.84, 95% CI 0.68 to 1.04; moderate-certainty evidence). No study that compared moxibustion plus usual care with sham moxibustion plus usual care reported on the clinically important outcomes of need for ECV, premature rupture of membranes, use of oxytocin, and cord blood pH less than 7.1, and one trial that reported adverse events reported data for the whole sample. When moxibustion was combined with acupuncture and usual care, there was very little evidence about the effect of the combination on non-cephalic presentation at birth (1 trial, 226 women; RR 0.73, 95% CI 0.57 to 0.94) and at the end of treatment (2 trials, 254 women; RR 0.73, 95% CI 0.57 to 0.93), and on the need for ECV (1 trial, 14 women; RR 0.45, 95% CI 0.07 to 3.01). There was very little evidence about whether moxibustion plus acupuncture plus usual care reduced the chance of caesarean section (2 trials, 240 women; RR 0.80, 95% CI 0.65 to 0.99) or pre-eclampsia (1 trial, 14 women; RR 5.00, 95% CI 0.24 to 104.15). The certainty of the evidence for this comparison was not assessed.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that moxibustion plus usual care probably reduces the chance of non-cephalic presentation at birth, but uncertain evidence about the need for ECV. Moderate-certainty evidence from one study shows that moxibustion plus usual care probably reduces the use of oxytocin before or during labour. However, moxibustion plus usual care probably results in little to no difference in the rate of caesarean section, and we are uncertain about its effects on the chance of premature rupture of membranes and cord blood pH less than 7.1.  Adverse events were inadequately reported in most trials.

Effects of Moxa Cone Moxibustion Therapy on Cognitive Function and Brain Metabolic Changes in MCI Patients: A Pilot 1H-MRS Study

Objective

To explore the effect of moxa cone moxibustion on N-acetyl aspartate/total creatinine (NAA/tCr) and choline/total creatinine (Cho/tCr) in the bilateral hippocampus (HIP) and bilateral posterior cingulate gyrus (PCG) in patients with mild cognitive impairment (MCI) using hydrogen proton magnetic resonance spectroscopy (¹H-MRS) and to provide imaging basis for moxa cone moxibustion treatment for MCI.

Methods

One hundred eight patients with MCI were served as the MCI group, and 67 age-matched subjects were enrolled as the normal control group. The MCI group was randomized and allocated into acupoint group, drug group, and sham acupoint group, with 36 cases in each group. Some patients in each group withdrew. Finally, 25 cases were included in the acupoint group, 24 cases in the drug group, and 20 cases in the sham acupoint group. The drug group was treated with oral donepezil hydrochloride. The acupoint group and sham acupoint group received moxa cone moxibustion treatment. Mini-mental state exam (MMSE) and Montreal cognitive assessment (MoCA) scores were recorded before intervention, at the end of the first and the second months of intervention, and in the 5th month of follow-up. The NAA/tCr and Cho/tCr ratios in the HIP and PCG were bilaterally measured by ¹H-MRS before and after intervention.

Results

Before intervention, compared with the normal control group, the MMSE and MoCA scores, the Cho/tCr ratio in the right HIP, the NAA/tCr ratio in the bilateral HIP, and the NAA/tCr ratio in the left PCG in the three treatment groups decreased significantly (both p < 0.01), and the NAA/tCr ratio in the right PCG significantly reduced in the acupoint and drug groups (p < 0.05). After two months of treatment, compared with the normal control group, there were no differences in the MoCA scores, the NAA/tCr, and Cho/tCr ratios in the bilateral PCG and bilateral HIP in the three treatment groups (p > 0.05). However, the MMSE scores in the drug group decreased when compared with the acupoint group and normal control group (p < 0.05, p < 0.01). The scores of MMSE and MoCA in the acupoint group and sham acupoint group at all time points were better than those in the drug group, which were similar to those in the normal control group.

Conclusion

Our findings suggest that moxibustion could improve the cognitive function of patients with MCI. The mechanism may be related to the improvement of abnormal brain metabolism in HIP and PCG.

Altered functional connectivity density in mild cognitive impairment with moxibustion treatment: A resting-state fMRI study

PURPOSE

Mild cognitive impairment (MCI) is a general neurodegenerative disease. Moxibustion has been shown to have remarkable effect on cognitive improvement, however, less is known about the effect of moxibustion on MCI and its underlying neural mechanism. This study aimed to investigate the ameliorative brain network in MCI after treatments of acupoint-related moxibustion.

METHODS

Resting-state functional MRI were derived from 47 MCI patients and 30 healthy controls (HCs). Patients were randomized as Tiaoshen YiZhi (TSYZ, n = 27) and sham (SHAM, n = 20) acupoint moxibustion groups. Functional connectivity density (FCD) method and repeated-measures two-way analysis of variance (ANOVA) were performed to ascertain the interaction effects between groups (TSYZ and SHAM) and time (baseline and post-treatment). Abnormal FCD was examined between baseline and post-treatment in TSYZ and SHAM groups, respectively.

RESULTS

Compared with HCs, MCI showed altered FCD in the middle frontal cortex (MFC), inferior frontal cortex, temporal pole, thalamus and middle cingulate cortex. After moxibustion treatment in MCI, 1) a significant time-by-groups interaction was observed in the medial prefrontal cortex (mPFC); 2) abnormal long-range FCD (lrFCD) in the mPFC and MFC were modulated in TSYZ group; 3) significantly improved clinical symptoms; 4) changed lrFCD in the MFC was significantly negatively correlated with the increased Montreal Cognitive Assessment scores in TSYZ group.

CONCLUSIONS

These imaging findings suggest that treatments of acupoint-related moxibustion could improve lrFCD in certain regions related to self-related cognitive and decision making. Our study might promote understanding of MCI neural mechanisms and expand the clinical application of moxibustion in MCI.

Effects of warm needling therapy on symptoms of benign prostatic hyperplasia: A protocol for a systematic review and meta-analysis

BACKGROUND

Benign prostatic hyperplasia (BPH) is the term for a type of non-malignant prostate enlargement that is most often diagnosed in men of middle age and older. Lower urinary tract symptoms (LUTS) are commonly observed in men afflicted with BPH. Evidence suggests that warm needling therapy could be applied clinically to relieve the LUTS associated with BPH, particularly in China, where experienced practitioners are readily available. In this review, the safety and effects of warm needling therapy are assessed in the context of treatment for LUTS associated with BPH.

METHODS

First, data for relevant randomised controlled trials and the initial periods of randomised cross-over trials will be obtained from four English databases (MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and Allied and Complementary Medicine Database) and six Chinese databases (China National Knowledge Infrastructure, Wanfang Database, SinoMed, Chongqing VIP Chinese Science and Technology Periodical Database, China Master's Theses Full-text Database and China Doctoral Dissertations Full-text Database). The primary outcomes analysed in this protocol are improvements in urological symptoms as measured by recognized urological symptom scores, while secondary outcomes include improvement of urine flow rate measures, residual urine volume, nocturia, prostate size, and quality-of-life score. In addition, safety outcomes will be analysed by assessing incidences of adverse events. Two reviewers will independently assess and select studies, extract data and assess the risk of bias. Data synthesis and risk bias assessment will be performed with Review Manager software (version 5.3).

RESULTS

This systematic review provides a synthesis to assess the therapeutic efficacy of warm needling therapy for LUTS associated with BPH.

CONCLUSION

The present study will provide a clinically relevant evaluation of the current state of evidence regarding the therapeutic efficacy of warm needling therapy for LUTS associated with BPH.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review, because private information will not be collected from the included participants. The results of the study will be published in a peer-reviewed journal.

REGISTRATION NUMBER

PROSPERO CRD42020198360.

Acupressure and Acupuncture Use in the Peripartum Period

Acupuncture is the procedure of inserting fine needles into specific points on the body for therapeutic purposes. Acupuncture and its derivatives (acupressure, moxibustion, electroacupuncture, and transcutaneous electric nerve stimulation on acupoints) are a popular treatment choice in the peripartum period (32 wk' gestation to 14 d postdelivery). There is substantial research evidence supporting acupuncture and its derivatives in the peripartum period. Benefits in the use of acupressure to reduce labor pain intensity and a reduction in the duration of labor with acupressure have been found. There is mixed evidence for the use of both moxibustion and moxibustion with acupuncture for noncephalic presentations and for acupressure for reducing intraoperative nausea. There is limited evidence available on acupuncture use in women with high-risk pregnancies or multifetal gestations.

[Acupuncture for pain and allergic rhinitis-from clinical experience to evidence]

BACKGROUND

Acupuncture is a traditional Chinese medicine therapy method that is also frequently used in the western world. It has been the subject of intensive scientific research over the past two decades.

AIM OF THE WORK

To describe the efficacy, therapy safety, and health economic relevance of acupuncture for chronic pain disorders and allergic diseases.

MATERIAL AND METHODS

In the context of a review (narrative review) the relevant literature was selected, presented, and interpreted.

RESULTS

Acupuncture is effective in chronic pain disorders such as chronic knee joint pain in osteoarthritis, migraine, tension headache, chronic lumbar spine pain, chronic cervical spine pain, shoulder pain, dysmenorrhea, and fibromyalgia under routine conditions. In addition, specific efficacy is shown in most chronic pain indications. Acupuncture is also effective in patients with allergic diseases. In large clinical studies, acupuncture has proven to be a relatively safe therapy, but severe complications (e.g. pneumothorax cases, hepatitis B) also occur in rare instances. Acupuncture is usually associated with higher therapy costs, but is considered a cost-effective treatment strategy for pain disorders.

DISCUSSION

As a nonpharmacological procedure, acupuncture is becoming increasingly important in pain and allergy therapy and is therefore increasingly included in current guidelines. In further studies, the efficacy of acupuncture should be determined in other indications and the mechanisms of action of this therapy method should be investigated.

Effects of moxibustion on symptoms of mild cognitive impairment: protocol of a systematic review and meta-analysis

INTRODUCTION

Mild cognitive impairment (MCI) is considered the intermediate phase between normal age-related cognitive decline and dementia. Moxibustion has gained increased popularity for the management of MCI in China.This study aimed to evaluate the effects and safety of moxibustion on symptoms of MCI.

METHODS AND ANALYSIS

Four English databases and six Chinese databases will be searched from their inception to October 2019: Embase, MEDLINE, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database, China National Knowledge Infrastructure, Chongqing VIP Chinese Science and Technology Periodical Database, Wanfang Database, SinoMed, China Doctoral Dissertations Full-text Database and the China Master's Theses Full-text Database. Only clinical randomised controlled trials and the first period in randomised cross-over trial related to moxibustion for MCI will be included. The primary outcomes include the improvement of cognitive function, as measured by validated assessment tools. The secondary outcomes include changes in the activity of daily living scale, effective rate and the incidences of adverse events. The selection of studies, data extraction and risk of bias assessment will be carried out by two independent reviewers. Review Manager V.5.3 software will be used for statistical analyses. Heterogeneity test, data synthesis and subgroup analysis will be performed if necessary. The risk of bias of included studies will be assessed by the Cochrane Handbook risk of bias tool. Evidence quality will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation system.

ETHICS AND DISSEMINATION

Ethics approval is not required as no private information from individuals are collected. The results will be published in a peer-reviewed journal or disseminated in relevant conferences.

TRIAL REGISTRATION NUMBER

CRD42018112657.

The Efficacy and Underlying Mechanism of Moxibustion in Preventing Cognitive Impairment: A Systematic Review of Animal Studies

Cognitive impairment is age-related and manageable only with early diagnosis and prevention. Moxibustion is widely accepted in East Asia as useful for preventing cognitive impairment. This systematic review of animal studies was conducted to verify the efficacy of moxibustion in preventing cognitive impairment and to elucidate the underlying mechanism. Randomized controlled animal trials that established the efficacy of moxibustion in preventing cognitive impairment were included in the analysis. Results of behavioral tests and the signaling pathways elucidated were extracted and a meta-analysis was conducted with the behavioral test results. The risk of bias was evaluated using 9 items, and reporting quality was evaluated using the ARRIVE (Animal Research: Reporting In Vivo Experiments) Guidelines Checklist. Ten trials involving 410 animals met the inclusion criteria. All studies reported the benefit of moxibustion in preventing cognitive deficits caused by Alzheimer's disease (AD). Among five studies using the Morris water maze test, a significant effect of moxibustion in decreasing the escape time was reported in three studies, increasing the crossing times in four studies, and prolonging the dwelling time in two studies. The effects of moxibustion were demonstrated to be mediated by an increase in the activity of neurotrophins and heat shock protein, modulation of the cell cycle, and suppression of apoptosis and inflammation. However, considering the small number of included studies, the lack of studies investigating entire signaling pathways, and a high risk of bias and low reporting quality, our results need to be confirmed through more detailed studies.

Effect of Electro-Acupuncture and Moxibustion on Brain Connectivity in Patients with Crohn's Disease: A Resting-State fMRI Study

Acupuncture and moxibustion have been shown to be effective in treating Crohn’s disease (CD), but their therapeutic mechanisms remain unclear. Here we compared brain responses to either electro-acupuncture or moxibustion treatment in CD patients experiencing remission. A total of 65 patients were randomly divided into an electro-acupuncture group (n = 32) or a moxibustion group (n = 33), and treated for 12 weeks. Eighteen patients in the electro-acupuncture group and 20 patients in the moxibustion group underwent resting-state functional magnetic resonance imaging at baseline and after treatment. Seed-based analysis was used to compare the resting-state functional connectivity (rsFC) between bilateral hippocampus and other brain regions before and after the treatments, as well as between the two groups. The CD activity index (CDAI) and inflammatory bowel disease questionnaire (IBDQ) were used to evaluate disease severity and patient quality of life. Electro-acupuncture and moxibustion both significantly reduced CDAI values and increased IBDQ scores. In the electro-acupuncture group, the rsFC values between bilateral hippocampus and anterior middle cingulate cortex (MCC) and insula were significantly increased, and the changes were negatively correlated with the CDAI scores. In the moxibustion group, the rsFC values between bilateral hippocampus and precuneus as well as inferior parietal lobe (IPC) were significantly elevated, and the changes were negatively correlated with the CDAI scores. We conclude that the therapeutic effects of electro-acupuncture and moxibustion on CD may involve the differently modulating brain homeostatic afferent processing network and default mode network (DMN), respectively.

An In Vitro and Numerical Study of Moxibustion Therapy on Biological Tissue

OBJECTIVE

Moxibustion therapy achieves satisfactory therapeutic effects largely depending on the heat stimulation of burning moxa. Understanding the thermal characteristics of heating process is an effective way to reveal the underlying mechanisms of moxibustion therapy.

METHODS

This paper performs experimental study on temperature distributions of burning moxa sticks and fresh in vitro porcine abdominal tissue using an infrared camera and thermocouples. Meanwhile, a moxibustion model incorporating moxa stick burning model and tissue heat transfer model was established with consideration of radiation propagation and water evaporation.

RESULTS

The burning features of moxa sticks were acquired and the radiation energy generated by the burning moxa stick was absorbed and scattered in biological tissue, resulting in a large temperature gradient in the skin layer. And the water evaporation led to a mass loss and reduced skin surface temperature. The numerical model was verified by experimental results and the effects of moxibustion treatment distance and duration can be quantified based on model calculation.

CONCLUSION

The detailed heat transfer process of moxibustion was obtained experimentally and numerically. During moxibustion, the radiation attenuation and water evaporation have a significant influence on the energy transport in biological tissue which cannot be ignored. The treatment distance of 3 cm is the recommended value to achieve the treatment efficacy without thermal damage and pain.

SIGNIFICANCE

This research would reveal the underlying mechanisms of moxibustion therapy. Besides, the developed models are expected to establish a guideline for moxibustion clinical treatment.

Development of Acupuncture and Moxibustion Protocol in a Clinical Trial for Irritable Bowel Syndrome

Traditional Chinese medicine encompasses many different practices, most notably acupuncture and moxibustion. Traditionally, these modalities are used in combination to augment treatment but seldom are they tested together in clinical studies. Numerous acupuncture studies have been conducted in Asia, Europe, and the United States but there have been few randomized controlled trials utilizing moxibustion outside of East Asia. Limited studies have described the use of a moxibustion control or placebo procedure. The methods for developing an acupuncture and moxibustion protocol used in a randomized controlled trial for irritable bowel syndrome, diarrhea predominant in adults are described here. Our approach conformed to the scientific rigor for a clinical trial and was consistent to the foundations of traditional Chinese medicine.

Different brain responses to electro-acupuncture and moxibustion treatment in patients with Crohn's disease

This study aimed to investigate changes in resting state brain activity in remissive Crohn’s Disease (CD) patients after electro-acupuncture or moxibustion treatment. Fifty-two CD patients and 36 healthy subjects were enrolled, and 36 patients were equally and randomly assigned to receive either electro-acupuncture or moxibustion treatment for twelve weeks. We used resting state functional magnetic resonance imaging to assess Regional Homogeneity (ReHo) levels, and Crohn’s Disease Activity Index (CDAI) and Inflammatory Bowel Disease Questionnaire (IBDQ) scores to evaluate disease severity and quality of life. The results show that (i) The ReHo levels in CD patients were significantly increased in cortical but decreased in subcortical areas, and the coupling between them was declined. (ii) Both treatments decreased CDAI, increased IBDQ scores, and normalized the ReHo values of the cortical and subcortical regions. (iii) ReHo changes in multiple cortical regions were significantly correlated with CDAI score decreases. ReHo changes in several subcortical regions in the electro-acupuncture group, and those of several cortical regions in the moxibustion group, were correlated with reduced CDAI. These findings suggest that both treatments improved cortex-subcortical coupling in remissive CD patients, but electro-acupuncture regulated homeostatic afferent processing network, while moxibustion mainly regulated the default mode network of the brain.

Moxibustion treatment for diarrhea-predominant irritable bowel syndrome: study protocol for a randomized controlled trial

BACKGROUND

Irritable bowel syndrome (IBS) is a worldwide disease with high morbidity. The effect of current treatment with Western medicine is not satisfactory. Although moxibustion treatment is widely used for gastrointestinal diseases, randomized controlled trials on the use of this treatment for IBS are limited. This study aims to evaluate the clinical efficacy and safety of moxibustion treatment in patients with diarrhea-predominant irritable bowel syndrome (IBS-D).

METHODS/DESIGN

A multi-center, randomized, single-blind and placebo-controlled trial is employed. 104 cases will be divided into two groups: (1) a mild-warm moxibustion group in which moxa stick is 3-5 cm away from acupuncture points and the skin temperature is maintained at 43 ± 1 °C; and (2) a placebo moxibustion group in which moxa stick is 8-10 cm away from acupuncture points and the skin temperature is maintained at 37 ± 1 °C. Moxibustion is performed on bilateral ST25 and ST36 in the two groups for 30 min each time, three times a week for 6 weeks. The patients are followed up at the 12th and 18th weeks. Adequate relief is used as a primary outcome measure; IBS symptom severity score, Bristol stool form scale, IBS quality-of-life questionnaire, and hospital anxiety and depression scale are used as secondary outcome measures.

DISCUSSION

This study aims to demonstrate the safety and efficacy of moxibustion treatment for IBS-D, which may validate moxibustion as an effective therapy for treating IBS-D.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT02421627 (8 April 2015).

Moxibustion Treatment for Knee Osteoarthritis: A Systematic Review and Meta-Analysis

To determine whether the administration of moxibustion is an effective treatment for knee osteoarthritis (KOA).We conducted a search of relevant articles using Medline, EMBASE, the Web of Science, and the Cochrane Library published before October 2015. The Western Ontario and McMaster Universities' Osteoarthritis Index (WOMAC scale) and the short form 36 questionnaire (SF-36 scale) were assessed. Evidence grading was evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system.Four studies containing 746 participants fulfilled the inclusion criteria in the final analysis. In terms of quality of life (QOL), the meta-analysis of 2 randomized clinical trials (RCTs) showed significantly effects of moxibustion only in bodily pain (BP) compared with those in the control group (n = 348; weighted mean difference [WMD], 4.36; 95% confidence intervals [CIs], 2.27-6.44; P < 0.0001; heterogeneity: χ = 1.53, P = 0.22, I = 34%) in all of the subcategories of the SF-36 scale, with moderate quality. The meta-analysis of the 2 included trials showed that there was not a statistically significant difference in the pain or function subscale for the WOMAC scale when the 2 groups were compared (n = 322; WMD, 17.63; 95% CI, -23.15-58.41; P = 0.40; heterogeneity: χ = 19.42, P < 0.0001, I = 95%), with low or moderate quality separately.The administration of moxibustion can to some extent alleviate the symptoms of KOA. More rigorous, randomized controlled trials are required in the future.

Standardisation of Moxibustion: Challenges and Future Development

International organisations such as WHO and the International Organization for Standardization are increasingly committed to the development of traditional Chinese medicine (TCM). Moxibustion is an integral modality of acupuncture that has been in use for thousands of years. It stands out as a health choice due to its potential effects in disease prevention, health promotion and maintenance, as well as affordability and accessibility. As the use of moxibustion increases, concerns are being raised regarding its safety and quality. The need to establish standards to protect patient safety is paramount in all medical fields. As a form of medical practice, it is essential to develop moxibustion standards in the areas of terminology, moxibustion products, treatment rooms and practice to ensure its harmonisation and safe usage. The evidence base guiding policy and decision making has to be based on evidence from basic and clinical research. Promoting strategic basic and clinical research on the safety and effectiveness of moxibustion will answer some of the fundamental questions surrounding moxibustion, create a climate of awareness and acceptance and, in turn, drive its standardisation.

Effectiveness of moxibustion treatment as adjunctive therapy in osteoarthritis of the knee: a randomized, double-blinded, placebo-controlled clinical trial

Introduction

Our objective was to compare the effectiveness and safety of traditional Chinese moxibustion to that of sham moxibustion in patients with chronic knee osteoarthritis (KOA) pain.

Methods

We conducted a randomized placebo-controlled trial involving 110 patients with KOA who met the inclusion criteria. These patients randomly received either active moxibustion (n = 55) or sham moxibustion control (n = 55) at acupoints Dubi (ST 35), extra-point Neixiyan (EX-LE 4), and an Ashi (tender) point three times a week for 6 weeks. Effects were evaluated with Western Ontario and McMaster Universities’ Osteoarthritis Index (WOMAC VA 3.1) criteria at the end of the course of treatment and 3, 12, and 24 weeks after the initial treatment.

Results

The WOMAC pain scores showed greater improvement in the active treatment group than in control at weeks 3 (P = 0.012), 6 (P <0.001), 12 (P = 0.002), and 24 (P = 0.002) as did WOMAC physical function scores of the active treatment group at week 3 (P = 0.002), 6 (P = 0.015), and 12 (P <0.001) but not 24 (P = 0.058). Patients and practitioners were blinded successfully, and no significant adverse effects were found during the trial.

Conclusions

A 6-week course of moxibustion seems to relieve pain effectively and improve function in patients with KOA for up to 18 weeks after the end of treatment. Moxibustion treatment appears to be safe, and the usefulness of the novel moxa device was validated.

Trial registration

Current controlled trial: ISRCTN68475405. Registered 4 April 2014.

On the hazard caused by the heat of acupuncture needles in warm needling (wēn zhēn)

Due to its simplicity and convenience, acupuncture has become popular as a complementary therapy. In this Chinese medicine, doctors have to find the traditional meridian acupuncture points before puncturing the needles into them. Moxibustion (艾灸 Ài Jiǔ) is also an important part of the acupuncture remedy. Treatment by acupuncture can be classified roughly into two types – direct moxibustion and indirect moxibustion. Warm-needling acupuncture (溫針灸 Wēn Zhēn Jiǔ) is classified under the method of indirect moxibustion. In the present study, 10 standard stainless steel acupuncture needles with 10 pieces of cylinder-shaped moxa cone (艾柱 Ài Zhù) as the heat source of warm needles were used. In order to prevent the practitioners from getting burns, it is necessary to study the temperature changes in some designated parts of the needles. Two sizes, 0.6 g and 1.0 g, of moxa cones were used for comparison of the measured temperatures. The needles are typically divided into two parts – the handle part and the needle body. In our experiment, the temperatures of WNA at different parts of the needles were measured. The larger the size of moxa cone is, the longer is the burning time. Based on the observations we suggest that when 0.6 g moxa is used, the physicians should better pick out the needles around 9 min after ignition; however, while using the 1 g moxa, it might be safer to pick out the needles around 13 min after ignition.

Comparison of temperature time characteristics of two indirect moxibustion products

The aim of this experiment was to investigate the thermal properties of a new indirect ceramic moxibustion (ICM) in comparison with conventional indirect stick moxibustion (ISM) and to interpret the clinical implications of the data. A thermocouple was installed underneath each moxibustion unit to record temperature, and 10 units were burned for each moxibustion trial. The procedure began when the unit temperature reached 27 ± 1°C and finished when the temperature had returned to 27°C. The maximum unit temperature, time to reach maximum temperature, and duration of combustion were measured for each moxibustion modality. The maximum temperatures for ISM and ICM were 62.5 ± 2.59°C and 50.2 ± 2.53°C, respectively. The times to reach maximum temperature for ISM and ICM were 5.6 and 16.8 minutes, respectively. The two modalities exhibit different thermal properties as ISM showed a higher maximum temperature (p < 0.0001), which can immediately cause third-degree burns, and a steeper slope of temperature change. ICM, however, showed a lower maximum temperature, more slowly reached the maximum temperature (p < 0.0001), and had a longer and stable duration of combustion. This study suggests that ISM and ICM have statistically different thermal properties, and ICM showed safer thermal properties and a more stable heating pattern. Randomized controlled trials involving various moxibustion modalities are required for further clinical evaluation.

Temperature and safety profiles of needle-warming techniques in acupuncture and moxibustion

The needle-warming technique combines acupuncture and moxibustion, and it is commonly practised in China to relieve pain conditions. However, burning of moxa has many disadvantages. This study examined the temperature and safety profiles of such technique. First, skin temperature changes during needle-warming were examined in anesthetized animals to determine the safe distance for needle-warming moxibustion in human subjects. Then, the practical distance for needle-warming in human subjects were verified. Finally, the temperature profiles of the needle during needle-warming moxibustion were examined using an infrared camera. Our results show that during needle-warming moxibustion there is little heat being conducted into deep tissue via the shaft of the needle, and that the effective heating time to the acupoint is rather short compared to the period of moxibustion. These findings suggest that the needle-warming technique is an inefficient way of acupoint thermal stimulation and should be modified and improved using new technologies.

Cephalic version by moxibustion for breech presentation

BACKGROUND

Moxibustion (a type of Chinese medicine which involves burning a herb close to the skin) to the acupuncture point Bladder 67 (BL67) (Chinese name Zhiyin), located at the tip of the fifth toe, has been proposed as a way of correcting breech presentation.

OBJECTIVES

To examine the effectiveness and safety of moxibustion on changing the presentation of an unborn baby in the breech position, the need for external cephalic version (ECV), mode of birth, and perinatal morbidity and mortality for breech presentation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (26 March 2012), MEDLINE (1966 to 1 August 2011), EMBASE (1980 to August 2011), CINAHL (1982 to 1 August 2011), MIDIRS (1982 to 1 August 2011) and AMED (1985 to 1 August 2011) and searched bibliographies of relevant papers.

SELECTION CRITERIA

The inclusion criteria were published and unpublished randomised controlled trials comparing moxibustion (either alone or in combination with acupuncture or postural techniques) with a control group (no moxibustion), or other methods (e.g. external cephalic version, acupuncture, postural techniques) in women with a singleton breech presentation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and trial quality and extracted data. The outcome measures were baby's presentation at birth, need for external cephalic version, mode of birth, perinatal morbidity and mortality, maternal complications and maternal satisfaction, and adverse events.

MAIN RESULTS

Six new trials have been added to this updated review. One trial has been moved to studies awaiting classification while further data are being requested. This updated review now includes a total of eight trials (involving 1346 women). Meta-analyses were undertaken (where possible) for the main and secondary outcomes. Moxibustion was not found to reduce the number of non-cephalic presentations at birth compared with no treatment (P = 0.45). Moxibustion resulted in decreased use of oxytocin before or during labour for women who had vaginal deliveries compared with no treatment (risk ratio (RR) 0.28, 95% confidence interval (CI) 0.13 to 0.60). Moxibustion was found to result in fewer non-cephalic presentations at birth compared with acupuncture (RR 0.25, 95% CI 0.09 to 0.72). When combined with acupuncture, moxibustion resulted in fewer non-cephalic presentations at birth (RR 0.73, 95% CI 0.57 to 0.94), and fewer births by caesarean section (RR 0.79, 95% CI 0.64 to 0.98) compared with no treatment. When combined with a postural technique, moxibustion was found to result in fewer non-cephalic presentations at birth compared with the postural technique alone (RR 0.26, 95% CI 0.12 to 0.56).

AUTHORS' CONCLUSIONS

This review found limited evidence to support the use of moxibustion for correcting breech presentation. There is some evidence to suggest that the use of moxibustion may reduce the need for oxytocin. When combined with acupuncture, moxibustion may result in fewer births by caesarean section; and when combined with postural management techniques may reduce the number of non-cephalic presentations at birth, however, there is a need for well-designed randomised controlled trials to evaluate moxibustion for breech presentation which report on clinically relevant outcomes as well as the safety of the intervention.

Local thermal therapy effects on menopausal symptoms and bone mineral density

OBJECTIVES

The aim of this study was to evaluate the effects of local thermal therapy with far-infrared rays (FIR) on menopausal symptoms and bone mineral density (BMD) in postmenopausal women.

SUBJECTS AND METHODS

A prospective randomized, controlled trial was conducted in female volunteers from communities in Northern Taiwan. The intervention group (n=22) received local thermal therapy with the help of FIR from an FIR emitter, for approximately 20 minutes per day, twice a week, for 20 sessions. They received the therapy on their backs while lying in a supine position. The control group (n=21) received no treatment. The primary outcome was the change in the Perceived Perimenopausal Disturbances Scale, designed for the measurement of menopause-related symptoms (MRS) before and after completion of treatment in a 10-week period. Secondary outcome parameters included serum levels of estradiol (E2) with osteocalcin (OC), and calcaneal BMD by quantitative ultrasound.

RESULTS

After 10 weeks of intervention, MRS determined by the scale decreased in mean total scores and mean scores for vasomotor, musculoskeletal, urologic, reproductive, and psychologic domains (p<0.05), except for reproductive (sexuality-related) symptoms. In the control group, mean total scores and scores of each domain had no significant difference between baseline and follow-up examination after 10 weeks. There was no significant difference between the quantitative ultrasound parameters in the calcaneus, serum E2, and OC levels either at the baseline or in the changes from the baseline between the intervention and control groups of women (p>0.05).

CONCLUSIONS

Local thermal therapy with FIR results in a significant reduction of MRS in postmenopausal women. Serum E2, OC levels, and calcaneal BMD showed no significant changes between the two groups. These results suggest that FIR local thermal therapy may be a potential alternative for the management of postmenopausal symptoms.

Moxibustion for cephalic version: a feasibility randomised controlled trial

Background

Moxibustion (a type of Chinese medicine which involves burning a herb close to the skin) has been used to correct a breech presentation. Evidence of effectiveness and safety from systematic reviews is encouraging although significant heterogeneity has been found among trials. We assessed the feasibility of conducting a randomised controlled trial of moxibustion plus usual care compared with usual care to promote cephalic version in women with a breech presentation, and examined the views of women and health care providers towards implementing a trial within an Australian context.

Methods

The study was undertaken at a public hospital in Newcastle, New South Wales, Australia. Women at 34-36.5 weeks of gestation with a singleton breech presentation (confirmed by ultrasound), were randomised to moxibustion plus usual care or usual care alone. The intervention was administered over 10 days. Clinical outcomes included cephalic presentation at birth, the need for ECV, mode of birth; perinatal morbidity and mortality, and maternal complications. Feasibility outcomes included: recruitment rate, acceptability, compliance and a sample size for a future study. Interviews were conducted with 19 midwives and obstetricians to examine the acceptability of moxibustion, and views on the trial.

Results

Twenty women were randomised to the trial. Fifty one percent of women approached accepted randomisation to the trial. A trend towards an increase in cephalic version at delivery (RR 5.0; 95% CI 0.7-35.5) was found for women receiving moxibustion compared with usual care. There was also a trend towards greater success with version following ECV. Two babies were admitted to the neonatal unit from the moxibustion group. Compliance with the moxibustion protocol was acceptable with no reported side effects. Clinicians expressed the need for research to establish the safety and efficacy of moxibustion, and support for the intervention was given to increase women's choices, and explore opportunities to normalise birth. The sample size for a future trial is estimated to be 381 women.

Conclusion

Our findings should be interpreted with caution as the study was underpowered to detect statistical differences between groups. Acceptance by women and health professionals towards moxibustion suggest further research is warranted.

Trial Registration

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000985280

A design of RF stimulator which is similar to temperature distribution by moxibustion (preliminary study)

We developed a novel radio-frequency (RF) stimulator to mimic heat effects similar to the temperature distributions created by moxibustion in porcine tissue. Moxibustion is a traditional Oriental medicine technique using moxa, which is utilized not only to cure disease, but also to increase immunity. However, it may lead to undesired effects including severe pains, blisters, and burns because of the difficulty of controlling heat intensity during the process. To overcome these problems, a novel RF stimulator that can conduct thermal energy to the deep tissue of the body and also easily control the power of heat stimulation was proposed. RF stimulating protocols were designed to mimic the temperature profiles of two types of moxibustion. In our results, the temperature distributions created by the proposed protocols were similar to those attained by moxibustion. It was also shown that the proposed protocols were more effective than moxibustion for transferring heat effects into deep tissues.