Moxibustion

The Primary Moxibustion Points
There are certain points mentioned repeatedly in the literature on moxibustion; the accumulated experience with using these points suggests that they might be uniquely effective. Aside from zusanli (ST-36), which is also the most frequently mentioned of all the points used for needling, the primary moxibustion points are located on the governing and conception vessels. On the conception vessel, points 4, 6, 8, 12, and 17 are mainly utilized. On the governing vessel, points 4, 14, and 20 are mainly used. One of the important moxa points is dazhui (GV-14), which is the meeting point of the governing vessel with the six yang channels of the hand and foot. An article reviewing the many uses of moxibustion at this point (31) listed the following examples of applications for moxa at this point:

Expelling wind, clearing heat, and dispersing the lung to relieve the exterior (for acute feverish diseases);
Dispersing the lung, eliminating cold, and activating yang to relieve asthma;
Restoring consciousness, tranquilizing the mind, and calming internal wind to relieve epilepsy;
Removing obstruction in the governing channel to relieve spasm and dispersing yang to eliminate pathogenic factors (for cervical spondylopathy and other disorders of the spinal column);
Warming the channels, restoring yang, and replenishing qi to consolidate resistance (protecting from recurrent common cold and influenza).
Dazhui was also described separately as the acupoint suitable for treating herpes zoster by moxibustion (23). Reflecting the common usage of the points, the students of Wang Leting noted that the points he used for moxibustion were relatively few. They included conception vessel points 4, 6, 8, and 12, and governing vessel points GV-4 and 20 (he also used the back shu points fenshu, BL-13, and shenshu, BL-23). A harmonizing treatment for the yin and yang is moxibustion at guanyuan (CV-4) and dazhui (GV-14). Robert Johns, in his book The Art of Acupuncture Techniques (32), mentions that this ancient formula is well suited to helping cancer patients recover from the adverse effects of modern cancer therapies. Other moxibustion therapies for helping patients with leucopenia mentioned in Chinese texts include dazhui with zusanli, usually along with one or two other points. One other point frequently mentioned is yongquan (KI-1), a point relied upon for treatment of collapse of yang, for which moxibustion seems appropriate. It might also be used, with slow heating, to help tonify yin.

Possible Mechanisms Of Action Of Moxibustion
One theory of the effects of both moxibustion and acupuncture is that the local tissue damage (twisting of tissue fibers when stimulating acupuncture needles, extended cellular damage by the intense heat of moxibustion) initiates a non-specific healing reaction that can have effects throughout the body. This healing reaction is stimulated by production of immunological mediators and neurotransmitters. Modern techniques of acupuncture and moxibustion therapy used in the West may rely, instead, on lesser stimulation that does not produce significant tissue damage (e.g., using thin needles minimally manipulated, using moxa to gently warm the skin). However, it must also be recognized that some modern techniques may do little more than induce general relaxation, without some of the other effects that Chinese physicians have long depended on.

The impact of the local heat stimulus was studied in the laboratory to follow-up on the suggestion that the production of inflammation mediators, mainly histamine, at the site of burning skin were important to the impact of moxibustion therapy (24). After burning a single cone of moxa, the authors found that:

The maximum temperature of the treated spot was about 130 at the outer skin, and about 56 at the inner skin. Therefore, moxibustion treatments are naturally considered heat stimulation with inflammatory response. In general, inflammatory response induces vascular changes. Our results of moxibustion as a heat stimulation induced vasoconstriction at the site under the moxibustion spot and vasodilation around the moxibustion spot. The cause of cutaneous vasodilation was histamine and substance .Our results indicate that moxibustion induces an increase in capillary permeability mediated by histamine; additionally, this enhancement of permeability can be correlated with the degree of mast cell degranulation [release of inflammation mediators by the cells], which relates to the weights of moxa cone used.

The authors concluded from this study and from others (25) that a likely mechanism of moxa was the enhanced activity of the host defense mechanism in response to the local inflammation. They described the response to the localized heating of cone moxibustion as distinctly different from that of a widespread burn, which can impair immunity. Other researchers have also indicated that carefully controlled moxibustion as performed in the laboratory produced immunological responses, including increased lymphocyte numbers, and that it could aid the restoration of immune functions impaired by radiation (26). Moxibustion was suggested to have potential use in treating cancer by virtue of enhancing immune activity mediated by the red blood cells (30). In a laboratory animal study of moxibustion at the point equivalent to dazhui (GV-14) in mice, it was claimed that growth of implanted tumors could be inhibited by enhanced cellular immune functions, probably mediated by enhanced production of favorable cytokines (e.g., IL-2) and resulting increased natural killer cell activity (42). While moxa therapy appears to bolster immune responsiveness, it does not necessarily exacerbate autoimmunity. For example, moxa treatment was shown to reduce delayed type hypersensivity reaction in mice; this action may be accomplished by enhancing the function of suppressor T-cells (37).

Substance P is a neurotransmitter, and one of several that are thought to be induced by acupuncture and moxibustion stimulation; for example, galanin is another neurotransmitter observed to be synthesized in response to moxibustion (38). These neurotransmitters are thought to be important in the regulation of pain, spasm, and neurological disorders, such as depression and anxiety; they are also invoked in response to exercise, and may be part of the explanation for several of the health benefits attributed to higher levels of physical activity (40).

In a laboratory study on rabbits, the point equivalent to zusanli (ST-36) was treated by moxibustion and it was shown that intestinal smooth muscle spontaneous movements declined (39), suggesting a role of the neurotransmitters. This antispasmodic effect is consistent with what is seen during clinical treatment of gastric and intestinal spasms with alleviation of diarrhea. The neurotransmitters evoked by acupuncture (especially electro-acupuncture) and moxibustion may act in parallel with the modulation of immune responses and contribute to a broad systemic change.

Moxibustion And Immune System Function In Human Clinical Work
One of the frequently investigated functions of moxibustion mentioned in modern Chinese clinical literature is boosting the immune system. It remains unclear whether moxibustion differs in its effects from acupuncture in this regard. In elderly patients, both acupuncture and warm needle acupuncture (with moxa applied to the needles for 20 minutes, using daily treatment for 10 days) applied to zusanli (ST-36) enhanced production of IL-2 (45). In a review article on research examining immunological effects of acupuncture and moxibustion (18), no distinction was made regarding the two techniques, only the points treated and the outcomes were noted for each method interchangeably.

The author of the review article concluded that the effect of the techniques on the immune system might be a secondary result of their effects on the whole body, rather than a specific action. This interpretation does not necessarily contradict the results of animal studies on mechanism of moxibustion: the technique might have an initial effect on the immune system that then produces, via the action of various mediators, a systemic effect that goes beyond the initial immune response, eventually causing a greater immunological improvement. In the report on moxibustion treatment of coronary heart disease, some immune parameters of the patients were measured (including lymphocyte conversion rates and levels of immunoglobulins), showing an enhanced immunological response. The authors had concluded that moxibustion treats coronary heart disease through regulating the internal environment of the organism and reinforcing its ability to fight disease. This interpretation of results is consistent with the idea that the techniques produce non-specific improvements in the entire body that manifest in better immune function as well as better function of all the internal organs.

In the TCM system, spleen deficiency (a subcategory of qi deficiency) syndrome is often associated with weak immune functions. Evaluation of immunological effects of moxibustion in spleen deficiency patients has been conducted (19, 20) with claimed benefits in immune function tests that accompany alleviation of symptoms. A clinical report on treatment of chronic diarrhea associated with ulcerative colitis or simple chronic colitis with moxibustion focused on immunologic mechanisms (29). Herb-interposed moxibustion was used with two sets of points alternated daily: zhongwan (CV-12), qihai (CV-6), and zusanli (ST-36) made up one set; dachangshu (BL-25), tianshu (ST-25), and shangjuxu (ST-37) made up the second set. The number of moxa cones used would vary by site and syndrome, but ranged from 2 to 7 cones. Daily treatment was provided for 12 days, followed by an interval of 3 days, and then another course of 12 days, for a total of 60 treatments. It was claimed that along with resolution of the diarrhea there was a reduction in the excess IgM and complement that were present at the beginning of treatment for those with ulcerative colitis, and an improvement in the T-lymphocyte subgroup of suppressor cells that inhibit autoimmune reactions.

An improvement in an autoimmune based disorder was also noted for Hoshimoto's thyroditis (28). Immune parameters that were normal at the beginning of the studies did not change. In an outline summary of laboratory and clinical studies of the immunological effects of moxibustion, it was reported that moxibustion could reduce the level of rheumatoid factor (considered a measure of the autoimmune aspect of the disease) in rheumatoid arthritis and improve symptoms of allergic rhinitis (41).

Such findings suggest that the immunological and organ system changes may reinforce and contribute to one another, and that the immune functions are regularized by reinforcing the weak portion of the immune system rather than simply stimulating the immune system generally.

Contraindications For Moxibustion
The primary contraindication for moxibustion has historically been the presence of a heat syndrome. This goes along with the idea that moxa introduces heat to the system and does so effectively, and thus the treatment method fails to meet the criteria of balancing a hot condition with a cooling therapy. Theoretically, it could cause the disease to worsen by increasing the imbalance. There are some who have argued against this, as noted above. In similar manner, there are cases where herbalists have argued against the view that in febrile diseases one must always avoid heating herbs and rely only on cooling herbs. However, this contraindication for moxibustion still remains listed in all standard texts. In particular, moxa is considered entirely inappropriate for a deficiency heat syndrome (one based on yin deficiency) and it must be used cautiously in cases where there is local dryness. In a report reviewing indications for acupuncture and moxibustion (43), the authors noted that We found in our practice that most of the herpes zoster patients responded to moxibustion and round needling卆lthough there were some cases with obvious local dryness due to skin injury where the patients experienced increased pain the more that moxibustion was applied. They suggested that since herpes zoster is a heat syndrome that responded well to the treatment in most of the cases, one should not automatically discount use of moxibustion for heat syndromes, especially those with localized heat as occurs with a zoster outbreak.

Other contraindications for moxibustion involve the sensitive areas of the body, such as the face (where one especially avoids the scarring therapy, but also avoids getting smoke directly into the eyes or nose), the nipples, and the genitals. Ancient texts specify certain points on the head as being contraindicated for moxibustion (27), such as shangxing (GV-23), chengqi (ST-1), sibai (ST-2), touwei (ST-8), jingming (BL-1), zanshu (BL-2), sizhukong (TB-23), heliao (LI-19), and yingxiang (LI-20). Concerns are raised about using moxa during pregnancy for the region of the abdomen and lower back (14, 27).

The Techniques Of Moxibustion
As noted in the Journal of Traditional Medicine review article on acupuncture and moxibustion in China (4), there are about 50 techniques that have been elaborated. Many of these are minor variations: different substances used in interposed moxibustion (mainly fresh ginger slice, garlic slice, aconite cake, salt), different methods of applying heat to a broad area (moxa rolls, containers with large amounts of moxa), different size cones, applying moxa to the end of an acupuncture needle, and using materials other than artemisia to burn (such as juncus) or to cause hot sensation and blistering without using fire (e.g., with mustard seed or mylabris, an insect with irritant properties). For purposes of this article, the techniques most likely to be used in the modern clinic will be described, taken primarily from the recent compendium Acupuncture and Moxibustion (14), prepared by the Beijing University of Traditional Chinese Medicine.

1. Non-Scarring Moxibustion with Moxa Cones
A moxa cone is placed on a point and ignited. When about 2/3 of it is burnt or the patient feels a burning discomfort, remove the cone and place another one. Three to seventeen cones are continuously burnt to cause flush in the local site, but no blister should be formed. This method is used widely, often for cold and deficiency disorders such as asthma, chronic diarrhea, and indigestion.

2. Indirect Moxibustion (Interposed Moxibustion)
The ignited moxa cone does not contact the skin directly, but is insulated from the skin by a layer of ginseng, salt, garlic, or aconite cake. Depending on the technique used, this kind of moxa may induce blistering, but it is often used for non-scarring moxibustion.

Ginger: cut a slice of ginger about 2-3 cm wide and 0.2-0.3 cm thick, punch numerous holes in it and place it on the point selected. On top of this, a moxa cone is placed and ignited. When the patient feels scorching, remove it and ignite another. Repeat this until all the cones burn and the skin becomes reddish. This method has the effects of warming the spleen and stomach and dispersing cold. It is therefore indicated for symptoms caused by weakness and cold of the spleen and stomach, such as abdominal pain, diarrhea, painful joints, and other symptoms due to yang deficiency.

Garlic: cut a slice of garlic 0.2-0.3 cm thick (a large single clove of garlic is desirable), punch holes in it, put it on the point with the ignited moxa cone on top. Renew the cone when the patient feels scorching. This method has the effect of relieving swelling and pain, and is often used for the early stage of skin ulcer with boils or scrofula.

Salt: this method is usually applied at the umbilicus. Fill the umbilicus with salt to the level of the skin, place a moxa cone on the top of the salt and then ignite it. When it burns out, renew another until all the cones have combusted. As this method has the action of restoring yang from collapse and warming the spleen and stomach, it is effective for the symptoms of sweating, cold limbs, and undetectable pulse resulting from acute vomiting and diarrhea, or flaccid-type of wind stroke and post-partum fainting.

Aconite cake: punch holes in a cake made of aconite powder mixed with alcohol, 3 cm in diameter and about 0.3 cm in thickness. Place on the site for moxibustion with the moxa cone, which is ignited and burnt on top of it. This method is good for warming and strengthening kidney yang, and thus, is adopted to treat impotence, infertility, and ruptured abscess resistant to healing.

3. Moxibustion with Moxa Stick
Mild-warm moxa: Ignite a moxa stick and place it 2-3 centimeters away over the site to bring mild warmth to the local place, but not burning, for some 15 minutes until the skin becomes slightly red. It is suitable for all the syndromes indicated for moxibustion.

Sparrow-pecking moxibustion: In this method, the ignited moxa stick is moved up and down over the point like a bird pecking, or moving left and right, or circularly. It is indicated for numbness and pain in the limbs.

4. Warming Needle Moxibustion
Moxibustion with warming needle is an integration of acupuncture and moxibustion, and is used for conditions in which both retention of the needle and moxibustion are needed. It is applied as follows: after the arrival of qi and with the needle retained in the point, get a small section of a moxa stick (about 2 cm long) and put on the handle of the needle; ignite the moxa stick from its bottom and let it burn out. This method has the function of warming the meridians and promoting the flow of qi and blood so as to treat bi-syndrome caused by cold-damp and paralysis. Application to cold-damp syndrome was the subject of a clinical evaluation involving patients with rheumatoid arthritis (46). Acupuncture was performed by deep needling of the shu (stream) points, and then moxa was applied to the needles for 30 minutes, performed daily (with short breaks) during a two month course of therapy. The original technique described in the classics is different and was called the fire needle. This involved holding the needle in a lamp flame until very hot, and then inserting to the appropriate depth in the body quickly and removing it (34). Warming needle, as now used, allows longer retention and gentler heating.

Tonification And Draining Startegies
Just as there are needling techniques associated with tonification (reinforcement) and draining (reducing), moxibustion can be applied with these two different approaches. The basis for the different methods is the intensity and duration of heating during the moxa treatment. The distinction has been described by the followers of Wang Leting and relayed here with slight editing:

As for the problem of supplementation and drainage by moxibustion, these are generally administered in the clinic based on the theory of the Lingshu chapter on back transporting points: 'To supplement by fire, do not blow on the fire, but let it burn out. To drain by fire, quickly blow on the fire and let it burn out spontaneously.' The former method involves letting a slow burning cone burn out by itself: although the heat power is weak, it is persistent and substantial. The latter is quickened by blowing on it. Although the heat power is violent, it is temporary and short. If the supplementing technique is to be used, do not blow on the moxa cone after igniting it. Just allow it to burn gradually and burn itself out. Then, press the point with the hand to concentrate the qi and make the warming persistent. If the drainage technique is to be used, blow on the ignited moxa to increase its speed of burning, then let it burn out or remove it when too hot; do not press the point, but let the pathogenic qi be scattered externally.

When using moxa rolls or other techniques, the basic approach to tonification or draining can still be applied. Tonification utilizes a more steady and prolonged heating, while drainage involves a more rapid and more intense but shorter duration heating of the point (bird pecking moxa is often used, with the end of the moxa roll being brought quite close to the skin with repeated thrusts to get more intense heating of the skin).

A description of reinforcing and reducing techniques of moxibustion was included in a broader report on these techniques for needling (35). The commentators noted:

In ancient times, reinforcement and reduction techniques were attributed to moxibustion, while in modern textbooks they are seldom mentioned. We treated a patient suffering from impotence due to deficiency of the kidneys with moxibustion using reinforcing manipulations; the patient was cured after 5 sessions of treatment. In herpes zoster, moxa cones were ignited and the fire blown with mouth to increase the temperature and thus produce a reducing effect. We have treated dozens of patients in this way with an alleviation rate of 95% immediately after the first session. All the patients were cured after 2 to 3 sessions of treatment. In a case of chronic cold syndrome of the insufficiency type, mild moxibustion (a moxa roll is held approximately 3.5 cm above the skin to produce a sensation of warmth until the skin becomes slightly flushed) and revolving moxibustion (circling the lighted end of a moxa roll around the acupuncture point until the skin becomes flushed) are most often used. In case of acute heat of the excess type, direct moxibustion and bird-pecking moxibustion are most often used?When mild moxibustion is applied to stimulate baihu (GV-20), an action of invigorating yang and arresting prostration is produced, curing organ prolapse. When garlic paste moxibustion or bird-pecking moxibustion is applied to stimulate yongquan (KI-1), an obvious effect of nourishing yin to purge pathogenic fire results, providing a cure for hemoptysis and epistaxis (i.e., bleeding due to heat).

Smokeless Moxa
Though not widely used in China, an increasingly popular method in the West is the use of smokeless moxa. The following is the description for use in the modern clinic.

Smokeless moxa is a rod of charcoal impregnated with moxa. It burns hot, but slowly, at an average rate of just 2.7 inches per hour; the rods are about 4.5 inches long, so the total burning time is about 90 minutes before the rod becomes too short to use. The moxa is not easily lit, so it is common to use a torch rather than a simple lighter. Once lit, it burns consistently.
?BR>The smokeless moxa pole produces ash at the burning end which tends to stick to the rod. When trying to safely remove the ash from smokeless moxa, the stick should not be tapped against something (e.g., against an ashtray). The tapping, aside from making undesired noise, can crack the charcoal, generating a risk for a piece to fall off and burn the carpet, treatment table, or patient. Instead, the burning end of the moxa stick should be gently rubbed against the top edge and inside of a moxa extinguisher, which will be a quiet operation that dislodges the ash and does not crack the moxa rod.

The moxa extinguisher can be carried in an ashtray, so that the ash is contained. At the end of the moxa session, the moxa stick may be carefully retained while still burning for use with another patient (if it is to be used within minutes) or put out. It is important to check from time to time that all moxa rods are in their proper place so that none are left burning where they can cause damage.

Moxa can be carried out using a single pole to provide intense heat to a specific point, or with two poles held side by side to heat a larger area. Moxa may be applied to acupuncture needles, but take care not to hold the lit end near the plastic holders, as this can cause melting or evaporation of the plastic (or rely on metal handle needles). While a brief moxa treatment can feel good to the patients, all Chinese texts refer to prolonged heating, usually by repeated application of heat to the same site over a period of several minutes. Be careful not to lose most of the potential benefits by applying moxa for a very brief period or by trying to apply moxa to too many sites, so that each site is only briefly treated.

Moxa Pads, Heat Lamps
In contrast to the intense direct heating of points for treating diseases, heat therapy may also be employed to relax tense muscles and gently relieve aching and mild pain. Self-heating moxa pads for these purposes have been available from Korea for more than 20 years. This technology involves having a bag of mugwort and charcoal with an oxygen-sensitive system (iron that reacts strongly with oxygen), so that when the sealed package containing the bag is opened and the bag of material is vigorously shaken for a moment, it heats up. Within five minutes, the pack is heated and it maintains a temperature of 60-75 (140-165) for hours. This is the same technology used for the popular new drugstore products, such as ThermaCare, which are self-heating pads applied to the body (but without the artemisia).

Typical applications of the moxa pads include treatment of injuries, back pain, knee pain, and menstrual pain. In addition, these pads are applied for chilliness and discomfort following exposure to excessive air conditioning, frigid outdoor winter conditions, or damp windy weather. A belt to hold the pad over the abdomen is also available. The pads can be used following a treatment with acupuncture and moxibustion to extend the effects of the initial therapy, or as an alternative to those treatments when professional help is not convenient. Moxa pads should not be applied to skin that is broken or to areas that display red inflammation or that develop greater discomfort with application of heat.

Another method of applying heat is the infra-red heat lamp; a useful variant of this was developed in China, called the TDP-lamp. It was invented in 1980 by a group of scientists and physicians headed by Dr. Gou Wenbin at the Chinese Medicine Institute in Chongqing. Unlike conventional infrared therapeutic devices, the TDP device features a plate coated with a mineral formation (a low conductance metal with diverse composition). When heated by an electric heating element, the mineral plate emits waves in the infrared range. It produces a uniform heating that makes it more useful than ordinary glass bulb lamps. To increase the heating of a region by the lamp, a medicated oil can be rubbed on the skin; the oil helps retain the heat and its herbal constituents may contribute to the improvement of local blood circulation. Although the makers of the TDP lamp make claims about the special value of its frequency of infrared emissions, there is no evidence that it performs a unique function on this basis.

Interpretation
The report presented here may offer the practitioner some insights into practical aspects of moxa applications. There are a number of unanswered questions about moxa, and this section contains some conclusions of the current author derived from this literature survey.

A certain part of the theory of applying moxibustion is simply based on the traditional Chinese medicine dogma and may not have important implications for practice. For example, the role of the moxa wool appears to be primarily for introducing heat rather than for pharmacological effects of artemisia promoting circulation, warming the meridians, and so on. Similarly, the special applications depicted for moxa with interposing herb materials (ginger, aconite, garlic, or complex herb formulations) appear to be based on the traditional roles of the herbs when taken internally, but these actions are probably not conferred by this method and would certainly be better accomplished by providing such herbs orally. The interposing substances serve primarily as suitable media for conveniently providing moxibustion without direct contact to the skin. Salt interposed moxa works well for treating the umbilicus because of its form; direct moxa would be inappropriate for this sensitive spot, especially in children who are likely to receive this particular therapy.

There has been a heavy reliance on scarring moxibustion in the Chinese tradition. This method is listed first in most of the modern texts that describe moxa, and is featured prominently in the review article about moxa in clinical applications. There is a theory of acupuncture whereby the main function is to induce tissue damage at the acupoints. The twirling, lifting, and thrusting is shown to grab and pull fibers in the subcutaneous level, forcing the body to respond. Another aspect is stimulation of nerves leading to effects in the brain as well as effects of locally-produced neurotransmitters; such stimulation is especially noted with the deqi reaction, including tugging of the tissues at the needle and sensations of distention, numbness, and radiating tingling. Scarring moxa also damages the tissues and produces a strong nerve stimulus. Such severe treatment may not be essential, but Chinese specialists repeatedly emphasize the benefits of strong stimulus to the points and laboratory studies suggest that the inflammatory response to local damage by moxibustion is important. At the least, the skin must become sufficiently reddened that there is a healing response to limited damage. Some of the reliance on scarring moxibustion may be based in archaic ideas that would no longer be widely accepted. In Treatment of External Diseases with Acupuncture and Moxibustion (15), it is pointed out that sometimes the sores induced by direct moxa not be allowed to heal:

The Thousand Pieces of Gold says: 'People who tour Wu and Shu should moxa some points regularly and leave the sores unhealed for some time. This will keep the toxic qi of miasma, leprosy, and warm malaria away from them.' The Great Compendium also says, 'If one intends to be safe and sound, one should keep zusanli (ST-36) wet' [that is, from the drainage of a moxibustion sore]?The blister and its sore are called a moxibustion flower. In former times and still by some practitioners, the production of such a moxa flower has been considered crucial for successful treatment. The Taiping Shenghui Fang (992 A.D.) says: 'Suppose a sufficient number of cones are burned up. Only when a sore develops and weeps pus may the disease be cured. If no sore is produced or no pus engendered, the disease will not be relieved.' In modern times, some Chinese practitioners continue with this practice, and their clinical experience confirms that intentionally produced moxa sores do have something to do with the curative effect. In spite of the effectiveness, only a few patients are undaunted enough to receive this therapy because of the pain it inflicts.

Clearly, the thinking about moxibustion by most modern clinicians is moving away from the concept that scarring (with or without maintaining the drainage) must be used. The claims for superior effectiveness of scarring moxibustion have to be questioned since there are no studies comparing scarring versus non-scarring moxibustion. These claims are only impressions of the practitioners who obviously believe enough in the therapy to put the patients through the ordeal. On the other hand, it might be reasonable to assume that intense heating of the skin by direct moxibustion is likely to produce more of a response than mild heating as sometimes administered with use of moxa rolls held at a distance from the skin.

When non-scarring moxibustion is used, the duration of treatment in reported clinical trials is usually long and probably much longer than administered by most Western practitioners. Numerous moxa cones and moxa sticks are applied typically for 15 minutes or more in total, with 5-15 minutes per point (longer for warm needle technique). Thus, the treatment is still strong in nature even if there is no blister formed.

Practitioners in the West might consider the following:

If one wishes to avoid the smoke of regular moxibustion, it seems acceptable to use other methods of heating, so long as they can provide similar levels of heat and as long as one can maintain adequate control over the heating (e.g., to prevent burning and also to prevent the heating from becoming too light). As such, smokeless moxa may be satisfactory. In fact, moxibustion may be replaced by acupuncture in most applications, providing that the acupuncture stimulus is sufficiently strong to generate an immunological and neurological response.
When using herb-slice or cake interposed moxibustion, do not forget to punch holes in the material; this allows the heat to penetrate. The thickness of the slice should be just 0.2-0.3 cm; thicker slices may prevent adequate heating. For practical purposes, ginger slices may be most convenient and it is not evident that one must choose the interposing substance based on its pharmacological properties in relation to the condition to be treated.
For moxibustion to be effective, it needs to cause significant local heating and inflammatory response and should be done for a prolonged period, not just a minute or two. Therefore, specific points for moxa heating should be chosen and treated effectively, rather than trying to warm numerous points with only a little stimulus. Warming a broader region is an acceptable treatment for relaxing tension and moderating pain at the site; this is a different application than trying to stimulate the immune system, alter internal organ functions, or otherwise rapidly heal a disease. For chronic ailments, Chinese physicians typically administer moxa daily for several treatments, up to 50-60 sessions. Moxa treatments might be alternated with acupuncture and patients may appreciate the variation in treatment methods.
The most frequently mentioned applications of moxa are gastro-intestinal disorders, asthma, organ prolapse, bi-syndromes, and herpes zoster. These are reasonable targets for modern clinicians to consider for this type of therapy, which may otherwise be too inconvenient as a method (at least, when done properly). In particular, herpes zoster is emphasized as a case where moxibustion is effective. For asthma, both acupuncture and cupping have also been claimed to be highly effective, and these might be more appropriate for those who are sensitive to inhaling smoke from moxibustion.
The risks of exposure to moxa smoke are probably similar to that for any other smoke, and total exposure time, particularly when it involves prolonged exposure, is the key concern. Occasional use of ordinary moxa would be associated with low risk, while routine exposure to moxa smoke during much of the day would be a moderate risk. Therefore, venting or filtering is an appropriate step when moxa is done regularly. There is no evidence that moxa smoke contains any unusually harmful substances. Standard commercial moxa materials do not contain realgar (an arsenic compound), though this substance has been rarely included in blends made by individual doctors in China for their own use.
There are certain points that are most frequently mentioned in the moxibustion literature which may be a good basis for consideration by modern practitioners. These points may be relatively convenient to treat from a physical perspective, may be well accepted by most patients, and may have a higher response rate than others. Most of the points are on the conception and governing vessels, plus zusanli and yongquan, and shu points on the back.
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 masses. Moxa may be utilized in some cases of heat syndromes.