While moxibustion can be used as an independent modality, it is not uncommon to combine acupuncture with moxibustion to enhance its therapeutic effect. Compared with needles, moxa is, relatively speaking, more yang in nature. Thus, it has the ability to penetrate to the channel level, promote the circulation of qi and blood in the channels, and to move qi and blood stasis. Additionally, its yang nature facilitates expelling wind, cold, and damp pathogens that can precipitate illness characterized by painful obstruction symptoms called bi-syndromes.

1. Penetrates to the channel level; promotes the circulation of qi and blood; moves qi and blood stasis; promotes blood and lymphatic circulation;
   
2. Raises the white blood cell count and sustains it; increases the speed of white blood cells to the affected area; increases the ability of white blood cells to perform their function;
   
3. Tonifies vacuity of qi, blood, yin, and yang; warms the cold, warms the yang, elevates the yang. Can be used preventatively; reduces excess;
   
4. Dries cold damp and transforms damp heat.

In Chinese medicine the two basic contraindications for moxibustion are excess heat, and yin vacuity with heat or fire. Excess heat characteristics include fever, inflammation, rapid full pulse; red tongue with yellow coat; red face, loud voice, feelings of heat; red, sore throat; red eyes; thirst for large amounts of cold drinks; dark scanty urine, constipation; and anger, agitation, irritability and restlessness.

A stroke can be precipitated if moxa is used on an excessively hot person because moxa increases body temperature, dilates blood vessels and raises blood pressure, so correct diagnosis as always is critical. Excess heat however, is relatively uncommon. In my clinical experience I would maintain that perhaps less than 5 % of the population has this presentation but it does occur. We all tend to have heat in some places, but overall, from an eight-principle perspective, the diagnosis is not excess heat.

Yin vacuity heat symptoms include five-palm heat, malar flush (afternoon fever), night sweats; red tongue with no coat, and a thin, rapid pulse. Moxa used on yin vacuity conditions with heat or fire will further consume the proper yin and lead to the dangerous development of fire syndromes and exuberance of yang. However, there are cases of yin vacuity that do not have heat manifestations.

Yin vacuity can be measured on a continuum. There can be yin vacuity, yin vacuity with heat, or yin vacuity with fire. Symptoms of yin vacuity without heat include a thin body, dry skin, throat and mouth; small, frequent thirst; fatigue; thin tongue with cracks, and little to no coat; and thin pulse. Moxa can be used in these cases; however, monitor closely for signs of heat aggravation that usually present as agitation, a sensation of heat, and a red tongue.

There are other cautions and limitations that circumscribe the use of moxibustion. The classics admonish us not to treat infants and children under theage of 7 with moxa because it can induce the inter-transformation or even separation of yin and yang. This means that the already yang natured child could become too hot, and treatment with moxa could result in death.

Exercise caution with patients who have decreased neurological functioning due to nerve damage, diabetes, age, or those with reduced mental status, as they might not be able to report the temperature sensation to you and serious burns could be induced. Certain drugs such as painkillers and steroids may also inhibit pain perception, so as is customary, a thorough medical history is essential.

My personal preference for acupuncture or moxibustion is not to treat during pregnancy. If you choose to use moxa however, under no circumstances should it be applied to the low back or abdomen of the pregnant women, nor on the standard points forbidden to needle or moxa during pregnancy as they may lead to miscarriage.

In general, moxa should be avoided on the face due to the relative delicacy of the facial skin, and the proximity of the heat, smoke, and flame to the hair, nose and eyes. The smell of the moxa may also be noxious to patients with respiratory disorders and allergies or in certain institutional settings or shared professional offices. Smoke detectors might also be activated with the use of moxa, so consider the sensitivities of your patients, the environment in which you work, and your own proclivities as well.

There are two discrete styles of moxa application—direct and indirect moxibustion. Both may be employed as an autonomous modality or to augment needle therapy. Direct moxa makes contiguous contact with the skin; indirect moxibustion does not touch the skin.

Direct moxa may purposely be used to cause scarring. This style is also referred to as open or festering moxibustion. It is believed that the mechanismby which it works is through the continuous stimulation of the acupuncture point created by the burn as it is being healed, as well as the elimination of the pathogen through the suppuration. Scarring moxa is used to treat painful joints due to cold and damp, hard masses, arthritis, and scrofula, or chronic, persistent or life-threatening diseases such as asthma or tuberculosis, and the prevention of stroke. Moxa has germicidal properties so that the risk of infection is theoretically fairly minimal when burned on the skin but it is a painful method and can cause a thirddegree burn. If the burn becomes infected, especially in those with weakened immunity, the wound must be treated.

Direct non-scarring moxa is also applied to the skin in the form of moxa cones or thread-size moxa. However, the moxa is removed before it creates a burn. This method of application can be used to treat many conditions such as asthma, chronic diarrhea, impaired digestion and more.

Personally I do not believe direct scarring or even direct non-scarring moxa needs to be done on most patients. The risk of burn or its potential is not proportionate to the therapeutic outcome. I neither do it nor recommend it. Exercise caution even with certain forms of indirect moxibustion, which can still cause serious burns if left unattended and if the size and frequency of the moxa is too much, or if the patient is at risk for burns such as a diabetic patient.

Remember that moxa may be used to both tonify and disperse although many practitioners think that it is only for tonification. Just as in needling, in order to accomplish these objectives, different parameters are involved. A complete moxa prescription involves the number, size, density, rate of burning, and the amount of time the moxa is burned, and also the selection of the specific acupuncture points, and the actual moxa modalities selected.

Tonification with moxa provides gentle reinforcement to the patient’s vacuity condition. There are several ways to achieve this end. In general, if moxa cones are selected, burn in odd incremental numbers such as three or five. Allow them to burn down slowly and naturally (meaning donot blow on them) for less than 5 minutes until the skin is warm. Fewer cones should be used for thin body areas as well as for older, younger, and weaker constitutional types if used at all and then use cautiously. While a smaller amount of moxa is used in tonification, the moxa should be applied for a longer period of time. If using a warming needle technique, burn the same number of cones on the needle.

If other moxa modalities such as the tiger thermie warmer or mini-thread moxas are utilized, small amounts should be adopted but with greater frequency such as two to three times a week. If an indirect moxa pole is preferred, the point should be gently warmed for 5 minutes by holding the stick far enough away from the body so that the acupuncture point stays warm but not hot. If a sparrow-pecking method is used, slowly heat the point by rotating the stick so that the point is gently warmed in a circular movement from outside to inside as you simultaneously move up and down in the sparrow-pecking manner. Hold the stick 0.5 to 1 in away from the point for about 10 seconds, withdraw for a few seconds, and then repeat for a total of 2 to 5 minutes without creating hot heat.

If vacuity is in the lower part of the body (i. e., prolapse, diarrhea), treat the upper part of the body first (i. e., moxa on GV-20, bai hui); if it is in the upper part of the body, treat the lower first (i. e., KI-1, yong quan). In general, the yang portion of the body is treated first, then the yin, that is, the back first, then the front; the top first, then the lower portion, the head and then the abdomen, the extremities, and then the torso.

Thread moxa is a Japanese modality. It comes in at least three sizes—small, medium, and large. It is especially useful in the treatment of yin vacuity because it is small and can be applied precisely to a point to confer the healing effects of moxa. Put a small amount of Ching Wan Hung or Vaseline on the skin to hold the thread moxa and then position the thread vertically on top of the ointment. Because the thread is so small it must be ignited with a small incense stick. The flame from a lighter or a match is too large—there is the risk of burning the patient with a larger implement.

On the needle is a primary way in which moxa is used in Chinese medicine. Metal handle needles, not plastic, must be used to burn the moxa. Silver needles work well at conducting the heat but stainless steel is also effective. This method is ideal for directing heat precisely into a particular point such as joints to promote the circulation of qi and blood through the channels, to remove external cold, wind, or damp, which can stagnate qi and blood flow, and to tonify cold due to yang vacuity. Specific instances of this application are to treat wind, cold, damp, and cold damp resulting in bi-syndromes, or general weakness, cold, numb limbs, diarrhea, or abdominal distention. Ignite from the bottom of the cone, not the top, to facilitate proper burning.

Apart from moxa on needles, moxa caps, loose impure moxa positioned on top of an ash catcher, or pre-cut (formed) moxa with or without an ash catcher are alternative modalities. An ash catcher can easily be made with a piece of cardboard. Carefully retrieve the ash so that the hot embers do not fall on the patient’s skin and cause burns.

This is an interesting style of moxa delivery. Before using the brass burner, first put a piece of cloth (the Chinese recommend red flannel) orseveral layers of gauze on top of the skin to be treated. The cloth or gauze is used as a method of insulation to protect the patient from being burned. The surface area of the burner allows for a broad area of the body to be treated. In this way it is useful to treat musculoskeletal problems such as spasms and muscular tightness.

Fill the burner with several grams of crude or semi-crude moxa and light with a match. Then, like an iron, move the burner back and forth over the cloth on the affected area. Do not touch the brass burner or allow it to come in contact with unprotected skin—the brass is an efficientconductor of the moxa heat but can cause serious burns to the patient and the practitioner.

The moxa box is one of the most ingenious methods of moxa usage, devised for the expansive areas of the back and the abdomen. It is especially effective for the treatment of external cold and yang vacuity. The two primary locations for the positioning of the moxa box are on the bare skin of the abdomen from CV-9 (shui fen)—CV-4 (guan yuan) area and the low back in the BL-23 (shen shu) to BL-25 (da chang shu) area. Do not place the moxa box on the mid-back or it can cause muscular spasm.

Take a moxa pole and break it into three equal pieces. Remove the outside decorative paper, which is labeled (not the inner wrapper that holds the moxa in a roll). Take two of these pieces and light each end. Place the cover on the box at an angle such that part of the cover is off to allow oxygen into the box. The rate of the burn can be controlled in this manner. A faster burn is achieved with more of the cover askew and a slowerone with less. Burn slowly. Do not cover the box completely or the moxa will go out. Also do not use loose moxa in the box—its low density will cause it to ignite and burn too quickly. Over a 10 to 20 minute period check the skin beneath the box about every 5 minutes to see that it is mildlywarm and not causing any burn. As with all moxa, exercise extreme caution with patients who have delicate skin such as the elderly, diabetics, or those on pain medication, and patients with neurological deficits or mental impairment who may not be able to report a temperature sensation.

Moxa boxes can cause very serious burns. The practitioner should never let the patient adjust the box or remove the box him/herself. The practitioner should always be in line of sight to monitor the patient’s reaction to the moxa box.

The belly bowl is a Korean adaptation analogous to the moxa box. The belly bowl is specifically for using on the navel although clinicians do use it on other areas. It is a small round metal apparatus that has a large single hole or several small holes in which the moxa is placed. The bigger hole is used on the navel and allows for more concentrated heat; more diffuse heat is achieved with the smaller ones. Like the moxa box, monitor the patient carefully when using the belly bowl because it can burn the delicate navel easily. Do not use the belly bowl on navels that are “outies” as they will burn because of their outward configuration.

An insulation is another method of administering moxa. An insulation is a form of protection that both serves to prevent the heat of the moxa from burning as well as to confer the curing benefits of the moxa and the insulated material. Historically, various substances have been used for this effect. They include, but are not limited to, clay, ginger, garlic, leeks, aconite, white mustard seed, miso, wine or water, salt, tangerine peel, tissue, and gauze.

Clay has the medicinal effect of drying due to its astringent properties. A cake of clay can be placed on the area of the body to be treated such as on damp skin suppurations and then a cone of moxa placed over it and ignited. The heat of the moxa will further assist in the drying aspect of the clay. Dermatological conditions such as eczema can be treated in this manner. Adjust the size and frequency of administration to the clinical condition.

Moxa on ginger is a classical method of moxa application to augment yang vacuity. The yang nature of the moxa with the yang characteristics of the ginger (Recens Zingiberis Officinalis) is ideal to strengthen the yang synergistically. Points that energetically regulate yang function such as ST-25 (tian shu) as in the case of chronic loose stools, or the navel to directly treat the spleen and kidney yang vacuity as manifested through cold hands and feet, loose stools with undigested food, painful menses, constipation, abdominal pain, malabsorption of nutrients, allergic rhinitis, and external cold invasion should be treated with this method.

Cut a piece of raw, fresh ginger root about 0.25–0.5 in thick, and perforate it several times with a needle. Position the ginger on an acupunc acupuncture point such as CV-4 (guan yuan) or CV-6 (qi hai) and place a cone of moxa on top of it. Light the moxa and allow it to burn. The heat and resin of the moxa as well as the fresh ginger juice will be deposited on the skin via the holes. Use three to five cones per slice of moxa. If needed, turn the ginger over to assist in the secretion of more resin and juice.

Garlic has antibacterial and antiviral properties that can be utilized along with the use of moxibustion. Therapeutically, it can be used to treat parasites, poisonous insect bites, skin ulcers, boils, and carbuncles. Perforate the garlic with a needle in several places. Then place a piece of wet tissue or paper towel on the area to be treated and the clove of garlic on top of it. Next put a cone of moxa on top of the garlic and light. Garlic can be insulated with miso paste too.

The garlic can be crushed and made into a paste on which to burn the moxa cones. Leeks may be similarly used. A paste of powdered aconite (fu zi, Radix Aconiti), the hottest Chinese herb, can be used to warm the yang as in the case of a cold ulcer, impotence, and nocturnal emission. Whitepepper powder mixed with flour can be used in the same manner.

Salt is a common moxa insulation, which is suitable only for the navel to aid the moxa in directly penetrating to the kidney area. It is used for interior cold conditions such as kidney yang vacuity, or chronic cold due to weak ming men fire. The navel can treat many kidney yang vacuity symptoms as well as the lung and spleen because the navel pertains to the spleen according to the Nan Jing five-element map, and the spleen, as the figurative mother of lung and the grandmother of kidney, can treat each of them.

Ideally, use unprocessed sea salt that contains trace minerals, or pan-fried salt, which has lower water content. A dual-ply tissue may be usedas an insulation to guard against burning the interior of the delicate navel. Simply place the tissue over the navel and then put the salt on it. The weight of the salt will sink to fill the size of the navel. Then place the moxa cone on the salt. Burn as many cones of moxa as deemed necessary. When the treatment is complete, simply lift the tissue to easily remove the salt. Remove the cones with a pair of tweezers. Place the used cones in a cup or ashtray. Be careful not to burn the patient. Because the salt conducts the heat so well remove the cones as soon as the patient perceives heat, as it will continue to heat the point while you are removing the cone. If the salt gets too hot, touch the salt with the tweezers to absorb some of the heat or remove the salt.

Tangerine peel insulation is useful to release external invasions as in the case of the common cold. In particular, place moxa on GV-14 (da zhui), point of greatest yang of the body, to mobilize the yang to expel cold pathogens.

Stick-ons are pre-cut and pre-formed moxa sticks that can be placed on an acupuncture point. They are insulated with cardboard and come mixed with a variety of other ingredients such as ginger, cloves, cinnamon, aloe, miso, and garlic, which make the smoke less acrid and pungent. Moreover, they bestow the benefits of the other ingredients. This moxa method can ensure treatment precision and is convenient for administration at home.

Poles are virtually identical to moxa sticks in terms of therapeutic use and are very common methods of indirect moxa administration. They can be used on all points for which moxa is suitable. Make sure to tell the patient to take the exterior paper off before burning if they take them home to use or it could be very dangerous because it will ignite. Moxa sticks are available in smokeless and non-smokeless varieties; the smokeless form is created by densely packing the moxa and mixing it with other ingredients as in the stick-on types. It is very difficult to light so the practitioner should procure a butane lighter for office use.

Spray moxa is a fascinating and modern moxa innovation. It comes in a non-aerosol dispenser and can easily be sprayed on the areas where moxa is used such as muscular zones, joints, bruises, swellings, and fractures. In order to “activate” the functions of moxa, a heat source needs to be employed. Personally I like to apply the spray moxa to the affected area and then place the TDP lamp over that area of skin for 10–20 minutes. When the TDP lamp is not available (as in home administration), I first put a layer of liniment like Zheng Gu Shui, the hottest liniment, on the affected area to penetrate through the skin to the channel and even the bone level, to open to the exterior and heat the body. Then I put a layer of spray moxa over it. In this way the restorative function of the moxa may be tapped. The reverse layering can also be used, however, one disadvantage of the spray moxa is that it tends to feel cold upon application, hence I prefer the former method. Because of this feature, let the patient know in advance how it will feel when you apply it so they are prepared for the cold sensation and do not cramp up.

Liquid moxa is also a useful form of moxa. It is especially beneficial for swellings and bruises and has energetics similar to Zheng Gu Shui or Tieh Ta Yao Gin. It disperses blood and fluid stagnation, invigorates qi, and blood, stops pain, and relaxes tendons and muscles. It may be applied to bone spurs, muscular aches and pains, bruises, and arthritic conditions. Apply generously with a cotton ball to the affected area and let it dry naturally. Avoid mucous membranes and open wounds. Do not use with massage. Do not bandage or warm up except externally with the TDP lamp. Applying after a hot bath is useful to assist in the penetration of the liquid. Liquid moxa will stain clothes.

These are also a new variety of moxa application. Clinically they may not be as effective as the traditional methods outlined above but the reader is encouraged to try all of these methods and to gain his/her own clinical experience. I have not used them and hence cannot evaluate their effectiveness.