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World Journal ofAcupuncture-Moxibustion (WJAM)

ELSEVIER Vol. 26, No.3, 30th Sep. 2016 • 31 •

Mechanism Research

To understand moxibustion from the biological effect of

local thermal stimulation *

HUANG Kai-yu (1't~JL~), LIANG Shuang (* A), LU Lu (M- ~), Patrick John Morgan,
ZHANG Jian-bin (5LtJtjt)[8J

The second clinical medical college, Nanjing University of Cbd, Nanjing 210023, China (~;ju:p~~*~m-=
rl$*~~~, ~* 210023, ~ 00 )


First author: Huang Kai-yu (1992- ), male, Moxibustion is one of treatment modalities in Traditional Chinese Medicine
postgraduate student. (TCM). Its working mechanism is activated through heat-induced local
Researchfield: study of clinical treatment thermal stimulation. By reviewing and compiling clear, scientific analysis of
and mechanism of acupuncture- the biological and physiological effects from local thermal heat, the authors
moxibustion provides a coherent and systemic source to aid us to form an understanding
E-mail: of the mechanism of moxibustion's promotion of qi and blood circulation
[8J Corresponding Author: throughout the body from local thermal stimulation. This has been done by
Zhang Jian-bin (1967- ), male, professor. a rigorous review of previous studies of the thermal effect on the body. The
Researchfield: morden research of following presents the local, distal and systemic biological effects from local
acupuncture-moxibustion theory thermal stimulation while also discussing the similarities and differences
E-mail: between local thermal stimulation and moxibustion.
* Supported by grants from the National
KEY WORDS: moxibustion; rule; local thermal stimulation; the biological effect
Natural Science Foundation of China:

Accepted on March 3, 2016

Moxibustion, literally meaning the burning of been confirmed that local thermal stimulation can
moxa (Artemisia Vulgaris, commonly referred to treat infectious skin diseases such as warts, herpes,
as mugwort), is one of the main external treatment cutaneous leishmaniasis and so forth'<". Successful
methods of TCM. Using moxa as its functional treatment on one target wart could lead to elimination
medium, moxibustion plays the role of promotion of other untreated lesions in patients with warts!",
of qi and blood circulation. This, in essence, forms Some researchersl'' used locally concentrated heat to
the unique warming-dredging functional theory of intervene in herpes labialis. The next day, the systemic
moxibustion. Local thermal stimulation induces a itching and swelling was relieved and the curative
series of biological and physiological effects'" which effect of heat was superior to that of topical acyclovir.
provides the fundamental basis for exploring the Leishmania, the parasite responsible for the disease
warming-dredging/promotion of qi and blood theory of leishmaniasis, is heat sensitive. Radiofrequency heat
moxibustion. In this review, we research moxibustion treatment which creates thermal energy generating
possible from the biological effect of local thermal heat that penetrates the subcutaneous skin layer was
stimulation. used to treat leishmania infection!", The cure rate
was 80.7%. It is worth noting that it was significantly
LOCAL THERAPUTIC EFFECT OF higher than intralesional meglumine antimoniate

The effect on the skin Promoting of wound healing: Local thermal

Treatment of infectious skin diseases: It has stimulation can remedy cutaneous necrosis and
World Journal ofAcupuncture-Moxibustion (WJAM)
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chronic wounds[5-6l . After skin sparing mastectomy, the cutaneous vascular conductance raised to a level
recurrence of skin necrosis has a high probability. A of 42.6 mV/mm Hg, which means that heat could
pilot study[5] showed that 36% of women without local improve blood perfusion to the arteriole's extremeties
heat-treatment developed skin flap necrosis whereas in Secondary Reynaud's phenomenon patients.
only 12% developed skin flap necrosis in the treatment
group, a 24% difference. Diabetic foot ulcer is difficult Increasing local capillaries perfusion: Local
to heal due to the poor circulation and damage to thermal stimulation enhances capillary perfusion and
sensory nerve endings. Petrofsky IS et al. [6] found promotes capillary dilation. Widmer RJ et al. [l2l found
that heating with electrical stimulation was effective. the number of perfused capillaries increased and the
After such, blood flow in the skin layers in and around percent time precapillary sphincters remained open
the wound increased and the average wound area increased after thermal stimulation.
decreased substantially. It is of significance to note
that local heat would appear to be a relevant part of Note, too high a temperature can also excite the
this therapy because electrical stimulation alone has sympathetic nerve and cause vasoconstriction. It was
produced little healing. found that after heat application around the ocular
area, the blood velocity of the retina and choroid
Enhancing percutaneous drug absorption: slowed and the blood flow of the superior temporal
Regarding trans dermal uptake of nicotine using retinal arteriole and the superior nasal retinal arteriole
a nicotine skin patch, the study!" displayed that were reduced'!",
controlled heat application caused a nine fold increase
in skin perfusion and a thirteen fold increase in DISTAL THERAPUTIC EFFECT OF
nicotine uptake. Therefore it is clear that local thermal LOCAL THERMAL STIMULATION
stimulation improves skin permeability and increases
The effect on distal blood vessels
the kinetic energy of drug molecules to make a
significant increase in nicotine uptake. Enhancing distal blood vessels perfusion: This
local stimulation increases remote skin blood flow
The effect on muscles and joints and bone blood perfusion. Ian YK et al.[I4l found that
Relieving sports fatigue: Heat stimulation can the skin's blood flow in areas remote to the applied
trigger a local muscle tissue reaction, facilitate the heat increased slightly. Further examination revealed
ability of muscle cells and augment the stress tolerance phase synchronization between neurogenic blood flow
of muscles to protect against subsequent stress or oscillations (BFa) was significantly higher. Using the
injury. It was reported that local thermal stimulation technique of positron emission tomography (PET),
applied onto the left quarter ventral abdomen muscle Heinonen I et al.[IS] confirmed that thermal stimulation
of male Sprague-Dawley rats could remove the increased bone blood flow so that heat can improve the
inflammation caused by muscle injury and relieve local blood supply after fracture and promote fracture
pain!", Other experiments" showed that muscle healing. But too high a temperature would inhibit
glycogen concentration increased with heat pack revascularization in bone grafts'",
application after exercise to alleviate sports fatigue.
Inhibiting arterial stenosis: Brasselet C et al. [17]
Muscle recovery and joint injury: Light exercise reported that thermal stimulation significantly reduced
raises the blood flow to the muscles and the muscle the speed of the rabbit iliac artery in-stent restenosis
temperature rises. But other tissues such as those and inhibited in-stent neointimal hyperplasia to prevent
surrounding the knee and its ligaments can only be in-stent restenosis. The way to inhibit restenosis is
heated effectively externally and even then, still may speeding up the artery blood flow and reducing the
be relatively rigid. Petrofsky IS et al. [10] reported that deposit of intravascular impurities.
hydrocollator heat packs and Therma Care heat wraps
The effect on the viscera
applied on the quadriceps and knee were beneficial for
the flexibility of both the muscles and ligaments. (1) Heart
Surface thermal stimulus protects the myocardium
The effect on the skin's (dermal and and prevents heart damage!"?", Diode laser radiation
subcutaneous layers) blood vessels was used to locally heat the left ventricle by irradiating
Increasing local arterioles perfusion: Boignard the epicardial surface of a rat's heart. Gong B et al.[I8]
A et al. [II] used thermal hyperemia to intervene in found a significant degree of reduction in infarct
Secondary Raynaud's phenomenon. They found that size observed in animals with infarcted left coronary
World Journal ofAcupuncture-Moxibustion (WJAM)
ELSEVIER Vol. 26, No.3, 30th Sep. 2016 ·33 •

artery. And local thermal stimulation was brought over region. The results showed that local somatothermal
and above the left median nerve area. Then Chiu JH stimulation inhibited internal anal sphincter motility,
et al. [19] found that this could significantly decrease another example showing us the direct effect that
the level of creatine kinase, duration of arrhythmia, thermal stimulation can have both biologically and
mortality rate and improve mitochondrial respiratory physiologically on the body.
function to protect the rat's heart against ischemia-
reperfusion injury. Particularly, the gene expression of (5) Uterus
heat shock protein 70 (HSP70) was upregulated in the Primary dysmenorrhea is related to excessive
heart, although not in the liver. uterine contractions and poor blood flow. Potur DC
et al. [27] used a heat patch on the patient's lower
(2) Lung abdomen. It was found that such heat patches could
The heat and warm stimulation of the windpipe relieve smooth muscle and promote blood flow. Simply
is beneficial for lung function. Ribeiro SP et al. [20] put, the heat patch is an effective method for reducing
harvested the rat's lungs after warm intervention and painful dysmenorrhea.
then ventilated them mechanically. The results showed
a smaller decrease in chord compliance, a significant (6) Brain
attenuation in cytokine levels (TNF-alpha, IL- Distal thermal stimulation can induce marked
lbeta, MIP-2) and a significant increase in surfactant physiological changes in the cerebral cortex and
properties. Moreover, Huang KL et al.[21] found warm brainstem[28-29]. Wijayanto T et al. [28] found that after
intervention could inhibit the wet-to-dry ratio of stimulating the lower legs, oxyhemoglobin in pre-
lung weight and increase the protein concentration in frontal cortex increased to preserve oxygenation.
bronchoalveolar lavage fluid and shorten the recovery Heat stimulation on the left forehead and the left
time of profound hypoxemia. mental region created bilateral brainstem activity and
induced the activation of the spinal trigeminal nucleus.
(3) Liver Whereas left forehead region stimulation induced
Warm stimulation can stimulate the liver's self- activity more so in caudal (posterior) parts, left mental
defence protective mechanisrn'F?". Preconditioning region stimulation induced activity in more rostral
somatothermal stimulation on the right seventh (anterior) parts [29].
intercostal nerve area increases hepatic heat shock
protein 70 (HSP70) and protects the liver from SYSTEMIC EFFECT OF LOCAL
ischemic-reperfusion injury in rats[22]. Oka Y et al.[23] THERMAL STIMULATION
found that pre-treatment with heat shock reduces liver
injury and promotes liver regeneration capablility.
Moreover, after heat shock, HSP70 levels in the Invoking antitumor immunoresponse: Local heat
liver are clearly increased and serums Aspartate stress leads to the activation of anti-cancer CD/ T
Transaminase, alanine transferase and interleukin-6 cells and reduces the rate of tumor relapse and
levels are all significantly reduced. It is stated that metastasis'I", Chen T et al.[31] reported that the level of
heat shock can prevent liver damage and inhibit liver tumor necrosis factor-a (TNF-a) of dendritic cells in
inflammation. tumors showed an obvious increase after hyperthermia
treatment. And that Kida Y et al. [32] also found heat
(4) Stomach and Intestines can enhance the level of serum IFN in the liver. TNF
Local warm stimulation has a positive regulating inhibits cell division and regulates immunity to kill
effect on the blood flow and smooth muscle of the tumor cells specifically.
stomach and intestines[24-26]. Takayama S et al.[24] gave
Bioactive substances
abdominal thermal stimulation to the para-umbilical
region. It was measured that both the volume of Promoting nitric oxide production and platelet
blood flow in the superior mesenteric artery and activation: The increased nitric oxide (NO) production
intestinal peristalsis were significantly increased. in endothelial cells was promoted by local thermal
Some researchers'Y' have found that the electrical stimulation. The level of serum NO was enhanced,
synergy between the stomach and intestine could causing vessel dilation. Using nitric oxide synthase
be enhanced and that the gastrointestinal electrical inhibitor inhibited releasing NO and vessels dilation'i".
activity could be excited to improve gastrointestinal In addition, Blunk JA et al. [34] concluded that local
motility by employing a local warming technique. platelet activation was induced by the heating stimulus
Jiang JK et al.[26] stimulated volunteers' right popliteal and then the platelet-specific protein, beta-TG, had a
World Journal ofAcupuncture-Moxibustion (WJAM)
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long-lasting significant increase. The research shows that different kinds of

thermal stimulation used on certain areas can cause
THE GENERAL CHARACTERISTICS OF different biological and physiological responses. For
MOXIBUSTION example, when the stimulating temperature is below
Moxibustion involves the use of heat generated 50 ·C, it can lead to vasodilation of blood vessels
by burning herbs to stimulate specific spots on the and stimulation of the speed of blood flOW[II-I2 1;
skin[3s1• It is classified as direct moxibustion or indirect when the stimulating temperature is above 50 ·C, it can
moxibustion. Direct moxibustion is defined as burning cause vasoconstriction and the slowing of the speed
moxa cones or sticks placed directly on the skin, of blood flow'!". Warm temperatures inhibit artery
while indirect moxibustion means that some special restenosis, while high temperatures may cause serious
materials (usually ginger, garlic or salt) is placed thrombosis-'". Warm temperatures improve bone blood
between the moxa and skin [361• flow and promotes fracture healing, while extreme
high temperatures may inhibit revascularization and
Materials are very important to moxibustion and ostosis (bone formationpS-I6].
primarily Artemisia vulgaris. Compendium ofMateria
Medica had said that moxa leaf are slightly bitter and Moxibustion creates and provides a warming,
over-spicy when raw, and slightly spicy and over- heating sensation when applied close to the skin. The
bitter when processed. Moxa leaves (raw) turn warmer control of the localised thermal energy is carried out
ater being processed and then become moxa wool by an array of different techniques while also using
(processed) which are suitable for moxibustion [37]. moxa in a variety of different forms. Moxibustion
Importantly, the older the better. The ancient chose can generally be classified as direct moxibustion
moxa as moxibustion material is mainly for these drug (burning the moxa directly on the skin) and indirect
properties. moxibustion (providing thermal stimulation without
direct contact between the burning moxa and skin's
The mechanism of moxibustion is very surface). Both high intensity heat application and
complex. It mainly related to thermal effects and direct moxibustion involve localised, high level
pharmacological actions of moxa and its combustion heat stimulation which causes pustules and scars.
products!"! The warming-dredging function is Indirect moxibustion of lower level heat application
the high summarization of moxibustion effect[391• involves local warming stimulation which creates a
Moxibustion acts on expelling cold, promoting the superficial, temporary, reddening of the skin surface.
circulation in meridian and collateral, clearing away In addition, another form of moxibustion, neither
heat, detoxification, strengthening the antipathogenic classified as high intensity heat nor low intensity
qi, preventing from diseases and healthcare et al. All heat but located in between such, examples include
of these functions depend on the effect of moxibustion Thunder-Fire Moxibustion Technique and Acupoint
for circulating qi and blood flow. Heat Senitization Technique, both of which can cause
temporary inflammation but no heavy blistering'",
MOXIBUSTION When the optimal treatment temperature has been
Moxibustion will give a warm feeling, so set, the next essential influencing factor, duration of
some people think that it is essentially a kind of heat application, must be decided. Generally, when
thermotherapy. Moxibustion thermal stimulation stimulating temperature is below 50 ·C, the duration
affects both shallow and deep tissues of the skin. It of stimulation is 15-30 minutes. When stimulating
can raise temperature around acupoint tissues and then temperature is above 50 ·C, the duration of stimulation
stimulate local specific receptors and immune cells. So is less than I minute, possibly just seconds. Such
that warming-dredging function of moxibustion comes research data implies that the stimulating temperature
up. This is similar to local thermal stimulations, so that is always comparitively higher, as is the duration
many researchers think that moxibustion is a kind of always shorter, when we treat acute, of a proliferative
local thermal stimulations. The stimulating parameters nature, and hyperplastic diseases; the stimulating
and biochemical mechanisms of moxibustion and local temperature is always comparitively milder and more
thermal stimulation are partly similar. moderate, as is the duration always longer, when we
treat diseases of a chronic, wasting nature.
Stimulating parameters
(l) Stimulating temperature In moxibustion treatment, the duration depends
World Journal ofAcupuncture-Moxibustion (WJAM)
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on the state, location and course of the disease. If a moxibustion. The theoretical guidance is different
deficiency syndrome is being treated, when using and moxibustion can induce not only thermal effects
the reinforcing method the moxa should neither be but also pharmacological actions of moxa and its
blown on nor fanned to further intensify the lighting combustion products.
moxa's heat intensity. When an excess condition is
Theoretical guidance
being treated, in order to use the reducing method
the lighting moxa should be blown upon in order to Thermal stimulation has a direct effect on the
intensify the heat generated. If the disease is serious local area being heated. Due to this, the skin and
or deep, the time of moxibustion duration is generally subcutaneous layers of such at the site of the problem-
long; If the disease is light or shallow, the time of affected area are typically targeted for stimulation.
moxibustion duration is generally short. Thermal therapy are used to reduce pain and stiffness
and enhance tissue extensibility to alleviate muscle
Biochemical mechanisms
spasm, to increase ROM, and to improve tissue healing
The biochemical mechanisms of moxibustion and by increasing blood flow and nutrients to an area[43].
local thermal stimulation are partly similar. They are
both related to TRPY; Langerhans cells, dendritic cells In contrast, the theories of moxibustion are
and so on which are sensitive to heat to induce thermal rich in meaning. In TCM theory, moxibustion can
effects. be used widely if diseases cannot be cured by drugs
and acupuncture. Moxa fire is hot and speedy so
(1) Transient receptor potential vanilloid (TRPV) that it can warm nourishing and warm dredging. In
At the beginning of moxibustion or local thermal detail, moxibustion is often applied in deiciency-cold
stimulation, it activates thermoreceptor. When syndrome to warm yang and eliminate cold, deficiency
temperature rises more than 44 ·C, nociceptor will of qi and blood to tonify qi and blood, syndrome of qi
be activated toO[40]. TRPV-l is the main receptor of stagnation and blood stasis to promote qi and activate
moxibustion. TRPV-l receptors will be activates when blood, meridian impassability to dredge channels
temperature is more than 43 ·C. TRPV-2 receptors are and so forth'", Moxibustion is mainly based on the
also related to warm moxibustion and will be activated theory of meridian system which is reflected in the
when temperature is more than 52 ·C. So, TRPV-2 positions of moxibustion points. Meridian system
is always related to blistering moxibustion. These can communicate internal and external, contact
receptors existing in peripheral nerve will send signals organs, run qi-blood, and regulate the whole body.
to the central, and then produce a series of effects. The body surface can show the status of internal
organs, also it can receive treatment stimulation and
(2) Langerhans cells and dendritic cells then make effects. In the moxibustion treatment
Langerhans cells and dendritic cells belong to process, acupoints are the terminals of the meridian
the antigen presented cells and they are sensitive system. Moxibustion on acupoints can correct the
to thermal stimulations including moxibustion. disease state through activating meridian systemself-
Langerhans cells and dendritic cells can be activated healing function. Different acupoints can activate
after moxibustion warm stimulation. They migrate different meridian vessels and cure diferent diseases.
to local lymph nodes. Naive T cells in lymph nodes All of these proved that the meridian system plays an
identify the oral antigens and reproduce themselves. important role in the treatment of moxibustion.
Then naive T cells differentiate into effector T cells
and memory T cells. All effector T cells and most Pharmacological actions
memory T cells give play to local immune effect. The Moxibustion has its unique role in
rest of memory T cells spread the whole body through pharmacological actions, while most modem thermal
fluids cycles and then they activate the body immune stimulations just induce thermal effect.
The ingredients of moxa are complicated. The
volatile oils of moxa include 1, 8-Cineole, camphor,
THERMAL STIMULATION AND borneol, ketones, phenols, alkanes and so on[44]. The
combustion products of moxa play a role by entering
Part of doctors of traditional Chinese medicine into the human body through the skin[37]. The moxa ash
do not agree that moxibustion is completely classified and smoke are the main products. The ash can clearing
as a kind of thermal stimulations. Because there are the free radicals and lipid peroxidation and be used
many differences between thermal stimulation and to treat pressure sores[45]. Moxa smoke is produced in
World Journal ofAcupuncture-Moxibustion (WJAM)
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quantity during moxibustion. The components of moxa John Morgan revised the manuscript. Zhang Jian-bin
smoke are complex. They include ammonia, alcohols, obtained funding for the research project and drafted
aliphatic hydrocarbons, aromatic hydrocarbons, the protocol. The first two authors contributed equally
terpene compounds and their oxides, and so forth. to this work. All authors read and approved the final
The smoke can be used in air disinfection and as manuscript.
antiviral and antifungal. It was also reported that it
has applications in wound infections, vaginal itching, PROVENANCE AND PEER REVIEW
uterine prolapse, anal istula, common warts and so Not commissioned; externally peer reviewed.
on[46l .
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