Journal of Chinese Medicine • Number 103 • October 2013 Differences Between Moxa Punk And Smokeless Moxa Cones

es During Warm Needling: A Comparative Study 33

Differences Between Moxa

Punk And Smokeless Moxa
Cones During Warm Needling:
A Comparative Study
Abstract
This article compares the capacity of moxa punk (MP) and smokeless moxa (SM) to transfer heat to the end of an By: Steve
acupuncture needle during warm needling (WN). Two forms of moxa of equivalent weight were compared: the McCulloch
Ondan SM cone and Japanese MP rolled into a ball (12 of each type). The moxa was positioned on the handle of
two types of filiform needles (40mm x 0.3mm and 40mm x 0.25mm) and the temperature measured at the needle Keywords:
tip. The key findings were that SM produced 10 per cent more energy than MP, but that MP produced a 41 per cent Moxa,
greater and more rapid temperature increase than SM cones. Conversely, SM maintained maximum temperature moxibustion,
four times longer than MP. It is suggested that the temperature characteristics of MP during WN correlate with moxa punk,
the Chinese medicine treatment method of dispersing, while those of SM correlate to tonification. The lack of smokeless moxa,
studies addressing the therapeutic effects of these different temperature characteristics, as well as the unknown warm needling,
temperature characteristics of WN using acupuncture needles in-vivo, prevents further conclusions being drawn. tonification,
dispersion,
wenjiu, kyutoshin,
Introduction in WN was MP, the switch to smokeless moxa (SM) mugwort,
The use of moxa in Chinese medicine is thought to cones is being made with surprisingly little evidence therapeutic effect,
have originated between 400BCE and 260BCE (Wilcox, to support a comparative therapeutic benefit (much acupuncture.
2008). According to O’Connor and Bensky (1981) of the current evidence on the efficacy of WN uses
moxa is commonly used in Chinese medicine to move MP as the heat source: see Liu, 2006; Kim et al., 2009;
qi and blood, treat cold diseases and warm yang. Sun & Xu, 2010; Leeguo, 2011). This article describes a
Traditionally, moxa was formed into a cone, placed study to investigate whether MP and SM differ in their
directly on the skin and burnt. However, Wang (1984) capacity to transfer heat to the tip of the acupuncture
claims that because this method caused pain and needle during WN, and discusses the possible clinical
scarring, during the Ming dynasty moxa techniques implications of this.
were developed to apply heat indirectly. One of the
techniques developed was called ‘lightning needle’ The therapeutic effects of warm
(Wang, 1984, p.26), whereby moxa was applied to the needling
handle of a needle and burned to direct heat into the It has been suggested that the therapeutic effect of
body. In China this technique is known as wenjiu, in burning MP is due to the dual aspects of heat and
Japan it is called kyutoshin technique and in modern smoke, which penetrate into the channels through
English texts it is commonly called warm needling the skin (Dharmananda, 2004). However, because
(WN). cardboard is often placed against the skin during WN
Traditionally in WN, loose mugwort (commonly to protect the patient from excessive heat any bits of
known as moxa punk [MP]) is rolled into a ball and burning moxa (this is stipulated, for example, in the
attached to the handle of an acupuncture needle British Acupuncture Council [2010] Guide to Safe
inserted into the patient’s body. However, burning MP Practice), any therapeutic effect is likely to be the result
gives off a large amount of smoke, which is impractical of heat transmitted via the needle into the body. In
in some modern clinical settings, especially multi- discussing musculoskeletal conditions, Birch and Ida
tenanted buildings where other people are sensitive to (1998) state that the therapeutic effect of WN comes
the smell or where there are smoke alarms. This has from its ability to deliver a ‘deeper penetration of heat
led some practitioners to use a readily available pre- along the needle shaft into the body tissue’ (p.81).
formed moxa cone made out of a mix of charcoal and Though no studies have been published in English
mugwort that fits onto the needle handle and emits conclusively showing that heat is transferred past the
less smoke. Given that the traditional heat source used superficial skin layer during WN, Kim et al. (2009)
34 Differences Between Moxa Punk And Smokeless Moxa Cones During Warm Needling: A Comparative Study
compared the analgesic effects of WN with acupuncture
and sham WN (moxa held in the same position but without
insertion of the needle) on rats subjected to a sharp-point
test. In this study acupuncture and sham WN showed little
analgesic effect, whereas WN showed significant effects,
leading the authors to conclude that it was the transmission
of the heat below the skin through the needle that was
causing pain relief.
Cohen et al. (1997) offer an alternative theory to explain
the therapeutic effects of WN. They theorise that a
temperature differential between the needle handle and tip
during WN sets up a difference in electrical potential, thus
creating an electrical current in the needle (at a strength that
has been shown to have biological effects). Their experiment
showed that the current through the needle increased with
higher temperature differentials. If the amount of current
produced in this way is directly related to the therapeutic
effect, the moxa that produces the highest temperature at
the handle should theoretically provide the greatest effect.
It is interesting to note that Obaidey (2011) also ascribes the
therapeutic effect of WN to a differential, albeit couched
in Chinese medical terms; his supposition is that burning
moxa creates a ‘powerful splitting’ (p.157) between yin and
yang, which is transmitted through the needle and received
as a signal by the body.
Based on the supposition that the therapeutic effect of
WN is achieved either through heat transmitted down the
needle or through creation of a temperature differential
along the needle, this study aimed to find out if there is a
difference between SM and MP as heat sources. Although
Figure 1: Diagrammatic elevation view of experimental set-up
Journal of Chinese Medicine • Number 103 • October 2013
studies have been carried out to determine how SM and
MP differ as heat sources (Shen et al., 2006; Pachetal, 2009),
none has compared their differences when applied during
WN in a structured and consistent manner.
The study
In order to compare SM and MP in WN, an experiment was
designed focusing on their respective capacities to transfer
heat to the tip of an acupuncture needle. A secondary aim
was to determine if using 0.25 or 0.3 millimetre diameter
needles (that are commonly used in acupuncture clinics)
affected the heat transfer. The experiment was carried out
in several stages:
• The first stage was to baseline the energy (calories per
gram) of each sample of moxa used in the experiment.
This energy is directly related to the heat that each moxa
type gives off when burnt - the amount of heat available
to transfer and raise the temperature of the needle.
Establishing a baseline allowed comparison between
the potential of each moxa type to transfer heat versus
the actual temperature measured at the needle tip. This
measurement was carried out using a standard bomb
calorimeter (a device used to combust samples and
measure how much the sample changes the temperature
of a standard volume of water). Figures 1, 2 and 3
illustrate the experimental set-up.
• The next stage consisted of setting up and running an
experiment, using MP and SM as heat sources, to gather
comparative temperature readings at the needle tip.
Journal of Chinese Medicine • Number 103 • October 2013 Differences Between Moxa Punk And Smokeless Moxa Cones During Warm Needling: A Comparative Study 35

Sensor wire Sensor pad • The weight of the commercial pre-formed SM cones
(Ondan, Japan) varied around 0.42g (± 0.01g). Loose
MP was therefore weighed at 0.42g (± 0.01g) and rolled
to form a ball 20mm (± 2mm) in diameter (Figure 4).
Japanese MP (Wakakusalbuki, medium grade) was used
due to its ability to hold together when rolled into a ball.
• The Japanese MP samples were fitted onto the needle
handle at a set distance 22mm from the inferior edge of
the MP to the bottom of the needle handle.
• The needle was inserted into the silicone until there was
10mm distance from the cardboard shield to the bottom
of the needle handle (in order to ensure the temperature
probe consistently contacted the same point of each
needle). After igniting the moxa sample the temperature
Needle insertion point
was recorded every 30 seconds for eight minutes.
Figure 2: Temperature sensor position in relation to needle

Figure 4: Size of moxa punk ball

• The experiment was repeated six times for each moxa

Figure 3: Actual experiment setup
Points to note in relation to this experiment are:
• Stainless steel 40mm filiform needles from Acumedic
(UK) were used. Two diameters (consistent with those
used in previous WN experiments) were chosen: 0.3mm
and 0.25mm.
type and needle diameter combination. Results were
then analysed using mean and standard deviation (SD).
Confidence that the means of the two samples are large
compared to the means uncertainty were calculated
using the two-sided t-test method described by Peters
(2001). Significance was set at p<0.01. The protocol
for measuring the temperature is shown in Figure 5.
[Full details of the experimental set-up can be found
online at www.focusacupuncture.co.uk in the original
dissertation from which this paper was adapted.]

Start

Needle retained Cardboard Moxa inserted Needle retaining

in device and left placed on on needle device inserted
for 5 minutes container handle into glass tank

Intitial
temperature
recorded

Needle removed
and device left
for 3 minutes
Yes
Ignition from Smokeless
bottom for 6 sec moxa
Temp recorded Lid placed on
every 30 sec for glass tank No
8 minutes Stop watch started
Ignition from
bottom for 2 sec

Figure 5: Protocol for measuring temperature change at needle tip

36 Differences Between Moxa Punk And Smokeless Moxa Cones During Warm Needling: A Comparative Study Journal of Chinese Medicine • Number 103 • October 2013

Results Max change in temp at needle

Calorific value and (˚C) 0.25mm diameter
The calculated calorific values for equivalent weights Smokeless moxa Moxa Punk
(0.42g) of each type of moxa are summarised in Table 1. n=12 n=12
The mean of the measured calorific value per gram of SM 1.6 2.5
1.7 2.4
was higher than MP (4951Hg1 ± 35 versus 4488Hg ± 112 in
1.7 2.4
3 samples, p<0.01). SM cones produced approximately 10 1.9 2.5
per cent more energy (and hence heat) on a gram per gram 1.7 2.3
basis than Japanese MP. 1.8 2.6
1.8 2.5
1.8 2.5
Calculated calorific value Hg 1.9 2.4
([tW-e3]/m)2 1.7 2.5
1.6 2.3
Sample size Smokeless moxa Moxa punk 1.6 2.5
n=3 n=3 1.7 2.5
4937 4647 Average Sample SD 0.1 0.1
4991 4410
4926 4408 Table 2: Maximum temperature change at needle tip per moxa type
4951 4488 (different needle diameters combined)
Average sample SD 35 112

Table 1: Calculated calorific values of different moxa types

Temperature at needle tip

The diameter of the needle had no effect on the mean
temperature increase at the needle tip. This allowed the
results to be pooled, thus increasing the sample size.
Japanese MP balls raised the temperature of the needle tip
41 per cent higher than SM cones (2.5°C± 0.1 versus 1.7°C±
0.1 for a sample of 12, p=0.00). The results are shown in
Table 2.
Figure 6: Comparison of measured mean temperature change (n=12) at
When the results for these temperature increases were needle tip of two moxa types.
plotted across the eight-minute time period for each moxa
type, an interesting profile was discovered (see Figure Out of interest, two other forms of moxa were burnt, using
6). The rate of temperature increase using Japanese MP the same experimental set-up, to observe how differing
was faster than that of SM cones (maximum temperature amounts of MP change the temperature (n=3). The two
reached in 120 seconds [±15] compared to 270 seconds additional forms used were:
[±15]). However, although the maximum temperature
change recorded was less than Japanese MP (1.7°C versus • A 2.2g ball of Chinese MP tightly packed into a ball 2.4mm
2.5°C), SM cones maintained it over three times longer than in diameter (as recommended by Obaidey, 2006).3
Japanese MP (150 seconds [±15] versus 30 seconds [±15]). • A pre-formed 0.33g moxa roll (made from MP), 10mm
high x 11mm diameter (commonly available from
acupuncture suppliers such as Acumedic, UK).

As can be seen in Figure 7, the maximum temperature

change at the needle end increases with a greater weight
of MP. However, independent of their size or weight,
MP samples show a similar characteristic: a rapid rate of
temperature increase to the peak temperature, followed by
an almost immediate decline.
Journal of Chinese Medicine • Number 103 • October 2013 Differences Between Moxa Punk And Smokeless Moxa Cones During Warm Needling: A Comparative Study
Figure 7: Comparison of measured mean temperature change at needle tip
of various moxa types
Discussion
This study was based on the presupposition that it is the
heat applied below the skin via the needle that makes
WN therapeutically more effective than acupuncture or
direct moxa for some conditions. As such, the experiment
produced two core findings that may have significant
clinical implications:
1) The temperature change using MP was 41 per cent
greater than SM.
2) SM cones maintained the raised temperature four times
longer than MP.
The higher temperature change at the tip of the needle
produced by MP was contrary to expectations, as the
baseline calorific measurements of the samples had showed
that SM produced 10 per cent more energy than MP. Density
appears to be the major factor causing the differential.
Although equivalent in weight, the 20 millimetre MP
balls used in this experiment were considerably larger
than the SM cones (11 millimetre x 8 millimetre), and less
dense. Therefore they burnt more intensely, with a greater
change in temperature at the needle tip maintained for a
shorter time than SM cones. In summary, moxa density is
inversely related to temperature change at the needle tip,
and positively related to the duration of the temperature
increase, so that increasing the weight of the MP ball
increases the temperature.
Although Chinese medicine texts generally state that
WN is used to apply heat via the acupuncture needle, any
discussion regarding the therapeutic effects of temperature
magnitude or duration is lacking.4 Dharmananda (2004),
Wilcox (2008) and Soulié de Morant (1994) all argue that,
just as with acupuncture, moxibustion (in the form of direct
moxa) can disperse or tonify, and recommend a steady and
longer heat for tonification, and a more rapid and intense heat
for dispersing. Young and Craig (2010) additionally posit
that large moxa cones (applied directly) provide a strong
heat and stimulate the sympathetic nervous system, which
in turn activates aspects of the innate immune system. In
37
contrast small moxa cones (applied multiple times) provide
a mild heat that activates the parasympathetic system and
boosts the adaptive immune system. As shown in this
study, the temperature characteristic at the needle tip – and
potentially therefore the therapeutic effect - can be altered
by changing the type of moxa. Based on the therapeutic
strategies described above, the temperature characteristics
produced by MP correspond to dispersing, while that of SM
cones correspond with tonifying. Knowing this difference,
practitioners are able to choose a specific therapeutic
effect through their choice of moxa type. However, further
investigation is required to confirm that the therapeutic
action of dispersing or tonifying ascribed above to directly
applied moxa cones also applies in the case of WN.
Both moxa samples used in this study increased the
temperature at the tip of the needle. However, this does
not mean that the results would be the same if the needle
were inserted into a human body. The thermal conductivity
of the body and its ability to maintain a homeostatic
temperature (Habashet al., 2006) may negate any increase
in temperature. If the therapeutic effect of WN relies on
introducing heat below the skin surface, then the moxa
heat source needs to raise the temperature at the needle tip
higher than that of the body. This implies that MP, which
produces a higher temperature, may have more effect than
SM cones. Additionally, in practice the weight of MP can
be increased to provide a higher temperature (as shown in
this study), or the ball of MP can even be moved further
down the handle (an option not available with fixed-form
SM cones). The same would apply if it is the temperature
differential that causes the therapeutic effect (as posited by
Cohen et al., 1997) - MP produces the higher temperature
and therefore the greater effect.
Conclusion
This study shows that there are significant differences
between MP and SM when used for WN. MP burns
more intensely and results in the needle temperature
rising faster and 41 per cent higher than SM, but with a
shorter duration. Conversely SM burns more moderately,
producing a smaller temperature change that is maintained
four times longer. The use of 0.25mm or 0.3mm diameter
needles does not seem to affect the temperature change at the
end of the needle. MP is less dense than SM, which appears
to be the main factor causing the difference in temperature
characteristics within this study. In addition, temperature
change at the needle tip also has a positive relationship with
MP weight. Interestingly, MP weight does not appear to affect
the rate of temperature increase or decrease, suggesting that
temperature can be increased without affecting the character
of the heat applied. The temperature characteristic at the tip
of the needle from MP correlates to dispersion, while that
from SM cones correlates to tonification. This is the first
study to clarify how different moxa types might be used for
tonification or dispersion in WN.
38 Differences Between Moxa Punk And Smokeless Moxa Cones During Warm Needling: A Comparative Study Journal of Chinese Medicine • Number 103 • October 2013

These findings might be used to increase the efficacy of
WN in treating conditions involving qi and blood stagnation
and cold. However, further research is required to confirm
these outcomes in clinical practice. Although the possible
therapeutic relevance of the results is explored above,
definitive interpretation of the results in terms of clinical
practice cannot be made, as the thermal characteristics may
change when the needle is inserted into a human body.
Nevertheless, based on these findings practitioners can
begin the process of gathering their own personal body
of knowledge by correlating therapeutic outcomes with
different types of moxa application.
In current clinical practice the practitioner has more
control over the utilisation of MP than SM cones. Differing
weights and sizes of MP ball can be formed as required by
the practitioner in order to vary the amount and intensity
of heat. However, SM has distinct advantages as it emits
less smoke and delivers a longer and less intense heat. In
order to provide practitioners with an informed choice,
manufacturers should be encouraged to provide multiple
sizes and densities of SM cones, with associated information
on how much heat would be delivered.
Given the lack of available evidence and guidelines for
WN - especially in relation to temperature magnitude and
duration - this study is a first step in providing insight into
the temperature produced at the needle tip, and therefore
the heat that is possibly being introduced below the skin.
Knowing the different temperature characteristics of
MP and SM gives the practitioner some basis for making
decisions on how moxa-type and -weight might be used for
different therapeutic effects.
Steve McCulloch obtained his BSc degree in Chinese Medicine
Acupuncture from the University of Westminster (UK) and is
currently studying with Andrew Nugent-Head from the Association
of Traditional Studies. He practises acupuncture in London (UK). He
would like to acknowledge the support and guidance given by James
Cattermole in defining, carrying out and publishing this experimental
study.

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Differences Between Moxa Punk And Smokeless Moxa Cones During Warm Needling: A Comparative Study 39
Endnotes
1 Hg - the gross heat of
combustion.
2 Calculation for the gross heat
of combustion (Hg) where:
t =  net temperature rise
W = 2426 (energy equivalent
of the calorimeter in calories
per degrees Celsius)
e3 = 2.3 (calories/cm) x cm of
fuse wire used/burnt (the fuse
wire combusts the sample in
the chamber and therefore
needs to be taken into account
for the energy calculation).
m = mass of the sample in
grams
3 Chinese MP is coarser than
Japanese MP but will hold
together when rolled into a
larger ball; it is often used
in preference to Japanese MP
because it is cheaper when
used in larger quantities.
4 This conclusion was reached
from a review of seven core
recommended texts for
acupuncture students at the
University of Westminster
(UK).