Eastern Part 2

A SCIENTIFIC LOOK AT ALTERNATIVE MEDICINE

Eastern Approaches

Part 2: Electroacupuncture, auriculotherapy, dry needling, acupressure, moxibustion, and cupping

Thomas J. Wheeler, Ph.D.

Associate Professor (retired), Department of Biochemistry and Molecular Biology,

University of Louisville School of Medicine, Louisville KY

thomas.wheeler@louisville.edu

Revised 2019

This original version of this material was a handout for an elective course given to medical students at the University of Louisville.

DISCLAIMER: The material presented here is not medical advice. It represents the author's summary of scientific evidence concerning various topics. For medical advice, see your physician.

A pdf file containing all parts and references can be downloaded from ARTICLES or EASTERN.

CONTENTS OF PART 2

Electroacupuncture

Selected reviews, meta-analyses, and trials

Auriculotherapy

Background

Practice and scope

Proposed mechanisms

Selected reviews, meta-analyses, and trials

Scientific critique

Characteristics of pseudoscience

Dry needling

Acupressure

Reviews

Shiatsu

Moxibustion

Reviews

Cupping

Reviews

Scientific critique

ELECTROACUPUNCTURE

Langevin and others (2015. J Altern Complement Med. 21(3):113-28) wrote, "manual and electrical stimulation of the acupuncture needle are commonly assumed to be equivalent means of achieving therapeutic benefit, with electrical stimulation mainly considered as a means to provide stronger treatment. Further, electrical stimulation is frequently favored in basic science research because of its readily quantifiable stimulation parameters of frequency, intensity, and duration... In clinical trials of acupuncture, manual needle stimulation techniques are nearly always applied for a much shorter duration than is electrical stimulation (i.e., seconds rather than minutes). Even when manual stimulation is repeated a few times at intervals during the treatment, the total duration of active stimulation is much shorter in MA than EA. Furthermore, MA and EA are not always clearly separated. For example, in a study of EA, manual stimulation is frequently performed briefly first to 'obtain de qi,' followed by electrical stimulation, such that MA is actually compared to a combination of MA plus EA."

Han (2011. Pain. 152(3 Suppl):S41-8) noted that "it may take years to master any kind of manipulation (tonifying or dissipating, warming or cooling) sufficient to 'direct the flow of Qi.' Thanks to the introduction of EA, one can readily and precisely set the parameters of the electric pulses in scientific studies. Among the important parameters of the electric pulses, the frequency seems to be the most critical element...2-, 15- and 100-Hz are commonly employed as the standard settings for low-, medium-, and high-frequency EA, respectively..."

"Analyses of surveys and insurance claims in the United States indicate that EA is used in 12–15% of all acupuncture treatments...When treating chronic back pain, the reported use of EA in the United States increases to 24–32%...In a survey of United States acupuncturists treating chronic low back pain, 51% of practitioners reported using EA because 'something simpler hadn't worked'" (Langevin et al. 2015. Op. cit.).

Zhou et al. (2005. J Appl Physiol 98:872-80) described differences between electroacupuncture (EA) and manual acupuncture (MA): “EA causes the release of β-endorphin and ACTH into plasma, whereas MA releases only β-endorphin. EA increases the concentrations of vasoactive intestinal peptide, neuropeptide Y in the hippocampus and occipital cortex, and substance P and neurokinin A in the hippocampus, whereas MA does not influence the concentrations of these neuropeptides.” (Because of these and other differences, research studies indicating benefits of electroacupuncture do not validate manual acupuncture.) Zhang et al. (2014. Anesthesiology. 120(2):482-503) wrote that "Electroacupuncture blocks pain by activating a variety of bioactive chemicals through peripheral, spinal, and supraspinal mechanisms. These include opioids, which desensitize peripheral nociceptors and reduce proinflammatory cytokines peripherally and in the spinal cord, and serotonin and norepinephrine, which decrease spinal N-methyl-D-aspartate receptor subunit GluN1 phosphorylation."

Transcutaneous electrical nerve stimulation (TENS) uses surface electrodes rather than needles. In contrast, in percutaneous electrical nerve stimulation (PENS) there is similar stimulation of electrodes, but their placement is around the pain areas rather than at acupuncture points.

D. Gorski ("Orac"), in one of his critiques of acupuncture, has argued that "Electroacupuncture is in essence nothing more than transcutaneous electrical nerve stimulation (TENS), an accepted modality to treat pain"

(2010 Aug 19. Respectful Insolence blog).

Zhao et al. 2017 (see migraine study below) wrote, "We added electrostimulation to manual acupuncture because manual acupuncture requires more time until it reaches a similar analgesic effect as electrical stimulation. Previous studies have reported that electrostimulation is better than manual acupuncture in relieving pain and could induce a longer-lasting effect."

Many published articles treat electroacupuncture and true acupuncture as if they were the same, which is not the case, and it sometimes one needs to read beyond the abstract to discover that an "acupuncture" trial actually employed electroacupuncture. For example, the Suarez-Almador paper below describes electroacupuncture as "traditional Chinese acupuncture" in the abstract. (In the text, the authors wrote, "We chose electroacupuncture as the modality of choice because it is currently the most commonly used method.")

Selected reviews (R), meta-analyses (M), and trials (T)

Arthritis (osteoarthritis of the knee) - Suarez-Almazor et al. 2010. Arthritis Care Res (Hoboken). 62(9):1229-36 (T). "TCA [traditional Chinese acupuncture] was not superior to sham acupuncture. However, acupuncturists' styles had significant effects on pain reduction and satisfaction, suggesting that the analgesic benefits of acupuncture can be partially mediated through placebo effects related to the acupuncturist's behavior."

Constipation

Liu et al. 2016. Ann Intern Med. 165(11):761-9 (T). Was beneficial.
Chen et al. 2018. Neurogastroenterol Motil. 30(7):e13393 (R). "EA when applied appropriately...is expected to have a great potential for treating various functional GI diseases."

Migraine - Zhao et al. 2017. JAMA Intern Med. 177(4):508-15 (T). Beneficial compared to sham. Gelfand (2017. JAMA Intern Med. 177(4):516-7) expressed concern over blinding. She also noted that "if the true acupuncture regimen studied in this trial is truly effective for migraine prevention, the logistical barriers inherent in patients being able to access it clinically are likely to be substantial...To replicate the studied treatment, a patient must live close enough to an acupuncture provider to be able to access near-daily treatment for a month."

Polycystic ovary syndrome - Wu et al. 2017. JAMA. 317(24):2502-14 (T). No benefit.

Tinnitus - He et al. 2016. PLoS One. 11(3):e0150600 (R). "Due to the poor methodological quality of the primary studies and the small sample sizes, no convincing evidence that electroacupuncture is beneficial for treating tinnitus could be found."

Urinary stress incontinence - Liu et al. 2017. JAMA. 317(24):2493-2501 (T). Beneficial compared to sham.

AURICULOTHERAPY

Background

Auriculotherapy involves stimulation of acupuncture points in the ear. The treatment can be insertion of acupuncture needles (auricular acupuncture or ear acupuncture), or the application of pressure as a form of acupressure.

"The history of AT can be traced back to more than 2000 years ago in ancient China, and the modern theory and practice of AT was developed by Paul Nogier, a French physician, in the late 1950s. Different from the Chinese body acupuncture/acupressure which is based on the traditional meridian-collateral theory that 12 regular meridians (six yin meridians and six yang meridians) run throughout the body with a number of acupuncture points distributed along their paths, AT focuses on the connection between the specific acupoints located in the auricle and pathological conditions in particular zang-fu organs of the body. The modern theory of AT recognizes that the external ear has a somatotopic pattern with an inverted fetus within the uterus, with the head and facial areas towards the bottom of the auricle and the feet areas towards the upper rim of the auricle. Each part of the body corresponds to an auricular acupoint or a specific area which reflects the pathological and/or physiological condition. By stimulating sensitive auricular acupoints which correspond to particular zang-fu organs or specific parts of the body, AT could generate a positive impact on treating or relieving a variety of health problems" (Tan et al. 2014. Evid Based Complement Alternat Med. 2014:430796). The representation of the body on the ear is referred to as "Nogier's homunculus."

"Auricular Acupuncture/Auriculotherapy is an empiric therapeutic method which is historically based on hot-iron cauterizations made by healers on the auricle for treating sciatic pain in the past centuries, especially in Mediterranean countries like France and Italy. In the nineteen-fifties Dr. Paul Nogier of Lyon, observing patients carrying burn scars on the lower border of the antihelix, associated the site of these scars to the lumbar-sacral zone of the spine and started pioneering work to identify the head-down fetal-like representation of the body on the outer ear" (Romoli et al. 2016. Complement Ther Med. 26:61-5).

"After Dr. Paul Nogier's initial cartography of the ear, multiple cartographies have been developed by different authors/countries/schools. Until recently, the construct of these cartographies was anatomically based. Basically, the ear was divided in anatomic zones (helix, Antihelix, Tragus, Lobule, etc.) and each zone was subdivided in areas. This led to the description of each point by a letter referring to the zone and a number referring to an area within the zone. The World Health Organization (WHO) recognized it in 1987 and developed its first International Nomenclature in 1990..." (Alimi et al. 2018. J Altern Complement Med. 24(1):7-14).

Practice and scope

Points on the ear (auricular points) are stimulated by various means to treat illness. Pathological auricular points are located by measuring electrical resistance of skin. "Various methods currently existing for ear stimulation are needles, seeds, magnetic stones, lasers, ultrasound, bloodletting, moxibustion, electric treatment, and pressure by hands" (Hou et al. 2015. Evid Based Complement Alternat Med. 2015:495684).

“When there is a pain problem involving a given area of the body, the corresponding auricular point is said to be ‘reactive,’ manifesting greatly increased tenderness and electrical conductivity as compared to the surrounding areas of the ear. It is also purported that in some cases, there are also morphological changes or discolorations at these auricular loci” (Oleson et al. 1980. Pain. 8(2):217-29). "Healthy adults usually have no electrically active ear points, while the number of active ear acupuncture points correlates with disease severity" (Kurath-Kollet et al. 2016. J Altern Complement Med. 22(10):788-93).

"Contemporary auricular acupuncture charts now commonly display both European and Chinese acupoints, and are largely a result of the World Health Organization's international meetings that sought to standardize auricular acupuncture nomenclature and anatomy...However, even with standardized auricular acupuncture charts, the practice of auricular acupuncture varies among countries and practitioners" (King et al. 2013. Mil Med. 178(8):867-7).

Needles are inserted and left in for 6 to 10 minutes, and possibly are rotated. They are then removed and may be replaced with semipermanent steel needle, with which the patient can administer self-treatment by turning a magnet.

Auriculotherapy has been used for treatment of pain, nausea, vomiting, other gastrointestinal conditions, hypertension, anxiety, weight reduction, smoking and other forms of addiction, migraine, and other conditions.

Battlefield acupuncture - The "United States military has introduced battlefield acupuncture (BFA) in an effort to treat wounded soldiers in the field without sedating them. After the 9/11 attacks, Richard Niemtzow, a military physician, created this five-point ear protocol using ASP semipermanent needles, which is now being taught to military medical providers who are not certified or licensed acupuncturists" (Murakami, Fox, and Dijkers 2017. Pain Med. 18(3):551-64). "BFA takes only 3 to 10 minutes to administer to patients...BFA is a simple protocol that can be learned in a single 4-hour session by nonacupuncturists. The procedure does not require specific follow-up. The body expels the semipermanent needles as skin re-epithelializes over several days, or needles can be removed by the patient" (Moss and Crawford 2015. J Am Board Fam Med. 28(6):697-705).

"Although there is some support for auricular therapy in general, the evidence base for BFA is relatively meager. Regardless, the Defense and Veterans Center for Integrative Pain Management and the Veterans Health Administration National Pain Management Program Office recently completed a 3-yr $5.4 million acupuncture education and training program, which deployed certified BFA trainers to receptive Department of Defense and Veterans Administration medical centers. Over 2800 providers were trained to provide BFA" (Levy et al. 2018. Am J Phys Med Rehabil. 97(3):e18-e19).

The National Acupuncture Detoxification Association (NADA) protocol for substance abuse involves a standardized 3- to 5-point ear acupuncture treatment. The needles are left in place for 45 minutes. "According to its website, NADA has trained more than 10,000 counselors, social workers, nurses, MDs, psychologists, acupuncturists, chiropractors, corrections officers, and others to use its protocol and over 1,000 addictions programs in the U.S. and Canada 'now use acupuncture.' Graduates of their 70-hour program earn certificates which, in a number of states, entitle them to practice auricular acupuncture for addiction treatment. NADA also claims that over 25,000 providers worldwide have been trained and that the protocol is offered in 40 countries...NADA actively lobbies for laws permitting those who are not licensed acupuncturists to perform the NADA protocol" (Bellamy 2016 Sept 1. Science-Based Medicine blog).

"Furthermore, the NADA protocol is also not just the insertion of five ear needles. The NADA protocol is a style of engaging in which the environment and intention of the practitioner play significant roles in the outcome of the treatment. NADA treatments are usually done in a group setting, creating an environment that is reassuring and validating" (Stuyt and Voyles 2016. Subst Abuse Rehabil. 7;7:169-80). Thus, it would be difficult to ascribe any benefits to the acupuncture as opposed to the social and psychological aspects.

Proposed mechanisms

"Numerous prior studies have confirmed the effectiveness of somatic and auricular acupuncture regarding pain control, but the scientific mechanism behind how auricular acupuncture produces analgesia is not completely understood although multiple theories exist and are supported by studies investigating these proposed models. A neural mechanism relates to the ear receiving innervation from the auricular branch of the vagus nerve, the auriculotemporal branch of the trigeminal nerve, the great auricular nerve from the second and third cervical roots as well as the facial and glossopharyngeal...In addition, it is known that there exists neurovascular complexes in the ear composed of myelinated and unmyelinated nervous fibers, capillaries, and lymphatics. These sites serve as the proposed acupoint, and when stimulated, a possible neurohormonal release occurs producing a corresponding effect. Cholinergic and adrenergic fibers are also found throughout the ear which may also be the etiology of neurotransmitter release. Furthermore, general somatic acupuncture has been linked to the central nervous system through multiple functional MRI studies. In addition, auricular acupuncture has also shown a link to the central nervous system and brain through functional MRI in both somatic representation as well as cortical and limbic areas related to the pain pathway" (Graff and McDonald 2018. Pediatr Emerg Care. 34(4):258-62).

Related to detoxification treatment, Hou et al. (2015. Op. cit.) proposed "AA can activate the neuronal release of serotonin in the hypothalamus via the ABVN [auricular branches of the vagus nerve]. Serotonin can activate met-enkephalin, which can inhibit the release of γ-aminobutyric acid (GABA). GABA can inhibit dopamine output in the brain. Finally, AA can increase dopamine levels by inhibiting GABA."

Selected reviews (R), meta-analyses (M), and trials (T)

(note: the techniques may be acupuncture and/or acupressure) (* = review by Edzard Ernst and colleagues)

Chemotherapy-induced nausea and vomiting - Tan et al. 2014. Evid Based Complement Alternat Med. 2014:430796 (R). "AT seems to be a promising approach ... However, the level of evidence was low and the definite effect cannot be concluded as there were significant methodological flaws identified in the analyzed studies."

Cognitive impairment and dementia - Kwon et al. 2018. Evid Based Complement Alternat Med. 2018:3426078 (R). "The evidence reveals mixed efficacy... However, the results were inconclusive because of the small number and poor methodological quality of the included studies."

Constipation - Yang et al. 2014. J Altern Complement Med. 20(8):590-605 (R, M). "...probably beneficial...However, most of the eligible RCTs had a high risk of bias, and all were conducted in China."

Lactation - Chen et al. 2017. Complement Ther Clin Pract. 29:169-84 (R). Data show benefits, "However, research using a more stringent design, standardized protocol, and valid outcome measures are warranted before it can be considered to be evidence-based practice."

Pain (general) - Yeh et al. Evid Based Complement Alternat Med. 2014:934670 (R, M). Significant benefits with acupressure better than acupuncture. "Further large-scale RCTs are needed."

Pain (chronic) - Zhao et al. 2015. Complement Ther Clin Pract. 21(2):68-78 (R). May be useful, but "due to the significant heterogeneity and methodological flaws identified in the analyzed trials, the current evidence on AT for chronic pain management is still uncertain."

Pain (immediate relief) - Murakami et al. 2017. Pain Med. 18(3):551-64 (R, M). May be promising. "Rigorous research is needed to establish definitive evidence of a clinically significant difference from controls or from other pain treatments."

Pain (postoperative) - *Usichenko et al. 2008. Anaesthesia. 63(12):1343-8 (R). Evidence is "promising but not compelling."

Overview for all conditions - Vieira et al. 2018.Complement Ther Clin Pract. 33:61-70 (R). Positive effects for insomnia, chronic and acute pain.

Scientific critique

Auricular points vary in their location, susceptibility to detection, and response to stimuli.

The neurological relationships in the theory are dubious. "No anatomical pathways exist to directly connect inner organs with the ear. The innervation of the central part of the aurical...comes from the trigeminal, geniculate and superior vagal ganglions, whereas the peripheral regions receive the innervation mainly from the spinal nerves" (Usichenko et al. 2008. Op. cit.).

Different neurological circuits are said to be activated by clockwise or counterclockwise rotation of needles, which is inconsistent with how nerves work

As with hypnosis, distraction and relaxation can be useful in dealing with pain. These may these explain the apparent success of this technique. The patient focuses attention on the auricular needles rather than on the pain; in addition, the expectation that the treatment will bring relief may aid in relaxation.

A case of shingles following auricular acupuncture was reported by Kewish (2017. J Am Board Fam Med 30:552-5).

"Steve Salzberg quite correctly points out that the form of auricular acupuncture touted by Col. Dr. Niemtzow and being adopted by the VA [Veterans Administration] was 'made up out of whole cloth' in 2001 and not yet put under any significant review. He’s absolutely correct. The evidence base for battlefield acupuncture is weak, even by acupuncture standards" (Gorski 2018 Jan 11. Respectful Insolence blog).

A critique of the NADA detoxification protocol by Bellamy (2016 Sep 1. Science-Based Medicine blog)

noted that there are "many studies and systematic reviews concluding that acupuncture, auricular acupuncture and/or the NADA protocol are not effective in the treatment of addiction..."

Characteristics of pseudoscience

Vague, unscientific terminology. Auricular points said to have high or low "energy levels." For these, use of silver or gold needles, respectively, have been recommended because gold has a more positive oxidation-reduction potential.

DRY NEEDLING

Dry needling is "the insertion of needles into nodules within taut bands of muscle, more commonly referred to as ‘trigger points’ (TrPs) or ‘myofascial trigger points’ (MTrPs)" (Dunning et al. 2014.Phys Ther Rev. 19(4):252-265). However, "dry needling neither attempts to move qi along meridians, nor does it rely on diagnoses from traditional Chinese acupuncture or Oriental medicine" (ibid). On the other hand, "Dorsher and Fleckenstein...both medical physicians, found that 238 (93·3%) of 255 common MTrPs anatomically corresponded with classical acupoints" (ibid).

There is a dispute between physical therapists and acupuncturists concerning dry needling. The former view it as distinct from acupuncture. The latter view it as a form of acupuncture, and feel it should be subject to acupuncture regulations. "Just because the technique is similar to needle acupuncture, the American Physical Therapy Association points out, does not mean it constitutes the practice of acupuncture. Acupuncturists say it is just that and are trying to lock PTs out of using dry needling" (Bellamy 2018 Jan 9. Science-Based Medicine blog).

A review of dry needling for myofascial trigger points found no significant difference vs. lidocaine (Ong et al. 2014. J Bodyw Mov Ther. 18(3):390-8).

ACUPRESSURE

"Acupressure is based on the same theoretical model as acupuncture but is non-invasive. It comprises gentle but firm pressure applied manually over meridians and acupuncture pressure points" (Frost and Stewart-Brown 2006. BMJ 332(7543):680-1). Because it is noninvasive, "it is likely to be more appealing to children than a technique involving needles. It is important to note, however, that there are several acupressure techniques that can be used in clinical settings. Acupressure can be applied by direct finger pressure with or without circular motion or with constant pressure resulting from the application of a bead/pellet over a targeted acupuncture point" (Wang et al. 2008. Anesth Analg. 107(3):811-6).

The most common application is the stimulation of the PC6 Nei-Guan point (on the inner wrist) to treat nausea and vomiting. A device such as Sea-Band® may be used for this purpose; some of these are FDA-approved. "Some authors have demonstrated that stimulation through P6 acupressure causes an increase of the electrical discharge of the dorsal motor nucleus of the vagus nerve in the brainstem and subsequently induces prolonged slow waves of gastric peristalsis...The prolonged slow waves, together with decreased spike waves, reduce antiperistalsis, which is the cause of nausea and vomiting" (Alessandrini et al. 2012. J Altern Complement Med 18(12):1121-6).

The ear is held to be a location connected to all major meridians. "However, due to the anatomical structure of the ear, needling is not commonly used because of the relatively higher risk of skin infection and degree of discomfort than for body acupuncture. Therefore, ear-acupressure is commonly used as an alternative stimulation method on ear acupoints" (Zhang et al. 2010. Clin Otolaryngol. 35(1):6-12). Auricular (ear) acupressure has been used for smoking cessation.

"Various types of sham acupressure have been reported in the literature which mainly differ in three aspects, the selected acupoints, the acupressure approach, and the acupressure intensity. Acupoints adopted in sham procedures commonly include non-acupoints, true acupoints as the active acupressure group, and non-therapeutic acupoints. Non-acupoints generally refer to ineffective body points which cannot be found on established acupuncture-point charts, while non-therapeutic acupoints means irrelevant true acupoints considered to be ineffective for the targeted health problem...researchers should prudently select the non-acupoints because currently there are more than 2000 established extra-points which are not linked with meridians, and this cannot exclude the possibility that the so called 'non-acupoints'” in some trials may be unintentionally therapeutic points in nature...It is believed that light stimulation on the true acupoints would not activate the deqi sensation, and thus, avoid the generation of specific treatment effects. But recent studies on pain concluded that light stimulation on the skin could evoke the activity of the cutaneous afferent nerves and/or the insular region of the brain, and may result in some augmented therapeutic benefits...Acupressure devices can be an adequate method for retaining blinding. In our analyzed studies, acupressure bands with or without the pressure button were commonly incorporated as sham interventions." (Tan et al. 2015. PLoS One. 10(7):e0132989).

Reviews

Allergic rhinitis - Zhang et al. 2010. Op. cit.. Benefit "is unknown due to the poor quality of included studies."

Cognitive function - Liu et al. 2018. J Altern Complement Med. 24(6):532-40. "...is an effective intervention for maintaining cognitive function in older adults."

Pain - Chen and Wang 2014. Pain Manag Nurs. 15(2):539-50. "Acupressure has been shown to be effective for relieving a variety of pains..."

Postoperative nausea and vomiting

Allen and Habib 2008. Anesth Analg. 107(4):1308-12. "The presence of heterogeneity and inconsistent results among the included trials prevents any definitive conclusions on the efficacy of P6 stimulation in reducing IONV and PONV associated with cesarean delivery..."
Doran and Halm 2010. Am J Crit Care. 19(6):553-6. "Overall, 'class 1' [definitely recommended] evidence exists for the efficacy of acupressure on PONV in surgical populations."
Lee et al. 2015. Cochrane Database Syst Rev. CD003281. Effect is comparable to antiemetics. (This review considered all types of stimulation at PC6.)

Symptom management (self-acupressure for various conditions) - Song et al. 2015.Complement Ther Med. 23(1):68-78. Positive effects seen, but "the evidence level...was difficult to evaluate due to the moderate quality of the studies..."

Shiatsu

Ernst (2016 May 10. Edzard Ernst blog) wrote: "Shiatsu is a popular alternative therapy with a remarkable void of research. According to one of the rare reviews on the subject, Shiatsu is a form of Japanese massage, working on the meridian system of the body; the energetic pathways along which the acupuncture points are placed. The theory for shiatsu is based in the system of traditional Chinese medicine, understood in China for over 2000 years. Shiatsu can be valuable for reintegrating the body, mind and spirit, helping with the general energy level of the body as well as specific symptoms…" However, Ernst found that "There is no good evidence for effectiveness and some evidence of risk..."

MOXIBUSTION

"Moxibustion describes a technique that applies heat to acupoints by burning compressed powdered herbal material at the acupoints to be stimulated...Based on descriptions in the ancient Chinese literature, the therapeutic effects of moxibustion are associated with treating chronic symptoms related to 'deficiencies' and to the prevention of human disorders" (Chiu 2013. Evid Based Complement Alternat Med. 2013:198584). The sticks are usually made of fibers from mugwort leaves.

"There are several types of moxibustion: direct moxibustion, indirect moxibustion, and the warm needle technique. In direct moxibustion, the moxa fiber is applied on the skin, without any barrier, in a form of a cone or a rice grain, sometimes with the intention of causing scarring. Indirect moxibustion uses a barrier between the skin and the moxa: a slice of ginger or garlic or simply a little distance between the skin and the moxa when rolled stick moxa is used. The warm needle technique is burning a small amount of moxa fiber on the handle of an acupuncture needle after the needle is inserted into the acupuncture point. The application of moxibustion is not limited to only acupuncture points, but it is usually administered at acupuncture points as opposed to nonacupuncture points" (Schlaeger et al. 2018. J Midwifery Womens Health. 63(3):309-22).

"Herb-partitioned moxibustion, a critical component of moxibustion therapy, is performed by placing a cake of herbs (dispensing a traditional Chinese medicine (TCM) formula) on the patient's acupoints, followed by placement and ignition of moxa cones..." (Bao et al. 2014. World J Gastroenterol. 20(31):11000-11).

Moxibustion is alleged to be "effective for chronic disorders and deficient symptoms because it provides warm energy, expels Cold-Damp Stagnation, and enhances immunity" (Kim et al. 2013. J Altern Complement Med. 19(2):134-40). "Since the late 20th century, it has been suggested that moxibustion increases fetal activity during the treatment period, cephalic presentation after the treatment period, and cephalic presentation at delivery" (Chiu 2013. Op. cit.).

"As moxibustion is defined as a technique that applies heat to acupoints by burning herbal materials on the body surface, factors such as temperature, smoke, odor, and herbs are likely to be involved in the possible mechanisms by which moxibustion may work" (Ibid.) These include local somatothermal stimulation, leading to release of nitric oxide and induction of heat shock protein 70 (HSP70) in "corresponding organs" (resulting in preconditioning against ischemia-reperfusion injury); somatovisceral reflex regulation, leading to effects on hormones, neurotransmitters, and the immune system; effects from the herbs; and effects from the smoke.

"When the traditional moxibustion technique is carried out, many herbs, including Artemisia argyi leaf and ginger, are widely used between the moxa sticks and the skin surface...a total of fifty-three compounds, including cylcofenchene, alpha-pinene, alpha-myrcene, D-limonene, caryophyllene, and germacrene D, were identified as well as two volatile components (borneol and borneol acetate) from Artemisia argyi flowers. In addition, various nonvolatile substances, such as juniper camphor, caryophyllene oxide, and caryophyllene, have been found in a high proportion of moxa wools. Furthermore, there is evidence supporting that the hypothesis that the increase in temperature induced by moxibustion increases the permeability of the skin to high molecular [mass] compounds, as well as acting as an aid to the entry of any topical application of salicylate" (Ibid.).

Reviews

* = review by Edzard Ernst and colleagues.

Cancer care - *Lee et al. 2010. BMC Cancer. 10:130. "The evidence is limited to suggest moxibustion is an effective supportive cancer care in nausea and vomiting. However, all studies have a high risk of bias so effectively there is not enough evidence to draw any conclusion."

Cephalic version of breech presentation

Coyle et al. 2012. Cochrane Database Syst Rev. CD003928. Limited evidence in support.
Schlaeger et al. 2018. Op. cit. Holds promise, but "there is currently a paucity of research."

Chemotherapy-induced leukopenia - *Choi et al. 2015. Support Care Cancer. 23(6):1819-26. Low level of evidence in support, "too low to draw firm conclusions."

Chemotherapy or radiotherapy side effects - Zhang et al. 2018. Cochrane Database Syst Rev. CD010559. Limited, low-quality evidence suggests useful, but "There is presently no good evidence to support or oppose the use of moxibustion in people receiving treatment for cancer."

Essential hypertension - Xiong et al. 2014. Complement Ther Med. 22(1):187-95. Low methodological quality, no firm conclusion could be made.

Knee osteoarthritis - Li et al. 2016. Medicine (Baltimore). 95(14):e3244. "The administration of moxibustion can to some extent alleviate the symptoms of KOA. More rigorous, randomized controlled trials are required in the future."

Tinnitus - Pang et al. 2019. Complement Ther Med. 42:205-13. Concluded was effective.

Ulcerative colitis - *Lee et al. 2010. BMC Gastroenterol. 10:36. Evidence insufficient to show that it is effective.

Reported adverse effects of moxibustion include allergic reactions, burns, and infections.

CUPPING

"This classic Chinese medicine treatment is a technique that applies suction cups over soft tissue. A jar or cup is attached to the skin surface to cause local congestion though negative pressure. This negative pressure is created by removing oxygen from the cup by using a mechanical hand pump or a flame (creating a vacuum inside the cup) and quickly applying the cup to the body. This therapy is used as an auxiliary method of acupuncture and is now used in physical therapy and massage practices. According to Chinese medical theory, cupping promotes the free flow of qi and blood...in the meridians, dispelling chronic pain and swelling" (Markowski et al. 2014. J Altern Complement Med 20(2):113-7).

There are two types, dry and wet cupping. The latter involves making an incision or puncture into the skin, followed by suction. "Both dry and wet cupping have been claimed to drain excess fluids and toxins, loosen adhesions and lift the connective tissue, bring blood flow to skin and muscles, and stimulate the peripheral nervous system. In addition, cupping is said to reduce pain and high blood pressure, as well as modulate neurohormones and immune system" (Arslan et al. 2014. J Altern Complement Med 20(4):318-21).

"In the Middle East and in Muslim countries, wet cupping is called Hijamah [or Hijama] and is linked to religious beliefs because it was favored by the Prophet of Islam" (Al Bedah et al. 2016. J Altern Complement Med 22(10):768-77). In this version suction is applied before and after the incisions.

"Some opinion holds that cupping-induced blisters are embodiment of 'damp evil' suction to excrete the 'toxin' in vivo, so it’s beneficial to recovery, and symptoms including edema, crepitation and stiffness were significantly relieved after blister formation. But some others argue that cupping-induced blisters might be similar to blisters caused by scalds which manifest the production of severe skin damage, and the blisters could leave skin scars and will affect the patient’s appearance, or induce erythematous based vesiculobullous plaque. So practitioners should try to avoid blisters when applying cupping therapy" (Liu et al. 2018. Complement Ther Med 36:25-9).

Cupping is used for muscle pain, hypertension, stroke rehabilitation, fibromyalgia, herpes zoster pain, gastrointestinal disorders, lung disease, headache, and numerous other conditions. It has also been thought to improve athletic performance via stimulating microcirculation. The use of cupping by athletes in the 2016 Olympics gave enormous publicity for the method.

Facial cupping, a gentler form using silicone cups that do not produce marks on the skin, is now being promoted.

Reviews

General - Cao et al. 2012. PLoS One. 7(2):e31793. Positive results for herpes zoster and other conditions. However, most trials were at high risk of bias.

General (Hijama wet cupping) - Al Bedah et al. 2016. Op. cit. "There is a promising evidence in favor of the use of wet cupping for musculoskeletal pain, specifically NSLBP [nonspecific low back pain], neck pain, CTS [carpal tunnel syndrome], and brachialgia. Better quality trials are needed..."

Athletes - Bridgett et al. 2018. J Altern Complement Med 24(3):208-19. "Overall, while the trials...found beneficial effects...there are several limitations in the reporting of these outcomes that preclude definitive statements on the efficacy." Ernst (2018 Feb 14. Edzard Ernst blog) was critical of this review. "The RCTs were mostly not on cupping but on cupping in combination with some other treatments. More importantly, they were of such deplorable quality that they allow no conclusions about effectiveness."

Hypertension (Hijama wet cupping) - Al-Tabakha et al. 2018. J Pharm Bioallied Sci. 10(1):1-6. "Our study shows clear relationship between Hijama and the reduction and control of SBP [systolic blood pressure] in patients with hypertension. Therefore, Hijama can be used as an adjunct to conventional therapy..."

Neck pain - Kim et al. 2018. BMJ Open. 8(11):e021070. "Cupping was found to reduce neck pain in patients compared with no intervention or active control groups, or as an add-on treatment... however, due to the low quality of evidence of the included studies, definitive conclusions could not be drawn from this review."

Scientific critique

A problem with clinical trials of cupping "is that it is difficult, if not impossible, to control for the significant placebo effect that this treatment undoubtedly generates...and there is no easy way to blind either the patient or the therapist" (Ernst 2016 Aug 9. Edzard Ernst blog).

"The bottom line of all of this is that research into cupping is mostly negative or of poor quality and with high bias. There is no good compelling evidence for any real physiological effect from cupping" (Novella 2016 Aug 10. Science-Based Medicine blog).

Side effects can include burns from the heated cups, as well as more serious skin damage from repeated application of the cups to the same spots.

It has been claimed that cupping sucks out bad energy.

REFERENCES for this and other parts can be found at: Eastern Ref

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