There are analyzed different methods of moxibustion in this work, including the contact wormwood cauterization with the burn scab formation. On an example of the chronic low back pain syndrome there was made an attempt to analyze the action mechanism of the above-named method from TCM and classical European pathophysiology points of view.
The group of the methods of thermal influence on a point generally named "moxibustion" takes its particular place among the methods of acupuncture.
The main reasons for the prescription of moxibustion are the states which in TCM are called the syndromes of Yang-emptiness, internal coldness (nei han) and dampness with the manifestation of symptoms accordingly to the affected meridians. In conformity with the TCM, coldness has the property "to pull and to compress". "Su Wen" (book 1) says: "Coldness compresses Qi". Penetrating into the channels, coldness blockades Qi and blood flowing that leads to their stagnation and local pain. The typical symptoms of such states are bad enduring of cold and wind, paralyzing, sensitivity to cold, numbness of extremities, pain and stiffness of muscles and joints. Most often these symptoms are fixed and they abate under the influence of warmth. So-called "Bi-syndrome of coldness and dampness" is classical example. Recently there are primarily used distant methods of points heating with moxa rolls (Pic.1); heating with wormwood cones through salt (Pic.2), garlic or ginger plates (Pic.3) and "hot needles" (Pic.4) are used fewer. The contact moxibustion with the burn scab formation can be considered wrongly forgotten. Only sometimes we can find the mentions of Zu San Li (St.36) prophylactic cauterization.
The reasons, preventing from the dissemination of this method are:
doctors' misunderstanding of principle difference between the contact and distant moxibustion;
intensive sensation of pain (through short term, till 15-20 seconds) in the time of procedure;
small cosmetic defects in the form of a heightened pigmentation spots on the skin (? 7-8 mm), remained during 5-6 months after scab's coming off and epithelization;
modern urban population's lack of psychological orientation at "pain which can bring relief"
the estimation of the treatment effectiveness immediately after procedures finishing.
Purposes and methods.
The purpose of this investigation is an analysis of the effectiveness and mechanism of contact moxibustion on an example of often met chronic low back pain with the radicular syndrome. In the Hospital of Rehabilitation Cure 51 patients were treated with this method during last three years. The effectiveness reaches 90% even in case of long-term suffering. The estimation of effectiveness was made after complete epithelization of the points, in some cases it was required to repeat a treatment course.
In cases of low back pain with radiculopathy the criterions for the contact moxibustion are:
the duration of the radicular syndrome longer than 3-4 months;
neurosurgeon's examination and conclusion about lack of the intervertebral disk rupture;
disorder of peripheral nervous system in motor and sensitive functions;
lack or inadequate effectiveness of previous treatment, including acupuncture.
For example, outpatient, woman 52 years old, saw a doctor in July 1997 and complained of strong pain in lumbosacral area, which was irradiating to the left hip, knee and lateral surface of shin. Besides she complained of the weakness in the left foot and numbness there.
Anamnesis. About 15 years ago there was a coccyx trauma, after the treatment nothing inconvenienced her. In summer 1996 after the weight bearing she felt sudden pain in the low back with irradiation into and along the left leg. She hadn't taken a medical aid for half a year, trying to treat on hers own. Since January 1997 pain in the lumbosacral area gradually increased. Outpatient treatment didn't produce an effect. Ache syndrome remained, besides leg numbness and myasthenia appeared. Then she went through the course of osteopathy treatment, in May-June took inpatient treatment at the osteology department (skeletal traction, non-steroid anti-inflammatory agents, vitamins and physiotherapy) with a small effect - the pain syndrome abated. Then (in July) she came to the Hospital of Rehabilitation Cure for the further treatment.
In the time of examination - low back lordosis is straightened, muscular tension, lumbosacral movements are limited. Palpation of paravertebral points on the level L4-L5-S1 is sharply painful. Knee and Achilles reflexes are hypoactive. There is hypesthesia on the lateral surface of the shin, foot back. The strength of the left foot and toes' extensors is lowered.
From the TCM point of view this condition is considered as the affection of the leg meridians Tai Yang (Bladder) and Shao Yang (Gall Bladder) with pathogenic cold and blood stagnation syndrome.
At the Rehabilitation Hospital she took pharmacotherapy again, massage and therapeutic physical training. Besides the course of acupuncture ("hot needles"-12 treatment) was carried out, then infrared lasertherapy (10 sessions), but all these efforts didn't take any effect. It was made a decision to use the contact moxibustion, its burn variant.
The technique of moxibustion is the next: on the skin in the chosen point there is set a moxa cone or a small ball measuring from a rice grain to a pea, then the cone is set on fire (Pic.5). Vietnamese colleagues recommend to take of the cone after its 2/3 part has been burnt and the patient begins to fell an intensive warm. Korean doctors prefer to burn the cone completely, the same method was used in our research. 2-3 cones (max. 9-10) are usually burnt on each point, odd number for men and even one for women. 3-4 points for one treatment, after the procedure finishing the burn spots are cleaned with alcohol 70%. Besides the local points at the affected area there are used the ancient (wu shu) points, Bladder's shu-points and also so-called system points. Every point is cauterized 3-4 times during the course of treatment. Sometimes it is expedient to finish the acupuncture course with 2-3 procedure of contact moxibustion. The burns don't require any special care and treatment, because they don't hurt. Small inflammatory reaction, taking place around the burn scab is exactly the medicinal factor.
Thus, after the first course (10 treatment) the pain syndrome was considerably abated, the motions in the lumbosacral area and the strength of the left foot increased. The second course of moxibustion was carried out in two months after the first course finishing and point epithelization. When it had been finished the pain syndrome disappeared completely, sensitivity of the left foot was restored and toes' strength increased.
Control examination in February 1998. No pains and any sensitive disorders, motor reflexes are lively D>=S, strength of the left foot is normal. At patient's request there was made a short prophylactic course of moxibustion. We met once more in March 2000 and she hadn't got any complaints.
Let us try to analyze the mechanism of contact moxibustion from TCM and European pathophysiology points of view. It is well known that every chronic pain process is accompanied by the prolonged breaches of microcirculation. Long-term pain impulses induce the stable constriction of vasa nervorum, the vessels which supply vertebrae and nerves' roots with blood. The breaches of nerves trophic are gradually developed and then the tissue structure in the affected segment and its nerve supply zone is changed. The vicious circle "pain® vessels constriction® inadequate microcirculation® ischemia of tissues® structure alteration® pain etc." closes soon (Pic.6).
Many medicinal manipulations while the treatment of radicular syndrome have an aim to stimulate the blood microcirculation. Only there we can interrupt this vicious circle. The efficiency of the medicament stimulation is limited with the time of remedy activity and has no any local orientation. And what is more, there is described a "bypass phenomenon", that the bloodstream through the affected area reduces after the injection of vasodilators. The hyperemia duration after thermal procedures and physiotherapy doesn't exceed 2-3 hours.
The contact moxibustion's influence begins from the pronounced anaesthetic effect, owing to the competition blockade of the pain impulsion from the pathological center with a strong afferent stream from the cauterized point. The local burn, made in an acupuncture point, passes all the stages of inflammation, including artery and vein hyperemia. Apparently, the similar changes of microcirculation take place both at the corresponding segment of a spine and at the organ with which an acupoint is connected by means of channel's internal run. It occurs both reflexively (thermal hyperemia) and in consequence of secretion of the inflammation mediators at the burn point (serotonin, histamine, kinines), which bring the pronounced dilating effect for arterioles and capillaries. Above-named mediators also give rise to the opening of reserve capillaries that leads to the increase of volumetric bloodflow, and it lasts continuously round the clock during 1,5-2 months. This stimulation of the microcirculation creates conditions for the gradual elimination of tissues' morphological damages at the affected areas.
From the TCM point of view the prescription for contact moxibustion is expedient under the coldness syndrome (nei han). In spite of the data of some authors about the stimulating and sedative methods of moxibustion, Chinese colleagues contend that moxibustion is always the stimulation of body's Yang-energy. Pathogenic Yin-energy is supplanted by Yang thermal factor, the total Yang-level is rising and that eliminates the blockade of Qi and blood flowing along the channels. The burn jiu differs from all the other moxibustion methods in just high intensity of the acting factor, which gives rise to a qualitatively different result. The Function protects and restores the Structure, Yang treats Yin.
You should not assess the result of the treatment in the day of the last procedure. The clinical effect continues for 1,5-2 months after the course of cauterization. Figuratively speaking, the point works actively until it skins over. But even after the epithelization, the scar at the point acts a part of the "kept needle", prolonging a medicinal effect. According to the numerous observations, in the most complicated cases the patient doesn't feel a pain relief right away after the therapy course. Pain abates gradually and disappears after a while, sometimes imperceptibly for the patient. It is interesting a feedback between the pathological center and the burn at the corresponding acupuncture point. The more the structure damages are expressed and the more serious pathology is, the longer the burn skins over, sometimes this process is dragged on for 2-2,5 months. For comparison: when we make a prophylactic cauterization of "point of health" Zu San Li (St36), the burn skins over in one month.
Contact moxibustion can be recommended for the treatment of diseases, which in the TCM are called coldness and dampness syndromes. These procedures must be made if the other acupuncture methods were not effective. It's possible to use this method independently or right after the needling.
The contact jiu has a good cure and prophylactic effect for the therapy of spine and joint diseases, chronic inflammatory processes and some vessel's illness.
After the right psychological training a patient endures the procedure without an acute pain.
We foresee a skepticism in regard to the above-described method from some colleagues. Yes, at first look it seems cruelly. But, if on one cup of scales lies the long-term suffering with a constant pain and on another cup - a possibility to be really treated by means of the painful procedure, a patient chooses the second. Besides, our patients usually are not young people and small skin defects after moxibustion are less important than the state of health for them.
The doctor's position is very important. A patient, who has already taken a big number of different procedures, always doubts. Only the doctor, who is sure himself at successful finishing of the treatment can help such patients. They mustn't see the diffidence on your face.
The authors are grateful to Korean colleague Dr. Pack Tae Pong who kindly showed us the method of contact moxibustion and helped to overcome the indecision before its use on his own example.
We are also thankful to our friend Nick Lyubogoschev who helped with the translation redaction.