Subtlety and Specificity in Penetrating Moxibustion By Mark Petruzzi MS, LAc, LMT

Subtlety and Specificity in Penetrating Moxibustion

from NOJOM By Mark Petruzzi MS, LAc, LMT

“in the beginners mind, there are many possibilities...In the expert’s mind, there are few”
-Zen precept

The traditional Japanese styles are renowned for their variety in applications and the multitude of needling methods to address a patient’s presentation. The same foundational techniques can be adjusted to elicit more tonifying, dispersing or moving effects; to target the surface or deeper tissues, upper or lower body, etc. There is a fluidity to the sequencing of needles placed, the manor in which they are inserted/ stimulated, the order of removal, etc; all of which will amplify or vary treatment responses. There is much more to a treatment than what points are used. This same focus and attention to detail holds true when utilizing our moxibustion treatments. ... “points don’t work..you work the point” – Isaburo Fukaya

Practitioners beginning to incorporate tonestukyu into their treatment flow will start with one or two basic points, often added at the end of the treatment. While it is wonderful to conclude with 3 rounds of 1⁄2 rice grain on ST36 or DU12; a more nuanced perspective can be explored, utilizing precise application, timing, directionality and order to amplify the clinical effectiveness of penetrating moxibustion.

Tonetsukyu has a twofold effect on the body; thermal and chemical. The thermal effect comes from moxa burning down to a pure carbon, emitting a far infrared heat which penetrates into the connective tissues and relaxes peripheral arteries to enhance vascularization. The chemical effect derives from the moxa burning the skin (I prefer to keep this closer to a sunburn rather than a blister) stimulating a combination of heat shock proteins (HSPs), Transient Receptor Potentials (TRPs) and Keratinocytes,
setting off multiple positive responses including anti-inflammatory mediators, arterial wall relaxation and immune enhancing activity.

Timing

“You may delay, but time will not” – Benjamin Franklin

Timing is important in all things. From when to extinguish each moxa cone individually; to burning one cone at a time vs multiple cones simultaneously. Broadening our view, we can look at the timing of moxibustion employment throughout your treatment. Certain acute situations may be optimized by opening the treatment with moxibustion. This could be utilizing a distal special effect point to decrease an acute pain situation or an 8 Extraordinary Vessel pair in the Miyawaki style. With excess fluid congestion and swelling, tonetsukyu on a few select points can activate/enhance fluid metabolism,
increasing your acupuncture’s effectiveness while lessening the number of points needed.

If you have moved a lot with your needling during the course of a session, you may choose to conclude the treatment with moxa to ground the patient. Finishing with moxa permits further infiltration into musculoskeletal imbalances that have been addressed with needling. Another reasoning may be to firm the wei qi and tonify the immune system after pathogenic attack.

Eventually, your acu-moxa treatment becomes a fluid interchange of modalities, implementing what is
needed at the optimal time for your patient on the table.

Application

While there will inevitably be overlap, I believe we can leverage certain functions of penetrating moxibustion to emphasize more of the thermal vs chemical effects, along with depth and direction of this “active qi of the sun”. (Peter Eckmann 1996 “In the Footsteps of the Yellow Emperor” (Cypress Book Company)

Utilization of the bamboo tube in the Mizutani Style, allows for a deeper penetration of heat, along with an opportunity to specify it’s angle and direction. A key element here is to allow the tube to steadily progress thru the tissues without forcing. Appreciate the skin, fascia and muscle response against the tube as the body allows you to go deeper. This is especially advantageous in larger or broader areas of fascial restriction.

On more specific/pinpoint locations I will gently tent over the moxa cone with two fingers, moderating the influence on the surrounding tissues. This is an efficient application to decrease perifascial tension around a nerve or artery. 

Piercing moxa (burning moxa on either side of a joint) is excellent for joint pains and arthritis. Heating both sides concurrently will amplify effectiveness.

Burning the rice grain fully to the skin can elicit stronger blood building and immune enhancement effects. Patients with anemia and weakened immune systems (congenitally or medication induced) are good candidates for this type of application.

Hachibu kyu (80% moxa) utilizes small cone moxa like shijo kyu/sesame size that is pinched or covered with the bamboo tube to extinguish it before burning all the way to the skin. Mizutani sensei uses this to great effect in dispersing heat, inflammation and swelling in/around a joint. The small amount of targeted heat activates the movement of stagnant fluids and metabolites, decreasing swelling. At the same time, it provides an external source of heat in the same frequency that the cells resonate at, signaling to the body that it can calm the inflammatory process.

When working with extremely weakened patients, a version of the Hachibu Kyu, focusing more on putting qi into the system, can be used. Half rice grain to thread size cones are rolled softly and burned down 80-90%, carefully timing the “tenting” with the fingers to prevent it from burning fully to the skin. This targeted gentle heat is leveraging qi activation. Without burning the skin, we decrease additional energy expenditure from the chemical reactions, lessening the chance of fatiguing the weakened patient during their recovery.

Penetrating moxibustion has traditionally been contraindicated in cases of leukemia/lymphoma because of its strong immune boosting properties. This qi activation moxa application could open up a deeper level of nuance, with windows of opportunity for moxibustion treatment in conjunction with chemotherapy for these blood cancers. Timing is key, as this type of qi activating moxa would ideally be applied when awaiting count recovery; ie: after the chemo has been fully flushed from the system and the subsequent decline in WBC count plateaus (roughly a week to 10 days later). This warrants further exploration and research.

Directionality, Order and Treatment Flow

“Movement is Life” – Jules Verne
A core tenant of treatment is to optimize the circulation of qi, blood and fluids. While much thought and study is placed on point selection and combinations, I believe an equal discussion can be had on the directionality, order and treatment flow of our moxibustion treatments.

Linear Directionality

In cases of nobose with qi rushing upward (ie: hypertension, dizziness and headaches) we want to the treatment flow of our moxibustion to move energy downward. Working our way from the abdomen or upper limbs to the lower limbs, ending on feet.

In more severe cases, “priming an area” with a distal point first can enhance the effectiveness of the linear directional movement. Moxa on the jing-well, bafeng points, and shitsumin are a few good examples.

When there is qi sinking/prolapse, we want to bring the energy upward. I tending to work in a vertical line moving up the DU channel, picking a few key points and finishing at DU20; harnessing the yang energy of the moxa thru the Sea of Yang. I will often do this in rounds...Ex. 1. josen, DU6, DU12, DU20...2. josen, DU6, DU12, DU20...3. Josen, DU6, DU12, DU20. Each pass often reveals positive palpatory changes, and 3 rounds is typically enough for one session.

For a restricted nerve, I’ll treat linearly along it’s path, working proximal to distal, resonating with it’s embryological development. I will “tent” the 1⁄2 rice grain cones along the pathway of the inflamed nerve, to limit the chance of further irritation. I light my first cone, and about midway thru, light the second...put the first out and then light the 3rd before extinguishing the 2nd, etc... working my way down the line, continuously having the cone ahead lit, before tenting the one before. A patient referred to this as the “piano technique”.

Zig-Zag, Wave and Infinity directionality

Wave

When there is a specific zone of pain, cramping or spasming in the abdomen, I will use the “abdominal wave”. Often there is scar tissue from a surgery or underlying internal condition that is restriction optimal circulation in the digestive or reproductive organs. I split the abdomen into 6 zones (left, right, center with upper and lower sections). I start on the problem side, in the zone opposite (above or below) the pain or spasm. I will work in a wave-like motion across the abdomen, alternating upper and lower sections until I return to the affected side, finishing at the problem area. Ex: a patient is complaining of spasming pain in the right upper quadrant in the area between LIV 13/14. I begin with
tonetsukyu to the lower right zone in the area of ST28/GB28. Next, I will heat the upper center zone (in this case a reactive spot between RN12/13) followed by the lower left zone in the area between ST28/GB28, upper left (around LIV13/14), lower center (RN6-4) and finishing in upper right zone at the hypertonic area between LIV13/14. 3 rounds of this abdominal wave moxa will activate fluid movement, stimulate peristaltic activity and relax muscle/fascial spasms.

Zigzag

Mizutani Sensei describes a dynamic moxa, or “zigzag” treatment alternating points on either side of the spine, relaying a strong parasympathetic activation. The rhythm of the bamboo tube moxa will have a relaxation effect as well (touch...heat...pressure; touch...heat...pressure). The diagonal stimulation elicits a greater effect on lines of tension as they naturally transmit thru the fascia (tensegrity). You can enhance this effect by having two points heating together.

If there is a strong restriction, you can fascially load the tissue to assess the “line of pull”. Heat the 1stpoint at the locus of fascial restriction and the 2nd at the area of complaint. These are often found contralaterally.

Infinity

I often use an infinity pattern with the moxa treatment. One common presentation is working points on the upper and lower back in a patient with hot flashes; especially when there is palpatory differences between right and left sides of the lower back. I’ll start with the deficient side UB23 to activate the KI Ki and begin bringing the energy down. I want to initiate a softening of the perifascial around the kidney and enhance circulation thru the renal arterial tree, which sends blood to both the right and left sides.
This will in turn, begin to vascularize (and soften) the more restricted side. 2nd I go to the contralateral UB43, 3rd: ipsilateral side UB43, and will finish on the restricted side UB23; further supplementing the KI qi and anchoring the energy down.

Invitation to explore

The body is an incredible thing, and there are many ways up the mountain. My hope is that this short discussion will ignite increased levels of curiosity and fluidity in the minds of new practitioners, adding a deeper layer of specificity in their application of penetrating moxibustion.