MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

Alternative medicine thrives in the realm of common chronic conditions which conventional medicine cannot cure and which respond well to treatment with placebos. Irritable bowel syndrome (IBS) is such a condition, and IBS-sufferers who are often frustrated with the symptomatic relief conventional medicine has to offer are only too keen to try any therapy that promises help. There is hardly an alternative therapy which does not claim to be the solution to IBS-symptoms: herbal medicine, mind-body interventions, homeopathy (the subject of my next post), acupuncture, even ‘MOXIBUSTION‘.

Moxibustion is a derivative of acupuncture; instead of needles, this method employs heat to stimulate acupuncture points. Proponents believe that the effects of moxibustion are roughly equivalent to those of acupuncture but many acupuncturists feel that they are less powerful. One website explains: Moxibustion is a traditional Chinese medicine technique that involves the burning of mugwort, a small, spongy herb, to facilitate healing. Moxibustion has been used throughout Asia for thousands of years; in fact, the actual Chinese character for acupuncture, translated literally, means “acupuncture-moxibustion.” The purpose of moxibustion, as with most forms of traditional Chinese medicine, is to strengthen the blood, stimulate the flow of qi, and maintain general health.

Many proponents of moxibustion claim that their treatment works for IBS. The evidence is, however, far less clear. Two recent meta-analyses might tell us more.

The first systematic review and meta-analysis was published by Korean researchers and aimed at critically evaluating the current evidence on moxibustion for improving global symptoms of IBS. The authors conducted extensive searches and found a total of 20 RCTs to be included in their analyses. The risk of bias in these studies was generally high. Compared with pharmacological medications, moxibustion significantly alleviated overall IBS symptoms but there was a moderate inconsistency among the 7 RCTs. Moxibustion combined with acupuncture was more effective than pharmacological therapy but a moderate inconsistency among the 4 studies was found. When moxibustion was added to pharmacological medications or herbal medicine, no additive benefit of moxibustion was shown compared with pharmacological medications or herbal medicine alone. One small sham-controlled trial found no difference between moxibustion and sham control in symptom severity. Moxibustion appeared to be associated with few adverse events but the evidence is limited due to poor reporting.

The authors concluded that moxibustion may provide benefit to IBS patients although the risk of bias in the included studies is relatively high. Future studies are necessary to confirm whether this finding is reproducible in carefully-designed and conducted trials and to firmly establish the place of moxibustion in current practice.

The way I see it, these conclusions are far too optimistic. There was only one RCT that controlled for placebo-effects, and the results of that study were negative. Thus I would conclude that some studies report effectiveness of moxibustion for IBS, yet the effects seem not to be caused by the treatment per se but are most likely due to a placebo-effect.

The second systematic review and meta-analysis was published by Chinese researchers and aimed at evaluating the clinical efficacy and safety of moxibustion and acupuncture in treatment of IBS. The authors included randomized and quasi-randomized clinical trials in their analyses and were able to include 11 trials. Their meta analysis suggests that the effectiveness of the combined methods of acupuncture and moxibustion is superior to conventional western medication treatment. The authors concluded that acupuncture-moxibustion for IBS is better than the conventional western medication treatment.

While the first meta-analysis was at least technically sound, the second seems to have too many flaws to mention: the search methodology was flimsy, many available studies were not included, their risk of bias was not assessed critically, the conclusions are based more on wishful thinking than on the available data, etc.

If we consider that moxibustion is a method of stimulating acupoints, we have to assume that it can at best be as effective as acupuncture, quite possibly slightly less. Thus it is relevant to see what the evidence tells us about acupuncture for IBS. The current Cochrane review of acupuncture for IBS shows that sham-controlled RCTs have found no benefits of acupuncture relative to a credible sham acupuncture control for IBS symptom severity or IBS-related quality of life.

I think I rest my case.

17 Responses to Two new meta-analyses of moxibustion for IBS

  • That last assumption about the stimulation of acupuncture points. Are you working on the basis that a stimulated point is a stimulated point, whether it is by heat or needle? Can you clarify because the equivalence of action would tend to suggest that to use an acupuncture point it must simply be stimulated, the nature of that stimulation not being relevant to its action.

    • correct, that was roughly my assumption.

    • It does seem that any mode of ‘stimulation’ will do whether it’s needling, pressure, heat or electro-stimulation. And it seems that acupuncturists would like to take ‘evidence’ from a trial of one type of stimulation as support for every other type.

      • Good to see there’s a precedent for this sort of thing then. As to the information about stimulation, thanks for your input. Can you source that? Also are there any differences between the results of different forms of stimulation or are they all exactly the same?

        • It was just an observation that I’ve seen acupuncturists take the results from some trial or other about, say, electro-acupuncture, to be a validation of needling. Is it the case that acupuncturists see all ‘stimulation’ of points to be equivalent?

          • No, moxa and deqi needling are qualitatively different, as are tuina manual techniques or very superficial needling that engage with the structures of the surface of the body when using the sinew meridians. Electro I don’t know so much about. There are a variety of different ways of integrating with the body, in Chinese medicine, other than deqi needling.

          • Any good quantitative evidence for any of them?

          • If we are forced to discount ‘sham ‘ needling as a methodological basis for acupuncture research, then quite possibly.

  • So your case would then rest on the assumption that stimulation of the point by a needle is equivalent to moxibustion, the Cochrane review has already covered this ground, so in the light of this presumed equivalence we can safely say that moxibustion doesn’t actually work based on this one study and a suspect one from China?
    Really? Do you have any further basis for this? Chinese medicine obviously doesn’t think this way because then why bother with both modalities. Moxa is a smelly, time consuming, fire risk, if what you’re saying is true, then why bother?
    Also if heat from a burning herb on the skin surface can stimulate a point in a way equivalent to a needle driven below the surface with, and here I presume, deqi sensation obtained, what then of ‘placebo’ needling? Can this stimulate a point?

    • no, my case rests on the evaluation of the moxibustion data as summarised in the 2 meta-analyses. the Cochrane review is merely in support of my point.

  • But ehy particularly mugwort?

    Is ther supposed to be something special in the plant that is somehow released in the smoke or fumesssssssssssssssss? If so, wouldn’t it make as much sense to inhale it as to put it on the skin?

    If mugwort is supposed to so special perhaps its proponents could idently the particular chemical which is important and it could then be synthesised by the pharmaceutical industry.

    Or is is simply tradition which says mugwort? Pwrhaps grass clippings would do as well.

    • It has been synthesized and is available as a spray to be used wirh a heat lamp. Mugwort is used more because is gives off an even burning well controlled infrared heat similar to body heat. People are are now using infrared lasers and lamps to good effect in stead of moxa bustion. It is considered however anti bacterial and used on wounds and for some lung conditions. Also there are numerous qualities of moxa punk as it is called and at least four meathods commonly used to apply the particular heat to the body.

      • So basically, you could substitute grass clippings as effectively as you could substitute aspirin for antibiotics. Unless your grass clippings are full of mugwort…

        I should be clear that I’m kidding with that. Trying to treat yourself with grass clippings, even if the clippings contain mugwort – would be like trying to treat an infection with mold from the fridge. Or trying to inhale the mold fumesssssssssssssssss. You should leave it to a professional, as you can do more damage than good if you don’t understand the basic theory.

        But, there’s no danger in playing around with it (moxa), because it’s natural, right? And as we all know, natural means safe and without any effect whatsoever.

  • Is it right to say that IBS responds well to treatment with placebos, or simply that IBS outcomes tend to be measured using subjective self-report measures that are prone to response bias?

    • both could be true at the same time.

      • what about this gut has a brain, runs on serotonin, opiates and cannabinoids, which is why yogurt is good gut analgesic, but also boosts mood – bacteria hack that system, but so does anything that makes us more relaxed the chemicals goo both ways, not a placebo response real response, to anything that hacks system of gut brain. Infrared is relaxing. It may increase serotonin – our levels are lower in winter due to lack of light.

  • There is no mention of direct moxa or indirect moxabustion. Also the number time or amount with needle or without.

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