Metamorphic Technique

The Metamorphic Technique is a gentle form of foot, hand and head massage that can be carried out by anyone with a brief training in the technique. It draws on reflexology in its theory and approach.

It does not claim any specific healing power but uses the idea that the massage helps the individual's own innate inner intelligence free deep blocks in their body's energy pattern (The scientific consensus it that there is no evidence for energy patterns) and somehow bring about resolution of stuck patterns at the root of problems in their life and health.

It focuses on reflexology meridians in the feet, hands and head which correspond to the spinal column and in turn to the incarnation, gestation and birth of the individual.

It was devised originally by British naturopath Robert St. John in the 1960s. He had been practising reflexology on his patients but found he had more success if he gave up trying to bring about a specific result and gave a general massage of the spinal reflexes. It was further developed by his student Gaston Saint-Pierre in the 1970s who coined the term Metamorphic Technique and founded the Metamorphic Association in 1979. Robert St.John preferred to stick with the name of Metamorphosis and was involved with the branch with this name until his passing . It is taught and practiced in UK and many places particularly in California, Ireland, Australia and South Africa. Metamorphic Technique is practiced and taught in UK and Europe amongst other places. There are subtle differences in viewpoint around the issue of intent, between the two schools but people learn the same simple basic practice in both although each school developed some extra practices that are unique to themselves at later stages.

Pseudoscience

Pseudoscience

Pseudoscience is a claim, belief, or practice which is presented as scientific, but which does not adhere to a valid scientific method, lacks supporting evidence or plausibility, cannot be reliably tested, or otherwise lacks scientific status.[1] Pseudoscience is often characterized by the use of vague, exaggerated or unprovable claims, an over-reliance on confirmation rather than rigorous attempts at refutation, a lack of openness to evaluation by other experts, and a general absence of systematic processes to rationally develop theories.

Distinguishing scientific facts and theories from pseudoscientific beliefs such as those found in astrology, medical quackery, and occult beliefs combined with scientific concepts, is part of science education and scientific literacy.[2]

The term pseudoscience is often considered inherently pejorative, because it suggests that something is being inaccurately or even deceptively portrayed as science.[3] Accordingly, those labeled as practicing or advocating pseudoscience normally dispute the characterization.[3]

Contents

    1 Etymology
    2 Overview
        2.1 The Scientific Method
        2.2 Falsifiability
        2.3 Refusal to acknowledge problems
    3 Arguments that the concept is uselessness or meaningless
    4 Identifying pseudoscience
        4.1 Use of vague, exaggerated or untestable claims
        4.2 Over-reliance on confirmation rather than refutation
        4.3 Lack of openness to testing by other experts
        4.4 Absence of progress
        4.5 Personalization of issues
        4.6 Use of misleading language
    5 Demographics
    6 Psychological explanations
    7 Boundaries between protoscience, science, and pseudoscience
    8 Impacts and concerns
        8.1 Political implications
        8.2 Health and education implications
   

The word "pseudoscience" is derived from the Greek root pseudo meaning false and the Latin word scientia meaning knowledge. Although the term "pseudoscience" has been in use since at least the late 18th century (used in 1796 in reference to alchemy,[4][5]) the concept of pseudoscience as distinct from real or proper science appears to have emerged in the mid-19th century. Among the first recorded uses of the word "pseudo-science" was in 1844 in the Northern Journal of Medicine, I 387: "That opposite kind of innovation which pronounces what has been recognized as a branch of science, to have been a pseudo-science, composed merely of so-called facts, connected together by misapprehensions under the disguise of principles". An earlier recorded use of the term was in 1843 by the French physiologist François Magendie.[6]
Overview
The Scientific Method
Main article: scientific method
A typical 19th century phrenology chart. In the 1820s, phrenologists claimed that the mind was located in areas of the brain, and were attacked for doubting that mind came from the non-material soul. Their idea of reading "bumps" in the skull to predict personality traits was later discredited.[7] Phrenology was first called a pseudoscience in 1843 and continues to be considered so.[6]

While the standards for determining whether a body of knowledge, methodology, or practice is scientific can vary from field to field, there are a number of basic principles that are widely agreed upon by scientists. The basic notion is that all experimental results should be reproducible, and able to be verified by other individuals.[8] These principles aim to ensure that experiments can be measurably reproduced under the same conditions, allowing further investigation to determine whether a hypothesis or theory related to given phenomena is both valid and reliable. Standards require that the scientific method will be applied throughout, and that bias will be controlled for or eliminated through randomization, fair sampling procedures, blinding of studies, and other methods. All gathered data, including the experimental or environmental conditions, are expected to be documented for scrutiny and made available for peer review, allowing further experiments or studies to be conducted to confirm or falsify results. Statistical quantification of significance, confidence, and error[9] are also important tools for the scientific method.

Falsifiability

In the mid-20th century Karl Popper put forth the criterion of falsifiability to distinguish science from non-science.[10] Falsifiability means that a result can be disproved. For example, a statement such as "God created the universe" may be true or false, but no tests can be devised that could prove it either way; it simply lies outside the reach of science. Popper used astrology and psychoanalysis as examples of pseudoscience and Einstein's theory of relativity as an example of science. He subdivided non-science into philosophical, mathematical, mythological, religious and/or metaphysical formulations on the one hand, and pseudoscientific formulations on the other, though he did not provide clear criteria for the differences.[11]
Refusal to acknowledge problems

In 1978, Paul Thagard proposed that pseudoscience is primarily distinguishable from science when it is less progressive than alternative theories over a long period of time, and its proponents fail to acknowledge or address problems with the theory.[12] In 1983, Mario Bunge has suggested the categories of "belief fields" and "research fields" to help distinguish between science and pseudoscience, where the first is primarily personal and subjective and the latter involves a certain systematic approach.[13]
Arguments that the concept is uselessness or meaningless

Philosophers of science such as Paul Feyerabend have argued from a sociology of knowledge perspective that a distinction between science and non-science is neither possible nor desirable.[14][15] Among the issues which can make the distinction difficult is variable rates of evolution among the theories and methodologies of science in response to new data.[16] In addition, specific standards applicable to one field of science may not be employed in other fields.

Larry Laudan has suggested that pseudoscience has no scientific meaning and is mostly used to describe our emotions: "If we would stand up and be counted on the side of reason, we ought to drop terms like 'pseudo-science' and 'unscientific' from our vocabulary; they are just hollow phrases which do only emotive work for us".[17] Likewise, Richard McNally states that "The term 'pseudoscience' has become little more than an inflammatory buzzword for quickly dismissing one’s opponents in media sound-bites" and that "When therapeutic entrepreneurs make claims on behalf of their interventions, we should not waste our time trying to determine whether their interventions qualify as pseudoscientific. Rather, we should ask them: How do you know that your intervention works? What is your evidence?"[18]
Identifying pseudoscience

A field, practice, or body of knowledge might reasonably be called pseudoscientific when (1) it is presented as consistent with the norms of scientific research; but (2) it demonstrably fails to meet these norms.[19]

Karl Popper stated that it is insufficient to distinguish science from pseudoscience, or from metaphysics, by the criterion of rigorous adherence to the empirical method, which is essentially inductive, based on observation or experimentation.[20] He proposed a method to distinguish between genuine empirical, non-empirical or even pseudo-empirical methods. The latter case was exemplified by astrology which appeals to observation and experimentation. While it had astonishing[citation needed] empirical evidence based on observation, on horoscopes and biographies it crucially failed to adhere to acceptable scientific standards.[20] Popper proposed falsifiability as an important criterion in distinguishing science from pseudoscience.

To demonstrate this point, Popper[20] gave two cases of human behavior and typical explanations from Freud and Adler's theories: "that of a man who pushes a child into the water with the intention of drowning it; and that of a man who sacrifices his life in an attempt to save the child."[20] From Freud's perspective, the first man would have suffered from psychological repression, probably originating from an Oedipus complex whereas the second had attained sublimation. From Adler's perspective, the first and second man suffered from feelings of inferiority and had to prove himself which drove him to commit the crime or, in the second case, rescue the child. Popper was not able to find any counter-examples of human behavior in which the behavior could not be explained in the terms of Adler's or Freud's theory. Popper argued[20] that it was that the observation always fitted or confirmed the theory which, rather than being its strength, was actually its weakness.

In contrast, Popper[20] gave the example of Einstein's gravitational theory which predicted that "light must be attracted by heavy bodies (such as the sun), precisely as material bodies were attracted."[20] Following from this, stars closer to the sun would appear to have moved a small distance away from the sun, and away from each other. This prediction was particularly striking to Popper because it involved considerable risk. The brightness of the sun prevented this effect from being observed under normal circumstances, so photographs had to be taken during an eclipse and compared to photographs taken at night. Popper states, "If observation shows that the predicted effect is definitely absent, then the theory is simply refuted."[20] Popper summed up his criterion for the scientific status of a theory as depending on its falsifiability, refutability, or testability.

Paul R. Thagard used astrology as a case study to distinguish science from pseudoscience and proposed principles and criteria to delineate them.[21] First, astrology has not progressed in that it has not been updated nor added any explanatory power since Ptolemy. Second, it has ignored outstanding problems such as the precession of equinoxes in astronomy. Third, alternative theories of personality and behavior have grown progressively to encompass explanations of phenomena which astrology statically attributes to heavenly forces. Fourth, astrologers have remained uninterested in furthering the theory to deal with outstanding problems or in critically evaluating the theory in relation to other theories. Thagard intended this criterion to be extended to areas other than astrology. He believed that it would delineate pseudoscientific practices as witchcraft and pyramidology, while leaving physics, chemistry and biology in the realm of science. Biorhythms, which like astrology relied uncritically on birth dates, did not meet the criterion of pseudoscience at the time because there were no alternative explanations for the same observations. The use of this criterion has the consequence that a theory can at one time be scientific and at another pseudoscientific.[21]

Science is also distinguishable from revelation, theology, or spirituality in that it offers insight into the physical world obtained by empirical research and testing.[22] For this reason, the teaching of creation science and intelligent design has been strongly condemned in position statements from scientific organisations.[23] The most notable disputes concern the evolution of living organisms, the idea of common descent, the geologic history of the Earth, the formation of the solar system, and the origin of the universe.[24] Systems of belief that derive from divine or inspired knowledge are not considered pseudoscience if they do not claim either to be scientific or to overturn well-established science. Moreover, some specific religious claims, such as the power of intercessory prayer to heal the sick can be tested by the scientific method, though they may be based on non-testable beliefs.

Some statements and commonly held beliefs in popular science may not meet the criteria of science. "Pop" science may blur the divide between science and pseudoscience among the general public, and may also involve science fiction.[25] Indeed, pop science is disseminated to, and can also easily emanate from, persons not accountable to scientific methodology and expert peer review.

If the claims of a given field can be experimentally tested and methodological standards are upheld, it is not "pseudoscience", however odd, astonishing, or counter-intuitive. If claims made are inconsistent with existing experimental results or established theory, but the methodology is sound, caution should be used; science consists of testing hypotheses which may turn out to be false. In such a case, the work may be better described as ideas that are not yet generally accepted. Protoscience is a term sometimes used to describe a hypothesis that has not yet been adequately tested by the scientific method, but which is otherwise consistent with existing science or which, where inconsistent, offers reasonable account of the inconsistency. It may also describe the transition from a body of practical knowledge into a scientific field.[26]

An example of characterization as pseudoscience by a national scientific body is provided by the US National Science Foundation (NSF), whose statements are generally recognized to harmonize with the scientific consensus in the United States.[27] In 2006 the NSF issued an executive summary of a paper on science and engineering which briefly discussed the prevalence of pseudoscience in modern times. It said that "belief in pseudoscience is widespread" and, referencing a Gallup Poll,[28] stated that belief in the ten commonly believed examples of paranormal phenomena listed in the poll were "pseudoscientific beliefs". The ten items were: "extrasensory perception (ESP), that houses can be haunted, ghosts, telepathy, clairvoyance, astrology, that people can communicate mentally with someone who has died, witches, reincarnation, and channelling."[27]

The following are some of the indicators of the possible presence of pseudoscience.
Use of vague, exaggerated or untestable claims

    Assertion of scientific claims that are vague rather than precise, and that lack specific measurements.[29]
    Failure to make use of operational definitions (i.e. publicly accessible definitions of the variables, terms, or objects of interest so that persons other than the definer can independently measure or test them).[30] (See also: Reproducibility)

    Failure to make reasonable use of the principle of parsimony, i.e. failing to seek an explanation that requires the fewest possible additional assumptions when multiple viable explanations are possible (see: Occam's razor)[31]
    Use of obscurantist language, and use of apparently technical jargon in an effort to give claims the superficial trappings of science.
    Lack of boundary conditions: Most well-supported scientific theories possess well-articulated limitations under which the predicted phenomena do and do not apply.[32]
    Lack of effective controls, such as placebo and double-blind, in experimental design.

Over-reliance on confirmation rather than refutation

    Assertions that do not allow the logical possibility that they can be shown to be false by observation or physical experiment (see also: falsifiability)[33]
    Assertion of claims that a theory predicts something that it has not been shown to predict.[34] Scientific claims that do not confer any predictive power are considered at best "conjectures", or at worst "pseudoscience" (e.g. Ignoratio elenchi)[35]
    Assertion that claims which have not been proven false must be true, and vice versa (see: Argument from ignorance)[36]
    Over-reliance on testimonial, anecdotal evidence, or personal experience. This evidence may be useful for the context of discovery (i.e. hypothesis generation) but should not be used in the context of justification (e.g. Statistical hypothesis testing).[37]
    Presentation of data that seems to support its claims while suppressing or refusing to consider data that conflict with its claims.[38] This is an example of selection bias, a distortion of evidence or data that arises from the way that the data are collected. It is sometimes referred to as the selection effect.
    Reversed burden of proof. In science, the burden of proof rests on those making a claim, not on the critic. "Pseudoscientific" arguments may neglect this principle and demand that skeptics demonstrate beyond a reasonable doubt that a claim (e.g. an assertion regarding the efficacy of a novel therapeutic technique) is false. It is essentially impossible to prove a universal negative, so this tactic incorrectly places the burden of proof on the skeptic rather than the claimant.[39]
    Appeals to holism as opposed to reductionism: Proponents of pseudoscientific claims, especially in organic medicine, alternative medicine, naturopathy and mental health, often resort to the "mantra of holism" to explain negative findings.[40]

Lack of openness to testing by other experts

    Evasion of peer review before publicizing results (called "science by press conference").[41] Some proponents of theories that contradict accepted scientific theories avoid subjecting their ideas to peer review, sometimes on the grounds that peer review is biased towards established paradigms, and sometimes on the grounds that assertions cannot be evaluated adequately using standard scientific methods. By remaining insulated from the peer review process, these proponents forgo the opportunity of corrective feedback from informed colleagues.[42]
    Some agencies, institutions, and publications that fund scientific research require authors to share data so that others can evaluate a paper independently. Failure to provide adequate information for other researchers to reproduce the claims contributes to a lack of openness.[43]
    Appealing to the need for secrecy or proprietary knowledge when an independent review of data or methodology is requested.[43]

Absence of progress

    Failure to progress towards additional evidence of its claims.[44] Terence Hines has identified astrology as a subject that has changed very little in the past two millennia.[45] (see also: Scientific progress)

    Lack of self correction: scientific research programmes make mistakes, but they tend to eliminate these errors over time.[46] By contrast, theories may be accused of being pseudoscientific because they have remained unaltered despite contradictory evidence. The work Scientists Confront Velikovsky (1976) Cornell University, also delves into these features in some detail, as does the work of Thomas Kuhn, e.g. The Structure of Scientific Revolutions (1962) which also discusses some of the items on the list of characteristics of pseudoscience.

    Statistical significance of supporting experimental results does not improve over time and are usually close to the cutoff for statistical significance. Normally, experimental techniques improve or the experiments are repeated and this gives ever stronger evidence. If statistical significance does not improve, this typically shows that the experiments have just been repeated until a success occurs due to chance variations.[citation needed]

Personalization of issues

    Tight social groups and authoritarian personality, suppression of dissent, and groupthink can enhance the adoption of beliefs that have no rational basis. In attempting to confirm their beliefs, the group tends to identify their critics as enemies.[47]
    Assertion of claims of a conspiracy on the part of the scientific community to suppress the results.[48]
    Attacking the motives or character of anyone who questions the claims (see Ad hominem fallacy).[49]

Use of misleading language

    Creating scientific-sounding terms in order to add weight to claims and persuade non-experts to believe statements that may be false or meaningless. For example, a long-standing hoax refers to water by the rarely used formal name "dihydrogen monoxide" (DHMO) and describes it as the main constituent in most poisonous solutions to show how easily the general public can be misled.
    Using established terms in idiosyncratic ways, thereby demonstrating unfamiliarity with mainstream work in the discipline.

Demographics

The National Science Foundation stated that, in the USA, "pseudoscientific" beliefs became more widespread during the 1990s, peaked near 2001 and have declined slightly since; nevertheless, pseudoscientific beliefs remain common in the USA.[50] As a result, according to the NSF report, there is a lack of knowledge of pseudoscientific issues in society and pseudoscientific practices are commonly followed. Bunge states that "A survey on public knowledge of science in the United States showed that in 1988 50% of American adults [rejected] evolution, and 88% believed astrology is a science."[51] Other surveys indicate that about a third of all adult Americans consider astrology to be scientific.[52][53][54]
Psychological explanations

Pseudoscientific thinking has been explained in terms of psychology and social psychology. The human proclivity for seeking confirmation rather than refutation (confirmation bias),[55] the tendency to hold comforting beliefs, and the tendency to overgeneralize have been proposed as reasons for the common adherence to pseudoscientific thinking. According to Beyerstein (1991), humans are prone to associations based on resemblances only, and often prone to misattribution in cause-effect thinking.

Lindeman argues that social motives (i.e., "to comprehend self and the world, to have a sense of control over outcomes, to belong, to find the world benevolent and to maintain one’s self-esteem") are often "more easily" fulfilled by pseudoscience than by scientific information.[56] Furthermore, pseudoscientific explanations are generally not analyzed rationally, but instead experientially. Operating within a different set of rules compared to rational thinking, experiential thinking regards an explanation as valid if the explanation is "personally functional, satisfying and sufficient", offering a description of the world that may be more personal than can be provided by science and reducing the amount of potential work involved in understanding complex events and outcomes.[56]

Boundaries between protoscience, science, and pseudoscience
Main article: Demarcation problem

The boundary lines between the science and pseudoscience are disputed and difficult to determine analytically, even after more than a century of dialogue among philosophers of science and scientists in varied fields, and despite some basic agreements on the fundaments of scientific methodology.[19][57] The concept of pseudoscience rests on an understanding that scientific methodology has been misrepresented or misapplied with respect to a given theory, but many philosophers of science maintain that different kinds of methods are held as appropriate across different fields and different eras of human history. According to Imre Lakatos, the typical descriptive unit of great scientific achievements is not an isolated hypothesis but "a powerful problem-solving machinery, which digests anomalies and even turns them into positive evidence."[58] Paul Feyerabend disputes whether any meaningful boundaries can be drawn between pseudoscience, "real" science, and what he calls "protoscience", especially where there is a significant cultural or historical distance.[citation needed]

Impacts and concerns
Political implications

The term pseudoscience can also have political implications that eclipse any scientific issues. Imre Lakatos, for instance, points out that the Communist Party of the Soviet Union at one point declared that Mendelian genetics was pseudoscientific and had its advocates, including well-established scientists such as Nikolai Vavilov, sent to a Gulag,[59] and that the "liberal Establishment of the West" denies freedom of speech to topics it regards as pseudoscience, particularly where they run up against social mores.[60]

The term is used frequently in political, policy-making discourse in allegations of distortion or fabrication of scientific findings to support a political position.[61][62]

Pseudoscience can be used to erode public support for scientific research and development[63]
Health and education implications

Distinguishing science from pseudoscience has practical implications in the case of health care, expert testimony, environmental policies, and science education.[64] Treatments with a patina of scientific authority which have not actually been subjected to actual scientific testing may be ineffective, expensive, and dangerous to patients, and confuse health providers, insurers, government decision makers, and the public as to what treatments are appropriate.[64] Claims advanced by pseudoscience may result in government officials and educators making poor decisions in selecting curriculum, for example, Creation Science may replace evolution in studies of biology.[64]

The book Trick or Treatment records several occasions where patient's faith in medical pseudoscience has led to complications, further injury and death.[65]

Alternative medicine

Alternative medicine

Alternative medicine is any healing practice "that does not fall within the realm of conventional medicine",[1] or "that which has not been shown consistently to be effective."[2] In some instances, it is based on historical or cultural traditions, rather than a scientific (e.g. evidence-based) basis. Critics assert that the terms “complementary” and “alternative medicine” are deceptive euphemisms meant to give an impression of medical authority.[3][4][5] Richard Dawkins has stated that "there is no alternative medicine. There is only medicine that works and medicine that doesn't work."[6]

The American National Center for Complementary and Alternative Medicine (NCCAM) studies examples including naturopathy, chiropractic medicine, herbalism, traditional Chinese medicine, Ayurveda, meditation, yoga, biofeedback, hypnosis, homeopathy, acupuncture, and nutritional-based therapies, in addition to a range of other practices.[7]

It is frequently grouped with complementary medicine or integrative medicine, which, in general, refers to the same interventions when used in conjunction with mainstream techniques,[8][9][10] under the umbrella term complementary and alternative medicine, or CAM. Some researchers in alternative medicine oppose this grouping, preferring to emphasize differences of approach, but nevertheless use the term CAM, which has become standard.[11][12] "Although heterogeneous, the major CAM systems have many common characteristics, including a focus on individualizing treatments, treating the whole person, promoting self-care and self-healing, and recognizing the spiritual nature of each individual. In addition, many CAM systems have characteristics commonly found in mainstream healthcare, such as a focus on good nutrition and preventive practices. Unlike mainstream medicine, CAM often lacks or has only limited experimental and clinical study; however, scientific investigation of CAM is beginning to address this knowledge gap. Thus, boundaries between CAM and mainstream medicine, as well as among different CAM systems, are often blurred and are constantly changing."[8]

Alternative medicine practices are as diverse in their foundations as in their methodologies. Practices may incorporate or base themselves on traditional medicine, folk knowledge, spiritual beliefs, or newly conceived approaches to healing.[13] Jurisdictions where alternative medical practices are sufficiently widespread may license and regulate them. The claims made by alternative medicine practitioners are generally not accepted by the medical community because evidence-based assessment of safety and efficacy is either not available or has not been performed for these practices. If scientific investigation establishes the safety and effectiveness of an alternative medical practice, it then becomes mainstream medicine and is no longer "alternative", and may therefore become widely adopted by conventional practitioners.[14][15]

Because alternative techniques tend to lack evidence, or may even have repeatedly failed to work in tests, some have advocated defining it as non-evidence based medicine, or not medicine at all. Some researchers state that the evidence-based approach to defining CAM is problematic because some CAM is tested, and research suggests that many mainstream medical techniques lack solid evidence.[16]

A 1998 systematic review of studies assessing its prevalence in 13 countries concluded that about 31% of cancer patients use some form of complementary and alternative medicine.[17] Alternative medicine varies from country to country. Edzard Ernst says that in Austria and Germany CAM is mainly in the hands of physicians,[12] while some estimates suggest that at least half of American alternative practitioners are physicians.[18] In Germany, herbs are tightly regulated, with half prescribed by doctors and covered by health insurance based on their Commission E legislation.[19]

Contents

    1 Terms
    2 Characterization
        2.1 Self characterization
        2.2 Scientific community
        2.3 Popular press
    3 Classifications
    4 Usage
        4.1 United States
        4.2 Denmark
    5 Education
    6 Regulation
    7 Criticism
    8 Alternative and evidence-based medicine
        8.1 Testing of efficacy
        8.2 Testing of safety
            8.2.1 Interactions with conventional pharmaceuticals
            8.2.2 Potential side-effects
            8.2.3 Treatment delay
            8.2.4 Unconventional cancer "cures"
        8.3 Research funding
    9 Integrative medicine, complementary medicine, fringe medicine
        9.1 History
    10 Appeal
    11 Academic resources
    12 See also
    13 References
    14 Further reading
        14.1 World Health Organization publication
        14.2 Journals dedicated to alternative medicine research
        14.3 Further reading
    15 External links
        15.1 Criticism

Terms

The term 'alternative medicine' is generally used to describe practices used independently or in place of conventional medicine. The term 'complementary medicine' is primarily used to describe practices used in conjunction with or to complement conventional medical treatments. NCCAM suggests "using aromatherapy therapy in which the scent of essential oils from flowers, herbs, and trees is inhaled in an attempt to promote health and well-being and to help lessen a patient's discomfort following surgery"[15] as an example of complementary medicine. The terms 'integrative' or 'integrated medicine' indicate combinations of conventional and alternative medical treatments that have some scientific proof of efficacy; such practices are viewed by advocates as the best examples of complementary medicine.[15]

Ralph Snyderman and Andrew Weil state that "integrative medicine is not synonymous with complementary and alternative medicine. It has a far larger meaning and mission in that it calls for restoration of the focus of medicine on health and healing and emphasizes the centrality of the patient-physician relationship."[20] The combination of orthodox and complementary medicine with an emphasis on prevention and lifestyle changes is known as integrated medicine.
Characterization

There is no clear and consistent definition for either alternative or complementary medicine.[21]:17 In Western culture it is often defined as any healing practice "that does not fall within the realm of conventional medicine",[1] or "that which has not been shown consistently to be effective."[2]
Self characterization

The National Center for Complementary and Alternative Medicine (NCCAM) defines CAM as "a group of diverse medical and healthcare systems, practices, and products, that are not currently part of conventional medicine."[15]

The Danish Knowledge and Research Center for Alternative Medicine (Danish abbreviation: ViFAB. ViFAB is an independent institution under the Danish Ministry of the Interior and Health. ViFAB's webstite: www.vifab.dk/uk) uses the term “alternative medicine” for: - Treatments performed by therapists that are not authorized healthcare professionals - Treatments performed by authorized healthcare professionals, but those based on methods otherwise used mainly outside the healthcare system. People without a healthcare authorisation must be able to perform the treatments.

The Cochrane Complementary Medicine Field finds that what is considered complementary or alternative practices in one country may be considered conventional medical practices in another. Their definition is, therefore, general: "complementary medicine includes all such practices and ideas that are outside the domain of conventional medicine in several countries and defined by its users as preventing or treating illness, or promoting health and well-being."[22]

For example, biofeedback is commonly used within the Physical Medicine & Rehabilitation community, but is considered alternative within the medical community as a whole, and some herbal therapies are mainstream in Europe, but are alternative in the United States.[23] David M. Eisenberg, an integrative medicine researcher,[24] defines it as "medical interventions not taught widely at US medical schools or generally available at US. hospitals,"[25] NCCAM states that formerly unproven remedies may be incorporated into conventional medicine if they are shown to be safe and effective.[15]

Barrie R. Cassileth, a researcher of complementary and alternative medicine, has summed up the situation as "not all mainstream physicians are pleased with CAM, with current efforts to integrate CAM into mainstream medicine, or with a separate NIH research entity for "alternative" medicine.[14][26]
Scientific community

Institutions

The United States' National Science Foundation has defined alternative medicine as "all treatments that have not been proven effective using scientific methods."[27] In a consensus report released in 2005, entitled Complementary and Alternative Medicine in the United States, the Institute of Medicine (IOM) defined complementary and alternative medicine (CAM) as the non-dominant approach to medicine in a given culture and historical period.[28] A similar definition has been adopted by the Cochrane Collaboration,[22] and official government bodies such as the UK Department of Health.[29] Proponents of evidence-based medicine, such as the Cochrane Collaboration, use the term alternative medicine but agree that all treatments, whether "mainstream" or "alternative", ought to be held to the standards of the scientific method.[30]

Scientists

Numerous mainstream scientists and physicians have commented on and criticised alternative medicine.

There is a debate among medical researchers over whether any therapy may be properly classified as 'alternative medicine'. Some claim that there is only medicine that has been adequately tested and that which has not.[14] They feel that healthcare practices should be classified based solely on scientific evidence. If a treatment has been rigorously tested and found safe and effective traditional medicine will adopt it regardless of if it was considered alternative to begin with.[14] It is thus possible for a method to change categories (proven vs. unproven), based on increased knowledge of its effectiveness or lack thereof. Prominent supporters of this position include George D. Lundberg, former editor of the Journal of the American Medical Association (JAMA).[31]

Stephen Barrett, founder and operator of Quackwatch, argues that practices labeled "alternative" should be reclassified as either genuine, experimental, or questionable. Here he defines genuine as being methods that have sound evidence for safety and effectiveness, experimental as being unproven but with a plausible rationale for effectiveness, and questionable as groundless without a scientifically plausible rationale. He has concerns that just because some "alternatives" have merit, there is the impression that the rest deserve equal consideration and respect even though most are worthless.[32] He says that there is a policy at the NIH of never saying something doesn't work only that a different version or dose might give different results.[33]

Edzard Ernst, professor of complementary medicine, characterizes the evidence for many alternative techniques as weak, nonexistent, or negative, but states that evidence exists for others, in particular certain herbs and acupuncture.[34] Ernst has concluded that 95% of the alternative treatments he and his team have studied, including acupuncture, herbal medicine, homeopathy, and reflexology, are, according to The Economist, "statistically indistinguishable from placebo treatments."[35]

Richard Dawkins, an evolutionary biologist, defines alternative medicine as a "set of practices that cannot be tested, refuse to be tested, or consistently fail tests."[36] He also states that "there is no alternative medicine. There is only medicine that works and medicine that doesn't work."[6] He says that if a technique is demonstrated effective in properly performed trials, it ceases to be alternative and simply becomes medicine.[37]

A letter by four Nobel Laureates and other prominent scientists deplored the lack of critical thinking and scientific rigor in National Institutes of Health supported alternative medicine research.[38] In 2009 a group of scientists made a proposal to shut down the National Center for Complementary and Alternative Medicine. They argued that the vast majority of studies were based on unconventional understandings of physiology and disease and have shown little or no effect. Further, they argue that the field's more-plausible interventions such as diet, relaxation, yoga and botanical remedies can be studied just as well in other parts of NIH, where they would need to compete with conventional research projects.[39]

These concerns are supported by negative results in almost all studies conducted over ten years at a cost of $2.5 billion by the NCCAM.[40] R. Barker Bausell, a research methods expert and author of "Snake Oil Science" states that "it's become politically correct to investigate nonsense."[33] There are concerns that just having NIH support is being used to give unfounded "legitimacy to treatments that are not legitimate."[39]

Wallace Sampson, an editor of Scientific Review of Alternative Medicine and a Stanford University professor of medicine write that CAM is the "propagation of the absurd" based on the example that alternative and complementary have been substituted for quackery, dubious and implausible and concerns that CAM tolerates contradiction without through reason and experiment.[41]
Popular press

The Washington Post reports that a growing number of traditionally trained physicians practice integrative medicine, which it defines as "conventional medical care that incorporates strategies such as acupuncture, reiki and herbal remedies."[42] The Australian comedian Tim Minchin, in his nine minute beat poem "Storm", states that alternative medicine is that which "has either not been proved to work or been proved not to work", and then he quips "You know what they call 'alternative medicine' that’s been proved to work? Medicine."[43]
Classifications

NCCAM has developed one of the most widely used classification systems for the branches of complementary and alternative medicine.[15][21] It classifies complementary and alternative therapies into five major groups, which have some overlap.[15]

    Whole medical systems: cut across more than one of the other groups; examples include Traditional Chinese medicine, Naturopathy, Homeopathy, and Ayurveda
    Mind-body medicine: takes a holistic approach to health that explores the interconnection between the mind, body, and spirit. It works under the premise that the mind can affect "bodily functions and symptoms"
    Biology-based practices: use substances found in nature such as herbs, foods, vitamins, and other natural substances
    Manipulative and body-based practices: feature manipulation or movement of body parts, such as is done in chiropractic and osteopathic manipulation
    Energy medicine: is a domain that deals with putative and verifiable energy fields:

        Biofield therapies are intended to influence energy fields that, it is purported, surround and penetrate the body. No empirical evidence has been found to support the existence of the putative energy fields on which these therapies are predicated.
        Bioelectromagnetic-based therapies use verifiable electromagnetic fields, such as pulsed fields, alternating-current, or direct-current fields in an unconventional manner.

Usage
Further information: List of branches of alternative medicine
Age-adjusted percent of adults who have used complementary and alternative medicine: United States, 2002[44]

Many people utilize mainstream medicine for diagnosis and basic information, while turning to alternatives for therapy or health-enhancing measures. Studies indicate that alternative approaches are often used in conjunction with conventional medicine.[44] This is referred to by NCCAM as integrative (or integrated) medicine because it "combines treatments from conventional medicine and CAM for which there is some high-quality evidence of safety and effectiveness."[15] According to Andrew T. Weil M.D., a leading proponent of integrative medicine, the principles of integrative medicine include: appropriate use of conventional and CAM methods; patient participation; promotion of health as well as treatment of disease; and a preference for natural, minimally-invasive methods.[45]

A 1997 survey found that 13.7% of respondents in the United States had sought the services of both a medical doctor and an alternative medicine practitioner. The same survey found that 96% of respondents who sought the services of an alternative medicine practitioner also sought the services of a medical doctor in the past 12 months. Medical doctors are often unaware of their patient's use of alternative medical treatments as only 38.5% of the patients alternative therapies were discussed with their medical doctor.[46]

Edzard Ernst, Professor of Complementary Medicine at the University of Exeter, wrote in the Medical Journal of Australia that "about half the general population in developed countries use complementary and alternative medicine (CAM)."[47] Survey results released in May 2004 by the National Center for Complementary and Alternative Medicine, part of the United States National Institutes of Health, found that in 2002 62.1% of adults in the country had used some form of CAM in the past 12 months and 75% across lifespan (though these figure drop to 36.0% and 50% if prayer specifically for health reasons is excluded); this study included yoga, meditation, herbal treatments and the Atkins diet as CAM.[44][48] Another study suggests a similar figure of 40%.[49]

A British telephone survey by the BBC of 1209 adults in 1998 shows that around 20% of adults in Britain had used alternative medicine in the past 12 months.[50] Ernst has been active politically on this issue as well, publicly requesting that Prince Charles recall two guides to alternative medicine published by the Foundation for Integrated Health, on the grounds that "[t]hey both contain numerous misleading and inaccurate claims concerning the supposed benefits of alternative medicine" and that "[t]he nation cannot be served by promoting ineffective and sometimes dangerous alternative treatments."[51] In general, he believes that CAM can and should be subjected to scientific testing.[30][34][52]

The use of alternative medicine in developed countries appears to be increasing. A 1998 study showed that the use of alternative medicine had risen from 33.8% in 1990 to 42.1% in 1997.[46] In the United Kingdom, a 2000 report ordered by the House of Lords suggested that "...limited data seem to support the idea that CAM use in the United Kingdom is high and is increasing."[53] In developing nations, access to essential medicines is severely restricted by lack of resources and poverty. Traditional remedies, often closely resembling or forming the basis for alternative remedies, may comprise primary healthcare or be integrated into the healthcare system. In Africa, traditional medicine is used for 80% of primary healthcare, and in developing nations as a whole over one-third of the population lack access to essential medicines.[54]

Advocates of alternative medicine hold that the various alternative treatment methods are effective in treating a wide range of major and minor medical conditions, and that recently published research (such as Michalsen, 2003,[55] Gonsalkorale 2003,[56] and Berga 2003)[57] proves the effectiveness of specific alternative treatments. They assert that a PubMed search revealed over 370,000 research papers classified as alternative medicine published in Medline-recognized journals since 1966 in the National Library of Medicine database. See also Kleijnen 1991,[58] and Linde 1997.[59]

Complementary therapies are often used in palliative care or by practitioners attempting to manage chronic pain in patients. Complementary medicine is considered more acceptable in the interdisciplinary approach used in palliative care than in other areas of medicine. "From its early experiences of care for the dying, palliative care took for granted the necessity of placing patient values and lifestyle habits at the core of any design and delivery of quality care at the end of life. If the patient desired complementary therapies, and as long as such treatments provided additional support and did not endanger the patient, they were considered acceptable."[60] The non-pharmacologic interventions of complementary medicine can employ mind-body interventions designed to "reduce pain and concomitant mood disturbance and increase quality of life."[61]

Physicians who practice complementary medicine usually discuss and advise patients as to available complementary therapies. Patients often express interest in mind-body complementary therapies because they offer a non-drug approach to treating some health conditions.[62] Some mind-body techniques, such as cognitive-behavioral therapy, were once considered complementary medicine, but are now a part of conventional medicine in the United States.[63] "Complementary medicine treatments used for pain include: acupuncture, low-level laser therapy, meditation, aroma therapy, Chinese medicine, dance therapy, music therapy, massage, herbalism, therapeutic touch, yoga, osteopathy, chiropractic, naturopathy, and homeopathy."[64]

In defining complementary medicine in the UK, the House of Lords Select Committee determined that the following therapies were the most often used to complement conventional medicine:[65] Alexander technique, Aromatherapy, Bach and other flower remedies, Body work therapies including massage, Counselling stress therapies, hypnotherapy, Meditation, Reflexology, Shiatsu, Maharishi Ayurvedic medicine, Nutritional medicine, and Yoga.
United States
A botánica, such as this one, caters to the Latino community and sells folk medicine alongside statues of saints, candles decorated with prayers, and other items.

A 2002 survey of US adults 18 years and older conducted by the National Center for Health Statistics (CDC) and the National Center for Complementary and Alternative Medicine indicated:[44]

    74.6% had used some form of complementary and alternative medicine (CAM).
    62.1% had done so within the preceding twelve months.
    When prayer specifically for health reasons is excluded, these figures fall to 49.8% and 36.0%, respectively.
    45.2% had in the last twelve months used prayer for health reasons, either through praying for their own health or through others praying for them.
    54.9% used CAM in conjunction with conventional medicine.
    14.8% "sought care from a licensed or certified" practitioner, suggesting that "most individuals who use CAM prefer to treat themselves."
    Most people used CAM to treat and/or prevent musculoskeletal conditions or other conditions associated with chronic or recurring pain.
    "Women were more likely than men to use CAM. The largest sex differential is seen in the use of mind-body therapies including prayer specifically for health reasons".
    "Except for the groups of therapies that included prayer specifically for health reasons, use of CAM increased as education levels increased".
    The most common CAM therapies used in the US in 2002 were prayer (45.2%), herbalism (18.9%), breathing meditation (11.6%), meditation (7.6%), chiropractic medicine (7.5%), yoga (5.1%), body work (5.0%), diet-based therapy (3.5%), progressive relaxation (3.0%), mega-vitamin therapy (2.8%) and Visualization (2.1%)

In 2004, a survey of nearly 1,400 U.S. hospitals found that more than one in four offered alternative and complementary therapies such as acupuncture, homeopathy, and massage therapy.[66]

A 2008 survey of US hospitals by Health Forum, a subsidiary of the American Hospital Association, found that more than 37 percent of responding hospitals indicated they offer one or more alternative medicine therapies, up from 26.5 percent in 2005. Additionally, hospitals in the southern Atlantic states were most likely to include CAM, followed by east north central states and those in the middle Atlantic. More than 70% of the hospitals offering CAM were in urban areas.[67]

The National Science Foundation has also conducted surveys of the popularity of alternative medicine. After describing the negative impact science fiction in the media has on public attitudes and understandings of pseudoscience, and defining alternative medicine as all treatments that have not been proven effective using scientific methods, as well as mentioning the concerns of individual scientists, organizations, and members of the science policymaking community, it commented that "nevertheless, the popularity of alternative medicine appears to be increasing."[27]

In the state of Texas, physicians may be partially protected from charges of unprofessional conduct or failure to practice medicine in an acceptable manner, and thus from disciplinary action, when they prescribe alternative medicine in a complementary manner, if board specific practice requirements are satisfied and the therapies utilized do not present "a safety risk for the patient that is unreasonably greater than the conventional treatment for the patient's medical condition."[68]
Denmark

45.2 % of the Danish population aged 16 or above had in 2005 used alternative medicine at some point in life. 22.5 % had used alternative medicine within the previous year. [69]

The most popular types of therapies within the previous year (2005) are:

    Massage, osteopathy or other manipulative techniques (13.2 percent)
    Reflexology (6.1 percent)
    Acupuncture (5.4 percent)

More results of statistical surveys on alternative medicine in Denmark is available on ViFABs (Knowledge and Research Center for Alternative Medicines) home page, see the pages on Statistics: http://www.vifab.dk/uk/alternative+medicine/statistics

Use among medical students

68 % of the medical students in Denmark were in 2008 using or had used alternative therapy. [70] The most commonly used types of alternative medicine were:

    Herbal medicines and Dietary supplements (50 percent)
    Acupuncture (18 percent)
    Reflexology (18 percent).

Education

In the United States, increasing numbers of medical colleges have started offering courses in alternative medicine. For example, in three separate research surveys that surveyed 729 schools (125 medical schools offering an MD degree, 25 medical schools offering a Doctor of Osteopathic medicine degree, and 585 schools offering a nursing degree), 60% of the standard medical schools, 95% of osteopathic medical schools and 84.8% of the nursing schools teach some form of CAM.[71][72][73] The University of Arizona College of Medicine offers a program in Integrative Medicine under the leadership of Andrew Weil that trains physicians in various branches of alternative medicine that "...neither rejects conventional medicine nor embraces alternative practices uncritically."[74] Accredited Naturopathic colleges and universities are also increasing in number and popularity in Canada and the USA. (See Naturopathic medical school in North America).

Similarly, "unconventional medicine courses are widely represented at European universities. They cover a wide range of therapies. Many of them are used clinically. Research work is underway at several faculties,"[75] but "only 40% of the responding [European] universities were offering some form of CAM training."[76]

In contrast to unconventional schools in Britain, no conventional medical schools offer courses that teach the clinical practice of alternative medicine.[77] The British Medical Acupuncture Society offers medical acupuncture certificates to doctors, as does the College of Naturopathic Medicine UK and Ireland. In his information book for the general public, Understanding Stress, Professor G. Wilkinson of Liverpool University, recommends various methods of alternative medicine to alleviate stress as follows: acupuncture, alexander technique, aromatherapy,autogenic training, biofeedback, meditation, and yoga.[78]
Regulation

Herbal medicine etc.

Due to the uncertain nature of various alternative therapies and the wide variety of claims different practitioners make, alternative medicine has been a source of vigorous debate, even over the definition of alternative medicine.[79][80] Dietary supplements, their ingredients, safety, and claims, are a continual source of controversy.[81] In some cases, political issues, mainstream medicine and alternative medicine all collide, such as in cases where synthetic drugs are legal but the herbal sources of the same active chemical are banned.[82]

In other cases, controversy over mainstream medicine causes questions about the nature of a treatment, such as water fluoridation.[83] Alternative medicine and mainstream medicine debates can also spill over into freedom of religion discussions, such as the right to decline lifesaving treatment for one's children because of religious beliefs.[84] Government regulators continue to attempt to find a regulatory balance.[85]

Jurisdiction differs concerning which branches of alternative medicine are legal, which are regulated, and which (if any) are provided by a government-controlled health service or reimbursed by a private health medical insurance company. The United Nations Committee on Economic, Social and Cultural Rights - article 34 (Specific legal obligations) of the General Comment No. 14 (2000) on The right to the highest attainable standard of health - states that

    "Furthermore, obligations to respect include a State's obligation to refrain from prohibiting or impeding traditional preventive care, healing practices and medicines, from marketing unsafe drugs and from applying coercive medical treatments, unless on an exceptional basis for the treatment of mental illness or the prevention and control of communicable diseases."[86]

Specific implementations of this article are left to member states.

A number of alternative medicine advocates disagree with the restrictions of government agencies that approve medical treatments. In the United States, for example, critics say that the Food and Drug Administration's criteria for experimental evaluation methods impedes those seeking to bring useful and effective treatments and approaches to the public, and that their contributions and discoveries are unfairly dismissed, overlooked or suppressed. Alternative medicine providers recognize that health fraud occurs, and argue that it should be dealt with appropriately when it does, but that these restrictions should not extend to what they view as legitimate healthcare products.

In New Zealand, alternative medicine products are classified as food products, so there are no regulations or safety standards in place.[87]

In Australia, the topic is termed as complementary medicine and the Therapeutic Goods Administration has issued various guidances and standards.[88] Australian regulatory guidelines for complementary medicines (ARGCM) demands that the pesticides, fumigants, toxic metals, microbial toxins, radionuclides, and microbial contaminations present in herbal substances should be monitored, although the guidance does not request for the evidences of these traits.[89] However, for the herbal substances in pharmacopoeial monographes, the detailed information should be supplied to relevant authorities [90]

The production of modern pharmaceuticals is strictly regulated to ensure that medicines contain a standardized quantity of active ingredients and are free from contamination. Alternative medicine products are not subject to the same governmental quality control standards, and consistency between doses can vary. This leads to uncertainty in the chemical content and biological activity of individual doses. This lack of oversight means that alternative health products are vulnerable to adulteration and contamination.[91] This problem is magnified by international commerce, since different countries have different types and degrees of regulation. This can make it difficult for consumers to properly evaluate the risks and qualities of given products.

Denmark [92]: Herbal and dietary supplements is the designation of a range of products, which have in common their status as medicine belonging under the Danish Medicines Act.In the Danish Medicines Act there exist four types of herbal and dietary supplements: Herbal medicinal products, [93] Strong vitamin and mineral preparations, [94] Traditional botanical medicinal products [95] and Homeopathic medicinal products.[96] Some dietary supplements [97] fall within a special category of products, which differ from the above in that they are not authorized medicinal products. Dietary supplements are regulated under the Food Act and are registered by the Danish Veterinary and Food Administration.


Alternative therapists

Denmark has a registration system for alternative therapy practitioners, RAB.[98]
Criticism

The NCCAM budget has been criticized[99] because despite the duration and intensity of studies, there have been exactly zero effective CAM treatments supported by scientific evidence to date.[100] Despite this, the National Center for Complementary and Alternative Medicine budget has been on a sharp sustained rise (with no apparent accountability to taxpayers[citation needed]) to support complementary medicine. In fact, the whole CAM field has been called by critics the SCAM.[100]

In a Huffington Post article on homeopathy in France a comment was made "Why is it that when your car is broken you don't seek out an "alternati­ve mechanic?" [101] "There really is no such thing as alternative medicine--only medicine that has been proved to work and medicine that has not." Dr. Arnold Relman, editor in chief emeritus of The New England Journal of Medicine.[102] Speaking of government funding studies of integrating alternative medicine techniques into the mainstream, Dr. Steven Novella, a neurologist at Yale School of Medicine wrote that it "is used to lend an appearance of legitimacy to treatments that are not legitimate." Dr. Marcia Angell, executive editor of The New England Journal of Medicine says, "It's a new name for snake oil." [99]
Alternative and evidence-based medicine
Testing of efficacy

Many alternative therapies have been tested with varying results. In 2003, a project funded by the CDC identified 208 condition-treatment pairs, of which 58% had been studied by at least one randomized controlled trial (RCT), and 23% had been assessed with a meta-analysis.[103] According to a 2005 book by a US Institute of Medicine panel, the number of RCTs focused on CAM has risen dramatically. The book cites Vickers (1998), who found that many of the CAM-related RCTs are in the Cochrane register, but 19% of these trials were not in MEDLINE, and 84% were in conventional medical journals.[21]:133

As of 2005, the Cochrane Library had 145 CAM-related Cochrane systematic reviews and 340 non-Cochrane systematic reviews. An analysis of the conclusions of only the 145 Cochrane reviews was done by two readers. In 83% of the cases, the readers agreed. In the 17% in which they disagreed, a third reader agreed with one of the initial readers to set a rating. These studies found that, for CAM, 38.4% concluded positive effect or possibly positive (12.4%) effect, 4.8% concluded no effect, 0.69% concluded harmful effect, and 56.6% concluded insufficient evidence. An assessment of conventional treatments found that 41.3% concluded positive or possibly positive effect, 20% concluded no effect, 8.1% concluded net harmful effects, and 21.3% concluded insufficient evidence. However, the CAM review used the 2004 Cochrane database, while the conventional review used the 1998 Cochrane database.[21]:135-136

Lists of the Cochrane Reviews on alternative medicine including summaries of the results sorted by type of therapy (updated monthly) are made available at ViFABs (Knowledge and Research Center for Alternative Medicines) home page, see the lists here: http://www.vifab.dk/uk/cochrane+and+alternative+medicine

Most alternative medical treatments are not patentable, which may lead to less research funding from the private sector. In addition, in most countries, alternative treatments (in contrast to pharmaceuticals) can be marketed without any proof of efficacy—also a disincentive for manufacturers to fund scientific research.[104] Some have proposed adopting a prize system to reward medical research.[105] However, public funding for research exists. Increasing the funding for research on alternative medicine techniques is the purpose of the US National Center for Complementary and Alternative Medicine. NCCAM and its predecessor, the Office of Alternative Medicine, have spent more than $2.5 billion on such research since 1992; this research has largely not demonstrated the efficacy of alternative treatments.[33][106][107]

Some skeptics of alternative practices say that a person may attribute symptomatic relief to an otherwise-ineffective therapy due to the placebo effect, the natural recovery from or the cyclical nature of an illness (the regression fallacy), or the possibility that the person never originally had a true illness.[108]

In the same way as for conventional therapies, drugs, and interventions, it can be difficult to test the efficacy of alternative medicine in clinical trials. In instances where an established, effective, treatment for a condition is already available, the Helsinki Declaration states that withholding such treatment is unethical in most circumstances. Use of standard-of-care treatment in addition to an alternative technique being tested may produce confounded or difficult-to-interpret results.[109]

Cancer researcher Andrew J. Vickers has stated:

    "Contrary to much popular and scientific writing, many alternative cancer treatments have been investigated in good-quality clinical trials, and they have been shown to be ineffective. In this article, clinical trial data on a number of alternative cancer cures including Livingston-Wheeler, Di Bella Multitherapy, antineoplastons, vitamin C, hydrazine sulfate, Laetrile, and psychotherapy are reviewed. The label "unproven" is inappropriate for such therapies; it is time to assert that many alternative cancer therapies have been "disproven.""[110]

Testing of safety
See also: List of herbs with known adverse effects
Interactions with conventional pharmaceuticals

Forms of alternative medicine that are biologically active can be dangerous even when used in conjunction with conventional medicine. Examples include immuno-augmentation therapy, shark cartilage, bioresonance therapy, oxygen and ozone therapies, insulin potentiation therapy. Some herbal remedies can cause dangerous interactions with chemotherapy drugs, radiation therapy, or anesthetics during surgery, among other problems.[111] An anecdotal example of these dangers was reported by Associate Professor Alastair MacLennan of Adelaide University, Australia regarding a patient who almost bled to death on the operating table after neglecting to mention that she had been taking "natural" potions to "build up her strength" before the operation, including a powerful anticoagulant that nearly caused her death.[112]

To ABC Online, MacLennan also gives another possible mechanism:

    "And lastly [sic] there's the cynicism and disappointment and depression that some patients get from going on from one alternative medicine to the next, and they find after three months the placebo effect wears off, and they're disappointed and they move on to the next one, and they're disappointed and disillusioned, and that can create depression and make the eventual treatment of the patient with anything effective difficult, because you may not get compliance, because they've seen the failure so often in the past".[113]

Potential side-effects

Conventional treatments are subjected to testing for undesired side-effects, whereas alternative treatments, in general, are not subjected to such testing at all. Any treatment — whether conventional or alternative — that has a biological or psychological effect on a patient may also have potential to possess dangerous biological or psychological side-effects. Attempts to refute this fact with regard to alternative treatments sometimes use the appeal to nature fallacy, i.e., "that which is natural cannot be harmful".

An exception to the normal thinking regarding side-effects is Homeopathy. Since 1938, the U.S. Food and Drug Administration (FDA) has regulated homeopathic products in "several significantly different ways from other drugs."[114] Homeopathic preparations, termed "remedies," are extremely dilute, often far beyond the point where a single molecule of the original active (and possibly toxic) ingredient is likely to remain. They are, thus, considered safe on that count, but "their products are exempt from good manufacturing practice requirements related to expiration dating and from finished product testing for identity and strength," and their alcohol concentration may be much higher than allowed in conventional drugs.[114]
Treatment delay

Those having experienced or perceived success with one alternative therapy for a minor ailment may be convinced of its efficacy and persuaded to extrapolate that success to some other alternative therapy for a more serious, possibly life-threatening illness.[115] For this reason, critics argue that therapies that rely on the placebo effect to define success are very dangerous. According to mental health journalist Scott Lilienfeld in 2002, "unvalidated or scientifically unsupported mental health practices can lead individuals to forgo effective treatments" and refers to this as "opportunity cost". Individuals who spend large amounts of time and money on ineffective treatments may be left with precious little of either, and may forfeit the opportunity to obtain treatments that could be more helpful. In short, even innocuous treatments can indirectly produce negative outcomes.[116]

Between 2001 and 2003, four children died in Australia because their parents chose ineffective naturopathic, homeopathic, or other alternative medicines and diets rather than conventional therapies.[117] In all, they found 17 instances in which children were significantly harmed by a failure to use conventional medicine.
Unconventional cancer "cures"

Perhaps because many forms of cancer are difficult or impossible to cure, there have always been many therapies offered outside of conventional cancer treatment centers and based on theories not found in biomedicine. These alternative cancer cures have often been described as "unproven," suggesting that appropriate clinical trials have not been conducted and that the therapeutic value of the treatment is unknown. However, many alternative cancer treatments have been investigated in good-quality clinical trials, and they have been shown to be ineffective. [118]
Research funding

Although the Dutch government funded CAM research between 1986 and 2003, it formally ended funding in 2006.[119]
Integrative medicine, complementary medicine, fringe medicine

Integrative medicine is the combination of the practices and methods of alternative/complementary medicine with conventional medicine.[120] It may include preventive medicine and patient-centered medicine. It may also include practices not normally referred to as medicine, such as using prayer, meditation, socializing, and recreation as therapies. Its academic proponents sometimes recommend misleading patients by using known placebo treatments in order to achieve a placebo effect.[121] However, a 2010 survey of family physicians found that 56% of respondents said they had used a placebo in clinical practice as well. Eighty-five percent of respondents believed placebos can have both psychological and physical benefits.[122][123] A number of universities and hospitals have departments of integrative medicine.[124][125][126][127][128][129][130]

Criticism of integrative medicine includes about proposing to lie to patients about alternative medicines known to be no more than a placebo in order to achieve a placebo effect, and “diverting research time, money, and other resources from more fruitful lines of investigation in order to pursue a theory that has no basis in biology”.[5][131]

"Quackademic medicine" is a pejorative term used for “integrative medicine”, when considered to be an infiltration of quackery into academic science-based medicine, and was picked up by science-based medicine anti-ACM critics.[5]
History

Fueled by a nationwide survey published in 1993 by David Eisenberg, which revealed that in 1990 approximately 60 million Americans had used one or more complementary or alternative therapies to address health issues.[132] A study published in the November 11, 1998 issue of the Journal of the American Medical Association reported that 42% of Americans had used complementary and alternative therapies, up from 34% in 1990.[133] However, despite the growth in patient demand for complementary medicine, most of the early alternative/complementary medical centers failed.[134]
Appeal

A study published in 1998[49] indicates that a majority of alternative medicine use was in conjunction with standard medical treatments. Approximately 4.4 percent of those studied used alternative medicine as a replacement for conventional medicine. The research found that those having used alternative medicine tended to have higher education or report poorer health status. Dissatisfaction with conventional medicine was not a meaningful factor in the choice, but rather the majority of alternative medicine users appear to be doing so largely because "they find these healthcare alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life." In particular, subjects reported a holistic orientation to health, a transformational experience that changed their worldview, identification with a number of groups committed to environmentalism, feminism, psychology, and/or spirituality and personal growth, or that they were suffering from a variety of common and minor ailments - notable ones being anxiety, back problems, and chronic pain.

Authors have speculated on the socio-cultural and psychological reasons for the appeal of alternative medicines among that minority using them in lieu of conventional medicine. There are several socio-cultural reasons for the interest in these treatments centered on the low level of scientific literacy among the public at large and a concomitant increase in antiscientific attitudes and new age mysticism.[135] Related to this are vigorous marketing[136] of extravagant claims by the alternative medical community combined with inadequate media scrutiny and attacks on critics.[135][137]

There is also an increase in conspiracy theories toward conventional medicine and pharmaceutical companies, mistrust of traditional authority figures, such as the physician, and a dislike of the current delivery methods of scientific biomedicine, all of which have led patients to seek out alternative medicine to treat a variety of ailments.[137] Many patients lack access to contemporary medicine, due to a lack of private or public health insurance, which leads them to seek out lower-cost alternative medicine.[44] Medical doctors are also aggressively marketing alternative medicine to profit from this market.[136]

In addition to the social-cultural underpinnings of the popularity of alternative medicine, there are several psychological issues that are critical to its growth. One of the most critical is the placebo effect, which is a well-established observation in medicine.[138] Related to it are similar psychological effects such as the will to believe,[135] cognitive biases that help maintain self-esteem and promote harmonious social functioning,[135] and the post hoc, ergo propter hoc fallacy.[135]

Patients can also be averse to the painful, unpleasant, and sometimes-dangerous side effects of biomedical treatments. Treatments for severe diseases such as cancer and HIV infection have well-known, significant side-effects. Even low-risk medications such as antibiotics can have potentiall tocause life-threatening anaphylactic reactions in a very few individuals. Also, many medications may cause minor but bothersome symptoms such as cough or upset stomach. In all of these cases, patients may be seeking out alternative treatments to avoid the adverse effects of conventional treatments.[135][137]

Its popularity may be related to other factors. In an interview with Edzard Ernst, The Independent wrote:

    "Why is it so popular, then? Ernst blames the providers, customers and the doctors whose neglect, he says, has created the opening into which alternative therapists have stepped. "People are told lies. There are 40 million websites and 39.9 million tell lies, sometimes outrageous lies. They mislead cancer patients, who are encouraged not only to pay their last penny but to be treated with something that shortens their lives. "At the same time, people are gullible. It needs gullibility for the industry to succeed. It doesn't make me popular with the public, but it's the truth."[139]

Academic resources

    Journal of alternative and complementary medicine

    Cochrane and alternative medicine full lists of updated reviews found on Knowledge and Research Center for Alternative Medicine

Effective Acupuncture

Acupuncture

Acupuncture is an alternative medicine that treats patients by insertion and manipulation of needles in the body. Its proponents variously claim that it relieves pain, treats infertility, treats disease, prevents disease, or promotes general health.[1] The efficacy of acupuncture, beyond the placebo effect has never been unequivocally demonstrated. Acupuncture typically incorporates traditional Chinese medicine as an integral part of its practice and theory. However, many practitioners consider 'Traditional Chinese Medicine' (TCM) to narrowly refer to modern mainland Chinese practice.[2] Acupuncture in Japan and Korea, and to a certain extent Taiwan, diverged from mainland China in theory and practice. In European countries such as the UK almost half the practitioners follow these non-TCM practices.[3] The most notable difference is that these other approaches often are primarily acupuncture, and do not incorporate Chinese herbal medicine. The term “acupuncture” is sometimes used to refer to insertion of needles at points other than traditional ones, or to applying an electric current to needles in acupuncture points.[4][5] Acupuncture dates back to prehistoric times, with written records from the second century BCE.[6] Different variations of acupuncture are practiced and taught throughout the world.[7]

Ideas of what constitutes health and healing differ from concepts used in modern scientific, evidence based medicine.[8][9][10] Traditional acupuncture was developed prior to the understanding of human anatomy and cell theory upon which modern biology is based, and there is no anatomical or scientific evidence for the existence of qi or meridians; concepts central to acupuncture theory.[11][12][13][14][15]

The evidence for acupuncture's effectiveness for anything but the relief of some types of pain and nausea has not been established.[16][17][18][19] Systematic reviews have concluded that acupuncture is no more effective than nonpenetrating stimulation of one point to reduce some types of nausea.[20] Evidence for the treatment of other conditions is equivocal.[21] Although evidence exists for a very small and short-lived effect on some types of pain, several review articles discussing the effectiveness of acupuncture have concluded it is possible to explain this as a placebo effect.[16][22][23] A 2011 review of review articles concluded that, except for neck pain, acupuncture was of doubtful efficacy in the treatment of pain and accompanied by small but serious risks and adverse effects including death, particularly when performed by untrained practitioners.[19] Publication bias is a significant concern when evaluating the literature. Reports from the US National Center for Complementary and Alternative Medicine In America (NCCAM), the American Medical Association (AMA) and various US government reports have studied and commented on the efficacy of acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles.[12][24][25][26]
Contents

    1 History
        1.1 Antiquity
        1.2 Middle history
        1.3 Modern era
    2 Traditional Chinese Medicine theory
        2.1 Qi, acupuncture meridians and points
        2.2 Blood
    3 Clinical practice
        3.1 Needles
        3.2 Traditional diagnosis
            3.2.1 Tongue and pulse
    4 Specific conditions
        4.1 Bacterial infection
        4.2 Reproduction
        4.3 Pain
    5 Scientific basis and research on efficacy
        5.1 Evidence-based medicine
        5.2 Criticism
            5.2.1 Qi, acupuncture points and meridians
        5.3 Possible mechanisms
        5.4 Efficacy study design
        5.5 Medical organizations
    6 Safety
        6.1 Adverse events
        6.2 Other injury
        6.3 Omitting modern medical care
    7 Legal and political status
        7.1 United States
        7.2 Canada
        7.3 United Kingdom
        7.4 Australia
        7.5 New Zealand
    8 Closely related practices
    9 See also
    10 Bibliography
    11 References
    12 Further reading
    13 External links

History
Acupuncture chart from the Ming Dynasty (c. 1368–1644)
Antiquity

The earliest written record of acupuncture is the Chinese text Shiji (史記, English: Records of the Grand Historian) with elaboration of its history in the 2nd century BCE medical text Huangdi Neijing (黃帝內經, English: Yellow Emperor's Inner Canon).[6]

Acupuncture's origins in China are uncertain. One explanation is that some soldiers wounded in battle by arrows were believed to have been cured of chronic afflictions that were otherwise untreated,[27] and there are variations on this idea.[28] Sharpened stones known as Bian shi have been found in China, suggesting the practice may date to the Neolithic[29] or possibly even earlier in the Stone Age.[30] Hieroglyphs and pictographs have been found dating from the Shang Dynasty (1600–1100 BCE) which suggest that acupuncture was practiced along with moxibustion.[31]

Despite improvements in metallurgy over centuries, it was not until the 2nd century BCE during the Han Dynasty that stone and bone needles were replaced with metal.[29] The earliest records of acupuncture is in the Shiji (史記, in English, Records of the Grand Historian) with references in later medical texts that are equivocal, but could be interpreted as discussing acupuncture. The earliest Chinese medical text to describe acupuncture is the Huangdi Neijing, the legendary Yellow Emperor's Classic of Internal Medicine (History of Acupuncture) which was compiled around 305–204 BCE.[6]

The Huangdi Neijing does not distinguish between acupuncture and moxibustion and gives the same indication for both treatments. The Mawangdui texts, which also date from the 2nd century BCE (though antedating both the Shiji and Huangdi Neijing), mention the use of pointed stones to open abscesses, and moxibustion but not acupuncture. However, by the 2nd century BCE, acupuncture replaced moxibustion as the primary treatment of systemic conditions.[6]

In Europe, examinations of the 5,000-year-old mummified body of Ötzi the Iceman have identified 15 groups of tattoos on his body, some of which are located on what are now seen as contemporary acupuncture points. This has been cited as evidence that practices similar to acupuncture may have been practiced elsewhere in Eurasia during the early Bronze Age.[32]
Middle history
Acupuncture chart from Hua Shou (fl. 1340s, Ming Dynasty). This image from Shi si jing fa hui (Expression of the Fourteen Meridians). (Tokyo : Suharaya Heisuke kanko, Kyoho gan 1716).

Acupuncture spread from China to Korea, Japan and Vietnam and elsewhere in East Asia.

Around ninety works on acupuncture were written in China between the Han Dynasty and the Song Dynasty, and the Emperor Renzong of Song, in 1023, ordered the production of a bronze statuette depicting the meridians and acupuncture points then in use. However, after the end of the Song Dynasty, acupuncture and its practitioners began to be seen as a technical rather than scholarly profession. It became more rare in the following centuries, supplanted by medications, and became associated with the less prestigious practices of shamanism, midwifery and moxibustion.[33]

Portuguese missionaries in the 16th century were among the first to bring reports of acupuncture to the West.[34] Jacob de Bondt, a Danish surgeon traveling in Asia, described the practice in both Japan and Java. However, in China itself the practice was increasingly associated with the lower-classes and illiterate practitioners.[35]

The first European text on acupuncture was written by Willem ten Rhijne, a Dutch physician who studied the practice for two years in Japan. It consisted of an essay in a 1683 medical text on arthritis; Europeans were also at the time becoming more interested in moxibustion, which Rhijne also wrote about.[36] In 1757 the physician Xu Daqun described the further decline of acupuncture, saying it was a lost art, with few experts to instruct; its decline was attributed in part to the popularity of prescriptions and medications, as well as its association with the lower classes.[37]

In 1822, an edict from the Chinese Emperor banned the practice and teaching of acupuncture within the Imperial Academy of Medicine outright, as unfit for practice by gentlemen-scholars. At this point, acupuncture was still cited in Europe with both skepticism and praise, with little study and only a small amount of experimentation.[38]
Modern era

In the early years after the Chinese Civil War, Chinese Communist Party leaders ridiculed traditional Chinese medicine, including acupuncture, as superstitious, irrational and backward, claiming that it conflicted with the Party's dedication to science as the way of progress. Communist Party Chairman Mao Zedong later reversed this position, saying that "Chinese medicine and pharmacology are a great treasure house and efforts should be made to explore them and raise them to a higher level."[39]

Acupuncture gained attention in the United States when President Richard Nixon visited China in 1972. During one part of the visit, the delegation was shown a patient undergoing major surgery while fully awake, ostensibly receiving acupuncture rather than anesthesia. Later it was found that the patients selected for the surgery had both a high pain tolerance and received heavy indoctrination before the operation; these demonstration cases were also frequently receiving morphine surreptitiously through an intravenous drip that observers were told contained only fluids and nutrients.[40]

The greatest exposure in the West came when New York Times reporter James Reston, who accompanied Nixon during the visit, received acupuncture in China for post-operative pain after undergoing an emergency appendectomy under standard anesthesia. Reston believed he had pain relief from the acupuncture and wrote it in The New York Times.[41] In 1973 the American Internal Revenue Service allowed acupuncture to be deducted as a medical expense.[42]

In 2006, a BBC documentary Alternative Medicine filmed a patient undergoing open heart surgery allegedly under acupuncture-induced anesthesia. It was later revealed that the patient had been given a cocktail of weak anesthetics that in combination could have a much more powerful effect. The program was also criticized for its fanciful interpretation of the results of a brain scanning experiment.[43][44][45]

The use of acupuncture as anesthesia for surgery has fallen out of favor with scientifically trained surgeons in China. A delegation of the Committee for Skeptical Inquiry reported in 1995: We were not shown acupuncture anesthesia for surgery, this apparently having fallen out of favor with scientifically trained surgeons. Dr. Han, for instance, had been emphatic that he and his colleagues see acupuncture only as an analgesic (pain reducer), not an anesthetic (an agent that blocks all conscious sensations).[40]
Traditional Chinese Medicine theory
Qi, acupuncture meridians and points
See also: Traditional Chinese medicine, Chinese astrology, Acupuncture point, and Meridian (Chinese medicine)
Old Chinese medical chart on acupuncture meridians

Traditional Chinese medicine (TCM) is based on a pre-scientific paradigm of medicine that developed over several thousand years and involves concepts that have no counterpart within contemporary medicine.[12] TCM is based in part on Daoism, with a belief that all parts of the universe are interconnected.[8]

According to the Chinese medical classic the Su Wen, disease is believed to be produced by a failure to live in accord with the Dao. Within the more systematized teachings of received Chinese medicine there are endogenous, exogenous and miscellaneous causes of disease.[9] Whereas in science based medicine disease is attributed to specific (often single) causes, for example bacteria, viruses, or genetic conditions. In contrast to the approach of evidence-based medicine which is based on the germ theory of disease, human anatomy and human physiology, Traditional Chinese Medicine attributes disease and pathology to perturbations in the metaphysical force known as qi (a word variously translated as "energy", "breath", or "vital energy"',[46] and imbalance of yin and yang, and the Wu Xing (known as the five phases or elements, earth, water, fire, wood and metal).[10] Qi is believed to flow in and around the body in channels called meridians. Heart-qi is believed to be a force that causes the blood to circulate through the body, whereas in science based medicine the blood is propelled by the heart pumping it. Modern practioners may consider qi to be no more than a metaphor for function, but many proponents consider it to be an actual 'substance'.

No force corresponding to qi (or yin and yang) has been found in the sciences of physics or human physiology.[11][12][13][14][15] Support for the existence of qi is often looked for in scientific fields such as bioelectricity[47] but this research is rarely verified and the connection with qi may be spurious.

The location of meridians is said in the Ling Shu to be based on the number of rivers flowing through the ancient Chinese empire, and acupuncture points were originally derived from Chinese astrological calculations.[11][48][49] and do not correspond to any anatomical structure. "It is because of the twelve Primary channels that people live, that disease is formed, that people are treated and disease arises." [(Spiritual Axis, chapter 12)].[citation needed] Channel theory reflects the limitations in the level of scientific development at the time of its formation, and therefore reflects the philosophical idealism and metaphysics of its period. That which has continuing clinical value needs to be reexamined through practice and research to determine its true nature.[50]

The anatomical system of TCM divides the body's organs into "hollow" and "solid" organs, for example, the intestines are "hollow", and the heart or liver are "solid". It is believed that solid organs are related, and hollow organs are related, and that there is a balance between the two "systems" of organs which is important to health. The zang systems are associated with the solid yin organs such as the liver, while the fu systems are associated with the hollow yang organs such as the intestines.[51] Health is explained as a state of balance between the yin and yang, with disease ascribed to either of these forces being unbalanced, blocked or stagnant.

It is believed that through birth or early childhood, a “weakness” in one of the five elements develops until it impedes the flow of qi cycling throughout the body, causing the symptoms of illness. Acupuncture is described as manipulating the qi to restore balance.[10] TCM also links the organs of the body to the stars, planets and astrological beliefs to explain the phenomena of the persistence of health and illness in the human body.[52]
Blood

TCM asserts that blood is propelled by qi, that there 100 blood “vessels are the pathways of the blood’, that the vessels gather at a specific acupuncture point (Taiyuan LU-9) associated with the lung (or lungs), and that when qi flow is not in balance, blood pools and stagnates.[53][54][55] Modern science based medicine has shown that blood is propelled by pumping action of the heart, and that there are many more than 100 blood vessels, that the vessels do not gather at that or any specific point, and that blood doesn't fail to circulate except by failure of pumping by the heart, and does not pool or stagnate except when a vessel is physically blocked or the heart pumping is disrupted.
Clinical practice
One type of acupuncture needle

In a modern acupuncture session, an initial consultation is followed by taking the pulse on both arms, and an inspection of the tongue; it is believed that this gives the practitioner a good indication of what is happening inside the body. Classically, in clinical practice, acupuncture is highly individualized and based on philosophy and intuition, and not on controlled scientific research.[56] In the United States, acupuncture typically lasts from 10 to 60 minutes, with diagnosis and treatment for a single session ranging from $25 to $80 in 2011.[57] Sometimes needles are left in the ear for up to 3 days.[57]
Needles

Acupuncture needles are typically made of stainless steel wire. They are usually disposable, but reusable needles are sometimes used as well, though they must be sterilized between uses.[58] Needles vary in length between 13 to 130 millimetres (0.51 to 5.1 in), with shorter needles used near the face and eyes, and longer needle in more fleshy areas. Needle diameters vary from 0.16 mm (0.006 in) to 0.46 mm (0.018 in), with thicker needles used on more robust patients. Thinner needles may be flexible and require tubes for insertion. The tip of the needle should not be made too sharp to prevent breakage, although blunt needles cause more pain.[59]

Both peer reviewed medical journals, and acupuncture journals reviewed by acupuncturists, have published on the painfulness of acupuncture treatments, in some cases within the context of reporting studies testing acupuncture’s effectiveness.[60][61][62][63] A peer reviewed medical journal on pain published an article stating that "acupuncture is a painful and unpleasant treatment".[63] There are other cases in which patients have found the insertion of needles in acupuncture too painful to endure.[61] An acupuncture journal, peer reviewed by acupuncturists, published an article describing insertion of needles in TCM acupuncture and random needling acupuncture as “painful stimulation”.[64] In a peer reviewed medical journal, one medical scientist published that Japanese acupuncture is “far less painful” than Chinese acupuncture, and that Japanese acupuncture needles are smaller than Chinese acupuncture needles.[60]
Traditional diagnosis

The acupuncturist decides which points to treat by observing and questioning the patient in order to make a diagnosis according to the tradition which he or she utilizes. In TCM, there are four diagnostic methods: inspection, auscultation and olfaction, inquiring, and palpation.[65]

    Inspection focuses on the face and particularly on the tongue, including analysis of the tongue size, shape, tension, color and coating, and the absence or presence of teeth marks around the edge.
    Auscultation and olfaction refer, respectively, to listening for particular sounds (such as wheezing) and attending to body odor.
    Inquiring focuses on the "seven inquiries", which are: chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; and menses and leukorrhea.
    Palpation includes feeling the body for tender "ashi" points, and palpation of the left and right radial pulses at two levels of pressure (superficial and deep) and three positions Cun, Guan, Chi (immediately proximal to the wrist crease, and one and two fingers' breadth proximally, usually palpated with the index, middle and ring fingers).

Tongue and pulse

Examination of the tongue and the pulse are among the principal diagnostic methods in traditional Chinese medicine. The surface of the tongue is believed to contain a map of the entire body, and is used to determine acupuncture points to manipulate. For example, teeth marks on one part of the tongue might indicate a problem with the heart, while teeth marks on another part of the tongue might indicate a problem with the liver.[66] TCM diagnosis also involves measuring for three superficial and three deep pulses at different locations on the radial artery of each arm, for a total of twelve pulses that are thought to correspond to twelve internal organs. The pulse is examined for several characteristics including rhythm, strength and volume, and described with terms like "floating, slippery, bolstering-like, feeble, thready and quick", which are used to ascribe a specific imbalance in the body. Learning TCM pulse diagnosis can take several years.[67]
Specific conditions
Bacterial infection

TCM proponents believe acupuncture cures some bacterial infections, which they believe are caused by problems in the flow of qi, and base their diagnosis on examination of the tongue and pulse, as well as other symptoms.[68] In 1676, it was discovered that bacterial infections are caused by bacteria, spurring the scientific field of bacteriology.[69] Since this discovery, evidence based medicine treats bacterial infections with specific antibiotics targeted to kill the specific bacteria, and base diagnoses on a laboratory analysis to determine the type of bacteria.

A prominent example of this difference appears in an article appearing in the Journal of Chinese Medicine, which describes the cause of bleeding from the mouth and nose as "Liver fire rushes upwards and scorches the Lung, injuring the blood vessels and giving rise to reckless pouring of blood from the mouth and nose."[70] Science based medicine would look for some other cause, for example, a tuberculosis bacterial infection, and not consider other causes.
Reproduction

Proponents believe acupuncture can assist with fertility, pregnancy and child birth, attributing various conditions of health and difficulty with the flow of qi through various meridians.[71]
Pain

Steven E. Braverman published his belief that needling has been successful in treating some pain in the acupuncture journal Medical Acupuncture, which is reviewed by other members of the acupuncture community.[7] They believe that acupuncture may be considered as a complementary therapy for various conditions. They also believe that definitive conclusions based on research findings are rare because the state of acupuncture research is poor, but they believe it is improving.[7] They believe that treatment for drug detoxification may be suggested by some studies.[72] but evidence is poor.[73][74][75]
Scientific basis and research on efficacy

Acupuncture has been the subject of active scientific research both in regard to its basis and therapeutic effectiveness since the late 20th century, but it remains controversial among medical researchers and clinicians.[21] Research on acupuncture points and meridians has not demonstrated their existence or properties.[76] Clinical assessment of acupuncture treatments, due to its invasive and easily detected nature, makes it difficult to use proper scientific controls for placebo effects.[12][21][77][78][79]

Different types of comparison are made in the scientific literature and terminology can vary, therefore care is needed when assessing research. “Acupuncture” may refer only to insertion of needles in traditionally determined acupuncture points; in which case, it is contrasted with randomly inserting needles, which is called a “sham treatment”, “placebo”, “needling” or "medical acupuncture" if the points are determined by anatomy and not by TCM. In some sources “acupuncture” refers to random needling with needle insertion, and this is compared to pressing telescoping needles against the skin at the same points but not puncturing the skin, which is called a "sham treatment" or "placebo".[7][12][80]

The World Health Organization[81] and the United States' National Institutes of Health (NIH)[12] have stated that acupuncture can be effective in the treatment of neurological conditions and pain, though these statements have been criticized for bias and a reliance on studies that used poor methodology.[82][83] Reports from the USA's National Center for Complementary and Alternative Medicine (NCCAM), the American Medical Association (AMA) and various USA government reports have studied and commented on the efficacy of acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles, but not on its efficiency as a medical procedure.[12][24][25][26]

There are more than one usages of expressions such as "need for further research"; some may mean by this that spending money on additional research is a good expenditure of highly limited medical research funds, while others mean by it that, if conclusions are to be drawn, more research funds would have to be spent, but express no opinion as to whether or not they think it is a good place to spend limited research funds.[7][12][24][25][26][80]
Evidence-based medicine

There is scientific agreement that an evidence-based medicine (EBM) framework should be used to assess health outcomes and that systematic reviews with strict protocols are essential. Organizations such as the Cochrane Collaboration and Bandolier publish such reviews. In practice, EBM is "about integrating individual clinical expertise and the best external evidence".[84][85] Scientific disagreement over methodological aspects of research into acupuncture is not uncommon.[86]

An updated list of all the reviews from the Cochrane Collaboration on acupuncture etc. is available at the Danish governmental institution Knowledge and Research Center for Alternative Medicines home page.[87]

Over the last decade, researcher Edzard Ernst and colleagues have produced regular systematic reviews of the acupunture literature. In 2007, they concluded that "the emerging clinical evidence seems to imply that acupuncture is effective for some but not all conditions."[21] A 2011 review of the literature on pain concluded "numerous systematic reviews have generated little truly convincing evidence that acupuncture is effective in reducing pain.".[19][88]

Several review articles discussing the effectiveness of acupuncture have concluded it is possible to explain its effects as a placebo effect.[16][22][23] Evidence for the treatment of psychological conditions other than pain is equivocal.[21]

For acute low back pain there is insufficient evidence to recommend for or against either acupuncture or dry needling, though for chronic low back pain acupuncture is more effective than sham treatment but no more effective than conventional and alternative treatments for short-term pain relief and improving function. However, when combined with other conventional therapies, the combination is slightly better than conventional therapy alone.[22][89] A review for the American Pain Society/American College of Physicians found fair evidence that acupuncture is effective for chronic low back pain.[90] Conducting research on low back pain is unusually problematic since most patients have experienced "conventional care" – which is itself relatively ineffective – and have low expectations for it. As such, conventional care groups may not be an adequate scientific control and may even lead to nocebo effects that can further inflate of the apparent effectiveness of acupuncture.[91]

There are both positive[92] and negative[93] reviews regarding the effectiveness of acupuncture when combined with in vitro fertilisation.

A 2004 Cochrane Review initially concluded that acupuncture appeared to be more effective than antiemetic drugs in treating postoperative nausea and vomiting,[94] but the authors subsequently retracted this conclusion due to a publication bias in Asian countries that had skewed their results.[95] An updated Cochrane Review published in 2009 concluded that penetrative or non-penetrative stimulation of the P6 acupuncture point was approximately equal to, but not better than, preventive antiemetic drugs for postoperative nausea and vomiting.[20] Another Cochrane Review concluded that electroacupuncture can be helpful in the treatment of vomiting after the start of chemotherapy, but more trials were needed to test their effectiveness versus modern antivomiting medication.[96]

There is moderate evidence that for neck pain, acupuncture is more likely to be effective than sham treatment and offers short-term improvement compared to those on a waiting list.[97] This is tentatively supported by a recent review.[19]

There is evidence to support the use of acupuncture to treat headaches that are idiopathic, though the evidence is not conclusive and more studies need to be conducted.[98] Several trials have indicated that migraine patients benefit from acupuncture, although the correct placement of needles seems to be less relevant than is usually thought by acupuncturists. Overall in these trials acupuncture was associated with slightly better outcomes and fewer adverse effects than prophylactic drug treatment.[99]

There is conflicting evidence that acupuncture may be useful for osteoarthritis of the knee, with both positive,[100][101] and negative[102] results. The Osteoarthritis Research Society International released a set of consensus recommendations in 2008 that concluded acupuncture may be useful for treating the symptoms of osteoarthritis of the knee.[103]

A systematic review of the best five randomized controlled trials available concluded there was insufficient evidence to support the use of acupuncture in the treatment of the symptoms of fibromyalgia.[104]

For the following conditions, the Cochrane Collaboration has concluded there is insufficient evidence to determine whether acupuncture is beneficial, often because of the paucity and poor quality of the research, and that further research is needed: chronic asthma,[105] Bell's palsy,[106] cocaine dependence,[107] depression,[108] primary dysmenorrhoea (incorporating TENS),[109] epilepsy,[110] glaucoma,[111] insomnia,[112] irritable bowel syndrome,[113] induction of childbirth,[114] rheumatoid arthritis,[115] shoulder pain,[116] schizophrenia,[117] smoking cessation,[118] acute stroke,[119] stroke rehabilitation,[120] tennis elbow,[121] and vascular dementia.[122]

Positive results from some studies on the efficacy of acupuncture may be as a result of poorly designed studies or publication bias.[95][123][124] Edzard Ernst and Simon Singh state that (as the quality of experimental tests of acupuncture have increased over the course of several decades through better blinding, the use of sham needling as a form of placebo control, etc.) the "more that researchers eliminate bias from their trials, the greater the tendancy for results to indicate that accupuncture is little more than a placebo."[125]
Criticism

The National Council Against Health Fraud stated in 1990 that acupuncture’s “theory and practice are based on primitive and fanciful concepts of health and disease that bear no relationship to present scientific knowledge.”[126] In 1993 neurologist Arthur Taub called acupuncture “nonsense with needles.”[127] Physicist John P. Jackson,[128] Steven Salzberg, director of the Center for Bioinformatics and Computational Biology and professor at the University of Maryland,[129] Yale University professor of neurology, and founder and executive editor of Science Based Medicine, Steven Novella,[130] and Wallace I. Sampson, clinical professor emeritus of medicine at Stanford University and editor-in-chief at the Scientific Review of Alternative Medicine, have all characterized acupuncture as pseudoscience[131] or pseudomedical.[132]

According to the 1997 NIH consensus statement on acupuncture:

    Despite considerable efforts to understand the anatomy and physiology of the "acupuncture points", the definition and characterization of these points remains controversial. Even more elusive is the basis of some of the key traditional Eastern medical concepts such as the circulation of Qi, the meridian system, and the five phases theory, which are difficult to reconcile with contemporary biomedical information but continue to play an important role in the evaluation of patients and the formulation of treatment in acupuncture.[12]

Qi, acupuncture points and meridians
Modern acupuncture model.

The locations of acupuncture points were originally based on Chinese astrological considerations.[49] No research has established any consistent anatomical structure or function for either acupuncture points or meridians.[14][15] The nervous system has been evaluated for a relationship to acupuncture points, but no structures have been clearly linked to them. Controversial studies using nuclear imaging have suggested that tracers may be used to follow meridians and are not related to veins or lymphatic tissues, but the interpretation of these results is unclear. The electrical resistance of acupuncture points and meridians have also been studied, with conflicting results.[15]

The meridians are part of the controversy in the efforts to reconcile acupuncture with conventional medicine. The National Institutes of Health 1997 consensus development statement on acupuncture stated that acupuncture points, Qi, the meridian system and related theories play an important role in the use of acupuncture, but are difficult to relate to a contemporary understanding of the body.[12] Chinese medicine forbade dissection, and as a result the understanding of how the body functioned was based on a system that related to the world around the body rather than its internal structures. The 365 "divisions" of the body were based on the number of days in a year, and the 12 meridians proposed in the TCM system are thought to be based on the 12 major rivers that run through China.[11]

These ancient traditions of Qi and meridians have no counterpart in modern studies of chemistry, biology and physics and to date scientists have been unable to find evidence that supports their existence.[14][15]

Acupuncturist Felix Mann, who was the author of the first comprehensive English language acupuncture textbook Acupuncture: The Ancient Chinese Art of Healing has stated that "The traditional acupuncture points are no more real than the black spots a drunkard sees in front of his eyes" and compared the meridians to the meridians of longitude used in geography – an imaginary human construct.[133] Mann attempted to join up his medical knowledge with that of Chinese theory. In spite of his protestations about the theory, he was fascinated by it and trained many people in the west with the parts of it he borrowed. He also wrote many books on this subject. His legacy is that there is now a college in London and a system of needling that is known as "Medical Acupuncture". Today this college trains doctors and western medical professionals only. Reviewers Leonid Kalichman and Simon Vulfsons have described the use of dry needling of myofascial trigger points as an effective and low risk treatment modality.[134] A systematic review of acupuncture for pain found that there was no difference between inserting needles into "true" acupuncture on traditional acupuncture points versus "placebo" points not associated with any TCM acupuncture points or meridians. The review concluded that "A small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear."[23]

A history of medical science article published in the journal Biocommunications states that "the Chinese drew mystical numerical associations, called the Da shu, or “great numbers.” It was no coincidence to the ancient Chinese, for example, that our four limbs matched the number of seasons and directions, and that in the one record of a human dissection on the body of the rebel Wangsun Qing, the hired butchers of his captor, Wang Mang, reported finding five zang (liver, gall bladder, heart, spleen, kidneys) corresponding to the five planets; 12 vessels circulating blood and air corresponding to the 12 rivers flowing toward the Central Kindgom; and 365 parts of the body, one for each day of the year (Lingshu 13/311 ), and the Ling shu cited says “There are 365 days in the year, while humans have 365 joints (or acupoints)... There are 12 channel rivers across the land, while humans have 12 channel” – Ling Shu[11][135]

A report for CSICOP on pseudoscience in China written by Wallace Sampson and Barry Beyerstein said:

    A few Chinese scientists we met maintained that although Qi is merely a metaphor, it is still a useful physiological abstraction (e.g., that the related concepts of yin and yang parallel modern scientific notions of endocrinologic [sic] and metabolic feedback mechanisms). They see this as a useful way to unite Eastern and Western medicine. Their more hard-nosed colleagues quietly dismissed Qi as only a philosophy, bearing no tangible relationship to modern physiology and medicine.[136]

Possible mechanisms

Evidence supports that stimulation of one acupuncture point reduces post-operative nausea and vomiting, although insertion of needles at that point does not increase the reduction over nonpenetrating stimulation,[20] and pain,[22] but evidence for the treatment of other conditions is equivocal,[21] and several review articles discussing the effectiveness of acupuncture have concluded it is possible to explain through the placebo effect.[16][23] Endorphin release, stimulation of the peripheral nervous system, and pain mediation through the effects of other neuropeptides are thought to be the most likely explanations for the effects of the insertion of needles.[12] Publication bias is a significant concern when evaluating the literature. Other claims of efficacy have not been tested. Reports from the US National Center for Complementary and Alternative Medicine (NCCAM), the American Medical Association (AMA) and various US government reports have studied and commented on the efficacy (or lack thereof) of acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles.[12][24][25][26] The neural mechanisms underlying minute pain relief from insertion of needles are unknown, but it has been suggested that it may involve recruitment of the body's own pain reduction system, and an increased release of endorphins, serotonin, norepinephrine, or gamma-Aminobutyric acid.[137]
Efficacy study design

One of the major challenges in acupuncture research is in the design of an appropriate placebo control group.[77] In trials of new drugs, double blinding is the accepted standard, but since acupuncture is a procedure rather than a pill, it is difficult to design studies in which both the acupuncturist and patient are blinded as to the treatment being given. The same problem arises in double-blinding procedures used in biomedicine, including virtually all surgical procedures, dentistry, physical therapy, etc. As the Institute of Medicine states: "Controlled trials of surgical procedures have been done less frequently than studies of medications because it is much more difficult to standardize the process of surgery. Surgery depends to some degree on the skills and training of the surgeon and the specific environment and support team available to the surgeon. A surgical procedure in the hands of a highly skilled, experienced surgeon is different from the same procedure in the hands of an inexperienced and unskilled surgeon... For many CAM modalities, it is similarly difficult to separate the effectiveness of the treatment from the effectiveness of the person providing the treatment."[79]:126 Acupuncture itself is also a very strong placebo, and can provoke extremely high expectations from patients and test subjects; this is particularly problematic for health problems like chronic low back pain, where conventional treatment is often relatively ineffective and may have been unsuccessfully used in the past. In situations like these, it may be inappropriate to consider "conventional care" a proper control intervention for acupuncture since patient expectations for conventional care are quite low.[91]

Blinding of the practitioner in acupuncture remains challenging. One proposed solution to blinding patients has been the development of "sham acupuncture", i.e., needling performed superficially or at non-acupuncture sites. Controversy remains over whether, and under what conditions, sham acupuncture may function as a true placebo, particularly in studies on pain, in which insertion of needles anywhere near painful regions may elicit a beneficial response.[12][78] A review in 2007 noted several issues confounding sham acupuncture: "Weak physiologic activity of superficial or sham needle penetration is suggested by several lines of research, including RCTs showing larger effects of a superficial needle penetrating acupuncture than those of a nonpenetrating sham control, positron emission tomography research indicating that sham acupuncture can stimulate regions of the brain associated with natural opiate production, and animal studies showing that sham needle insertion can have nonspecific analgesic effects through a postulated mechanism of “diffuse noxious inhibitory control”. Indeed, superficial needle penetration is a common technique in many authentic traditional Japanese acupuncture styles."[102]

An analysis of 13 studies of pain treatment with acupuncture, published in January 2009 in the journal BMJ, concluded there was little difference in the effect of real, sham and no acupuncture.[23]
Medical organizations

In 1997, the American Medical Association Council on Scientific Affairs stated:

    Critics contend that acupuncturists, including many traditionally trained physicians, merely stick needles in patients as a way to offer another form of treatment for which they can be reimbursed, since many insurance companies will do so. Critical reviews of acupuncture summarized by Hafner4 and others19 conclude that no evidence exists that acupuncture affects the course of any disease...Much of the information currently known about these therapies makes it clear that many have not been shown to be efficacious. Well-designed, stringently controlled research should be done to evaluate the efficacy of alternative therapies.[138]

Also in 1997, the United States National Institutes of Health (NIH) issued a consensus statement on acupuncture that concluded that despite research on acupuncture being difficult to conduct, there was sufficient evidence to encourage further study and expand its use.[12] The consensus statement and conference that produced it were criticized by Wallace Sampson, founder of the Scientific Review of Alternative Medicine, writing for an affiliated publication of Quackwatch who stated the meeting was chaired by a strong proponent of acupuncture and failed to include speakers who had obtained negative results on studies of acupuncture. Sampson also stated he believed the report showed evidence of pseudoscientific reasoning.[139] In 2006 the NIH's National Center for Complementary and Alternative Medicine stated that it continued to abide by the recommendations of the 1997 NIH consensus statement, even if research is still unable to explain its mechanism.[24]

In 2003 the World Health Organization's Department of Essential Drugs and Medicine Policy produced a report on acupuncture. The report was drafted, revised and updated by Zhu-Fan Xie, the Director for the Institute of Integrated Medicines of Beijing Medical University. It contained, based on research results available in early 1999, a list of diseases, symptoms or conditions for which it was believed acupuncture had been demonstrated as an effective treatment, as well as a second list of conditions that were possibly able to be treated with acupuncture. Noting the difficulties of conducting controlled research and the debate on how to best conduct research on acupuncture, the report described itself as "...intended to facilitate research on and the evaluation and application of acupuncture. It is hoped that it will provide a useful resource for researchers, health care providers, national health authorities and the general public."[81] The coordinator for the team that produced the report, Xiaorui Zhang, stated that the report was designed to facilitate research on acupuncture, not recommend treatment for specific diseases.[83] The report was controversial; critics assailed it as being problematic since, in spite of the disclaimer, supporters used it to claim that the WHO endorsed acupuncture and other alternative medicine practices that were either pseudoscientific or lacking sufficient evidence-basis. Medical scientists expressed concern that the evidence supporting acupuncture outlined in the report was weak, and Willem Betz of SKEPP (Studie Kring voor Kritische Evaluatie van Pseudowetenschap en het Paranormale, the Study Circle for the Critical Evaluation of Pseudoscience and the Paranormal) said that the report was evidence that the "WHO has been infiltrated by missionaries for alternative medicine".[83] The WHO 2005 report was also criticized in the 2008 book Trick or Treatment for, in addition to being produced by a panel that included no critics of acupuncture at all, containing two major errors – including too many results from low-quality clinical trials, and including a large number of trials originating in China where, probably due to publication bias, no negative trials have ever been produced. In contrast, studies originating in the West include a mixture of positive, negative and neutral results. Ernst and Singh, the authors of the book, described the report as "highly misleading", a "shoddy piece of work that was never rigorously scrutinized" and stated that the results of high-quality clinical trials do not support the use of acupuncture to treat anything but pain and nausea.[140]

The National Health Service of the United Kingdom states that there is "reasonably good evidence that acupuncture is an effective treatment" for nausea, vomiting, osteoarthritis of the knee and several types of pain but "because of disagreements over the way acupuncture trials should be carried out and over what their results mean, this evidence does not allow us to draw definite conclusions". The NHS states there is evidence against acupuncture being useful for rheumatoid arthritis, smoking cessation and weight loss, and inadequate evidence for most other conditions that acupuncture is used for.[86]
Safety

Because acupuncture needles penetrate the skin, many forms of acupuncture are invasive procedures, and therefore not without risk. Injuries are rare among patients treated by trained practitioners in some countries.[26][141] Sometimes, needles are required by law to be sterile, disposable and used only once; in some places, needles may be reused if they are first resterilized, e.g. in an autoclave. When needles are contaminated, risk of bacterial or other blood-borne infection increases, as with re-use of any type of needle.[142]
Adverse events

Estimates of adverse effects due to acupuncture range from 671[143] to 1,137 per 10,000 treatments.[25] A 2010 systematic review found that acupuncture has been associated with a possible total of up to 86 deaths over the years surveyed, most commonly due to pneumothorax.[144] Some reported adverse effects include 50 cases of bacterial infections, and more than 80 cases of Hepatitis B since 1970.[142][145] A 2011 review stated that "ninety-five cases of severe adverse effects including 5 fatalities" were evident in the literature reviewed. "Pneumothorax and infections were the most frequently reported adverse effects... serious adverse effects continue to be reported."[19]
Other injury

Other risks of injury include: nerve injury, resulting from the accidental puncture of any nerve, brain damage or stroke, which is possible with very deep needling at the base of the skull,[146] kidney damage from deep needling in the low back. Haemopericardium, or puncture of the protective membrane surrounding the heart, which may occur with needling over a sternal foramen.[147]
Omitting modern medical care

Receiving alternative medicine as a replacement for standard modern medical care could result in inadequate diagnosis or treatment of conditions for which modern medicine has a better treatment record.

As with other alternative medicines, unethical or naive practitioners may also induce patients to exhaust financial resources by pursuing ineffective treatment.[148][149] Profession ethical codes set by accrediting organizations such as the National Certification Commission for Acupuncture and Oriental Medicine require referrals to make "timely referrals to other health care professionals as may be appropriate."[150] In Canada, public health departments in the provinces of Ontario and British Columbia regulate acupuncture.[151][152]
Legal and political status
Main article: Regulation of acupuncture
United States

Those who specialize in Acupuncture and Oriental Medicine are usually referred to as "licensed acupuncturists", or L.Ac.'s. The abbreviation "Dipl. Ac." stands for "Diplomate of Acupuncture" and signifies that the holder is board-certified by the NCCAOM.[153] Twenty three states require certification, according to that body.[154]

A poll of American doctors in 2005 showed that 59% believe acupuncture was at least somewhat effective for treatment of pain.[155] In 1996, the United States Food and Drug Administration changed the status of acupuncture needles from Class III to Class II medical devices, meaning that needles are regarded as safe and effective when used appropriately by licensed practitioners.[156][157] As of 2004, nearly 50% of Americans who were enrolled in employer health insurance plans were covered for acupuncture treatments.[158][159]
Canada

In Ontario, the practice of acupuncture is now regulated by the Traditional Chinese Medicine Act, 2006, S.O. 2006, chapter 27.[160] The government is in the process of establishing a college[161] whose mandate will be to oversee the implementation of policies and regulations relating to the profession.
United Kingdom

Acupuncturists are not a regulated profession. The principal body for professional standards in traditional/lay acupuncture is the British Acupuncture Council,[162] The British Medical Acupuncture Society [163] is an inter-disciplinary professional body for regulated health professional using acupuncture as a modality and there is the Acupuncture Association of Chartered Physiotherapists.[164]
Australia

Traditional/lay acupuncture is not a regulated health profession; traditional/lay acupuncture or Chinese Medicine was not included in the National Health Regulation Law.[165] Acupuncture will not be recognized as a profession in Australia but as a modality, either within Chinese Medicine / traditional Asian healing systems or within the scope of practice of regulated health professions. The practice of acupuncture is governed by a range of state / territory laws relating to consumer protection and infection control. Victoria is the only state of Australia with an operational registration board.[166] Currently acupuncturists in New South Wales are bound by the guidelines in the Public Health (Skin Penetration) Regulation 2000,[167] which is enforced at local council level. Other states of Australia have their own skin penetration acts.
New Zealand

Traditional/lay acupuncture is not a regulated health profession. Osteopaths have a scope of practice for Western Medical Acupuncture and Related Needling Techniques.[168] The state-owned Accident Compensation Corporation reimburses for acupuncture treatment by registered health care practitioners and some traditional/lay acupuncturists that belong to voluntary professional associations.[169]
Closely related practices
Moxibustion
Acupressure

    Medical acupuncture is using needles to penetrate the skin at the location of real anatomical structures instead of points determined by tradition.
    Moxibustion – Acupuncture is often accompanied by moxibustion, the burning of cone-shaped preparations of Artemisia vulgaris (mugwort) on or near the skin, often but not always near or on an acupuncture point. Traditionally acupuncture was used to treat acute conditions while moxibustion was used for chronic diseases. Moxibustion could be direct (the cone was placed directly on the skin and allowed to burn the skin producing a blister and eventually a scar), or indirect (either a cone of mugwort was placed on a slice of garlic, ginger or other vegetable, or a cylinder of mugwort was held above the skin, close enough to either warm or burn it).[170]
    Sonopuncture or acutonics is a stimulation of the body similar to acupuncture, but using sound instead of needles.[171] This may be done using purpose-built transducers to direct a narrow ultrasound beam to a depth of 6–8 centimetres at acupuncture meridian points on the body.[172] Alternatively, tuning forks or other sound emitting devices are used.[173]
    Electroacupuncture is a form of acupuncture in which acupuncture needles are attached to a device that generates continuous electric pulses. Another term is Percutaneous Electrical Nerve Stimulation (PENS).
    Acupressure is the application of pressure such as with nonpenetrating needles to acupuncture points.
    Acupuncture point injection is the injection of various substances (such as drugs, vitamins or herbal extracts into acupuncture point.[174]
    Cosmetic acupuncture is the use of acupuncture in an attempt to reduce wrinkles on the face.[175]