Perspectives on Integrative Medicine

Commentary

Opinions on New Reporting Guidelines for Acupuncture Studies Using Sham Acupuncture as a Control Intervention: Advances Needed: Tae-Hun Kim; Perspect Integr Med. 2024;3(2):129-130. Published online June 21, 2024; DOI: https://doi.org/10.56986/pim.2024.06.009

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Protocol

Protocol for a Scoping Review of Traditional and Complementary Medicine Governance Across Sub-Saharan Africa: Tendayi R. Chihaka, Nadine Ijaz, Ossy M.J. Kasilo, Peter B. James, Daniel F. Gallego Pérez, Jon Wardle, Razak M. Gyasi; Perspect Integr Med. 2024;3(2):123-128. Published online June 21, 2024; DOI: https://doi.org/10.56986/pim.2024.06.008

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Abstract PDF Supplementary Material: Background
Since 1978, the World Health Organization (WHO) has repeatedly called on Member States to recognize the role of traditional and complementary medicine (T&CM) in primary healthcare, improve safety, and accessibility by governing T&CM. In the 2019 Global Report on T&CM, the WHO reported that 40 out of 47 (85%) Member States from African Region had enacted governance policies, and 20 out of 47 (43%) had regulatory policies on herbal medicines. The primary barriers to implementing T&CM policy were identified as an absence of data and inadequate financial support for research. The objective of this protocol was to detail how to perform a scoping review that will examine the policy, legislative, and regulatory landscape for T&CM practitioners and products in sub-Saharan Africa.
Methods
Databases will be searched (AMED, CINAHL Plus with Full Text, MEDLINE Plus with Full text, Web of Science, Scopus, PubMed, Google Scholar) for relevant articles. Searches will be limited to English, French, Portuguese, and Spanish language studies in peer-reviewed journals (1963-2023) that substantively report on legislation, bills, policies, governance approaches and regulations on T&CM (including successes and/or challenges in their design and implementation). Actual legislation, policies, and regulatory documents on T&CM and peer-reviewed studies with emphasis on integrating T&CM and biomedicine into healthcare systems will be excluded.
Expected Outcomes
This protocol has formulated the objectives for a scoping review to identify, map, and synthesize evidence on the governance of T&CM in sub-Saharan Africa.

Original Articles

Shilajit, a Natural Phytocomplex Acts as a Neuroprotective Agent Against Amyloid Beta-induced Cytotoxicity and Inflammation: Seoyoung Kim, Changon Seo, HyeJin Park, Jin Gwan Kwon, Jin Kyu Kim, Hyoun Jong Moon, Sunki Lim, Yujeong Gho, Wang Jun Lee, Yongmun Choi, Sanghun Lee; Perspect Integr Med. 2024;3(2):114-122. Published online June 21, 2024; DOI: https://doi.org/10.56986/pim.2024.06.007

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Abstract PDF Supplementary Material: Background
Shilajit is a natural phytocomplex known for centuries in Ayurveda traditional medicine for its antioxidant, immunomodulatory, and neuroprotective properties. However, there is little published scientific evidence to support these acclaimed properties.
Methods
The safety, regarding the heavy metal content, component analysis, the neuroprotective effects and amyloid beta (Aβ)-induced cytotoxicity and inflammation of 3 samples of Shilajit derived from different geographical origins were assessed. Neuroprotective effects of Shilajit were examined using neuroblastoma cell lines (SH-SY5Y and IMR-32) and cell viability assays. The inhibitory effect on the proinflammatory cytokine derived from macrophage cells was assessed using bone marrow-derived macrophage cells in vitro and in a murine model of Aβ-induced inflammation (ex vivo analysis).
Results
The results showed that a daily dose of each Shilajit sample were within the permissible heavy metal limit established by the United States Food and Drug Administration. The 3 Shilajit samples alleviated Aβ-induced toxicity in neuronal cells. One sample derived from the Altai Mountains suppressed Aβ-induced processing of pro-interleukin (pro-IL)-1β into mature, biologically active IL-1β in macrophages. This Shilajit sample inhibited Aβ-induced production of the proinflammatory cytokine IL-1β in the brain (ex vivo analysis). In component analysis, this sample was enriched in salicyluric acid.
Conclusion
Shared and distinct properties were observed among the 3 Shilajit samples concerning their neuroprotective effects, and regarding safety, the daily dose of each Shilajit had a safe level of heavy metal content. Salicyluric acid in Shilajit may be important in mitigating Aβ-induced inflammatory cytokine but more research is necessary.

Evidence Map of Acupuncture: Where We Stand and Where We Should Go: Tae-Hun Kim, Jung Won Kang; Perspect Integr Med. 2024;3(2):106-113. Published online June 21, 2024; DOI: https://doi.org/10.56986/pim.2024.06.006

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Graphical Abstract Abstract PDF Supplementary Material: Background
Evidence mapping presents the current status of evidence on a specific field. The "Evidence Map of Acupuncture" published in 2014 gave an overall picture of the evidence on acupuncture treatments for various conditions/diseases. In this study, evidence in 2024 for the effect of acupuncture was reassessed.
Methods
The systematic reviews (SRs) on acupuncture for the 43 conditions/diseases where evidence was previously unclear or potentially effective in the "Evidence Map of Acupuncture" 2014 were searched in the PubMed and the Cochrane Library, and included SRs up to February, 2024. The Grading of Recommendations, Assessment, Development, and Evaluations assessment in the included SRs was used for assessing the confidence level in the evidence of each condition.
Results
When compared with the results of the "Evidence Map of Acupuncture" 2014, the average number of randomized controlled trials included in a SR increased from 11 to 19.5 by 2024. However, the confidence level showed an overall decrease. The reasons for unclear evidence were mainly methodological limitations such as poor research design, small sample size and small number of studies, and the results of the 2024 reassessment did not show a significant difference in the reasons compared with the "Evidence Map of Acupuncture" 2014.
Discussion
To improve clinical evidence for acupuncture, simple repetition and increasing the number of new randomized controlled trials does not seem to be effective. To reduce redundancy, large scaled studies should be conducted, and a new critical appraisal tool for acupuncture is needed to avoid unfair evaluation of risk of bias in acupuncture research.

The Status of Nationwide Implementation of Integrative Medicine Programs by Japanese Local Government from a “Social Model” Viewpoint: Hui-Yu Chung, Masaki Moroi, Yasutaka Hojo, Fu-Shih Chen, Keiko Yukawa, Yoshiharu Motoo, Ichiro Arai; Perspect Integr Med. 2024;3(2):98-105. Published online June 21, 2024; DOI: https://doi.org/10.56986/pim.2024.06.005

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Graphical Abstract Abstract PDF: Background
The world's demographics are transitioning, prompting governments globally to adopt diverse health promotion and disease prevention programs to enhance people's quality of life. While several integrative medicine (IM) programs, including traditional or alternative medicine, may be in place, the level of implementation nationwide is unknown. This research represents the first nationwide study in Japan, conducted in 2018 before local government health programs were cancelled due to the COVID-19 pandemic. The study examines the use of IM by local government in Japan and its safety and effectiveness as a “social model.”
Methods
IM programs for disease prevention and health promotion of all 1,944 Japanese local governments in 2018, were retrieved the using the Web Archive Project of the National Diet Library, which is a maintained website repository for all Japanese local government including IM and health programs.
Results
A total of 1,739 IM programs were implemented in 537 local governments (27.6% among all Japanese local governments). These included programs for Yoga (1,242; 71.4% of the projects), Qigong (211; 12.1%), and Aromatherapy (145; 8.3%). Among the providers of the programs, only 16 (0.9%) were national medical-related license holders. The purpose of disease prevention or health promotion was not described with scientific basis (safety and effectiveness).
Conclusion
Japanese local government conduct health-promoting IM programs, but untrained providers administer many of them. There needs to be more evidence to support the alleged health promotion objectives. Local governments require better support and evidence-based planning to rectify this situation.

Review Articles

Addressing the Challenges of Traditional, Complementary, and Integrative Medicine Research: An International Perspective and Proposed Strategies Moving Forward: Maheen Raja, Holger Cramer, Myeong Soo Lee, L. Susan Wieland, Jeremy Y. Ng; Perspect Integr Med. 2024;3(2):86-97. Published online June 21, 2024; DOI: https://doi.org/10.56986/pim.2024.06.004

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Graphical Abstract Abstract PDF: Traditional, complementary, and integrative medicine (TCIM) encompasses a broad range of healthcare practices beyond conventional Western medicine. Despite its use globally and increased research, many TCIM research challenges persist impeding its progress and integration into clinical practice. Key challenges involve financial constraints, insufficient research training and educational support, and the methodological barriers which arise from a lack of standardization. Financial limitations hinder investment into crucial research limiting both the quantity and quality of TCIM research. Inadequate training in research and educational support limit the development of TCIM research, hindering growth and recognition of TCIM in academic and clinical settings. The inherent dynamic nature of TCIM therapies poses additional challenges for applying standardized biomedical research models. These challenges not only impede the advancement of TCIM research but also perpetuate negative attitudes and biases within the healthcare and research communities. To overcome these challenges, a comprehensive strategy is necessary to increase funding, improve literacy, and the promotion of open science practices in TCIM. Addressing these confounding factors will enable well-informed TCIM research literacy and the development of TCIM skills and facilitate the integration of evidence based TCIM therapies into a more inclusive healthcare domain, ultimately reducing negative attitudes and biases towards TCIM.

Current Status and Challenges of the Evidence for Cupping Therapy in Clinical Practice Guidelines in Korea: Seungwon Shin; Perspect Integr Med. 2024;3(2):74-85. Published online June 21, 2024; DOI: https://doi.org/10.56986/pim.2024.06.003

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Graphical Abstract Abstract PDF Supplementary Material: Clinical practice guidelines (CPGs) published in Korea were reviewed to evaluate up-to-date evidence and the recommendations for cupping therapy (CT) to inform clinicians and researchers for future studies. There were 14 CPGs (allergic rhinitis, ankle sprain, cervical pain, chronic low back pain, cold hands and feet, facial nerve palsy, Hwabyung, knee osteoarthritis, lumbar herniated intervertebral disk, migraine, osteoporosis, postoperative syndrome, shoulder pain, and traffic accident injury) with 29 recommendations for CT determined from “low” to “moderate” rated evidence. The levels of evidence were mostly downgraded due to the risk of bias and imprecision. The majority of recommendations for CT were graded as B or C. This comprehensive analysis underscores the imperative need for robust clinical research, including randomized controlled trials and observational studies using real-world data to enhance the quality of the evidence for CT. In addition, recommendations providing definite phases or scope of the target conditions/diseases and treatment regimens should be employed. This work lays a foundational step towards integrating CT into evidence-based clinical practice, emphasizing strategic directions for future research to bridge the gap between evidence and practice.

Editorials

Korean Medicine Innovative Technologies Development Project: Integrative Advances and Comprehensive Overview of the National R&D Initiative: Yoon Jae Lee, Seungwon Shin, Junhyeok Yi, Minjung Park; Perspect Integr Med. 2024;3(2):69-73. Published online June 21, 2024; DOI: https://doi.org/10.56986/pim.2024.06.002

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Graphical Abstract PDF

Reporting Overviews of Reviews: PRIORitizing a Reporting Guideline: Lisa Hartling, David Moher; Perspect Integr Med. 2024;3(2):65-68. Published online June 21, 2024; DOI: https://doi.org/10.56986/pim.2024.06.001

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Graphical Abstract PDF

Letters

Tendon Rupture by Acupuncture? Reporting of Not Probable Causality Might Exaggerate Harm of Acupuncture: Sung-A Kim, Tae-Hun Kim, Jung Won Kang; Perspect Integr Med. 2024;3(1):63-64. Published online February 22, 2024; DOI: https://doi.org/10.56986/pim.2024.02.010

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Treatment Recommendations in Korea for Patients with Axial Spondyloarthritis: The Evidence for Acupuncture Treatment in Axial Spondyloarthritis Patients Should be Re-evaluated: Tae-Hun Kim, Myeong Soo Lee, Hyangsook Lee, Stephen Birch, Terje Alraek; Perspect Integr Med. 2024;3(1):61-62. Published online February 22, 2024; DOI: https://doi.org/10.56986/pim.2024.02.009

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Protocol

Validation of a New Sham Acupuncture Needle for Double-Blind Trials: A Study Protocol: Sung Min Lim; Perspect Integr Med. 2024;3(1):57-60. Published online February 22, 2024; DOI: https://doi.org/10.56986/pim.2024.02.008

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Abstract PDF: Background
To establish efficacy in acupuncture treatment, rigorous randomized controlled trials (RCT) are needed. Non-invasive sham acupuncture needles are an effective tool for practitioner/participant blinding. This study presents a protocol for the validation of a newly developed sham acupuncture needle.
Methods
A double-blind RCT will be conducted on 66 healthy adults who will be randomly assigned (using computer-generated random numbers) to either the verum (n = 33) or sham (n = 33) acupuncture needle group. The needles will be inserted at 2 acupuncture points: LI4 (upper limb) and ST36 (lower limb). The primary outcome measure is the practitioner/participants belief that they received verum or sham acupuncture. The secondary outcome measures are participant-rated sensations (penetration, pain, and de qi). Adverse events will be recorded with detailed explanations, categorizing occurrences according to related or unrelated to acupuncture. As the newly developed sham acupuncture has not been studied before, an exploratory approach has been adopted. Descriptive statistics, t test, and χ² test will be applied appropriately.
Results
This study is intended to provide a protocol for the validation of a sham acupuncture needle by using a double-blind RCT setting, and the results will hopefully contribute to the standardization of the needles used for sham acupuncture. The outcomes aim to determine the reliability of practitioner/participant blinding, participant experience of sensations, and lay groundwork for a standardized control group for clinical trials in the future. The newly developed non-invasive sham acupuncture needle may reduce bias and improve reliability in the size effect of acupuncture treatment.

Case Report

Complete Remission of Drug-Induced Acute Dizziness Using Eight Constitution Acupuncture and the Barbecue Maneuver: A Case Report: Younkuk Choi, Juhee Cho; Perspect Integr Med. 2024;3(1):51-56. Published online February 22, 2024; DOI: https://doi.org/10.56986/pim.2024.02.007

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Abstract PDF: Dizziness, often symptomatic of underlying conditions, presents management challenges especially when dealing with drug-induced vestibular disorders. Complementary therapies like acupuncture, specifically, Eight Constitution Acupuncture (ECA), offers a potential alternative to other management therapies. A 74-year-old female, experiencing sudden dizziness from medication for back pain, underwent a detailed examination, constitutional diagnosis, and targeted acupuncture involving 26 insertions over 4 sessions. The treatment for dizziness, which focused on constitutional differences, integrated ECA and the barbecue maneuver which resulted in significant efficacy. A 50% reduction in the Numeric Rating Scale score from 10 to 5 was observed after the 1^st session. Subsequent sessions of ECA combined with the barbecue maneuver significantly reduced symptoms of dizziness and ultimately alleviated symptoms. This case underscored the potential of ECA when combined with the application of the barbecue maneuver in treating drug-induced vestibular disorders and residual benign paroxysmal positional vertigo. The ECA's constitutional approach allows for precise targeting and symptom resolution, and integrating the principles of Traditional Asian Medicine with biological mechanisms. Notably, this is the 1^st case report of the efficacy of ECA and the barbecue maneuver in addressing drug-induced vestibular disorders. A holistic approach, considering constitutional differences, can offer insights and tailored solutions to present a promising avenue for patients experiencing such conditions. Rigorous research studies are essential to validate these findings.

Original Articles

A Survey of the Clinical Practice of Korean Medicine for Smoking Cessation in Public Health Centers: A Web-Based Survey of Public Health Doctors of Korean Medicine: Gyoungeun Park, Jeong-Hyun Moon, Eun-Jung Kim, Byung-Kwan Seo, Yong-Hyeon Baek, Won-Suk Sung; Perspect Integr Med. 2024;3(1):45-50. Published online February 22, 2024; DOI: https://doi.org/10.56986/pim.2024.02.006

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Graphical Abstract Abstract PDF Supplementary Material: Background
In South Korea, public health centers provide smoking cessation (SC) treatments including behavioral therapy and nicotine replacement treatment. Also, public health doctors of Korean medicine (PHDKMs) are providing Korean Medicine (KM) treatments. Several studies have reported the clinical usefulness of KM treatment, but in this study, the opinion of PHDKMs was explored to examine the current KM treatments for SC.
Methods
A web-based survey (Moaform) of the treatment for SC by PHDKMs consisted of 5 main sections including clinical practice status, SC participants, KM treatments for SC, progress and prognosis, and perception of KM. The survey was emailed twice to 621 PHDKMs on April 6 to 20, 2022. The frequencies and percentages of each question were calculated.
Results
There were 28 PHDKMs who participated in the survey. Among them, over 90% of PHDKMs had treated ≤ 10 SC participants, and about 10% of PHDKMs had treated 11-20 participants. The abstinence rate was 56.8% with an average 63.2% level of satisfaction in the treatment. Typically used, and recognized as important KM treatments, were auricular acupuncture, acupuncture, education, and herbal medicine. While auricular acupuncture and education were perceived as convenient KM treatment, PHDKMs thought that SC could not be achieved with KM treatment alone and needed be combined with other treatments.
Conclusion
This survey showed the effectiveness of KM treatments with withdrawal symptoms, and treatment satisfaction of SC participants. Respondents also thought that KM treatment combined with other treatments is more effective than KM monotherapy. Based on this small study, further research would be needed.

Effects of Pulsed Electromagnetic Field Therapy and Photontherapy in Cervicobrachialgia: A Randomized Controlled Trial: Bianca dos Santos Bobadilha, Talita Bonato de Almeida, Maria Imaculada de Lima Montebello, Maria da Luz Rosário de Sousa; Perspect Integr Med. 2024;3(1):37-44. Published online February 22, 2024; DOI: https://doi.org/10.56986/pim.2024.02.005

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Graphical Abstract Abstract PDF: Background
Cervicobrachialgia is a painful condition commonly treated with medication and physiotherapy. The aim was to evaluate pain following electromagnetic and photontherapy, and examine patient energy profiles.
Methods
There were 48 patients experiencing pain [Visual Analogue Scale (VAS) score ≥ 4] who were not receiving medication and physiotherapy and were randomized into Test Group (GT); electromagnetism using a Kenkobio device (intensity = 0.055 mT/frequency = 60 Hz) and photon therapy; a photon therapy blanket, and Placebo Group (GP); the Kenkobio device was turned off and the blanket was not used. Pain was assessed using the VAS, before, immediately after treatment, and the following day. Algometry was also carried out before and after the treatment to understand the pain threshold at bilateral acupoints GB20 and GB21. The energy profile was assessed using Ryodoraku measurements before and after the session.
Results
The GT achieved a greater reduction in pain the following day than GP. Both groups were equal for left GB20 and right GB21 points considering algometry and, after the intervention, a reduction in pain in the GT was noticed only in the left GB20 (CI [95%]: 0.09-0.99, p = 0.019). The average energy level was low and dropped further following treatment. Furthermore, energy from the Large Intestine Meridian tended towards balance in the GT compared with the GP [CI (95%): 0.58-15.75, p = 0.035]. No adverse effects were reported.
Conclusion
The combined use of electromagnetic and photontherapy were effective in reducing pain in patients and promoted energy rebalancing.

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