Visual abstract

Introduction

Integrative medicine (IM), which encompasses a broad range of therapies including acupuncture, herbal medicine, yoga, and meditation, and which falls under the broader definition of traditional, complementary, and integrative medicine (TCIM) [1], is gaining increasing prominence in the healthcare landscape [2]. These practices are often applied to manage chronic conditions such as pain, musculoskeletal disorders, and mental health issues, where conventional medicine approaches may fall short. Despite the growing popularity of IM, questions remain regarding the rigor and quality of evidence supporting the use of these interventions. The demand for robust, reliable evidence has become a central focus in the field.

The 5^th Annual Jaseng Academic Conference 2024, in Seoul, South Korea, themed “Robust Evidence in Integrative Medicine: Innovations, Challenges, and Future Directions,” brought these issues to the forefront (Table 1). Experts from around the world gathered to discuss the latest innovations in study design, evidence synthesis, and the implementation of reporting guidelines, as well as open science, all aimed at advancing the scientific foundation of research in IM (Figure 1). This article explores the insights shared during the conference, focusing on the innovations and challenges, and examines how these advancements can shape the future of IM research.

1. Study designs in IM research

The field of IM increasingly recognizes the importance of employing appropriate study designs to accurately assess the effectiveness of various interventions. Dr. Terje Alræk discussed the role of pragmatic randomized controlled trials (pRCTs) in this context [3,4]. Unlike efficacy trials, which are conducted under ideal and highly controlled conditions, pRCTs are designed to evaluate interventions in real-world clinical settings. This is particularly relevant for IM where treatments such as acupuncture are often personalized and applied in diverse environments. The generalizability of pRCTs is a key advantage, as they reflect the complexity of everyday practice. This makes pRCTs highly valuable for informing clinical decisions and supporting the integration of evidence-based practices into routine healthcare. However, conducting pRCTs in IM is not without challenges. The flexibility inherent in these trials, while advantageous for capturing real-world effectiveness, can lead to difficulties in standardizing interventions and measuring outcomes. This issue is particularly pronounced in acupuncture research, where the use of sham needles as a control has been widely debated. Dr. Stephen Birch’s presentation on sham acupuncture highlighted that even non-inserted or shallow needling can elicit biological responses, potentially functioning as an active treatment rather than an inert placebo. He suggested that these sham devices and techniques may directly influence trial outcomes [5–7], complicate the interpretation of results and underestimate acupuncture’s true effectiveness. Birch’s argument underscored the need for more rigorous preclinical testing of sham controls and suggested that pRCTs, with their focus on real-world applicability, may offer a more accurate reflection of acupuncture’s therapeutic value. Furthermore, he called for a revision of reporting guidelines for sham needles used in human studies [8–10].

2. Range of interventions in IM in chronic pain management

The scope of interventions in IM covers a variety of therapies that include, but are not limited to, acupuncture, herbal medicine, manual therapies like Chuna, and mind-body practices such as yoga and meditation. These interventions are often used in combination, tailored to individual patient needs, and applied to various conditions, particularly chronic pain and musculoskeletal disorders [11]. Dr. In-Hyuk Ha presented research (from Korean settings), where Korean medicine (KM) was integrated with Western practices. Studies on interventions such as Motion Style Acupuncture Treatment (MSAT) [12] and Chuna therapy [13] have been reported to be significantly more effective than the usual care for chronic pain management such as non-steroidal anti-inflammatory drugs and physiotherapy, while herbal formulations like Shinbaro have been reported to be effective in treating joint conditions/diseases [14,15].

Dr. Ha’s presentation highlighted the collaboration between research and health policy in Korea which allowed for the growth of research as well as the implementation of the results into National Health Insurance. The comprehensive research conducted in Korea were supported by government-backed R&D investments which enabled researchers not only evaluate the clinical efficacy of KM interventions but also play a crucial role in shaping health policy [16]. The integration of research findings into health policy underscores the importance of robust, well-designed studies in the field of IM. By providing reliable evidence on the effectiveness of various therapies, pRCTs and other rigorous study designs contribute to the development of evidence-based clinical practice guidelines (CPGs), enhance the quality of care, and support the broader adoption of IM practices within healthcare systems. Furthermore, the certification and designation of specialized hospitals for musculoskeletal and spinal disorders further demonstrate the impact of research on policy, as these institutions are recognized for their expertise in applying specialized interventions in their respective fields [17].

In addition to acupuncture, manual therapy, and herbal medicine, yoga and meditation have emerged as key mind-body interventions for managing chronic pain. Prof. Holger Cramer highlighted that yoga and meditation are frequently used by individuals dealing with chronic pain conditions, as extensively discussed in recent publications covering back pain [18–20], arthritis [21,22], anxiety [23], and depression [24,25]. Research has shown that yoga and meditation are effective in reducing pain intensity, improving functional capacity, and enhancing quality of life for patients living with chronic pain. Notably, studies have reported that yoga can help alleviate chronic back pain, while meditation can alter pain perception by allowing individuals to experience pain without the emotional distress typically associated with it [26,27]. This concept is referred to as the “first arrow” (sensory experience) and “second arrow” (emotional evaluation) [26,27]. In an animal model of tissue inflammation when using an intervention that mimicked yoga postures, a decrease in tissue inflammation was observed [28]. However, as Prof. Cramer noted, no additional studies using similar study designs have been published, and the challenge of accurately mimicking yoga remains a persistent issue to be addressed. Further research is necessary to fully understand how these interventions work in different chronic pain conditions and to refine their clinical applications.

3. Current evidence synthesis in IM: methodologies and challenges

Evidence synthesis in IM is reflected in a variety of methodologies, each contributing to a comprehensive understanding of the effectiveness and applicability of different interventions. Recent advancements in bibliometric analysis, evidence mapping, and the development of CPGs underscore the progress and challenges in this field.

Bibliometric analysis provides a quantitative overview of the research landscape in IM. For instance, the analysis conducted by Prof. Jianping Liu on musculoskeletal conditions/diseases within IM over the past 20 years highlighted key trends in research output, geographical distribution, and institutional contributions. This approach allows an understanding of where and how IM research has developed and where future research should be directed [29].

Evidence maps serve as visual tools that organize research findings to provide a clear overview of available evidence in specific areas of IM. Prof. Tae-Hun Kim’s presentation on acupuncture demonstrated the utility of evidence maps in systematically summarizing the state of research and identifying areas in need of more rigorous studies [30]. Comparing the evidence maps from 2014 and 2024 for conditions like chronic fatigue syndrome revealed that while the quantity of studies had increased, the certainty of evidence remained low due to persistent methodological challenges despite the growing number of RCTs. This highlighted a critical challenge and the ongoing need for improved research designs and methodologies, instead of simply increasing the amount of research, to enhance the reliability of findings in IM.

In addition to good-quality evidence syntheses, the development of evidence-informed CPGs and their implementation and dissemination is crucial in the overall improvement of healthcare and health policy. In Korea, the integration of KM into the national health system has been facilitated by rigorous clinical research and the development of CPGs [31]. Dr. Yoon Jae Lee presented the development of CPGs in KM [16], which represent a significant advancement in standardizing and improving the quality of care in IM. Supported by national R&D initiatives, these guidelines are formulated through rigorous methodologies [32], including systematic reviews and meta-analyses, and are categorized based on the level of evidence. The implementation of KM-CPGs bolstered by educational programs for practitioners and the dissemination of information, as well as inclusion of KM-CPGs in medical education curriculum reflects the growing recognition and application of these guidelines in clinical practice. However, despite these advancements, challenges remain in ensuring that CPGs are widely adopted and effectively used, which underscores the need for ongoing education and international collaboration.

IM encompasses a broad range of therapies that vary significantly in their application, patient populations, and treatment protocols. This inherent heterogeneity presents a major challenge. As Prof. Juan Franco discussed, the variability in how treatments are administered can lead to inconclusive results when considering average treatment effects, complicating the generalization of findings across different studies [33]. In addition, the lack of a deep understanding of patient preferences in relation to IM makes it difficult to provide definitive recommendations based solely on evidence of effectiveness without considering issues related to implementation, such as acceptability of IM.

Moreover, the potential for synergistic and antagonistic effects adds another layer of complexity and more evidence on the integration of complementary and conventional treatment is needed [34]. Prof. Franco discussed cases in which combining IM practices with conventional treatments may result in synergistic effects, enhancing the overall therapeutic outcome. Conversely, he also highlighted certain combinations may have antagonistic effects, where the interaction between treatments reduces the effectiveness of one or both treatments. For instance, the combination of prolotherapy with non-steroidal anti-inflammatory drugs may diminish the intended inflammatory response of prolotherapy, thereby reducing its efficacy. These interactions must be carefully considered in both the design of studies and the interpretation of results to avoid misleading conclusions about the efficacy of integrative therapies.

The current methodologies based on evidence synthesis, including bibliometric analysis, evidence mapping, and the development of CPGs, provide valuable insights into the effectiveness and application of integrative therapies. However, the heterogeneity in IM modalities and the potential for synergistic or antagonistic effects highlight the challenges that IM researchers often face. Addressing these issues will be crucial for improving the quality of evidence and ensuring that IM can be effectively integrated into clinical practice and health policy across various settings.

4. Better reporting, open science, and meta-research in IM research

Open science holds significant potential to enhance the quality, transparency, and reproducibility of research in the field of IM. As highlighted in Dr. Jeremy Y. Ng’s presentation, the integration of open science practices into IM research can address many of the existing challenges and pave the way for more robust and credible scientific findings.

The adoption of open science in the research field of IM has been gradual, and barriers such as data privacy concerns, cultural resistance to change, and limited resources have hindered its widespread implementation [35]. Despite these challenges, there is growing awareness within the community of the need to embrace open science to improve the reliability and impact of research [36]. In the context of IM, these practices are particularly relevant due to the diverse and individualized nature of diverse therapies which require tailored approaches to open science. Such approaches must balance respect for cultural and historical context with the promotion of transparency and collaboration [37].

To fully realize the potential of open science in IM, several key areas must be addressed. Education and training initiatives are essential, as is advocacy for increased funding to support these initiatives. Study registration and adherence to the Findability, Accessibility, Interoperability, Reusability principles for sharing data [38] can enhance the transparency and validation of research findings. Preprinting should also be encouraged to facilitate timely dissemination and peer feedback.

Adherence to reporting guidelines (such as CONSORT[39], PRISMA [40], and STRICTA [41]) are a crucial step, ensuring that research is not only accessible but also well-reported and reproducible. Dr. David Moher talked about reporting guidelines that have already played a critical role in improving the quality of research reporting by reducing bias and enhancing transparency. This integration is particularly important in IM as the complexity of its interventions often poses challenges for standardization and rigorous scientific evaluation. By actively adopting reporting guidelines, IM research can achieve greater transparency and reproducibility which are essential for building robust evidence. This will enhance the credibility of research and facilitate its acceptance within the broader scientific community. Technological advancements such as the application and monitoring of reporting guidelines, customizable guidelines, and learning platforms, are examples of enhanced quality and adherence to reporting standards in IM research using artificial intelligence, ultimately reducing wasteful research [1].

Conclusion

The future of IM research holds great promise, with advancements in study designs, evidence synthesis, and reporting methodologies poised to elevate the quality of evidence in the field. These topics were thoroughly discussed at the 5th Annual Jaseng Academic conference 2024. Study designs such as pRCTs have emerged as a crucial tool for evaluating the real-world effectiveness of integrative therapies. Challenges remain in ensuring standardization, especially in studies utilizing sham needles which may induce specific effects, potentially obscuring the true therapeutic effect of these treatments.

The wide range of interventions in IM have demonstrated efficacy in managing chronic pain. Research presented at the conference showed that these therapies not only reduce pain intensity but also improve functional outcome and quality of life, further supporting their integration into comprehensive pain management strategies. Government-supported research and CPGs in Korea exemplify how robust, well-designed studies can directly inform health policy, leading to the broader adoption of integrative practices within national healthcare systems.

Methodologies such as bibliometric analysis and evidence mapping provide a clear overview of research trends and gaps in IM. On the other hand, its heterogeneity of modalities presents a significant challenge. Variability in treatments, patient populations, and synergistic or antagonistic effects complicate the interpretation of results, and necessitate more sophisticated research design. Addressing these complexities will be critical in improving the reliability of evidence synthesis and ensuring that integrative therapies can be effectively applied in clinical practice.

Open science offers a pathway to overcoming many of these challenges, and integrating its practices into research frameworks, alongside established reporting guidelines (like CONSORT and PRISMA), can enhance credibility and the global impact of IM. Moving forward, the adoption of open science, supported by technological advancements such as artificial intelligence, and the commitment to rigorous reporting are crucial in advancing the quality of research. Through this effort, the field of IM can continue to build a strong evidence base, gain broader acceptance, and ultimately contribute to more effective, personalized, and patient-centered healthcare.

Article information

Author Contributions

Conceptualization, writing – original draft: YSL. Writing –review & editing: YSL, MSL, DM, IHH, JPL, TA, SB, THK, YJL, JF, JYN, and HC.

Conflicts of Interest

The authors (YSL, MSL, IHH, JPL, TA, SB, YJL, JYN) have served as editororial board members of Perpectives on Integrative Medicine, but this had no influence in the decision to publish this article. No other potential conflicts of interest relevant to this article were reported.

Funding

None.

Ethical Statement

This article did not include any personal information; therefore, no ethics approval was required.

Figure 1

Speakers and chairs of the 5^th Annual Jaseng Academic conference 2024, Seoul, South Korea (From the left: Ye-Seul Lee, Yoon Jae Lee, Holger Cramer, Juan VA Franco, David Moher, In-Hyuk Ha, Jian-Ping Liu, Jeremy Y. Ng, Terje Alraek, Stephen Birch, Myeong Soo Lee, Tae-Hun Kim).

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