Applying the International Classification of Functioning, Disability and Health to guide home health care services planning and delivery in Thailand.

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Applying the International Classification of Functioning, Disability and Health to guide home health care services planning and delivery in Thailand.

Home Health Care Serv Q. 2017 May 08;:

Authors: Pimdee A, Nualnetr N

Abstract
Home health care is an essential service for home-bound patients in Thailand. In this action research study, we used the International Classification of Functioning, Disability and Health (ICF) framework to modify home health care services provided by a university hospital. Staff responsible for delivering the services (physical therapist, nurses, and Thai traditional medicine practitioners) participated in the development of an ICF-based assessment tool and home health care service procedure. After an 8-month trial of implementing these changes, professional satisfaction and empowerment were high among the home health care team members. Patients and their caregivers were also satisfied with the services. In conclusion, the ICF is an effective means of guiding home health care.

PMID: 28481683 [PubMed – as supplied by publisher]

Is ‘The Butcher of New England’ Harming Patients with Undisclosed Conflicts of Interest?

Migraine is a common, debilitating condition that is notoriously difficult to treat1. While conventional treatments offer a poor effectiveness versus safety profile, acupuncture has been demonstrated to be at least as effective if not more effective than medication with far fewer side-effects2. For this reason, acupuncture is recommended in official evidence-based clinical guidelines such as the UK’s NICE Guidelines for Headaches.

However, Harvard neurologist Paul G. Mathew, who appropriately refers to himself as ‘The Butcher of New England’, seems to have a different opinion on the matter. In his recent blog post on the Harvard Health blog, which was riddled with questionable puns but largely devoid of demonstrable familiarity with the research literature on the subject under discussion, Dr Mathew argued that the benefits of acupuncture were small while the evidence for conventional treatments strong, that physical therapy is a great alternative to drugs even when it doesn’t work, and ended with a questionable anecdote pointing to an undisclosed financial conflict of interest, rather than a good-willed desire to inform patients on their treatment options, as a possible motivation for steering migraine sufferers away from a treatment with a proven record of efficacy and safety.

Modest at Best

Dr Mathew’s discussion of the literature on treatments for migraines was on the whole anecdotal and unreferenced, leading one to ask what exactly was the point of writing the post in the first place. (Get it? Point? POINT?! It’s a pun on acupuncture. Two can play this game).

However, in an uncharacteristic move, Dr Mathew dabbled with using an actual citation to support his prose, referring to a recent clinical trial on acupuncture for migraine3. According to Dr Matthew: “Twelve weeks after treatment, the acupuncture group had on average 3.2 fewer attacks per month, the sham acupuncture group had 2.1 fewer attacks per month, and the wait-list group had 1.4 fewer attacks per month. These results are modest at best.”

Zhao, L., Chen, J., Li, Y., Sun, X., Chang, X., Zheng, H., et al. (2017). The Long-term Effect of Acupuncture for Migraine Prophylaxis. JAMA Internal Medicine, 177(4), 508–8. http://doi.org/10.1001/jamainternmed.2016.9378

So compared to sham needling, which is an active control with specific effects in the treatment of migraine4, true acupuncture was significantly more effective at reducing migraines at all time points while sham acupuncture was not significantly different from the waitlist control. Of course, normally, evidence-based practitioners prefer to use systematic reviews where available over individual studies. The most recent Cochrane review found that for reduction in headaches, acupuncture was associated with an effect size of 0.19 compared to active sham needling control 5, which to compare is greater than the effect size of SSRIs compared to placebo.6 Compared to usual care, the effect size is -0.56 in favor of acupuncture.

At 16 weeks, 200mg/day of Topiramate is associated with a reduction of 1.08 migraines per month7, whereas acupuncture has a 1.10 migraine reduction compared to sham needling.

Another migraine treatment, Botox injections, has even weaker support for its use. The PREEMPT trials, which were multi-armed Phase III trials funded by Allergan, the makers of Botox, found the following results for reduction in headaches per month: at 24 weeks, the Botox group had 5.2 fewer attacks and the placebo group had 4.9 fewer attacks, a difference of less than half a headache per month. At 56 weeks, the Botox group had 7.4 fewer attacks and the placebo group had 7.5 fewer attacks, a difference of precisely zero. Nada. Zilch.

So, Dr Mathew, if you describe the difference in reduction of headaches between acupuncture and active sham needling to be “modest at best,” then precisely how would describe the total lack of difference in headache reduction with Botox compared to placebo?

Butchering the Evidence on Standard Treatment

What’s interesting about the drugs used in the prevention of migraine, whether it’s an ACE inhibitor, alpha-blocker, beta-blocker, SSRI, serotonin agonist or tricyclic antidepressant, is that they all have something in common: none of them are actually migraine medications. They all fall into the category of ‘off-label prescribing.’ That’s when a drug approved for one use, such as an anti-depressant, is used for another entirely different use, such as migraine prevention, which it hasn’t been licensed or approved for. This situation arises because there aren’t really any medications that work very well for preventing migraines. Since this is pretty much common knowledge amongst clinicians, it was particularly surprising that as Dr Mathew argued against using acupuncture while pointing to evidence of its efficacy, he claimed that there’s good evidence for standard treatment, without pointing to any data at all.

Dr Mathew, not to be slowed down by actually reading the literature before summarizing it, tells us: “In general, the effectiveness of standard treatment (medication and injectable therapies) is supported by much stronger scientific evidence than acupuncture, including large clinical trials with thousands of subjects.” Fascinating. A 2015 meta-analysis8 of all drugs for the prevention of migraine, which included 126 randomized placebo-controlled clinical trials, found that the number of participants included in the studies was 112 on average, ranging from 9 to 783, making one wonder, pray tell, exactly which clinical trials with ‘thousands of subjects’ providing strong ‘scientific evidence’ for treating migraines with drugs Dr Mathew is referring to . . .

The results of this review are as follows: most of the drugs that are regularly used have no effectiveness beyond placebo. Drugs with at least 3 trials that were more effective than placebo for episodic migraines were as following:
– Amitriptyline: SMD: -1.2 (-1.7 to -0.82)
– Flunarizine: -1.1 headaches/month (-1.6 to -0.67)
– Fluoxetine: SMD: -0.57 (-0.97 to -0.17)
– Metoprolol: -0.94 headaches/month (CI -1.4 to -0.46)
– Pizotifen: -0.43 headaches/month (CI -0.6 to -0.21)
– Propranolol: 1.3 headaches/month (-2.0 to -0.62)
– Topiramate: -1.1 headaches/month (-1.9 to -0.73)
– Valproate: -1.5 headaches/month (-2.1 to -0.8)

So the studies on drugs that reported the results in terms of headaches per month had about the same advantage or perhaps less over placebo pill as acupuncture had over active sham control. And since the drugs were compared to an inert placebo and the acupuncture was compared to an active control, then it’s likely that acupuncture’s effectiveness is underestimated.

If that were the case, we’d expect acupuncture to outperform drugs when tested head to head, which is precisely what the literature shows.

A randomized trial of acupuncture versus topiramate9, an anticonvulsant often used to treat migraines, demonstrated that acupuncture resulted in a significantly larger decrease in moderate/severe headaches (from 20.2 down to 9.8 versus 19.8 to 12 in the topiramate group). Additionally, acupuncture was more effective than topiramate for all secondary outcomes, such as pain intensity and quality of life. While adverse events occurred in 66% of the topiramate group, they only occurred in 6% of the acupuncture group, demonstrating a far superior benefit to risk profile for acupuncture.

Yang, C.-P., Chang, M.-H., Liu, P.-E., Li, T.-C., Hsieh, C.-L., Hwang, K.-L., & Chang, H.-H. (2011). Acupuncture versus topiramate in chronic migraine prophylaxis: a randomized clinical trial. Cephalalgia : an International Journal of Headache, 31(15), 1510–1521. http://doi.org/10.1177/0333102411420585

A 2013 study evaluating acupuncture vs valproic acid, another anti-epileptic drug, showed that at 6 months, pain intensity was lower in the acupuncture group, pain relief was greater, and the acupuncture group was taking significantly less acute medication (Rizatriptan). The rate of adverse events in the group given valproic acid was 47.8%; in the acupuncture group it was 0%.10

A recent Cochrane Systematic review confirms the findings of these studies. Compared to drugs, acupuncture is associated with -0.49 fewer migraine attacks at 8 weeks, -0.32 fewer migraines at 4 months, and -0.31 migraines 3.5 to 6 months after randomization compared to drugs. All results are statistically significant.

While self-styled acupuncture “Skeptics” (those who argue that acupuncture doesn’t work regardless of considerable evidence to the contrary) are quick to point out that head to head comparisons are biased because they are unblinded, researchers and clinical experts are quicker to point out that so is real life, where the patients are. Acupuncture’s superiority over sham and its many known biochemical mechanisms demonstrate specific effects. But of course, all of this is purely academic; head to head studies are the ones that tell you which treatments are most likely to benefit real patients in the real world comparing the treatment options that they are actually faced with, provided in the way that they would actually receive the treatment. The best evidence shows that acupuncture is more effective than drugs.

Side-effects?

“Side effects are not just limited to medications; procedures can also have negative effects,” Dr Mathew reminds us. Excellent point! According to an analysis of the safety and tolerability of Botox for chronic migraine, adverse events (AEs) were reported in a whopping 74% of those who received Botox. In fact, neck pain is such a common side-effect of the treatment that it results in unblinding in trials, as subjects know whether or not they’ve received the real deal based on how much pain they’re in afterwards.

Serious adverse events, which “were any that resulted in death, a life-threatening event, hospitalization (initial or prolonged), disability, a congenital anomaly or a medical event that could require medical or surgical intervention to prevent the above outcomes” was reported in 5.4% of those who were injected with Botox. The most common serious AE was (wait for it . . .) migraine. It’s unclear whether the common occurrence of migraines triggered by Botox treatment were classed as serious AE’s simply by causing disability or if a significant number of test subjects had migraines caused by Botox that were so severe they required hospitalization. Either way, causing serious migraines seems like sort of a counter-productive effect for a migraine treatment.

So what the data suggests is that not only does Botox not seem to reduce migraines compared to placebo, but the data shows that it actually causes them.11

After recommending against acupuncture based on a high-quality study that supports its efficacy, Dr Mathew has this advice for those who want to steer away from medication: “For those averse to medications, physical therapy is a great alternative — one based on actual human anatomy and scientific principles. My patients often complain that they do not feel significantly better after the five to 10 sessions of physical therapy that insurance companies typically approve. I advise them that the true benefit of physical therapy comes when the stretching and strengthening routines taught by the therapist are continued at home on a long-term basis.”

So physical therapy is ‘a great alternative’, even though a recent systematic review failed to show any effect on reducing migraines compared to control12 and even when his patients are telling him that it’s not working.

What would possibly compel Dr Mathew to write this?

The literature shows that acupuncture is an effective and safe treatment for migraine prophylaxis; indeed, it is one of the only ones clinical experts know of. It is more effective than sham needling, demonstrating specific effects and it’s more effective and safer than drugs, demonstrating that it should be offered as a first-line treatment and often is.

So why would Dr Mathew write a largely unreferenced blog post on Harvard’s Health Blog based on anecdote, opinion and conjecture that’s directly contradicted by the medical literature?

A possible clue comes at the finale of the piece, where we learn that a) Dr Mathew provides Botox injections for migraines, b) that he trains others to perform the procedure and c) that he thinks it’s appropriate to mock patients about how painful this procedure is (the safety data confirms that pain is a common result of the treatment and teasing patients about it just seems cruel).

Ok, so he’s a bit biased. He provides Botox and wants to rib the competition. Not very professional, appropriate or ethical, but we all get our kicks in different ways. It’s not like he’s received payment from Allergan, I mean that would be highly unethical not to mention totally inappropriate to write something so libelous and inaccurate without making his conflicts of interest crystal clear.

Just to double-check, I headed over to ProPublica and it would seem that Dr Mathew has indeed received money from Allergan, the makers of Botox.

I suppose we’ll never know if Dr Mathew would have taken it upon himself to steer patients away from a safe and effective treatment for a debilitating neurological condition towards a treatment that suffers from lack of evidence and a risky side-effect profile if he wasn’t financially incentivized to do so. One wonders if it is even appropriate for someone who is receiving money from the pharmaceutical industry to be writing about a non-pharmacological treatment such as acupuncture at all when they apparently lack any familiarity with the subject matter.

But one thing is crystal clear: Harvard, for the sake of public health and academic integrity, a highly visible conflict of interest declaration needs to be added to the top of this ‘blog post’ post-haste.

Herbal and dietary supplements related to diarrhea and acute kidney injury: a case report.

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Herbal and dietary supplements related to diarrhea and acute kidney injury: a case report.

J Complement Integr Med. 2017 Mar 01;14(1):

Authors: Wanitsriphinyo S, Tangkiatkumjai M

Abstract
Background There is very little evidence relating to the association of herbal medicine with diarrhea and the development of acute kidney injury (AKI). This study reports a case of diarrhea-induced AKI, possibly related to an individual ingesting copious amounts of homemade mixed fruit and herb puree. Case presentation A 45-year-old Thai man with diabetes had diarrhea for 2 days, as a result of taking high amounts of a puree made up of eight mixed fruits and herbs over a 3-day period. He developed dehydration and stage 2 AKI, with a doubling of his serum creatinine. He had been receiving enalapril, as a prescribed medication, over one year. After he stopped taking both the puree and enalapril, and received fluid replacement therapy, within a week his serum creatinine had gradually decreased. The combination of puree, enalapril and AKI may also have induced hyperkalemia in this patient. Furthermore, the patient developed hyperphosphatemia due to his worsening kidney function, exacerbated by regularly taking some dietary supplements containing high levels of phosphate. His serum levels of potassium and phosphate returned to normal within a week, once the patient stopped both the puree and all dietary supplements, and had begun receiving treatment for hyperkalemia. Results The mixed fruit and herb puree taken by this man may have led to his diarrhea due to its effect; particularly if the patient was taking a high concentration of such a drink. Both the puree and enalapril are likely to attenuate the progression of kidney function. The causal relationship between the puree and AKI was probable (5 scores) assessed by the modified Naranjo algorithm. This is the first case report, as far as the authors are aware, relating the drinking of a mixed fruit and herbal puree to diarrhea and AKI in a patient with diabetes. Conclusions This case can alert health care providers to the possibility that herbal medicine could induce diarrhea and develop acute kidney injury.

PMID: 28282296 [PubMed – in process]

The anatomical study of the major signal points of the court-type Thai traditional massage on legs and their effects on blood flow and skin temperature.

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The anatomical study of the major signal points of the court-type Thai traditional massage on legs and their effects on blood flow and skin temperature.

J Integr Med. 2017 Mar;15(2):142-150

Authors: Viravud Y, Apichartvorakit A, Mutirangura P, Plakornkul V, Roongruangchai J, Vannabhum M, Laohapand T, Akarasereenont P

Abstract
OBJECTIVE: This study aims to investigate the relationship between major signal points (MaSPs) of the lower extremities used in court-type Thai traditional massage (CTTM) and the corresponding underlying anatomical structures, as well as to determine the short-term changes in blood flow and skin temperature of volunteers experiencing CTTM.
METHODS: MaSPs were identified and marked on cadavers before acrylic color was injected. The underlying structures marked with acrylic colors were observed and the anatomical structures were determined. Then, pressure was applied to each MaSP in human volunteers (lateral side of leg and medial side of leg) and blood flow on right dorsalis pedis artery was measured using duplex ultrasound while skin temperature changes were monitored using an infrared themographic camera.
RESULTS: Short-term changes in the blood flow parameters, volume flow and average velocity, compared to baseline (P < 0.05), were observed on MaSP of the lower extremity, ML4. Changes in the peak systolic velocity of the area ML5 were also observed relative to baseline. The skin temperature of two different MaSPs on the lateral side of leg (LL4 and LL5) and four on the medial side of leg (ML2, ML3, ML4 and ML5) was significantly increased (P < 0.05) at 1 min after pressure application.
CONCLUSION: This study established the clear correlation between the location of MaSP, as defined in CTTM, and the underlying anatomical structures. The effect of massage can stimulate skin blood flow because results showed increased skin temperature and blood flow characteristics. While these results were statistically significant, they may not be clinically relevant, as the present study focused on the immediate physiological effect of manipulation, rather than treatment effects. Thus, this study will serve as baseline data for further clinical studies in CTTM.

PMID: 28285619 [PubMed – in process]

Liu Yousheng on Illness in the Lower Back

The following is a short excerpt from one of the books that I translated and self-published a few years back, actually the first book produced by Happy Goat Productions. It seems to me that the wisdom of Virtue Healing embodied in Wang Fengyi’s teachings is particularly relevant in our current political turmoil in the US. I am holding the very first copy of our new edition, hot off the press, in my hands and, while reviewing it one last time, just came across this passage, which I think is worth sharing. I love the conclusion in particular: 

…do not use reason to work things out. If you reason with each other to work things out, you will only explode in anger. These days, people all reason with each other, until they reason each other into the ground. If they don’t end up separating, they end up getting a divorce. Between husband and wife, you must use your feelings to work things out. If you use your feelings to work things out, you will end up dearly loving each other again.

I think this advice applies not only to domestic relationships but these days is also really important, at least in the US, as we learn once again to get along with our neighbors, relatives, and friends, who may have voted differently from us. The only thing that will save American democracy, peace, and civility, in my personal view, instead of spiraling further and further into the dark emotions of blame, fear, and hatred of different groups of “Others,” will be our ability to consistently and consciously recall our shared humanity and kindness, our heart-to-heart connections, regardless of who we voted for in the last election. The following is a literal excerpt from Lecture Two, “Lecturing About Illness.” As you can see, my animals like the book as well.

Where does illness in the lower back come from? It comes from anger between husband and wife. In the past, the man was considered Heaven and the woman was considered earth, so when women got angry with men, the illness manifested in the head. In our modern age, though, times have changed and women and men are now equal. Anything that a man can do, a woman can do likewise. So just like a man can mange the affairs of society or government, a woman can do likewise. For this reason, when a man now gets angry with a woman, the illness manifests in the lower back. And when a woman gets angry with a man, the illness likewise manifests in the lower back. Now where do diseases in the kidney or in the intervertebral disks of the lumbar spine, and gynecological diseases come from? In the vast majority of cases, they come from disharmony between yin and yang, disharmony between husband and wife. You look at the way I handle something and consider it wrong. I look at the way you are handling something and consider it wrong. You annoy me, and I annoy you. Under these circumstances, it is easy to contract such conditions. In 2005, when my teacher Wang Yuanwu and I were on our way to Putuoshan to give a lecture, we were met at the airport in Shanghai by a man, unknown to both of us, who held up a sign to meet us. When I asked him why he had come to meet us when he didn’t know either one of us, he answered: “Dr. Liu Lihong told me to go and meet you here.” When I asked him why Dr. Liu Lihong had sent him to meet us, he told us: “I have been suffering from an illness for three years already and have taken all sorts of medications and tried every method out there, all with no result. Then I happened to come across Doctor Liu’s book “An Investigation of Chinese Medicine” (Sikao Zhongyi), read it, and found this doctor of Chinese medicine to be quite insightful. Therefore I pulled a lot of strings until I finally got to meet him in person, hoping that he would give me some medicine. Nevertheless, who would have thought that not only did he not prescribe any medication for me but instead told me to find you two in Shanghai! He told me that you would be able to help me with my illness.” So I asked him what illness he was suffering from. He answered: “Lower back pain. Every single morning around four or five am, the pain is so severe that I can no longer stay in bed but have to get up and walk around, with my hands pressing against my lumbar area. I said: “Such a minor disease? You simply haven’t found the root of your illness yet! As soon as you discover its root, you will be fine.” He responded: “But I don’t know where the root of my illness is.” I told him: “Fine. Let me tell you where this illness has come from. It has come from your neighbor, from the person who lives closest to you.” “But I don’t have a neighbor,” he responded. “I live in a building all by myself.” At this point, Teacher Wang interjected: “Young man! Don’t you have a wife? Isn’t that the person who lives closest to you?” Surprised, he objected that they were divorced. So I told him: “This is indeed where the root of your illness lies. If you had not gotten annoyed with her, you would not have contracted this illness, and you also would not have gotten a divorce. Because you disdain her as being ugly and useless, you don’t like her but like somebody else. And because of this, you have contracted this illness.” He responded by asking what he could do about the situation at this point. When I asked him whether he or his ex-wife had remarried, he informed us that neither of them had found another partner but that they were still living in the same house, he in one room and she in another room. I said, “There is a thread between you two that is connecting you.” “What kind of a thread?” he asked. I responded: “You still have a child together, who is running back and forth between this room and that room, torn between you two. As you two are fighting with each other, this thread is being pulled tighter and tighter, right up to the point of snapping apart. Now you two want to divorce, but what about this child who is caught in the middle? If he follows his father, he will not have a mother; if he follows his mother, he will not have a father. Think for a moment, don’t you think your son is suffering greatly from this situation? You two have brought this child into this world. You were able to give birth to him but now you are unable to raise him. As a result you will leave a troublemaker behind for society to deal with. And as loafers and vagrants get out into society, without a solid education and proper guidance, they waste their life away, committing all sorts of senseless acts. What good does that do for society? Because you were not satisfied with a minor aspect of your life, you went selfishly looking for pleasure. And you might have found temporary happiness, but you have created limitless suffering later on.” He agreed with me, “Yes, yes, yes! But what can I do about it now?” I told him, “Make the circle that has been broken whole again by reconciling with your wife. You two will be happy, and your child will also be happy. Go back to living in the same room!” Like this, we had talked to him for about twenty minutes. Then we embarked on a boat and left for Putuoshan, where we stayed for three days. On our return, he came once again to meet us. Noticing how happy he looked even from a great distance away, I commented to Master Wang that he had most certainly recovered. When Master Wang asked me how I knew that, I answered: “Just look at how happy he looks and you know it. That day when he came to meet us for the first time, do you remember what his facial expression looked like? It was so full of pain and suffering.” So when he walked up to us, we asked him how he was. And he told us that he had been completely pain-free for the past three nights and had been able to sleep until well into the morning. I commented: “This proves that you have restored harmony with your wife. Just look at yourself! Doctor Liu’s medicine is surely working well!” Hearing this, he laughed out loud. Between husband and wife, do not use reason to work things out. If you reason with each other to work things out, you will only explode in anger. These days, people all reason with each other, until they reason each other into the ground. If they don’t end up separating, they end up getting a divorce. Between husband and wife, you must use your feelings to work things out. If you use your feelings to work things out, you will end up dearly loving each other again.

Introduction to Ruesi Dat Ton

Ruesi Dat Ton and the Foundations of Thai Massage

Reusi Dat Ton is a little known aspect of traditional Thai healing and culture. It consists of breathing exercises, self-massage, acupressure, dynamic exercises, poses, mantras, visualization and meditation.

“Reusi” in Thai, from the Sanskrit Rishi, is an Ascetic Yogi or Hermit. “Dat” means to stretch, adjust or train. “Ton” is a classifier used for a Reusi and also means oneself. So “Reusi Dat Ton” means the Hermit’s or Yogi’s self-stretching or self-adjusting exercises. Reusis were also known as “Jatila,” Yogi,” and “Chee Prai.” The Reusis were custodians and practitioners of various ancient arts and sciences such as: tantra, yoga, natural medicine, alchemy, music, mathematics, astrology, palmistry, etc. They have counterparts in many ancient cultures, such as: the Siddhas of India, the Yogis of Nepal and Tibet, the Immortals of China, the Vijjadharas of Burma and the Cambodian Eysey (from the Pali word for Reusi, Isii).

There are different Reusi traditions within Thailand. There is a Southern Thai/Malay Tradition, a Northeastern Thai/Lao Tradition, a Central Thai/Khmer Tradition and a Northern Thai/Burmese/Tibetan Tradition. In Thailand, there are Reusis as far South as Kanchanaburi Province who follow the Northern Thai/Burmese/Tibetan Reusi Tradition.

A typical Reusi Dat Ton program would begin with breathing exercises and self-massage, followed by dynamic exercises and poses (some of which involve self acupressure) and finish with visualization, mantras and meditation. The exercises and poses of Reusi Dat Ton range from simple stretches which almost anyone could do, to very advanced poses which could take many years to master.

Some of the Reusi Dat Ton techniques are similar to or nearly identical to some techniques in various Tibetan Yoga Systems, particularly “Yantra Yoga,” “Kum Nye” and the Tibetan Yoga Frescoes from the Lukhang Temple behind the Potala Palace in Lhasa Tibet. (See Norbu, Tulku and Baker) For example; some of the self massage techniques, exercises, poses, neuromuscular locks (bandhas in Sanskrit,) breathing patterns, ratios, visualizations and the way in which male and female practitioners would practice the same technique differently are almost identical. It is possible that Reusi Dat Ton and some of the Tibetan Yoga Systems are derived from a common source, which Rishis brought with them as they moved down the Himalayan foothills into Southeast Asia.

According to the Reusi Tevijo Yogi “The foundation and key to Traditional Thai massage is Reusi Dat Ton. Ancient Reusis, through their own experimentation and experience, developed their understanding of the various bodies (physical, energetic and psychic, etc.) They discovered the postures, channels, points, the winds and wind gates within themselves. Later it was realized that these techniques could be adapted and applied to others for their healing benefit, which is

how Thai massage was developed. So, in order to really understand Thai massage, as a practitioner, one should have a foundation in Reusi Dat Ton and be able to experience it within oneself and then apply it to others. It is not only the roots of Thai massage but it also unlocks the method for treating oneself and maintaining one’s own health.” (Reusi Tevijo Yogi)

It is also interesting to note that there are many similarities between the Reusi Dat Ton “Joint Mobilization Exercises,” many Thai massage techniques and some of the Indian Hatha Yoga therapeutic warming up exercises (the Pawanmuktasana or wind liberating and energy freeing techniques.) There is even an advanced Hatha Yoga pose, Poorna Matsyendrasana, which compresses the femoral artery and produces the same effect as “opening the wind gate” in Reusi Dat Ton Self Massage and Traditional Thai massage. (Saraswati)

Reusi Dat Ton in Traditional Art

In Northeast Thailand, in Buriram province atop an extinct volcano sits the Ancient Khmer temple of Prasat Phnom Rung. Built between 900 and 1200AD, this temple is dedicated to the Hindu God Shiva. The pediment over the eastern doorway features a sculpture of an avatar of Shiva in the form of Yogadaksinamurti. According to the Department of Fine Arts “Yogadaksinamurti means Shiva in the form of the supreme ascetic, the one who gives and maintains wisdom, perception, concentration, asceticism, philosophy, music and the ability to heal disease with sacred chants.” Here “Shiva is dressed as a hermit with crowned headdress holding a rosary in his right hand, seated in the lalitasana position…surrounded by followers. There are figures below him that…represent the sick and wounded.” (Department of Fine Arts). All over the temple one can see additional carvings of Reusis engaged in various activities. In one carving of the “Five Yogis” (or Reusis) the central figure is the God Shiva in his incarnation as Nagulisa, the founder of the Pasupata sect of Shivaite Hinduism. The four yogis on his sides are followers of this Pasupata sect, which is still active today in Nepal.

In 1767, invading Burmese armies destroyed the old Thai capital of Ayutthaya. Soon after his coronation in 1782, the Thai King Rama I established a new capital in what is today Bangkok. He initiated a project to revive the Thai culture after the disaster of Ayutthaya. An old temple Wat Potharam, (popularly known as “Wat Po,”) was chosen to become the site of a new Royal temple

and formally renamed Wat Phra Chetuphon. Beginning in 1789, a renovation and expansion project was begun on the temple. King Rama I also initiated a program to restore and preserve all branches of ancient Thai arts and sciences including: medicine, astrology, religion and literature. As part of this project, medical texts from across the kingdom were collected and brought to be stored at Wat Po. The King also ordered the creation of a set of clay Reusi statues depicting various Reusi Dat Ton techniques.

This restoration project was continued by the Kings Rama II and Rama III. As part of this work, scholars compiled important texts on various ancient arts and sciences and created authoritative textbooks for each of these fields. In 1832, a project to etch the medical texts into marble tablets was begun. Medical theories regarding the origin and treatment of disease, massage charts and over 1000 herbal formulas were all recorded on the marble tablets. Gardens of medicinal herbs were also planted on the temple grounds. Thus, Wat Po was to become “a seat of learning for all classes of people in all walks of life” which would “expound all braches of traditional knowledge both religious and secular,” and serve as “an open university” of traditional Thai culture with a “library of stone.” (Griswold, 319-321)

By 1836, the clay Reusi Dat Ton statues created by order of King Rama I had deteriorated. To replace these, King Rama III commissioned the creation of 80 new Reusi Dat Ton statues. Each statue depicted a different Reusi performing a specific Reusi Dat Ton technique. For each statue there was a corresponding marble tablet upon which was etched a poem describing the technique and it’s curative effect. These poems were composed by various important personalities of the day. Princes, monks, government officials, physicians, poets, and even the King himself contributed verses. The original plan was to cast the statues with an alloy of zinc and tin, but unfortunately only the more perishable material stucco was used. The statues were then painted and housed in special pavilions. Over the years most of the original statues have been lost or destroyed. Today only about 20 remain and these are displayed upon two small “Hermit’s Mountains” near the Southern entrance of Wat Po. The marble tablets have been separated from their corresponding statues and are now stored in the pavilion Sala Rai.

Beginning in 2009, the casting of metal Reusi Dat Ton statues was begun. These new statues are gradually appearing in and around the Wat Po Massage School near the Eastern entrance of Wat Po. So now after almost 200 years, Wat Po will soon finally have it’s complete set of 80 metal Reusi Dat Ton statues as originally envisioned by King Rama III.

Textual Sources of Reusi Dat Ton

We may never know what, if any Ancient texts on Reusi Dat Ton may have existed and were lost when the invading Burmese armies destroyed the old Thai capital of Ayutthaya in 1767. Today, the closest thing to an original source text on Reusi Dat Ton is an 1838 manuscript commissioned by Rama III entitled The Book of Eighty Rishis Performing Posture Exercises to Cure Various Ailments. Like other manuscripts of the time, this text was printed on accordion like folded black paper, known in Thai as “Khoi.” This text, popularly known as the Samut Thai Kao features line drawings of the 80 Wat Po Reusi Dat Ton statues along with their accompanying poems. In the introduction, it states that Reusi Dat Ton is a “…system of posture exercises invented by experts to cure ailments and make them vanish away.” (Griswold, 321) This text is housed in the National Library in Bangkok. There are also other editions of this text housed in museums and private collections as well.

The Benefits of Reusi Dat Ton

In both the Samut Thai Kao and The Book of Medicine, the texts not only describe the techniques, but also ascribe a therapeutic benefit to each pose or exercise. Some poems describe specific ailments while others use Sanskrit Ayurvedic medical terminology.

Some of the ailments mentioned include; abdominal discomfort and pain, arm discomfort, back pain, bleeding, blurred vision, chest congestion, chest discomfort and pain, chin trouble, chronic disease, chronic muscular discomfort, congestion, convulsions, dizziness and vertigo, dyspepsia, facial paralysis, fainting, foot cramps, pain and numbness, gas pain, generalized weakness, generalized sharp pain, headache and migraine, hand discomfort, cramps and numbness, heel and ankle joint pain, hemorrhoids, hip joint problems, joint pain, knee pain and weakness, lack of alertness, leg discomfort, pain and weakness, lockjaw, low back pain, lumbar pain, muscular

cramps and stiffness, nasal bleeding, nausea, neck pain, numbness, pelvic pain, penis and urethra problems, scrotal distention, secretion in throat, shoulder and scapula discomfort and pain, stiff neck, thigh discomfort, throat problems, tongue trouble, uvula spasm, vertigo, waist trouble, wrist trouble, vomiting, and waist discomfort.

Some of the Ayurvedic disorders described in the texts include; Wata (Vata in Sanskrit) in the head causing problems in meditation, severe Wata disease, Wata in the hands and feet, Wata in the head, nose and shoulder, Wata in the thigh, Wata in the scrotum, Wata in the urethra, Wata causing knee, leg and chest spasms, Wata causing blurred vision, Sannipat (a very serious and difficult to treat condition due to the simultaneous imbalance of Water, Fire and Wind Elements which may also involve a toxic fever) an excess of Water Dhatu (possibly plasma or lymph fluids,) and “Wind” in the stomach. Other benefits described in the old texts include; increased longevity and opening all of the “Sen” (There are various types of “Sen” or channels in Traditional Thai Medicine. There are Gross Earth Physical “Sen” such as Blood Vessels. There are also more Subtle “Sen” such as channels of Bioenergy flow within the Subtle Body, known as “Nadis” in Sanskrit. In addition, there are also “Sen” as channels of the Mind.)

In recent years, the Thai Ministry of Public Health has published several books on Reusi Dat Ton. According these modern texts, some of the benefits of Reusi Dat Ton practice include; improved agility and muscle coordination, increased joint mobility, greater range of motion, better circulation, improved respiration improved digestion, assimilation and elimination, detoxification, stronger immunity, reduced stress and anxiety, greater relaxation, improved concentration and meditation, oxygen therapy to the cells, pain relief, slowing of degenerative disease and greater longevity. (Subcharoen, 5-7)

A recent study at Naresuan University in Phitsanulok, Thailand, found that after one month of regular Reusi Dat Ton practice there was an improvement in anaerobic exercise performance in sedentary females. (Weerapong et al, 205)

Thai Reusi Dat Ton and Indian Hatha Yoga

A survey of the traditional Indian Hatha Yoga text Jogapradipaka of Jayatarama from 1737AD identified the following 45 Indian asanas as having similar or identical counterparts in Thai Reusi Dat Ton; Svastikasana, Padmasana, Netiasana, Udaraasana, Purvasana, Pascimatanasana, Suryasana, Gorakhajaliasana, Anasuyasana, Machendrasana, Mahamudrasana, Jonimudrasana, Sivasana, Makadasana, Bhadragorakhasana, Cakriasana, Atamaramasana, Gohiasana, Bhindokasana, Andhasana, Vijogasana, Jonisana, Bhagasana, Rudrasana, Machindrasana (2nd variety), Vyasaasana, Dattadigambarasana, Carapatacaukasana, Gvalipauasana, Gopicandasana, Bharathariasana, Anjanasana, Savitriasana, Garudasana, Sukadevasana, Naradasana, Narasimghasana, Kapilasana, Yatiasana, Vrhaspatiasana, Parvatiasana, Siddhaharataliasana, Anilasana, Parasaramasana and Siddhasana. To date over 200 different Indian Hatha Yoga techniques have been identified which have similar or identical counterparts in Thai Reusi Dat Ton.

One unique feature of Reusi Dat Ton is the absence of Viparitakarani (Inversions) such as Shirshasana (Headstand), Sarvangasana (Shoulderstand.) Reusi Dat Ton also has no equivalents to Mayurasana (Peacock) or Bakasana (Crow). In Hatha Yoga both men and women use the left heel to press the perineum in Siddhasana (Adepts Pose), while in Reusi Dat Ton, men use the

right heel and women use the left. Reusi Dat Ton includes a series of “Joint Mobilization” exercises, many of which are very similar or identical to the Pawanmuktasana (Joint Loosening and Energy Freeing Exercises) taught by the Bihar School of Yoga in Northeast India. (Saraswati) Reusi Dat Ton also includes a system of self-massage, which is typically done prior to the exercises.

Both Hatha Yoga and Reusi Dat Ton practice forms of Surya and Chandra Bhedana Pranayama (Solar and Lunar Breathing.) However in Hatha Yoga men and women both use the right hand when practicing Pranayama (Breathing Exercises), while in Reusi Dat Ton men use the right hand and women use the left. Both use Ashwini Mudra (Anal Lock) and Jivha Bandha (Tongue Lock.) However, Reusi Dat Ton has no counterparts to Uddiyana Bandha (Abdominal Lock) or Jalandhara Bandha (Throat Lock.)

In Traditional Indian Hatha Yoga one will generally maintain an Asana for a few minutes. In contrast, Reusi Dat Ton tends to be more dynamic. Generally, one will inhale while going into the pose, hold the pose for several breaths, and then exhale when coming out of the pose. This is done to encourage the strong, healthy flow of Prana thru the Nadis (or Loam thru the Sen in Thai)

 Reusi Dat Ton Today

Today in Thailand, Reusi Dat Ton is being used in various ways. Some practice Reusi Dat Ton poses and exercises as a way to improve and maintain overall health, in much the same way as Hatha Yoga and Chi Gong are used today. Others such as Ajan Pisit Benjamongkonware of Pisit’s Massage School in Bangkok used Reusi Dat Ton in combination with traditional Thai Massage techniques as a system of therapy. They will use specific techniques for specific ailments, rather like an ancient system of rehabilitation similar to modern day Chiropractic and Physical Therapy. Others consider the energetic effects with the aim of facilitating the normal healthy flow of bioenergy through the “Sen” or energy channels of the subtle body. There are also a few remaining Reusis who still use Reusi Dat Ton in the traditional way as part of their personal meditation and spiritual practice.

The Institute of Thai Traditional Medicine at the Ministry of Public Health requires all their students of Thai Massage and Thai Traditional Medicine to attend Reusi Dat Ton classes as part of their curriculum. In these classes, students learn some of the self-massage techniques as well as 15 poses and exercises. While based on Reusi Dat Ton, these 15 techniques are actually newly created modifications thought to be safe and easily practiced by anyone. In Bangkok, The Wat Po School of Traditional Medicine offers a formal Reusi Dat Ton certification course in which students learn 18 of the poses and exercises. The Massage School Chiang Mai offers a formal Reusi Dat Ton certificate course, which is accredited by the Thai Ministry of Education. Their course is based on the same 15 poses and exercises as taught by the Ministry of Public Health. There are also a number of other places offering Reusi Dat Ton classes. Most of these programs teach either one or a combination of both of the two different programs, as taught by the Ministry of Public Health and Wat Po. There are also a number of commercially available Reusi Dat Ton books and videos.

Today in Thailand, there are a dwindling number of true Reusis and few young people are interested in learning the traditional arts and sciences in their authentic forms. Much of the traditional knowledge of the Reusi traditions is in danger of being lost. Nowadays, most modern day students and teachers of Reusi Dat Ton have learned from second or third hand sources such as commercially available books, videos and classes. They have not had access to primary sources such as actual Reusis or even the Samut Thai Kao. If this trend continues, there is a danger of Reusi Dat Ton becoming diluted and distorted like Hatha Yoga has become in today’s popular culture. Today we may well be seeing the last generation of teachers with an actual living link to the ancient traditions of the past and who are able to transmit the authentic teachings of Reusi Dat Ton. Serious students of Reusi Dat Ton would do well to seek out actual Reusis who have themselves learned from older Reusis who serve as a living link in the lineage of this ancient tradition.

Possible Future Research 

A possible research project would be to seek out Reusis and traditional healers across Thailand. One would then learn as much as possible about Reusi Dat Ton from them and compile it. This way the authentic teachings of this ancient tradition would not be lost in case these people die without being able to pass their knowledge on to the next generation. It could also be well worth investigating the many claims about the therapeutic effects attributed to Reusi Dat Ton practices in the old texts.

Bibliography of Readings about Ruesi Dat Ton

English Language 

  • Baker, Ian A. and Thomas Laird. (2000). “The Dali Lama’s Secret Temple: Tantric Wall Paintings from Tibet.” Thames & Hudson Ltd., London, UK.
  • Buhnemann, Gudrun. (2007). “Eighty-Four Asanas in Yoga: A Survey of Traditions.” (Contains the Jogapradipika of Jayatarama). D. K. Printworld, New Delhi, India.
  • Chokevivat, Vichai and Chuthaputti, Anchalee. (2005). “The Role of Thai Traditional Medicine in Health Promotion.” Thai Ministry of Public Health, Nonthaburi, Thailand.
  • Chuthaputti, Anchalee. (2007). “National Traditional System of Medicine Recognized by the Thai Government.” Thai Ministry of Public Health, Nonthaburi, Thailand.
  • Covington, Laura. (2010). “Interview with a Reusi.” (Interview with Reusi Tevijjo Yogi). Bodhi Tree Learning Center. Richmond, USA.
  • Department of Fine Arts. “Phnom Rung Historical Park Visitors Guide.” (And displays in the Phnom Rung Museum.) Department of Fine Arts, Buriram, Thailand.
  • Evans-Wentz, W. Y. (2006). “Tibetan Yoga and Secret Doctrines.” Pilgrims Publishing, Varanasi, India. Gharote, M. L. (Editor). (2006). “Encyclopaedia of Traditional Asanas.” The Lonavala Yoga Institute. Lonavala, India.
  • Ginsburg, Henry. (2000). “Thai Art and Culture: Historic Manuscripts from Western Collections.” University of Hawaii, Honolulu, USA.
  • Griswold, A.B. (1965). “The Rishis of Wat Po.” In Felicitation Volumes of Southeast Asian Studies Presented to His Highness Prince Dhaninivat Kromamun Bidyalabh Brindhyakorn. The Siam Society, Bangkok, Thailand.
  • H.H. Prince Dhani Nivat, “The Inscriptions of Wat Phra Jetubon,” Journal of the Siam Society. Vol. 26, Pt. 2. The Siam Society, Bangkok, Thailand.
  • Hofbauer, Rudolf. “A Medical Retrospect of Thailand.” In Journal of the Thailand Research Society, 34: 183-200. Thailand Research Society, Bangkok, Thailand.
  • Linrothe, Rob, (Editor). (2006). “Holy Madness: Portraits of Tantric Siddhas.” Rubin Museum of Art and Serindia Publications. New York and Chicago, USA.
  • Miao, Yuan. (2002). “Dancing on Rooftops with Dragons: The Yoga of Joy.” The Philosophical Research Society, Los Angeles, USA.
  • Massage School of Chiang Mai. (2006). Yogi Exercise “Lue Sri Dadton” Student Handbook. Massage School of Chiang Mai, Chiang Mai, Thailand.
  • Matics, Kathleen Isabelle. (1978). An Historical Analysis of the Fine Arts at Wat Phra Chetuphon: A Repository of Ratanakosin Artistic Heritage, PhD Dissertation, New York University, New York, USA. Matics, K.I. (1977). “Medical Arts at Wat Pha Chetuphon: Various Rishi Statues.” In Journal of the Siam Society, 65:2: 2: 145-152. The Siam Society, Bangkok, Thailand.
  • Norbu, Chogyal Namkhai. (2008). “Yantra Yoga: The Tibetan Yoga of Movement.” Snow Lion Publications, Ithaca, USA.
  • Reusi Tevijo Yogi. Personal Communication. Bangkok and Chiang Mai, Thailand.
  • Salguero, C. Pierce, (2007). “Traditional Thai Medicine: Buddhism, Animism and Ayurveda.” Hohm Press, Prescott, USA.
  • Saraswati, Swami Satyananda. (2006). “Asana, Pranayama, Mudra, Bandha.” Bihar School of Yoga, Yoga Publications Trust, Munger, India.
  • Schoeppl, Adolf. (1981). Textbook of Thai Traditional Manipulative Medicine, MPH Thesis, Mahidol University, Bangkok, Thailand.
  • Sheposh, Joel. (2006). Reusi Dat Ton: Thai Style Exercises, Tao Mt., Charlottesville, USA.
  • Subcharoen, Pennapa and Deewised Kunchana, (Editors). (1995). “The Hermits Art of Contorting: Thai Traditional Medicine.” The National Institute of Thai Traditional Medicine, Nontaburi, Thailand.
  • Tulku, Tarthang. (1978). “Kum Nye Relaxation: Parts 1and 2.” Dharma Publishing, Berkeley, USA. Tulku, Tarthang. (2003). “Tibetan Relaxation: Kum Nye Massage and Movement.” Duncan Baird Publications, London, UK.
  • Venerable Dhammasaro Bhikkhu. “Textbook of Basic Physical Training- Hermit Style (Rishi).” Wat Po. Bangkok, Thailand.
  • Wat Po Thai Traditional Medical School, Ruesi Dat Ton; Student Handbook. Wat Po. Bangkok, Thailand. White, David Gordon. (1996). “The Alchemical Body: Siddha Traditions in Medieval India.” University of Chicago Press, Chicago, USA.

Thai Language 

  • Ajan Pisit Benjamongkonware. (2007). “Twenty One Self Stretching Exercises (21 Ta Dat Ton).” Village Doctor Press, Bangkok, Thailand.
  • Ajan Pisit Benjamongkonware. Personal Communication. Pisit’s Massage School, Bangkok, Thailand, Ajan Kong Kaew Veera Prajak (Professor of Ancient Languages). Personal Communication. The Ancient Manuscript and Inscription Department, National Library, Bangkok, Thailand.
  • Chaya, Ooh E. (2006). “Thai Massage, Reusi Dat Ton: Therapy for Illness and Relaxation, (Nuat Thai, Reusi Dat Ton: Bam Bat Rok Pai Klie Klieat).” Pi Rim Press, Bangkok, Thailand.
  • Karen Reusi. Personal Communication via Dr. Robert Steinmetz of Wildlife Fund Thailand. Thung Yai National Park in Kanchanaburi Province, Thailand,
  • Mr. Kayat, (Editor). (1995). “Eighty Poses of Reusi Dat Ton, Wat Po (80 Ta Bat Reusi Dat Ton, Wat Po).” Pee Wa Tin Press, Bangkok, Thailand.
  • Mulaniti Health Center. (1994). “41 Poses, The Art of Self Massage for Health, (41 Ta, Sinlaba Gan Nuat Don Eng Pua Sukapap).” Mulaniti Health Center, Bangkok, Thailand.
  • Patanagit, Arun Rawee. (1994). “Body Exercise, Thai Style: Reusi Dat Ton, (Gan Brehan Rang Gie Bap Thai: Chut Reusi Dat Ton).” Petchkarat Press. Bangkok, Thailand.
  • Saw Pai Noie. (2001). “Lang Neua Chop Lang Ya.” Sai Ton Press, Bangkok, Thailand.
  • Sela Noie, Laeiat. (2000). “Amazing Thai Heritage: Reusi Dat Ton.” Dok Ya Press, Bangkok, Thailand. Subcharoen, Pennapa (Editor). (2004). “Handbook of Thai Style Exercise: 15 Basic Reusi Dat Ton Poses, (Ku Mu Gie Brehan Bap Thai Reusi Dat Ton 15 Ta).” Thai Traditional Medicine Development Foundation, Bangkok, Thailand.
  • Subcharoen, Pennapa (Editor). (2006). “One Hundred Twenty Seven Thai Style Exercises, Reusi Dat Ton (127 Ta Gie Brehan Bap Thai, Reusi Dat Ton).” Thai Traditional Medicine Development Foundation, Bangkok, Thailand.
  • Various authors commissioned by King Rama III. (1838). “The Book of Eighty Rishis Performing Posture Exercises to Cure Various Ailments (Samut Rup Reusi Dat Ton Kae Rok Tang Tang Baet Sip Rup).” (Also known as Samut Thai Kao) Housed in the National Library Bangkok, Thailand,
  • Wat Po Thai Traditional Medicine School. (1990). “Reusi Dat Ton Handbook (Dam Ra Reusi Dat Ton Wat Po).” (Reproductions from the original Samut Thai Kao). Wat Po Press, Bangkok, Thailand.
  • Wat Po Thai Traditional Medicine School. (1958). “The Book Of Medicine (Dam Ra Ya).” (Contains a Reusi Dat Ton section based on the same verses as the 1838 manuscript, Samut Thai Kao, but with completely different illustrations). Wat Po Press, Bangkok, Thailand.
  • Weerapong Chidnok, Opor Weerapun, Chanchira Wasuntarawat, Parinya Lertsinthai and Ekawee Sripariwuth. (2007). “Effect of Ruesi-Dudton-Stretching-Exercise Training to Anaerobic Fitness in Healthy Sedentary Females.” Naresuan University Journal 2007; 15 (3) 205-214. Phittsanulok, Thailand.

Daoist Contemplation and Chinese Medicine, Part 1: History and definition of contemplation in Daoist texts

Different forms of contemplative practices have been one of the key elements in Daoist tradition. This essay will appear in four parts dealing with:

1. History and definition of contemplation in Daoist texts

2. Contemplative practices and concept of body-mind

3. Contemplation and dietary practices

4. Contemplation and art of medicine

In these short essays I define contemplative practices, look historical relevance and how has it affected the development Chinese medicine and what does it has to do with ideals of art of medicine. Some concepts presented might no longer fit to current understanding of Chinese medicine, but they have played consequential role in formulation of ideas and have been influential cultural context for ancient doctors who wrote some of the foremost classics of Chinese medicine. While reading these essays please keep in mind, that heart and mind are same word (xīn 心) in Chinese.

Defining Daoist contemplation

To be able to track down history of contemplative practices we first need to be able to define what we mean by contemplation. Modern practitioners usually prefer to use trendy terms like mindfulness often defined as conscious awareness and non-judgmental acceptance. While this might work well for some forms of practices, for more historical study we have to to rely on Daoist and Chinese Buddhist terms, definitions and context.

Mindfulness research literature often takes terms sati (Pāli) and smṛti (Sanskrit), which directly translates to Chinese niàn 念, to mean contemplation and mindfulness. Niàn means memory or recollection; to think on or to reflect upon something; to read or study. In Daoist context this term can be used for studying scriptures and contemplating or holding an object or idea in mind. Sometimes this is done by concentrating on a deity.

However, most of the Daoist texts use term guān 觀 in Chinese literature. It translates to looking and observing. Very often it is used in connection with word nèi 內 which means inner or internal to denote the nature and direction of observation. Therefore nèiguān 內觀 could be translated as inner observation. Nèiguān also serves as literal translation of Buddhist concepts of vipassanā (Pāli or vipaśyanā in Sanskrit). Inner contemplation or nèiguān is set of practices where one directs his awareness within himself. In different types and stages of the practice object of awareness can be body as whole or some part like an organ. Object can be an emotion and how it is experienced within body-mind in level qì or energy. Many of these techniques concentrate on breathing. Some of the breathing meditations are similar to what is described in Buddhist Ānāpānasati Sutta (Pāli) or Ānāpānasmṛti Sūtra (Sanskrit). However Daoist practitioners often start their practice by concentrating on subtleties of breathing felt on lower abdomen instead the mindfulness of breathing itself.

The aim of contemplation has usually been, especially in Daoist practice, to be able to slowly shift ones attention to mind itself. This is usually seen as the key element of the practice in Daoist context as the “real” contemplation is apophatic in nature, striving to attain total emptiness and complete negation or detachment from desires, concepts and contents of the mind. This emptiness is obtained by silencing the mind with sustained non-interfering observation or Nèiguān. The famous Qīngjìngjīng 清靜經 explains:

能遣之者,内觀於心,心無其心;外觀於形,形無其形;遠觀於物,物無其物。三者既悟,唯見於空。觀 空以空,空無所空。所空既無,無無亦無。無無既無,湛然常寂。寂無所寂,慾豈能生?慾既不生, 即是真靜。

“These [desires] can be removed by internally contemplating the heart (mind). The heart is not this heart. Externally contemplating form. The form is not this forms. From distance contemplating things. These things are not these things. After these three have been realized and [you are] just seeing these as emptiness, contemplate this emptiness with emptiness. Emptiness does not exists in emptiness. In [this] emptiness there is still [further] non-existence. Non-existence of non-existence is also non-existing. [When] non-existence of non-existence is non-existing, there is deepest and eternal stillness. In stillness [where even] stillness does not exists, how could desires arise? When desires cannot arise, it is true peace.”

Despite the epilogue by Gě Xuán 葛玄 (164–244) who attributed the text to goddess Xīwángmǔ 西王母, in reality the text is probably written during early Tang-dynasty (618 – 907)[1]. The wording is clearly influenced by Buddhism but it gives the essential idea about contemplative practice and its apophatic nature. Following this nature we can start tracing contemplative practices through history. This nature is crucial for understanding continuation of the practice, its ideals and importance to Chinese medical and philosophical culture.

Early views and history of contemplative practices in China

Nèiguān practices that flourished in China during Tang-dynasty (618 – 907) are usually thought to have their origin in Buddhism. Buddhism started spreading to China during the 2nd century CE and one of the most well known Buddhist missionaries during the time was Ān Shìgāo 安世高 (c. 148 – 180) who translated Buddhist texts to Chinese language[2]. Among these texts there was also Ānāpānasati Sutta containing outlines of same idea used in practice of nèiguān. But even before that the practice was already well known in China. One of the oldest and synonymous expression to nèiguān is kǎonèishēn 考內身 which can be found from scripture titled Báixīn 白心 or Purifying the mind. In Báixīn there is a passage which says:

欲愛吾身,先知吾情君親六合,以考內身。以此知象,乃知行情既知行情,乃知養生。

“Desires and affections [arise from] our own body. First we understand our emotions, ruling sentiments and six harmonies by looking inside the body. Then we’ll know images after which we understand movement of emotions. By knowing movement of emotions we then understand cultivation of life (yǎngshēng).”

I translate kǎonèishēn here as looking inside the body. It might have been more easily understood by Western readers of spiritual practices, if I had translated it to inspecting inner bodies but that might be a bit stretching for context of early Daoist texts. Therefore the word body (shēn 身) needs bit clarification. The view of body in many archaic Chinese texts was much more broad than our modern use of the word. It was not just torso with four limbs but more a vessel composed of and containing different energies, spiritual influences and essence (jīng 精). It was seen intimately connected to time and world around us. I’ll come back to nature of body-mind in next part but the important thing here is that Báixīn gives advice to turn our attention into our body-minds to become aware of emotions and mental images. Báixīn also belongs to the earliest texts using term yǎngshēng or cultivating life which later formed a central concept in many medical and religious practices.

Báixīn dates back to 285 – 235 B.C. being from last period of Jìxià Academy (Jìxià xuégōng 稷下學宮)[3]. It is included in collection of political and philosophical texts named Guǎnzǐ 管子. The collection contains three other meditative texts namely Xīnshù shàng 心術上, Xīnshù xià 心術下 and Nèiyè 內業. Both Xīnshù texts speak of emptiness of the heart or mind. “Empty it (mind) from desires and Shén (Spirit) enters its domain. Clean from impure and Shén will remain in its place.” (《心術上》:虛其欲,神將入舍。掃除不潔,神乃留處。)

Xīnshù texts expand the ideas presented in older text called Nèiyè and transform individual meditation practice to fit the fields of economics and politics. They advocate importance of contemplative mindfulness practice to rulers and bureaucrats. The ideal ruler must remain detached from confusion of emotions and doubts. Their mind must remain clear in order to rule efficiently. Xīnshù xià states that:

心安,是國安也。心治,是國治也。… 治心在於中,治言出於口,治事加於民;故功作而民從,則 百姓治矣。

“When mind is peaceful nation is at peace. When mind is governed nation is [under] governance…When governed mind stays at its center and controlled words come out of mouth then governed actions are guiding the subjects. Thus good results are achieved and people will follow. In this way the common people are governed.”

Many texts from Huáng-Lǎo School promote contemplation to gain understanding of laws of governing people and contemplation was seen as a mean to understand universal way or law which also controlled the society. This discourse is highly interesting when we compare it to modern mindfulness movement and especially mindful leadership where we see similar claims and uses. Meditative texts of Guǎnzǐ do not demand worship, divination or other ritualistic techniques. They are plain and simple self cultivation practices written by the literati to other members of ruling class of their time. The fact that these texts were included in highly political text collection gives us an impression that these practices were wide spread and not known only in religious circles. This is especially evident as many of the texts in Guǎnzǐ belong to strict Legalist school that saw tradition and softer values as weakness to be cut down[4].

The Guǎnzǐ collection also includes scripture called Nèiyè 內業 or Internal practice, which is probably the oldest of surviving Chinese meditation manuals and dates back to circa 325 B.C. The poetic style of Nèiyè suggests oral tradition and therefore even older origin.[3] Nèiyè presents very clear and plain description of meditation. Its themes are similar to many Tang-dynasty meditation texts and Nèiyè defines connection of man to universe, reason for contemplation, different attitudes and key elements for practice. The text begins with idea how human being is connected to cosmos:

凡物之精,比則為生下生五穀,上為列星。流於天地之間,謂之鬼神,藏於胸中,謂之聖人。

“From the essence of every being comes their life. Below it gives birth to five grains, above forms the constellations. Its flow between heaven and earth we call as spirits and gods. When it is stored within center of chest we call him a sage.”

During writing of Nèiyè the idea of essence (jīng 精) was still developing. The essence was seen as something having nature of divinity or spirit. Later it became described more substantial and bit liquid like as in texts like Huángdì Nèijīng Sùwèn 黃帝內經素問. The concept of Jīng-Shén 精神, which is usually translated as life-force or vigor it still retained its early intangibility. Some of the early texts see essence as one of the “bodily spirits” or shén.

The text proceeds defining how all the sorrows arise from the heart and they are ended with the heart. The heart was seen to effect everyone around us, bringing with it our fortunes or misfortunes. Only cultivation of the heart was seen as means for real moral development and thus Nèiyè states that:

賞不足以勸善,刑不足以懲過。氣意得而天下服。心意定而天下聽。

“Rewards are not sufficient to encourage virtue, nor punishments enough for disciplining. [Only] when qi-mind is obtained, that what is under the heaven will be subjugated. Only when heart-mind is stopped that what is under the heaven will obey.”

Same idea of shedding false morals, ethical values and empty rituals and replacing them by true nature was recurring theme in even earlier Zhuāngzǐ 莊子.

Author(s) of Nèiyè also pondered how or what in the mind can observe itself:

何謂解之,在於心安。我心治,官乃治。我心安,官乃安。治之者心也,安之者心也;心以藏心,心之中又有心焉。彼心之心,音以先言,音然後形,形然後言。言然後使,使然後治。不治必亂,亂乃死。

“How to explain that which is in peaceful heart? [When] I (ego) and heart are regulated, officials (organs) are regulated. [When] I and heart are at peace, officials are in peace. One regulating them is heart. One pacifying them is heart. There is heart hidden within heart. In the center of the heart there is another heart! This heart within heart is the voice before the words. From the voice follow forms, from the form follow the words. From the words follow actions and from the actions follow governing. [From that which] is not governed follows chaos and from the chaos follows death.”

As non-controlled mind was seen as main reason for chaos and destruction the often emphasized benefit from cultivation was freedom from internal conflict and outer catastrophes. In Nèiyè this freedom is describes thus:

中無惑意,外無邪菑,心全於中,形全於外。不逢天菑,不遇人害,謂之聖人。

“Without confusing thoughts within, one is externally without evil and disasters. Heart maintained in the center and form is maintained externally. [Thus one does] not encounter heavenly calamities nor face human troubles [therefore] we call him a sage.”

Freedom from human suffering later became exaggerated more and more until it became immortality and total untouchability during Han-dynasty and was still aim of contemplative practitioners during Tang-dynasty. See for example text called Preserving Shén and refining Qì.
The themes of freedom, emptiness and cultivation of heart were also present in many other writings of the time, but were often less instructive and more ambiguous in their poetic or prosaic expression. Of these texts Dàodéjīng 道德經 and Zhuāngzǐ are famous examples. Zhuāngzǐ for example describes fasting of the heart in following quote:

回曰:「敢問心齋。」仲尼曰:「若一志,无聽之以耳而聽之以心,无聽之以心而聽之以氣。聽止於耳,心止於符。氣也者,虛而待物者也。唯道集虛。虛者,心齋也。」

“[Yán] Huí said: Could I ask about fasting of mind?
Zhòng Ní answered: When having singular will, you’ll not hear with ears but you hear them with heart. When not hearing with heart you’ll hear them with qì. Hearing stops to listening with ears. Heart stops to symbols. The Qì is emptiness that receives things. Only Dào gathers in emptiness. Emptiness is fasting of the heart.”

Dàodéjīng as the best known Daoist text has collected many different translations around it. The text describes contemplation in its 16th chapter:

致虛極,守靜篤。萬物並作,吾以觀復。夫物芸芸,各復歸其根。歸根曰靜,是謂復命。復命曰常,知常曰明。不知常,妄作凶。知常容,容乃公,公乃天,天乃道,道乃久,沒身不殆。

“Reaching the utmost emptiness and guarding stillness and honesty, 10 000 things are working in union. Contemplating this, I’ll return. Countless humans and beings all return to their root. Returning to the root is called stillness. It is also described as returning to life (fù mìng is literally returning the destiny). Returning to life is called eternity. Knowing eternity is called enlightenment. Not knowing eternity [you just] arrogantly cause disasters. By knowing eternal you’ll accept. From accepting follows fairness. From fairness follows completion. From completion follows heavenly and from heavenly follows Dào. From Dào follows continuation and [then even] disappearance of body is not fatal.”

Considering this particular chapter we have to take into account that Dàodéjīng, as we now read it, was edited by Wáng Bì during early third century. The chapter found from the Mǎwángduī excavation, dating to second century B.C.[5] is very similar but a century older Guōdiàn[6] version does not mention contemplation at all. The importance of observing with empty mind is prominent in many other chapters as well.

Taking into account textual evidence about these contemplative practices and the idea of using them for returning to original state or to finding true nature had clearly been already developed before end of Warring States period. The Chinese still remained isolated from India centuries after writing the meditative texts of Guǎnzǐ or Dàodéjīng and Zhuāngzì. It was only at the first and second centuries during which trading of goods and thoughts between China and India really begun. If we consider the possible dating of historical Buddha to be somewhere around the commonly agreed 566–486 B.C.[7], it is hardly likely that Buddhist influence at the time could have induced such a wide spread of contemplative ideology in China. Buddhist tradition speaks of teachers Ārāḍa Kālāmalta ja Uddaka Rāmaputta as well reputed teachers, so we can say that these practices were also more wide spread in India during that time. But with lack of active trade routes, cultural exchange and having textual sources showing more wide spread cultural use of the contemplative ideas in China, we may conclude that it is highly likely that contemplative practices were developed independently in China and the Buddhist influences merged to Chinese contemplative ideologies and practices only later.

Rise of Buddhism in China however sparked new interest in contemplative practices. Old texts were edited, new texts were written and older classics were interpreted from viewpoint more fitting to contemplative practices. Zuòwàng lùn 坐忘論, which quotes heavily on Dàodéjīng and Zhuāngzǐ, is good example of reinterpreting older scriptures. The spread of Buddhism also influenced other areas of practices like dietary taboos and ethical codes. What remained the same was apophatic nature of contemplative practice. To quote a Tang-dynasty text called Nèiguānjīng 內觀經 – Classic of inner contemplation:

道也者,不可言傳口授而得之。常虛心靜神,道自來居。

“Dào cannot be put to words. By mouth it cannot be given or obtained. [By having] constantly empty heart and tranquil spirit, Dào naturally returns to its residence.”

 

References

  1. Verellen Franciscus and Schipper Kristofer. The Taoist Canon: A Historical Companion to the Daozang. University Of Chicago Press, 2005.
  2. Greene Eric M. Healing breaths and rotting bones: On the relationship between buddhist and chinese meditation practices during the eastern han and three kingdoms period. Journal of Chinese Religions, 4(2):145–184, 3 2014. (www)
  3. Roth Harold D. Daoism in the guanzi. In book Liu Xiaogan (editor), Dao Companion to Daoist Philosophy, pages 265–280. Springer, 2015.
  4. Rickett Allyn W. Guanzi: Political, Economic, and Philosophical Essays from Early China. Princeton University Press, 1998.
  5. Harper Donald. Early Chinese Medical Literature. Routledge, 1997.
  6. Meyer Dirk. Meaning-Construction in Warring States Philosophical Discourse: A Discussion of the Palaeographic Materials from Tomb Guōdiàn One. Doctoral thesis, Leiden University, 2008. (www)
  7. Heinz Bechert, editor. The Dating o fthe Historical Buddha. Die Datierung des Historischen Buddha. Symposien zur Buddhismusforschung, IV, 1, 1991. (www)

Wikipedia, We have a problem

In a nutshell: Acupuncture has been increasingly embraced by conventional care as an efficacious treatment for a variety of conditions. Evidence of this support comes from recommendations for acupuncture in numerous medical guidelines, Cochrane systematic reviews demonstrating clinical effectiveness, and an explosion of research interest into acupuncture’s effectiveness and mechanisms of action.

All of this support notwithstanding, the article devoted to acupuncture on Wikipedia, the most accessed source of medical information on the internet and supposedly an unbiased source of curated information that anyone who follows Wikipedia’s policies can edit, reflects a somewhat different perspective. The page, controlled by a group of staunch anti-acupuncture ‘pseudoskeptics’ – insists that the mainstream support for acupuncture from the medical and scientific community doesn’t exist, even when it is presented to them, and presents their subjective minority opinion as the dominant one. They mainly do this by a) ignoring high-quality sources that contradict their perspective and b) systematically intimidating, bullying and banning anyone who dares to say otherwise. This state of affairs is problematic on many levels, not least of which because it directly impedes access to informed health care choice. I’m hopeful that an open discussion of the evidence and my own recent (and short!) experience as a Wikipedia editor before being indefinitely banned for challenging their version of consensus can result in an improvement to the Wikipedia article vis-à-vis how well it reflects objective reality and better enforcement of Wikipedia’s anti-bullying guidelines.

Making the case for acupuncture’s mainstream support

The pejorative designation of ‘pseudoscience’ is defined by Wikipedia in reference to what is perceived as scientific and medical consensus. To say that ‘acupuncture is pseudoscience’, as the Wikipedia article flatly states, is to say that acupuncture enjoys little to no mainstream medical and scientific support. The administrators and (remaining) editors of the Acupuncture article on Wikipedia have claimed just that. Sure, acupuncture does have some fans, but these people are universally gullible morons who wouldn’t know a null hypothesis if it poked them in the eye, so their argument goes. Anyone with a medical degree and two brain cells to rub together will concur that acupuncture is woo-tastic, pseudo-scientific quackery.

Of course, any statement about what scientific consensus does or does not show needs to be backed by suitable references and Wikipedia provides specific guidance on what it considers to be  Reliable medical sources (or MEDRS, as they’re known in Wiki-speak):

“Ideal sources for biomedical information include: review articles (especially systematic reviews) published in reputable medical journals; academic and professional books written by experts in the relevant fields and from respected publishers; and guidelines or position statements from national or international expert bodies.”

In other words, one can reliably demonstrate that acupuncture enjoys mainstream scientific and medical support (and does not meet Wikipedia’s definition of pseudoscience) by providing review articles and position statements by expert bodies.

So what do medically reliable sources say on the subject of mainstream medical support for acupuncture?

Acupuncture is recommended in conventional medical guidelines

According to Tgeorgescu, who holds a Masters in Philosophy, is a Member of the Dutch Society against Quackery and long-time Wikipedia enforcer, not only is there no mainstream scientific support for acupuncture (reference not provided), but providing evidence that there is support is grounds for being banned from Wikipedia.

Medical guidelines produced by medical and clinical organisations constitute one of the most direct types of evidence we have to assess ‘medical consensus.’ Acupuncture is recommended by the following mainstream Medical Guidelines and Organisations

  • The World Health Organisation has developed a list of 27 conditions for which it recommends acupuncture after its evidence review1
  • The Joint Commission, which accredits more than 21,000 health care organizations and programs in the United States and globally, recommends acupuncture as a first-line treatment in the management of pain
  • The Agency for Healthcare Research and Quality (AHRQ) guideline on Non-invasive treatments for Low Back Pain found acupuncture to be amongst the most effective treatments 2
  • The Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society on the Diagnosis and Treatment of Low Back Pain recommends acupuncture 3
  • The American Academy of Family Physicians recommends acupuncture4 for a variety of pain conditions
  • The American college of occupational and environmental medicine’s practice guidelines recommend acupuncture5
  • The U.S. Department of Health and Human Services – National Institutes of Health Guidance on Low Back Pain recommend acupuncture6
  • The State of Colorado Division of Workers’ Compensation Medical Treatment Guidelines for Low Back Pain recommends acupuncture7
  • The Institute for Health Economics Evidence-Informed Primary Care Management of Low Back Pain Alberta, Canada recommend a course of acupuncture for chronic low back pain 8
  • Scotland’s National Clinical Guideline for the Management of chronic pain recommends acupuncture for low back pain and osteoarthritis, characterising the strength of the evidence as Grade A (the highest support available)9
  • The National Institute for Health and Care Excellence (NICE) recommends a course of acupuncture for the prevention of migraines and tension-type headaches. In fact, acupuncture is the only treatment recommended for the prevention of tension-type headaches.
  • The 4th Edition of “Acute Pain Management: Scientific Evidence,” Produced by the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, found Level I evidence for acupuncture for five different clinical indications 10

Wow, the WHO, the AHRQ, NICE and the Joint Commission, pretty much the ‘who’s who’ of prestigious mainstream medical consensus building institutions, all recommend acupuncture? I mean, a couple of acupuncture-recommending guidelines would have been sufficient to demonstrate that the ‘pseudoscience’ designation was controversial and the Wikipedia article needs to be changed to reflect this undisputed reality; the number and strength of the recommendations here are vastly surplus to requirement for that purpose. Sure, there are a few guidelines recommending against acupuncture11, but these guidelines simply provide support of another opinion and obviously don’t negate the existence of all the guidelines clearly supporting acupuncture.

So the most respected conventional medical organisations in the world, after rigorous scientific review, have created consensus time and again around recommending acupuncture for a variety of treatments. These guidelines ubiquitously steer clear of evaluating or recommending Angel Healing, Reiki, or Crystal therapy (no disrespect). The very existence of these guidelines automatically renders the statement “acupuncture is pseudoscience” completely invalid. They provide indisputable evidence that meaningful parts of the mainstream medical community recommend acupuncture. While one is welcome to discuss the quality or methods of the guideline development, one cannot dispute their existence.

Cochrane Reviews

According to Hob, every single Cochrane Review of acupuncture performed has found no significant difference between Acupuncture and sham (no reference provided). In reality, a number of Cochrane reviews have found acupuncture to be superior to sham (for example, migraine, tension-type headache). These reviews are referenced on the Wikipedia acupuncture page and on the very talk page where Hob has written his comment but Hob seems to prefer to ignore their existance.

While the guidelines listed above are surplus to requirement for demonstrating meaningful mainstream consensus for acupuncture’s recommendation, Cochrane Reviews are considered amongst the highest levels of evidence in medicine and provide additional high-quality support.

  • Cochrane Systematic Review published in April, found that for the prevention of tension-type headaches, acupuncture was more effective than usual care and pain medication (48% of those who received acupuncture vs 19% of those who received meds had a positive response) and acupuncture was more efficacious than sham (50% of acupuncture recipients vs 43% of patients who received sham acupuncture had a positive response)12
  • Another Cochrane Review for Acupuncture in the treatment of Migraines found that acupuncture is far more effective than usual care and also more effective than sham needling.13
  • Acupuncture was found to be superior to sham, waitlist and physical therapy for peripheral joint osteoarthritis14
  • Acupuncture is superior to usual care in the treatment of fibromyalgia 15
  • Acupuncture is superior to usual care for cancer-related pain and auricular (ear) acupuncture was found to be superior to placebo for chronic neuropathic pain related to cancer16
  • Acupuncture was found to be superior to anti-spasmodic drugs, which themselves have been shown to be better than placebo, in the treatment of Irritable Bowel Syndrome

Mechanism research

According to Hob Gadling, long-time Wiki-editor, admin, and fighter of Pseudoscience, ‘acupuncture is clearly a magic practice and has neither a viable mechanism nor evidence on its side” (references not provided). When provided high-quality evidence of mechanism (peer-reviewed evidence syntheses) and efficacy (for example, Cochrane Reviews), he has failed to address these but maintains his opinion: definitely pseudoscience. And not only does he think it’s pseudoscience but according to him, this is also the medical and scientific consensus (reference not provided).

  • The International Review of Neurobiology published a 363-page evidence review of acupuncture’s mechanisms and clinical areas where acupuncture has strong evidence of effectiveness. The IRN only publishes reviews on conventional and mainstream medical neurological subjects 17
  • A recent review published in the Neuroscientist has summarised the evidence for acupuncture’s effects through purinergic signalling.18 It notes: “The seminal hypothesis of Geoffrey Burnstock and the astounding findings of Maiken Nedergaard on the involvement of purinergic signaling in the beneficial effects of acupuncture fertilized the field and led to an intensification of research on acupurines.” Incidentally, Wikipedia tells us that the “The Neuroscientist is a peer-reviewed academic journal that publishes papers in the field of Neurology . . . aimed at basic neuroscientists (sic), neurologists, neurosurgeons, and psychiatrists in research, academic, and clinical settings, reviewing new and emerging basic and clinical neuroscience research. The journal evaluates key trends in molecular, cellular, developmental, behavioral systems, and cognitive neuroscience in a disease-relevant format.” The article must have forgotten to mention its studies of quackery and pseudoscience.

A recent review by Dr Thomas Lundeberg, a neurologist and Professor at the Karolinska Institute, one of the top medical schools in the world, and Irene Lund, adjunct at the Karolinska Institute’s department of Department of Physiology and Pharmacology, summarises acupunctures mechanisms thusly:

“The effects of acupuncture may be attributed to:

1) Peripheral effects (release of adenosine and nitric oxide, NO, by axonal and dorsal root reflexes).
2) Spinal effects (modulation of sympathetic tone and motor reflexes)
Modulation of endogenous descending pain inhibitory and facilitatory systems
3) Change in the functional connectivity of the brain. Activation or deactivation of:
a) limbic structures involved in stress/illness responses
b) the hypothalamus-pituitary-adrenal, HPA, axis
c) the prefrontal and frontal cortices.
4) Restoration of the default mode state.
5) Modulation of parasympathetic activity.
6) Activation of the reward and mirror systems
7) Modulation of activation of the immune system
8) Expectation, attention, conditioning and extinction of conditioned responses”19

Increasing use in Mainstream settings

Acupuncture has been used in the US military for over a decade and its use is expanding. 8 out of the top 10 rated cancer hospitals in the United States offer acupuncture treatment on site. Following trials that showed that acupuncture was twice as effective as usual care for low back pain relief, it is covered by national health insurance in Germany.

Ok, so there clearly are mainstream medical researchers and health-care policy makers from some of the most respected institutions in the world who do officially endorse acupuncture, as suitably demonstrated above. Surely when presented with all of this evidence, the pseudo-Skeptical admins would have to concede despite their own personal feelings that significant parts of the mainstream medical establishment do recommend acupuncture . . .

“Acupuncture is Pseudoscience,” says Wikipedia

Acupuncture clearly enjoys a staggering amount of mainstream scientific support. So how does one decide exactly what pseudoscience is?

Well, Wikipedia has a specific policy on when it is appropriate to apply the label. We find this policy under the content guideline on something called “Fringe Theories.”

“We use the term fringe theory in a very broad sense to describe an idea that departs significantly from the prevailing views or mainstream views in its particular field. For example, fringe theories in science depart significantly from mainstream science and have little or no scientific support.”

In other words, whether or not a theory is ‘fringe’ depends on the ‘prevailing’ or ‘mainstream’ views of the field. If a theory (or treatment) enjoys mainstream scientific support, it neither fringe nor pseudoscience. Wikipedia’s guidance on the matter goes even further to articulate what can and cannot be branded with the unfortunate mark of pseudoscience. The guidance describes the grand ‘spectrum of fringe theories’ thusly:

“Not all pseudoscience and fringe theories are alike.” Oh, no. “In addition, there is an approximate demarcation between pseudoscience and questionable science, and they merit careful treatment.

  • Pseudoscience: Proposals that, while purporting to be scientific, are obviously bogus may be so labeled and categorized as such without more justification. For example, since the universal scientific view is that perpetual motion is impossible, any purported perpetual motion mechanism (e.g. Stanley Meyer’s water fuel cell) may be treated as pseudoscience. Proposals which are generally considered pseudoscience by the scientific community, such as astrology, may properly contain that information and may be categorized as pseudoscience.
  • Questionable science: Hypotheses which have a substantial following but which critics describe as pseudoscience, may contain information to that effect; however it should not be described as unambiguously pseudoscientific while a reasonable amount of academic debate still exists on this point.”

Taking into account all of the medical guidelines, position papers, Cochrane reviews and increasing research interest, acupuncture very clearly falls into the latter category. Yes, acupuncture does court a small but vocal group of detractors – these groups are usually distinguishable by a variant of the word ‘Skeptic’ in their title (as in Guerilla Skepticism on Wikipedia, a group devoted to training and sending groups of self-styled ‘Skeptics’ to edit Wikipedia articles to be more in line with their particular world-view), a most ironic use of the word ‘Science’ in their name (as in Science-Based Medicine) and can be seen to frequently use terms like ‘woo’ and ‘quackery,’ which are almost entirely absent from the vocabulary of the majority of those involved with healthcare and scientific research. They almost exclusively reference narrative opinion pieces by other Skeptics, such as this cherry-picking tired old hag, who’s seen more action than a brothel in a seaport, rather than primary or valid secondary sources such as Cochrane, displaying an embarrassing lack of familiarity with Ye Olde Evidence Hierarchy. These groups engage, according to the mainstream medical community, in something called ‘pseudoskepticism‘ and are to rational scientific inquiry what religious extremists are to mainstream religion and spirituality.

Denial: Not Just a River in Egypt

Having been presented with Wikipedia-appropriate high-quality medical references, including the medical guidelines, systematic reviews, and mechanism research syntheses listed above, how does this reliable information about acupuncture mesh with the skeptical world-view? Well, it doesn’t.

So how do the admins on the acupuncture page justify continuing to present their view as the undisputed consensus view in the face of so much evidence to the contrary? I’ve observed a number of well-worn patterns, here are the most common:

Label supporters of Acupuncture as Idiots

According to user ‘Hob Gadling’:

“Acupuncture is clearly a magic practice and has neither a viable mechanism nor evidence on its side. Still, it is used by lots of folks who do not know how to tell valid methods from superstition. Those people clearly do not agree that acupuncture is pseudoscience, but the situation is exactly the same as with other pseudosciences: their proponents do not agree that they are pseudoscientists. We get that all the time, for instance from Intelligent Design proponents.” 5:07, 14 December 2016 (UTC)

Yes, superstitious folks unfamiliar with valid research methods, like those morons at Harvard, the utter simpletons found at The National Institute of Neurological Disorders and Stroke and the irredeemable idiots over at the Mayo Clinic all recommend acupuncture.

User ‘Guy’ tells us: “At this point everyone other than the pathological believers is basically ready to move on. The great tragedy of science: the slaying of a beautiful hypothesis by ugly fact. Guy 23:18, 15 December 2016 (UTC)”

Fascinating. And yet, according to the recent study produced by Harvard and IBM, “Acupuncture research has grown markedly in the past two decades, with a 2-fold higher growth rate than for biomedical research overall. Both the increases in the proportion of RCTs and the impact factor of journals support that the quality of published research has improved. . . These findings provide a context for analyzing strengths and gaps in the current state of acupuncture research, and for informing a comprehensive strategy for further advancing the field.”20 Looks like the ‘pathological believers’ at Harvard are developing a comprehensive strategy to further advance acupuncture.

“. . . Of course, your statements do not become true by repeating them. Acupuncture is not “mainstream”, and you will not find a reliable source that says it is. . . –Hob Gadling 21:28, 14 December 2016 (UTC)

Difficult to know quite how to respond, given that we had already presented dozens of very reliable sources that said just that (my mistake for thinking that repetition would somehow help the reality sink in).

“It’s implausible, there’s no remotely plausible mechanism, most of the claims made for it are patent nonsense, it’s practiced by people who for the most part have absolutely no valid medical training and do not use any kind of infection control techniques, and it shows absolutely no sign of getting its house in order . . . Guy 09:05, 22 December 2016 (UTC)

Fact-check: Globally, the majority of those who practice acupuncture are licensed doctors with medical degrees, including over 35,000 MDs outside of South East Asia.

Invent your own evidence

“Science is not done by majority vote, it is done by data and their publication in scientific journals. Gather all the Cochrane meta-analyses done about acupuncture and show that they agree that acupuncture is better than placebo, and you win. You can’t because they all say the opposite, so you lose. Bye. —Hob Gadling 23:20, 13 December 2016 (UTC)”

Fact check: Multiple Cochrane reviews show that acupuncture is better than sham acupuncture and much better than usual care. But because the public are being misinformed about their healthcare choices by a source they mistakenly trust, you’re right, we all lose.

User Alexbrn tells us: “the enlightened basis of what we do is the real world: scientific plausibility, common sense & reason. Acupuncture boosters, Bigfoot spotters, 9/11 conspiracists, cultists etc. don’t like this but it’s their problem with reality which causes friction, not Wikipedia itself. If exceptionally strong sources appear, then we can follow them: until then, Wikipedia shall take a properly skeptical stance.” 09:56, 29 October 2016 (UTC)

“I think it is fair to say by now that there is no robust evidence that acupuncture works for anything, and any area where the balance of P=0.05 is still positive, is an artifact.” Guy 20:24, 14 December 2016 (UTC)

“there is no good evidence it works for most conditions, and all we have left are a handful of conditions where counting the papers shows a majority passing P=0.05 on subjective endpoints (which is entirely consistent with the expected 5% false positive rate inherent in P=0.05) . . .” Guy 09:05, 22 December 2016 (UTC)

Translation: the Cochrane Reviews that demonstrate that acupuncture is superior to sham and usual care are wrong. Because Guy says so. Of course, all of the high-quality reviews of medical interventions ever gathered have an equal chance of being wrong – any of these results could equally be ‘artifacts.’ Thus using Guy’s logic, we would chuck out everything we think we know about medical science. Guy is happy to delete the entire corpus of medical knowledge in order to maintain the view that acupuncture doesn’t work, demonstrating what lengths people are willing to go to in order to protect a cherished belief.

“However there are ample sources in this article that acupuncture is pseudoscience and that it has no scientific base whatsoever. Carl Fredrik 00:23, 16 December 2016 (UTC)”

“”Wikipedia is heavily biased for mainstream science” (or mainstream anything) is exactly how I’d expect an encyclopedia to work. On science subjects, Wikipedia should present articles with a balance that is supported by reliable peer-reviewed sources that exercise proper editorial control and are based on accepted scientific method – mainstream science by definition. (talk) 08:23, 21 December 2016 (UTC)” says User “Boing! said Zebedee”, while failing to acknowledge the panoply of reliable peer-reviewed sources that exercise proper editorial control and are based on accepted scientific method supporting acupuncture’s efficacy.

“The comparison is to the point: although propagated by quackademics, both therapeutic touch and acupuncture lack mainstream scientific support. That’s the reality of mainstream science. So, if you claim that they have lots of mainstream scientific support, that’s a mystification.” Tgeorgescu 20:51, 21 December 2016 (UTC)

Sure, Tgeorgescu, I have ‘mystified’ over a dozen medical guidelines into existence. I’m just that good.

It only works for pain

A user called ‘Roxy the dog’, who agrees that acupuncture is pseudoscience, decisively breaks out from the pack and acknowledges the existence of the scientific resources that elucidate some of acupuncture’s biological mechanisms. His/her comment: “Doesn’t the hatted list of ‘sources’ demonstrate a pain response, and nothing more? 12:37, 15 December 2016 (UTC)”

User ‘Alexbrn’, ferociously anti-acupuncture, shares a similar sentiment: “Really? Isn’t it rather that they’re pretty much firmly decided that acupuncture is ineffective overall, with a possible exception in one area: pain relief? 17:07, 14 December 2016 (UTC)”

Yeah, because that would be useless. An effective treatment for pain. Roxy and Alex agree that acupuncture lacks any useful function whatsoever and that it be branded as “pseudoscience” because all it does is provide efficacious pain relief <facepalm>.

When all else fails, silence your critics

As a new editor, I thought that presenting new high-quality medical references to the discussion on acupuncture’s Talk page in order to ensure that the article reflected the most up to date scientific perspective would be appreciated. Boy was I wrong.

“@Ellaqmentry: You have done absolutely nothing right. A cursory inspection of the talk page archives should have shown you that your arguments have been made and rejected for years. . . if you persist in making those comments, you are likely to become another (editor banned from Acupuncture) . . .” — Arthur Rubin 16:57, 19 December 2016 (UTC)

In response to these comments, I asked Arthur to please not bully me. He responded by vandalising my user page, removing the ‘new user’ tag I had put there so that folks would know I was new to the community.

“You have to take into account that Wikipedia is heavily biased for mainstream science. Those who manifestly work against this bias are subjected to discretionary sanctions.” Tgeorgescu 23:02, 20 December 2016 (UTC)

“Let me put it simply: if you continue to claim that acupuncture has mainstream scientific validation, you have no future as an Wikipedia editor.” Tgeorgescu 21:05, 21 December 2016 (UTC)

“To reiterate and clarify: if you continue to claim that acupuncture has mainstream scientific validation, you have no future as an Wikipedia editor. That is true not “regardless of whether or not it actually has”, it is true because it hasn’t. . . ” Guy 23:04, 21 December 2016 (UTC)

We Follow the Sources

So what’s the other side of this coin? How do the acupuncture article admins justify branding acupuncture pseudoscience according to indisputable medical consensus in the face of so much evidence to the contrary? The comments you are about to read were made with the benefit of the above research references.

The Acu-Wiki admins have provided two sources that they feel prove without a shadow of a doubt that the medical and scientific consensus pretty much unanimously agree that acupuncture is pseudoscience: the first is an introductory undergraduate textbook for non-science majors.21 The second is a primer on science in education.22 Neither of these sources is peer-reviewed, referenced or bills itself as a representation of scientific or medical consensus.

But let’s hear what the pseudoskeptical admins say about the strength of their sources. In each of the following, the author is referring to these two non-medical, non-referenced, non-peer-reviewed books.

“No, those sources are fine.” 19:26, 29 October 2016 (UTC) Says Carl Fredrik, a 4th year medical student, when questioned about their validity.

User Someguy1221 was slightly more circumspect about the sources supporting acupuncture as pseudoscience: “We subject sources on the side of pseudoscience and pseudomedicine, such as acupuncture, to a far higher degree of scrutiny than we do sources on the side of actual science and medicine. Some sources used in the article may not meet the strict criteria of MEDRS, but no one cares, because these do not say anything controversial – if we were to exclude them in exchange for actual MEDRS-compliant sources, the article content would not change significantly. But articles that find something promising in acupuncture and appear on their face to be MEDRS compliant, on the other hand, are basically universally found to have serious problems that invalidate their reliability.” 08:50, 29 October 2016 (UTC)

Translation: because there’s nothing controversial about saying that acupuncture is pseudoscience (aside from the fact that Wikipedia editors have been arguing about this since 2001) we do not have to use appropriate references to support the statement. Conversely, high quality, appropriate references supporting acupuncture’s acceptance or efficacy are flawed because they support acupuncture. Ah, Someguy1221, your head sounds like a fascinating place to live.

But by far the largest advocate of ‘the sources,’ Alexbrn, who has a PhD in English but no scientific or medical background to speak of, was downright exuberant about the strength of the aforementioned sources.

“Most of these dodgy areas have studies trying to validate them (cf homeopathy and osteopathy). As far as pseudoscience goes, we have two excellent sources that address the categorisation and are explicit. Acupuncture is pseudoscience. Wikipedia reflects such sources. “Alexbrn 12:32, 15 December 2016 (UTC)

“Incorrect. Both sources, which are strong WP:MEDRS23 assert that acupuncture is pseudoscience. We follow such sources, not the musings of random WP:SPA wikipedia editors. Alexbrn 14:42, 15 December 2016 (UTC)

“Whatever way you look at it, reliably-published medical books (referring to the two non-medical books above) which specifically consider the non-scientific are the best possible sources available. To find sources on the question of acupuncture and its relation to pseudoscience, try searching collections with the search terms “acupuncture” and “pseudoscience” maybe? All you are doing is producing fallacious arguments and hand-waving. Stick to following sources and all shall be well. Alexbrn 15:01, 15 December 2016 (UTC)”

“More hand-waving and fallacy. We have two top-rate sources that are bang on topic, and they are explicit in what they say. No amount of trying to question how they came to be, to personalize the matter, or to big up your own credentials is remotely relevant to the formation of consensus here, which is based exclusively on the WP:PAG. Wikipedia reflects what the best sources say; they say acupuncture is pseudoscience, so Wikipedia shall too. It’s really very simple. The only thing that might give pause is an equally strong source which explicitly considered the pseudoscience categorisation and rejects it.” Alexbrn 15:52, 15 December 2016 (UTC)

“This “majority view” stuff is baloney. The sources we have which consider the pseudoscience question place acupuncture in that category. Show me sources that consider the question which don’t. Lots of nonsenses are studied at Masters level and beyond: homeopathy, ayurveda, cranial therapy … these novel arguments are irrelevant in any case since we follow the sources.” Alexbrn 15:56, 15 December 2016 (UTC)

“Luckily we have excellent sources which directly consider acupuncture’s relationship to pseudoscience. They tell us it is pseudoscience – Wikipedia accordingly follows because that is the way this place works.” Alexbrn 16:27, 15 December 2016 (UTC)

“Besides, my personal opinion counts for nothing: what matters is what our good sources say on the pseudoscience question. Here, they’re nice and clear.” Alexbrn 18:01, 15 December 2016 (UTC)

“On pseudoscience, all the sources we have agree, and nobody has produced any RS (reliable sources) in opposition . . . ” Alexbrn 18:50, 15 December 2016 (UTC)

And, my personal favourite:

“We’re citing two high-quality medical textbooks focusing directly on the topic of pseudoscience. Despite the fact we don’t need such super-strength sources, we have them and we use them. We reflect what our sources say; OTOH the “personal” WP:PROFRINGE preference here is yours.” 10:26, 29 October 2016 (UTC)

Super-strength, high-quality medical textbooks. Wow. I think the only accurate descriptor in that sentiment is “books”. It was shortly after this discussion about the super-strength medical textbooks that Alexbrn would recommend on the administrator forum that I be indefinitely banned from editing on Wikipedia and the community, already having banned anyone else of a different opinion, would agree.

Wikipedia, the Encyclopedia that anyone can edit, so long as you don’t violate consensus.

But surely with Wikipedia being the ‘Free Encyclopedia’ that anyone can edit, the contents of the acupuncture page reflects the consensus opinion of the global community of English-speaking editors who have participated in its development. If there were reasonable evidence that the contents were incorrect, one could just present this and have it changed, no?

Sadly this is not the case.

13 December 2016: I created my first and only editor account on Wikipedia.

13 – 19 December 2016: I made a total of 20 comments on Wikipedia’s acupuncture discussion page. I made no edits to the Acupuncture article itself. My comments were respectful, relevant, and referenced.

19 December 2016: An administrator who goes by Someguy1221, created a new notice in the administrator’s noticeboard accusing me of being a “Sock-puppet”, which is when an editor who has been banned from editing creates a new account to circumvent the ban.

According to Wikipedia’s policy on accusing someone of this type of misconduct:

“Before opening an investigation, you need good reason to suspect sock puppetry.

Evidence is required. When you open the investigation, you must immediately provide evidence that the suspected sock puppets are connected . . . You must provide this evidence in a clear way. Vaguely worded submissions will not be investigated. You need to actually show why your suspicion that the accounts are connected is reasonable.”

No evidence was provided for his allegation that I’m a Sock, which is a violation of Wikipedia’s policy on making such an accusation.

Someguys1221 also accused me of being a “Point of View Pusher,” which is where someone makes an ‘aggressive’ presentation of a particular point of view in a Wikipedia article; I never made a single edit to any Wikipedia article, aggressive or otherwise.

For my alleged crimes, Someguy1221 recommended that I be indefinitely banned from using Wikipedia or Topic banned from participating in the editing of the Acupuncture article.

19 December 2016: Guy, a Wikipedia administrator who disagreed with my perspective on acupuncture’s mainstream support, indefinitely blocked me from editing Wikipedia articles. Given his involvement in the discussion, this was a clear violation of Wikipedia’s policies which state that admins who are involved should not do the blocking. After this, he had another administrator block me instead.

Since this time, I have been indefinitely banned from editing any part of the Wikipedia project, even though I have not violated a single one of Wikipedia’s policies in either letter or spirit. It seems that simply making the argument that acupuncture enjoys mainstream medical support is sufficient grounds for being banned from editing Wikipedia.

Unfortunately, my experience of being banned for providing high-quality evidence that acupuncture enjoys mainstream support is not an isolated incident. A Wikipedia editor who goes by the username A1candidate provided the following contribution. Following this contribution, he/she was also banned from editing the acupuncture article.

“Acupuncture should not be classified as fringe science because

  1. The American Heart Association‘s consensus statement says that acupuncture’s mechanism of effect appears to be through sensory mechanoreceptor and nociceptor stimulation induced by “connective tissues being wound around the needle”.[1]
  2. Britain’s National Health Service says that acupuncture is used in the majority of pain clinics and hospices in the UK and it is “based on scientific evidence that shows the treatment can stimulate nerves under the skin and in muscle tissue”.[2]
  3. Cancer Research UK says that “medical research has shown that acupuncture works by stimulating nerves to release the body’s own natural chemicals.” [3]
  4. The New England Journal of Medicine says that “some physiological phenomena associated with acupuncture have been identified” [4]
  5. Harrison’s Principles of Internal Medicine says that “the emerging acceptance of acupuncture results in part from its widespread availability and use in the United States today, even within the walls of major medical centers where it is used as an ancillary approach to pain management” Chapter e2, Page 5, McGraw-Hill, 2011, ISBN 978007174890224

Additionally, on 16 December, a long-time editor called LesVegas was also banned from editing the acupuncture page. The reason given? That he had repeatedly tagged the acupuncture article as violating Wikipedia’s neutral point of view policies – specifically, because it incorrectly refers to acupuncture as pseudoscience.

More recently, an editor called LesVegas posted a comment to the page of Jim Wales, founder of Wikipedia, asking the following:

“. . .I can’t help but wonder if your strong and necessary response to some pseudoscience pushers has, unwittingly, emboldened a group of editors who see it as their mission to disparage all fields they deem pseudoscience. Take a look at the Acupuncture article, for instance. In the lede it says that “acupuncture is a pseudoscience”, definitively as if it came from the Mouth of God (and not merely the opinions of a couple of scientific authors.) Since there are numerous Cochrane Reviews which show acupuncture’s efficacy for various conditions, as well as WHO, NHS and NIH consensus statements about acupuncture’s efficacy for certain conditions, how can such a statement fall within our neutrality guidelines? Of course the entire scientific community hasn’t established the consensus that acupuncture is pseudoscience. States don’t have licensing boards for obvious pseudoscience, nor do scientists publish hundreds if not thousands of studies on obvious pseudoscience each year like they do with acupuncture . . . Whenever high-quality systematic reviews or meta-analyses show acupuncture in a positive light, they are rejected or deleted by these same editors who cherry-pick their own reviews and give them prominence . . . Do you believe articles like Acupuncture, which give QuackWatch more prominence than the NIH, fall within the spirit of this project? LesVegas (talk) 01:09, 16 December 2016 (UTC)”

Hours after posting this, LesVegas was indefinitely banned from editing the acupuncture article or anything remotely related to it.

Indisputably Pseudoscience? There’s No Contest

While every issue has multiple perspectives, what’s amazing is how woefully lopsided this particular debate is. The view expressed by the Wikipedia admins, which they are systematically bullying and banning Wikipedia compliant editors to defend, is one backed by un-referenced, easily disproven, error-prone opinions and fabrications. The majority of the remaining Wikipedia ‘community,’ after banning dissenters, appears to have no background in medicine or medical research. The crux of their argument relies on denying the existence of dozens of documents that demonstrate medical consensus in favour of acupuncture that clearly do exist. And this behaviour is from individuals claiming to speak on behalf of scientific rigour and rationality! It would be quite funny if it didn’t actually cause serious, systematic harm by steering people away from one of the most effective and safest treatment options ever studied. Meanwhile, as opposed to other areas of medicine, where topic experts are encouraged to participate if not relied upon for accuracy, acupuncture researchers and medical professionals who use this intervention and are versed on the literature are discouraged and banned from editing.

While Jimmy Wales and other decision-makers at Wikipedia have historically been anti-complementary medicine, the maintenance of the perspective that acupuncture is incontrovertibly pseudoscience in the face of so much evidence to the contrary comes at a steep price. It depends on censorship, denialism, and the compromising of every standard for judging scientific consensus and efficacy, not to mention escalating violations of Wikipedia’s own policies of conduct. The silly thing is that real scientists and the most rational people regularly update their theories on how things work based on new evidence. Hopefully, in the not too distant future, the acupuncture article will benefit from these rational perspectives.

Wai Khruu ไหว้ครู honour/pay respect to the teacher

The front of the lecture hall in the grounds of a hospital in Chiang Mai is adorned by a long table laden with offerings of all kinds. An otherwise utilitarian space large enough to hold some 200 people has been transformed by the table bearing offerings on the raised dais at the front of the hall. There are garlands of gardenia, Indian marigolds strewn loosely and in piles, and lotus flowers are poking out of small brass urns; the perfume is overwhelming. Pyramids of limes, bananas and hot-pink dragon fruit are piled on the offering plates. There are coconut and sago desserts, pumpkin and coconut balls, and rice flour cakes all beautifully presented on plates in patterns and decorated with carved flowers. Incense sprouts from every possible flower arrangement and yellow temple candles stand among the many brightly colored floral arrangements and sweet–meats. There are fresh herbs such as ginger (khing ขิง Zingiber officinalis), cassumar ginger (phlaii ไพล Zingiber cassumar) and decorative glass jars of dried and powdered herbs, including cinnamon (opchoei อบเชย Cinnamomum zeylandicum). On a raised altar, there is an image of the Buddha (head and shoulders above all others as is usual: this is a way of expressing his pre-eminent status), the hermit (ruesi ฤษี the ascetic figure closely associated with healing and wisdom) and Jivaka Komarpaj, (ชีวกโกมารภัจจ์) the Buddha’s physician and the head of the Thai healing pantheon. Continue reading Wai Khruu ไหว้ครู honour/pay respect to the teacher

International Workshop May 8-10, 2015: Developing an interdisciplinary and multilingual digital knowledge base on Tibetan medical formulas with a focus on stress-related ‘wind’ (rlung) disorders

This report first appeared in the IASTAM newsletter: http://iastam.org/wp-content/uploads/2013/12/IASTAM-newsletter-Summer-2016.pdf

The three-day long workshop brought together international expert physicians and scholars of Tibetan medicine – medical anthropologists, historians, (ethno)botanists, pharmacologists, pharmacists – working with and/or on Tibetan medicine, and also experts in Chinese medicine, as well as IT specialists. The aim was to discuss and contribute toward how an interdisciplinary and multilingual digital knowledge base should look like that could be used in the future as an analytic tool for documenting and analysing Tibetan medical formulas. Processes of cultural translation are intrinsic to such translations between different languages, medical concepts of health and disease, and disciplinary approaches and interests, and therefore are often vexed and problematic.

Prepared by a one-month-long pilot study by visiting scholar-physician of Tibetan medicine, Dr Cairang Nanjia from the Tibetan Medical College, Qinghai University, PRC, and the author of this report, at the time a Wellcome Trust research fellow at EASTmedicine, University of Westminster (2012-2015), this ensuing workshop proved a fruitful platform for discussing some of the outcomes and issues involved in such a complex endeavour. Both pilot project and workshop were co-funded by the British Academy/Leverhulme Small Research Grant combined with private funds by The Sino-British Fellowship Trust. Asian workshop participants were supported by an additional IASTAM fund. The author would like to express her gratitude to these foundations and to IASTAM that made this encounter between scholars from different disciplines truly special and fruitful. This included scholars who rarely discuss their different interests and approaches, physicians-cum-pharmacists from Asia, and pharmaceutical producers focusing on Tibetan formulas.

We focused on a particular Tibetan formula complex containing the main ingredient eaglewood (Lat. different types of Aquillaria; Tib. a ga ru or a gar)—in the following Agar-formulas (Agar 8, Agar 15, Agar 20, Agar 35, Sogdzin 11). These were chosen as case studies for they are usually prescribed in relation to specific classifications of ‘wind’ (Tib. rlung) disorders that can be correlated with what we understand as classic ‘stress’ symptoms, such as insomnia and depression.

Dr Cairang Nanjia began the inquiry by documenting Agar-formulas in Tibetan medical, botanical and pharmacological texts used at present in Amdo, the Tibetan populated parts of Qinghai and Gansu provinces of China, focusing also on their structure, single ingredients and relations to each other. The author related her ethnographic material on different styles of production and prescription practices of Agar-formulas in both China and parts of Europe, and both Cairang and Schrempf co-developed, together with advice from IT specialist Kapetanios a possible multi-level digital knowledge base structure of synonyms and homonyms in order to deal with the complexity of different languages, concepts and terminologies. The preliminary results were presented at the workshop for discussion.

Workshop participants used different sources and analysed them following up on specific questions, such as which texts are important for understanding Tibetan materia medica and formulae and by whom they are produced, prescribed and used today; which ingredients are we actually talking about in a formula; how and why are certain rare or endangered materia medica ingredients in a formula substituted; why and how does a formula work; what is its local, regional, botanical identification; what are ’wind’ (Tib. rlung) disorders in Tibetan medicine and how can one correlate them with biomedical diseases related to ’stress’ (let alone trying to define the fluid concept and the Tibetan dynamic of ’wind’, or what does stress mean to body and mind). Complex issues without doubt constantly required our own translation exercises between Tibetan, English and Chinese languages.

Sources used and topics addressed by the workshop participants ranged from analysing Tibetan historical medical and botanical texts to develop a feasible structure for​ Tibetan formulas (Czaja) to Chinese publications on minority medicines and how information on their materia medica is collected in China (Springer); how the seminal Tibetan medical text, the Four Tantras or rGyud bzhi explains the classification and treatment of rlung disorders (Cuomu); how specific rlung disorders, specially ‘heart wind’ (Tib. snying rlung) and ‘life sustaining wind’ (Tib. srog ’dzin rlung), are taught to Tibetan medical students in Xining (Sanjijia); presenting his experiences as a physician-cum-pharmacist by the eminent co-founder and teacher at the Tibetan medical hospital in Xining (Dr Nyima); how Agar-compounds in their various forms and styles are prescribed in both Asian and European contexts (Schrempf); presenting patient case studies and related prescription practices for ‘wind’ disorders in the UK (Millard) in which, however, no Agar-compounds were used; asking socio-cultural and ethno- as well as medical botanical questions about the difficulties in identifying plant names, such as Aquillaria agallocha (van der Valk, Allkin, Leon); demonstrating salient issues of sustainability of materia medica growing in Ladkah (Padma Gurmet); demonstrating the life work for Tibetan medicine by the eminent scholar and teacher Akong Rinpoche in both his home area of Kham and the UK, focusing on the sustainability of medical plants (Sweeney); how to understand Tibetan materia medica and formulas in relation to TCM while both address stress-related symptoms (Ploberger); how the pharmaceutical company Padma AG has created and adapted the Tibetan formula Sogdzin 11 into Padma Nervotonin (Schwabl and Vennos); and, last but not least, what a digital data base can offer if one is interested in mapping drugs across time and space (Stanley-Baker, Chen Shi-Pei, Brent Haoyang Ho).

The aim of the workshop was to relate and analyse formula and substitution patterns, culturally distinct ideas of efficacy and safety and different disease categories/body images in relation to ways of diagnosing, formulating/producing, prescribing and using these chosen Tibetan formulas. Only careful translations will allow to properly correlate different concepts of Tibetan, Chinese and bio-medicine, keeping regional, national and global regulatory regimes in mind. It would desirable if in the future we could pursue an integrative and synthesising approach to Tibetan Medicine with a sensitivity to various interpretations in this multi-lingual endeavour, as well as trying to correlate different disciplines and practices.

The aim would be to explore careful and meaningful ways of representing Tibetan cultural and medical knowledge and develop suitable key search terms in different semantic networks in order to make such a digital knowledge base a useful tool for researchers and practitioners alike.

For more information concerning the EASTmedicine research group and the workshop, see the group’s website at https://www.westminster.ac.uk/eastmedicine-research-group