Reiki and related therapies in the dialysis ward: an evidence-based and ethical discussion to debate if these complementary and alternative medicines are welcomed or banned

  • Martina Ferraresi1Email author,

    Affiliated with

    • Roberta Clari1,

      Affiliated with

      • Irene Moro1,

        Affiliated with

        • Elena Banino2,

          Affiliated with

          • Enrico Boero2,

            Affiliated with

            • Alessandro Crosio2,

              Affiliated with

              • Romina Dayne2,

                Affiliated with

                • Lorenzo Rosset2,

                  Affiliated with

                  • Andrea Scarpa2,

                    Affiliated with

                    • Enrica Serra2,

                      Affiliated with

                      • Alessandra Surace2,

                        Affiliated with

                        • Alessio Testore2,

                          Affiliated with

                          • Nicoletta Colombi3 and

                            Affiliated with

                            • Barbara Giorgina Piccoli1Email author

                              Affiliated with

                              BMC Nephrology201314:129

                              DOI: 10.1186/1471-2369-14-129

                              Received: 4 October 2012

                              Accepted: 3 June 2013

                              Published: 21 June 2013

                              Abstract

                              Background

                              Complementary and Alternative Medicines (CAMs) are increasingly practiced in the general population; it is estimated that over 30% of patients with chronic diseases use CAMs on a regular basis. CAMs are also used in hospital settings, suggesting a growing interest in individualized therapies. One potential field of interest is pain, frequently reported by dialysis patients, and seldom sufficiently relieved by mainstream therapies. Gentle-touch therapies and Reiki (an energy based touch therapy) are widely used in the western population as pain relievers.

                              By integrating evidence based approaches and providing ethical discussion, this debate discusses the pros and cons of CAMs in the dialysis ward, and whether such approaches should be welcomed or banned.

                              Discussion

                              In spite of the wide use of CAMs in the general population, few studies deal with the pros and cons of an integration of mainstream medicine and CAMs in dialysis patients; one paper only regarded the use of Reiki and related practices. Widening the search to chronic pain, Reiki and related practices, 419 articles were found on Medline and 6 were selected (1 Cochrane review and 5 RCTs updating the Cochrane review). According to the EBM approach, Reiki allows a statistically significant but very low-grade pain reduction without specific side effects. Gentle-touch therapy and Reiki are thus good examples of approaches in which controversial efficacy has to be balanced against no known side effect, frequent free availability (volunteer non-profit associations) and easy integration with any other pharmacological or non pharmacological therapy. While a classical evidence-based approach, showing low-grade efficacy, is likely to lead to a negative attitude towards the use of Reiki in the dialysis ward, the ethical discussion, analyzing beneficium (efficacy) together with non maleficium (side effects), justice (cost, availability and integration with mainstream therapies) and autonomy (patients’ choice) is likely to lead to a permissive-positive attitude.

                              Summary

                              This paper debates the current evidence on Reiki and related techniques as pain-relievers in an ethical framework, and suggests that physicians may wish to consider efficacy but also side effects, contextualization (availability and costs) and patient’s requests, according also to the suggestions of the Society for Integrative Oncology (tolerate, control efficacy and side effects).

                              Keywords

                              Chronic pain Chronic kidney disease Alternative Allied and complementary medicine Reiki Touch therapy

                              Background

                              Complementary or allied-alternative medicines (CAMs) are increasingly being used, in particular in patients affected by chronic diseases or diseases “without therapy” [13]. The world prevalence of CAMs varies considerably (35-75% in non-selected general populations); in this context, the reluctance to admit CAM use may underestimate it [415]. On the other hand, the inclusion of prayer, which is usually considered as a part of the CAMs, can double their prevalence; this is an interesting and highly discussed issue, as not all Authors agree to consider religious beliefs as a part of a therapeutic pathway. However, for the sake of the present review, we would like to mention that one of the first randomized controlled trials on CAMs published on a core clinical journal, the MANTRA trial, regarded the healing effect of prayer [12].

                              A few reports have dealt with the use of CAMs in Nephrology and Dialysis, underlining their growing diffusion and the need for specific education in renal medicine [16, 17].

                              The opening of the “conventional” to the “complementary” raises new problems: the rapid increase in demand for CAMs requires an adequate medical education and a change in the attitude of hospitals and physicians towards CAMs. According to a 2001 survey, CAMs were taught in about 40% of European medical schools and in 64% of USA ones [1820]. While several problems remain to be solved (primarily the lack of certification and controls), the position statements of some leading medical societies highlight the responsibility of medical doctors to counsel and guide patients along this complex pathway [21]. Resolution No. 400, May 1997 of the European Parliament and Resolution No. 1206, November 1999 of the Council of Europe stress the need to guarantee citizens the greatest freedom of choice of treatment, ensuring the highest level of security and the most accurate information on the safety, quality and effectiveness of non-conventional treatments, inviting member states to provide information on CAMs [22].

                              The National Institutes of Health of the USA has a dedicated centre and a site (National Center for Complementary and Alternative Medicine, NCCAM). CAMs are also acquiring space in the Cochrane Collaboration and some important series, such as the BMC, have dedicated a journal to CAMs dealing with studies supported by the National Institutes of Health [2325]. The Qualitative Methods Working Group of NIH developed a methodological manifesto in 1997 to identify study designs and analyses applicable to CAMs, pursuing standardization or suggesting new approaches, such as the “Whole System Approach”, aimed at respecting the personalization of therapies, which is often basic to the practice of CAMs [2433]. Within these limits, the application of evidence-based medicine (EBM) to the analysis of CAMs confirms the versatility of EBM as a problem-solving approach, disentangling the complex relationship between “Medicine and Medicines” [3437].

                              The discussion of the case of Reiki may highlights the controversial points in the discussion on the attitude towards CAMs in the dialysis ward, and the problem-solving approach integrating EBM with a formal ethical outline, developed in the context of the EBM course of the san Luigi Medical School, may represent an example applicable on other CAMs in similar settings [3842].

                              Discussion

                              The interest for Reiki and related CAMs is high in the western population, but the “usual” sources of information are limited and often of low quality

                              The increasing interest in “non-conventional” approaches is a leading theme in our society [13, 4346]. In this context, the so-called “mind and body therapies”, healing touch or Reiki, may represent a prototype of non-medical approaches in a highly “medicalized” population such as dialysis patients.

                              Reiki (霊気) is a Japanese word meaning “universal life energy”; it is a healing practice consisting in the light laying of hands on or just above the person, with the theoretical goal of facilitating the person’s healing response by getting in touch with the universal energy, which is thought to support the body’s innate capacity for self-healing [47]. Reiki can also be practiced as self-treatment (self-help) [4851].

                              Reiki was described in detail by the Japanese master Dr. Mikao Usui in the early 1900s through his study of ancient Tibetan healing arts and the laying on of hands healing tradition. It was brought to the mainland United States via Hawaii during the 1940s, and was introduced into Europe in the 1980s. Treatment consists in at least four sessions of 30–90 minutes, in which the practitioner places his/her hands lightly on or just above the client’s body, palms down, using different hand positions [47].

                              The popularity of Reiki is increasing in several countries, probably because the healing approach is non-traumatic and easily integrated with conventional therapies [52, 53]. In spite of its diffusion, the baseline mechanism of action has not been demonstrated, as the few attempts to investigate it have led to inconsistent results [54].

                              For the sake of the present analysis, the evidence was retrieved by two pathways, mimicking the patient’s and the physician’s side.

                              The first search (patient’s perspective) was performed as a tool to define “what the patient knows” as basis for an evidence-based, informed discussion. A non-systematic search on Google and Yahoo, increasingly used both as a tool to better understand patients’ requests and as a clinical problem-solving strategy, confirms the interest in the subject. The large number of citations retrieved with the single term “Reiki” on the most common search engines, plus over 1000 relevant titles on Medline, provided preliminary contextualization and support of the patient’s request. However, the high number of commercial sites on Google and Yahoo should be a warning about the economic pressure (Table  1) [5561].
                              Table 1

                              Evidence retrieved on web search engines: quantitative analysis of the first 2 pages of Google and Yahoo

                              Search terms

                              Search engine

                              Items

                              Commercial/non-commercialsites in the first 2 pages

                              Sites providing references (non-commercial links in the first 2 pages)

                              No. sites in common in Google and Yahoo

                              Reiki

                              Google

                              58500000

                              6/14

                              3

                              6

                              Yahoo

                              44900000

                              6/14

                              6

                              Reiki medicine

                              Google

                              17800000

                              17/3

                              2

                              1

                              Yahoo

                              5690000

                              19/1

                              1

                              Reiki Torino

                              Google

                              3680000

                              18/2

                              0

                              0

                              Yahoo

                              51100

                              10/10

                              0

                              Reiki use

                              Google

                              3060000

                              18/2

                              2

                              0

                              Yahoo

                              55300

                              20/0

                              0

                              Reiki pain

                              Google

                              10700000

                              1/19

                              9

                              4

                              Yahoo

                              7150000

                              2/18

                              4

                              Reiki dialysis

                              Google

                              590000

                              4/16

                              0

                              7

                              Yahoo

                              193000

                              6/14

                              0

                              Reiki cost effectiveness

                              Google

                              333000

                              12/8

                              12

                              5

                              Yahoo

                              112000

                              15/5

                              9

                              Reiki contra- indications

                              Google

                              120000

                              9/11

                              2

                              9

                               

                              Yahoo

                              30900

                              6/14

                              1

                               

                              Legend: * number of links retrieved in first 2 pages in Google and Yahoo.

                              The classic EBM approach, based upon treatment efficacy, underlines the limited evidence on Reiki and related CAMs and the low-grade effect on pain

                              This conclusion stems from a second search (physician’s perspective), that was performed on Pubmed and CINAHL, according with the classic rules of EBM database searches.

                              Dialysis is a very specific niche for complex heterogeneous patients, often with high comorbidity; it is rare to find efficacy studies on CAMs tailored to this population. In fact, during a first, preliminary search analysis combining the free terms “Reiki”, “Dialysis” and “Pain”, very few papers were retrieved (8 papers matching “Reiki” and “Dialysis”, 3 also with “Pain”), but only one paper dealt with such a case, leading us to broaden the search strategy to “Reiki and pain” [62].

                              Therefore, a second broader search was built on Pubmed and CINAHL, combining the following terms: (Dialysis OR Amyloidosis OR Myeloma OR Pain OR Fatigue) AND (Reiki OR (Healing touch) OR (Touch therapy) OR (Therapeutic touch) OR (Laying on of hands)). The search, limited to the last 5 years, on the account of the date of last updating of the Cochrane Review and to article in English, retrieved both a relevant Cochrane review and a series of 5 recent RCTs on Reiki and chronic pain (Table  2, Figure  1) [6367]. The studies are highly heterogeneous, both in the Cochrane review (24 studies) and in the subsequent years (5 RCTs). Pain was assessed by various methods, with a visual analogue scale being the one most commonly used; control groups were different and the reasons for pain encompassed different diseases. Within these limits, the main results support a significant reduction of pain in patients undergoing touch therapies in general and Reiki in particular (Table  2). The overall quality of the review and of the selected RCTs was high (Table  2), in line with recent reports of a comparable quality of studies on CAMs and “mainstream Medicine” at least in the English language [34].
                              Table 2

                              Characteristics of selected articles

                              Author, year

                              Study design

                              Participants

                              Measurements

                              Treatment

                              Comparison

                              Outcomes

                              Results

                              Side effects

                              CASP score

                              So, 2008

                              Review

                              24 studies (1153 participants)

                              VAS, NRS, McGill Pain Index, SF-36, analgesic usage, MPAC, FACT

                              Touch therapies(TT): Reiki, Healing Touch, Therapeutic Touch

                              Sham placebo or ’no treatment’ control

                              Pain (acute or chronic)

                              Statistically significant reduction of pain with different treatment, especially with Reiki (95% CI: -1.16 to −0.50)

                              Not evaluated

                              7/10

                              McCormack, 2009

                              RCT

                              n=90 elderly patients with post-surgical pain: n=30 non-contact therapeutic touch, n=30 metronome treatment, n=30 no treatment

                              VAS, MPAC,TAS,HAT,pupil size

                              Reiki

                              Routine care, placebo

                              Post-operative pain

                              Statistically significant reduction of pain in the Reiki group, worsening of pain in the metronome group (p<0.01)

                              Not reported

                              7.5/10

                              MacIntyre, 2008

                              RCT, not blinded

                              n= 290 patients (mean age 64) undergoing first time elective coronary artery bypass surgery n=237 at the end of the study

                              MEDD, STAI

                              Healing Touch

                              Visitors and no intervention

                              Post-operative pain, anxiety, physical and mental status, length of stay

                              Significant reduction of hospital stay and anxiety. No significant reduction of pain

                              Not reported

                              7.5/10

                              Frank, 2007

                              RCT, patients, data collection staff and data analyst blinded

                              n= 82 females undergoing Stereotactic Core Breast Biopsy: n=42 intervention, n=40 placebo

                              VAS

                              Therapeutic Touch (TT)

                              Sham Reiki

                              Post-biopsy pain, lidocaine/ epinephrine dosage

                              Increase of pain in both groups, not statistically significant

                              Increase of pain in both groups

                              7.5/10

                              Assefi, 2008

                              RCT, patients, data collection staff and data analyst blinded

                              n=100 adults with fibromyalgia (23 real direct Reiki: 24= real distant Reiki, 23= sham direct Reiki, 23=sham distant Reiki)

                              VAS

                              Reiki

                              Sham Reiki

                              Pain, fatigue, sleep quality, well-being

                              Neither Reiki nor touch improve the symptoms of fibromyalgia in all groups

                              Not reported

                              7.5/10

                              Aghabati 2010

                              RCT

                              n= 90 patients with cancer and normal level of consciousness, age 15–65: n=30 TT, n=30 placebo, n=30 control

                              VAS, RFS

                              Therapeutic Touch (TT)

                              Mimic therapeutic touch and no intervention

                              Pain, fatigue

                              Statistically significant decrease in pain and fatigue in TT vs placebo or control (p=0.04)

                              Excess energy and anxiety in both groups

                              8/10

                              Legend: RCT Randomized Controlled Trial, VAS Visual Analogue Scale, NRS Numeric Rating Score, SF-36 questionnaire for health-related quality of life, MPAC Memorial Pain Assessment Card, FACT Functional Assessment of Cancer Therapy, TAS Tellegen Absorption Scale, HAT Health Attribution Test, MEDD Morphine-Equivalent Dosage, STAI State Trait Anxiety Inventory, RFS Rhoten Fatigue Scale.

                              http://static-content.springer.com/image/art%3A10.1186%2F1471-2369-14-129/MediaObjects/12882_2012_552_Fig1_HTML.jpg
                              Figure 1

                              Flow chart of the papers retrieved. Legend: PICO: Patient/Population, Intervention, Comparison, Outcome, a method of putting together the better search strategy; CINAHL: Cumulative Index to Nursing and Allied Health Literature, a data bank.

                              Nevertheless, statistical significance is not synonymous with clinical relevance: in the Cochrane review, the mean reduction of pain was less than one unit on a 0–10 scale, a limit probably not perceived by human beings, and in the 5 RCTs published after the review, Reiki was effective on pain in 2 studies and had no significant benefit in 3. Pain reduction was measured with a VAS scale in both articles and can be approximated to 1.5 cm (Table  2).

                              No study reported adverse events linked to the procedure.

                              Side effects were not specifically reported in the Cochrane review. Only one out of the 5 RCTs published after the Cochrane review reported specifically on side effects; they were described both in the Reiki and Sham Reiki groups. The main side effects were “excess energy” or anxiety (41%); 18% reported worsening of sleep or depression. The side effects were no different with Reiki or placebo [66]. One other study showed an increase of pain in groups of patients undergoing Stereotactic Core Breast Biopsy treated with Touch Therapies and with Sham Reiki [65]. This increase in pain-anxiety was presumably linked to the fact of “being studied”, suggesting that even the placebo effect may be two-faceted and that physicians should also control for the negative interferences of “sham” treatments.

                              The EBM approach may not be sufficient to answer whether or not to facilitate Reiki in the dialysis ward without the application of an ethical framework

                              The overall picture deriving from the first steps of our analysis is thus of a widely used treatment of significant but limited efficacy, devoid of side effects, in no case inferior to placebo or the controls (Table  2).

                              While decisions on vital treatments, such as antibiotics or anti-neoplastic drugs, are mainly based on efficacy, decisions on chronic therapies, such as antihypertensives or on support therapies take into great account the expected side effects, leading some experts to conclude that the least effective treatment may occasionally be the best choice [16, 6870].

                              The shift from efficacy to tolerance has important philosophical implications.

                              The analysis according to the four main principles of principlist ethics may be a useful pragmatic guide for analysis [3842]. The principles may be defined and contextualized as follows: beneficence - actions intended to benefit the patient; this was considered equivalent to therapeutic efficacy. Non-maleficence- actions intended not to harm or bring harm to the patient; this was considered equivalent to side effects. Justice - defined as being fair or just to the wider community in terms of the consequences of an action; this was considered to include the costs of therapy and the eventual integration with other treatments. Autonomy - respect for individuals and their ability to make decisions with regard to their own health and future; this was considered a reason to favour all non-maleficent therapies when chosen by the patient. The principle of beneficence supports a limited positive effect of Reiki, hardly perceivable in terms of pain decrease, thus questioning the opportunity of the integration of this therapy in the dialysis ward. However, the lack of relevant side effects (non-maleficence), the potential integration with other therapies and the negligible costs, at least in settings where Reiki is offered by non-profit volunteer associations (justice), together with the desire of the patient to “do something” for his pain (autonomy), on the contrary clearly support the choice of integrating Reiki into the patient’s therapies.

                              These considerations are in line with the suggestions of the Society for Integrative Oncology in the case of treatments with limited efficacy but without relevant side effects: “tolerate, encourage caution, closely monitor effectiveness” [71].

                              Conclusions

                              The growing diffusion of CAMs in chronic diseases will increasingly confront the Nephrologist with the problem of integrating CAMs into Renal Replacement Therapies; this topic is a novelty for most Nephrologists and there is a need to acquire problem-solving tools.EBM offers an analytical pathway that is very interesting in the case of new diseases or non-codified therapies and is particularly suitable to the study of CAMs. The integration of an ethics-based discussion may offer interesting tools to systematically face such issues.

                              In the case of Reiki, the results of a systematic review, supplemented by a further updating, demonstrate a statistically significant but clinically barely relevant benefit. The use of Reiki should therefore be probably discouraged if only efficacy is considered, but chosen if the emphasis is on “non-maleficium” or the patient’s autonomy; the issue of justice modulates the choice according to the burden of overall costs, and the availability of the treatment in the different settings.

                              The additional need of an ethical discussion based on sound evidence-based results to tackle new problems in our “old” context is in line with the approaches suggested in a different field by the Society for Integrative Oncology in the case of treatments with limited efficacy but without relevant side effects: “tolerate, encourage caution, closely monitor effectiveness” [71].

                              Summary

                              The present debate, integrating evidence based approaches and ethical framework, tries to balance the pros and cons of the systematic introduction of such approaches in the dialysis ward. In spite of the wide use of CAMs in the general population, few studies deal with the pros and cons of an integration of mainstream medicine and CAMs in dialysis patients; one paper only regarded the use of Reiki and related techniques. According to the EBM approach, Reiki allows a statistically significant but very low-grade pain reduction without specific side effects. However, the ethical discussion leads to a permissive-positive attitude.

                              This paper suggests that physicians may wish to consider efficacy but also side effects, contextualization (availability and costs) and patient’s requests, according also to the suggestions of the Society for Integrative Oncology (tolerate, control efficacy and side effects).

                              Declarations

                              Acknowledgements

                              The authors would like to greatly thank the staff of the medical Library of the san Luigi Medical School for their continuous support and dr. Peter Christie for his careful language editing.

                              Authors’ Affiliations

                              (1)
                              SS Nephrology ASOU, san Luigi (regione Gonzole 10)
                              (2)
                              Medical School, Università degli Studi di Torino, san Luigi, (regione Gonzole 10)
                              (3)
                              Biomedical Library Università degli Studi di Torino

                              References

                              1. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL: Unconventional medicine in the United States, Prevalence, costs, and patterns of use. N Engl J Med 1993,328(4):246–52.PubMedView Article
                              2. Staud R: Effectiveness of CAM therapy: understanding the evidence. Rheum Dis Clin North Am 2011,37(1):9–17.PubMedView Article
                              3. NCCAM: What is complementary and alternative medicine. Available at: http://​nccam.​nih.​gov/​health/​whatiscam. Accessed April 24, 2012.
                              4. Eisenberg DM, Davis RB, Ettner SL, et al.: Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA 1998,280(18):1569–75.PubMedView Article
                              5. Ernst E: Obstacles to research in complementary and alternative medicine. Med J Aust 2003,179(6):279–80.PubMed
                              6. Barnes PM, Powell-Griner E, McFann K, Nahin RL: Complementary and alternative medicine use among adults: United States, 2002. Adv Data 2004, 343:1–19.PubMed
                              7. Jantos M, Kiat H: Prayer as medicine: how much have we learned? Med J Aust 2007,186(10 Suppl):S51–3.PubMed
                              8. McCaffrey AM, Eisenberg DM, Legedza AT, Davis RB, Phillips RS: Prayer for health concerns: results of a national survey on prevalence and patterns of use. Arch Intern Med 2004,164(8):858–62.PubMedView Article
                              9. O’Connor PJ, Pronk NP, Tan A, Whitebird RR: Characteristics of adults who use prayer as an alternative therapy. Am J Health Promot 2005,19(5):369–75.PubMedView Article
                              10. White MR, Jacobson IG, Smith B, Wells TS, Gackstetter GD, Boyko EJ, Smith TC, Millennium Cohort Study Team: Health care utilization among complementary and alternative medicine users in a large military cohort. BMC Complement Altern Med 2011, 11:27.PubMedView Article
                              11. Thomas KJ, Nicholl JP, Coleman P: Use and expenditure on complementary medicine in England: a population based survey. Complement Ther Med 2001,9(1):2–11.PubMedView Article
                              12. Krucoff MW, Crater SW, Gallup D, Blankenship JC, Cuffe M, Guarneri M, Krieger RA, Kshettry VR, Morris K, Oz M, Pichard A, Sketch MH Jr, Koenig HG, Mark D, Lee KL: Music, imagery, touch, and prayer as adjuncts to interventional cardiac care: the Monitoring and Actualisation of Noetic Trainings (MANTRA) II randomized study. Lancet 2005,366(9481):211–7.PubMedView Article
                              13. Ernst E, Cassileth BR: The prevalence of complementary/alternative medicine in cancer: a systematic review. Cancer 1998,83(4):777–82.PubMedView Article
                              14. Patterson RE, Neuhouser ML, Hedderson MM, Schwartz SM, Standish LJ, Bowen DJ, Marshall LM: Types of alternative medicine used by patients with breast, colon, or prostate cancer: predictors, motives, and costs. J Altern Complement Med 2002,8(4):477–85.PubMedView Article
                              15. Richardson MA, Sanders T, Palmer JL, Greisinger A, Singletary SE: Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol 2000,18(13):2505–14.PubMed
                              16. Burrowes JD, Van Houten G: Use of alternative medicine by patients with stage 5 chronic kidney disease. Adv Chronic Kidney Dis 2005,12(3):312–25.PubMedView Article
                              17. Nowack R, Birck R: Complementary and alternative medicine is popular among chronic renal failure patients–renal teams must increase their competence to advise patients with respect to efficacy and safety. Evid Based Nurs 2012,15(1):29–30.PubMedView Article
                              18. Aratani L: Mainstream Physicians Try Such Alternatives as Herbs, Acupuncture and Yoga. Washington Post; 2009. 2009–06–09
                              19. Press Release: Latest Survey Shows More Hospitals Offering Complementary and Alternative Medicine Services. American Hospital Association; 2008–09–15 – Available at: http://​www.​aha.​org/​presscenter/​pressrel/​2008/​080915-pr-cam.​shtml - Accessed April 24, 2012.
                              20. Expert Committee on Complementary Medicines in the Health System: Complementary Medicines in the Australian Health System. Report to the Parliamentary Secretary to the Minister for Health and Ageing. Canberra: Commonwealth of Australia; 2003. Available at: http://​www.​tga.​gov.​au/​pdf/​archive/​committees-eccmhs-report-031031.​pdf Accessed April 24, 2012
                              21. Steyer TE: Complementary and alternative medicine: a primer. Fam Pract Manag 2001,8(3):37–42.PubMed
                              22. A European approach to non-conventional medicine: Official Journal L 144, 04/06/1997 P. 0019–0027 Resolution 1206 (1999) Extract from the Official Gazette of the Council of Europe – (November 1999).
                              23. The BMC-series journals. 2012. Available at: http://​www.​biomedcentral.​com/​authors/​bmcseries. Accessed April 24, 2012.
                              24. The National Institutes of Health: The National Institutes of Health. Available at: http://​www.​nih.​gov/​. Accessed April 24, 2012.
                              25. Ezzo J, Berman BM, Vickers AJ, Linde K: Complementary medicine and the Cochrane Collaboration. JAMA 1998,11(280):1628–30.View Article
                              26. Margolin A, Avants SK, Kleber HD: Investigating alternative medicine therapies in randomized controlled trials. JAMA 1998,11(280):1626–8.View Article
                              27. Hansen K, Kappel KJ: The proper role of evidence in complementary/alternative medicine. Med Philos 2010, 35:7–18.View Article
                              28. Mason S, Tovey P, Long AF: Evaluating complementary medicine: methodological challenges of randomized controlled trials. BMJ 2002,325(7368):832–4.PubMedView Article
                              29. Levin JS, Glass TA, Kushi LH, Schuck JR, Steele L, Jonas WB: Quantitative methods in research on complementary and alternative medicine, A methodological manifesto, NIH Office of Alternative Medicine. Med Care 1997,35(11):1079–94.PubMedView Article
                              30. Tonelli MR, Callahan TC: Why alternative medicine cannot be evidence-based. Acad Med 2001,76(12):1213–20.PubMedView Article
                              31. Ernst E: Complementary and alternative medicine: between evidence and absurdity. Perspect Biol Med 2009,52(2):289–303.PubMedView Article
                              32. Klassen TP, Pham B, Lawson ML, Moher D: For randomized controlled trials, the quality of reports of complementary and alternative medicine was as good as reports of conventional medicine. J Clin Epidemiol 2005,58(8):763–8.PubMedView Article
                              33. Verhoef MJ, Lewith G, Ritenbaugh C, Boon H, Fleishman S, Leis A: Complementary and alternative medicine whole systems research: beyond identification of inadequacies of the RCT. Complement Ther Med 2005, 13:206–12.PubMedView Article
                              34. Walach H: The Campaign Against CAM and the Notion of “Evidence-Based”. J Altern Complement Med 2009, 15:1139–42.PubMedView Article
                              35. Power M, Hopayian K: Exposing the evidence gap for complementary and alternative medicine to be integrated into science-based medicine. J R Soc Med 2011, 104:155–61.PubMedView Article
                              36. Barry CA: The role of evidence in alternative medicine: contrasting biomedical and anthropological approaches. Soc Sci Med 2006, 62:2646–57.PubMedView Article
                              37. Ventegodt S, Greydanus DE, Merrick J: Alternative medicine does not exist, biomedicine does not exist, there is only evidence-based medicine. Int J Adolesc Med Health 2011,23(3):153–5.PubMedView Article
                              38. Gillon R: Medical ethics: four principles plus attention to scope. BMJ 1994,309(6948):184–8.PubMedView Article
                              39. McCarthy J: Principlism or narrative ethics: must we choose between them? Med Humanit 2003,29(2):65–71.PubMedView Article
                              40. Beauchamp T: Principles of biomedical ethics. Oxford University Press; 1979.
                              41. Veatch R: A theory of medical ethics. Basic Books; 1981.
                              42. Engelhardt HT: The Foundations of Bioethics. UK: Oxford University Press; 1986.
                              43. Cugelman A: Therapeutic touch: an extension of professional skills. J CANNT 1998,8(3):30–2.PubMed
                              44. Barnes PM, Bloom B, Nahin RL: Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report 2008, 12:1–23.PubMed
                              45. Nahin RL, Barnes PM, Stussman BJ, Bloom B: Costs of complementary and alternative medicine (CAM) and frequency of visits to CAM practitioners: United States, 2007. Natl Health Stat Report 2009, 18:1–14.PubMed
                              46. Herman PM, Craig BM, Caspi O: Is complementary and alternative medicine (CAM) cost-effective? A systematic review. BMC Complement Altern Med 2005, 5:11.View Article
                              47. NCCAM: Reiki: An Introduction. 2012. Available at: http://​nccam.​nih.​gov/​health/​reiki/​introduction.​htm. Accessed April 24, 2012
                              48. Mulloney SS, Wells-Federman C: Therapeutic touch: a healing modality. J Cardiovasc Nurs 1996, 10:27–49.PubMed
                              49. Gallob R: Reiki: a supportive therapy in nursing practice and self-care for nurses. J N Y State Nurses Assoc 2003,34(1):9–13.PubMed
                              50. Richeson NE, Spross JA, Lutz K, Peng C: Effects of Reiki on anxiety, depression, pain, and physiological factors in community-dwelling older adults. Res Gerontol Nurs 2010,3(3):187–99.PubMedView Article
                              51. Burden B, Herron MS: The increasing use of Reiki as a complementary therapy in specialist palliative care. Int J Palliat Nurs 2005,11(5):248–253.PubMed
                              52. Center for Reiki Research. 2012. Available at: http://​www.​centerforreikire​search.​org
                              53. Reiki for all creatures: Reiki for all creatures. 2012 edition. 2012. Available at: http://​www.​reikiforallcreat​ures.​com
                              54. Rosa L, Rosa E, Sarner L, Barrett S: A close look at therapeutic touch. JAMA 1998,279(13):1005–10.PubMedView Article
                              55. Siempos II, Spanos A, Issaris EA, Rafailidis PI, Falagas ME: Non-physicians may reach correct diagnoses by using Google: a pilot study. Swiss Med Wkly 2008,138(49–50):741–5.PubMed
                              56. Tang H, Ng JH: Googling for a diagnosis–use of Google as a diagnostic aid: internet based study. BMJ 2006,333(7579):1143–5.PubMedView Article
                              57. Eysenbach G, Kohler C: What is the prevalence of health-related searches on the World Wide Web? Qualitative and quantitative analysis of search engine queries on the internet. AMIA Annu Symp Proc 2003, 225–9.
                              58. Eysenbach G, Powell J, Kuss O, Sa ER: Empirical studies assessing the quality of health information for consumers on the world wide web: a systematic review. JAMA 2002,287(20):2691–700.PubMedView Article
                              59. Thiele RH, Poiro NC, Scalzo DC, Nemergut EC: Speed, accuracy, and confidence in Google, Ovid, PubMed, and UpToDate: results of a randomised trial. Postgrad Med J 2010,86(1018):459–65.PubMedView Article
                              60. Giustini D: How Google is changing medicine. BMJ 2005,331(7531):1487–8.PubMedView Article
                              61. Steinbrook R: Searching for the right search–reaching the medical literature. N Engl J Med 2006,354(1):4–7.PubMedView Article
                              62. So PS, Jiang Y, Qin Y: Touch therapies for pain relief in adults. Cochrane Database Syst Rev 2008., 4: CD006535
                              63. McCormack GL: Using non-contact therapeutic touch to manage post-surgical pain in the elderly. Occup Ther Int 2009,16(1):44–56.PubMedView Article
                              64. MacIntyre B, Hamilton J, Fricke T, Ma W, Mehle S, Michel M: The efficacy of healing touch in coronary artery bypass surgery recovery: a randomized clinical trial. Altern Ther Health Med 2008,14(4):24–32.PubMed
                              65. Frank LS, Frank JL, March D, Makari-Judson G, Barham RB, Mertens WC: Does therapeutic touch ease the discomfort or distress of patients undergoing stereotactic core breast biopsy? A randomized clinical trial. Pain Med 2007, 8:419–24.PubMedView Article
                              66. Assefi N, Bogart A, Goldberg J, Buchwald D: Reiki for the treatment of fibromyalgia: a randomized controlled trial. J Altern Complement Med 2008,14(9):1115–22.PubMedView Article
                              67. Aghabati N, Mohammadi E, Pour EZ: The effect of Therapeutic Touch on pain and fatigue of cancer patients undergoing chemotherapy. Evid Based Complement Alternat Med 2010,7(3):375–81.PubMedView Article
                              68. Nowack R, Ballé C, Birnkammer F, Koch W, Sessler R, Birck R: Complementary and alternative medications consumed by renal patients in southern Germany. J RenNutr 2009,19(3):211–9.
                              69. Duncan HJ, Pittman S, Govil A, Sorn L, Bissler G, Schultz T, Faith J, Kant S, Roy-Chaudhury P: Alternative medicine use in dialysis patients: potential for good and bad! Nephron Clin Pract 2007,105(3):c108–13.PubMedView Article
                              70. Hess S, De Geest S, Halter K, Dickenmann M, Denhaerynck K: Prevalence and correlates of selected alternative and complementary medicine in adult renal transplant patients. Clin Transplant 2009,23(1):56–62.PubMedView Article
                              71. Deng GE, Frenkel M, Cohen L, Cassileth BR, Abrams DI, Capodice JL, Courneya KS, Dryden T, Hanser S, Kumar N, Labriola D, Wardell DW, Sagar S: Society for Integrative Oncology. Evidence-based clinical practice guidelines for integrative oncology: complementary therapies and botanicals. J Soc Integr Oncol 2009,7(3):85–120.PubMed
                              72. Pre-publication history

                                1. The pre-publication history for this paper can be accessed here:http://​www.​biomedcentral.​com/​1471-2369/​14/​129/​prepub

                              Copyright

                              © Ferraresi et al.; licensee BioMed Central Ltd. 2013

                              This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.