to adverse events including gastrointestinal problems as well as sudden death from cardiomyopathy. products adulterated with pharmaceuticals for weight loss or erectile dysfunction are one of the main concerns. chinese herbal medicine has been a major cause of acute liver failure in china. the harvesting of guano from bat caves (ye ming sha) brings workers into close contact with these animals, increasing the risk of zoonosis. the chinese virologist shi zhengli has identified dozens of sars-like coronaviruses in samples of bat droppings. acupuncture and moxibustion main articles: acupuncture and moxibustion needles being inserted into the skin a bronze acupuncture statue from the ming dynasty being displayed inside a museum acupuncture is the insertion of needles into superficial structures of the body (skin, subcutaneous tissue, muscles) – usually at acupuncture points (acupoints) – and their subsequent manipulation; this aims at influencing the flow of qi. according to tcm it relieves pain and treats (and prevents) various diseases. the us fda classifies single-use acupuncture needles as class ii medical devices, under cfr 21. acupuncture is often accompanied by moxibustion – the chinese characters for acupuncture (针灸; 針灸; zhēnjiǔ) literally meaning "acupuncture-moxibustion" – which involves burning mugwort on or near the skin at an acupuncture point. according to the american cancer society, "available scientific evidence does not support claims that moxibustion is effective in preventing or treating cancer or any other disease". in electroacupuncture, an electric current is applied to the needles once they are inserted, to further stimulate the respective acupuncture points. a recent historian of chinese medicine remarked that it is "nicely ironic that the specialty of acupuncture -- arguably the most questionable part of their medical heritage for most chinese at the start of the twentieth century -- has become the most marketable aspect of chinese medicine." she found that acupuncture as we know it today has hardly been in existence for sixty years. moreover, the fine, filiform needle we think of as the acupuncture needle today was not widely used a century ago. present day acupuncture was developed in the 1930s and put into wide practice only as late as the 1960s. efficacy further information: acupuncture § efficacy, and acupuncture § safety a 2013 editorial in the american journal anesthesia and analgesia stated that acupuncture studies produced inconsistent results, (i.e. acupuncture relieved pain in some conditions but had no effect in other very similar conditions) which suggests the presence of false positive results. these may be caused by factors like biased study design, poor blinding, and the classification of electrified needles (a type of tens) as a form of acupuncture. the inability to find consistent results despite more than 3,000 studies, the editorial continued, suggests that the treatment seems to be a placebo effect and the existing equivocal positive results are the type of noise one expects to see after a large number of studies are performed on an inert therapy. the editorial concluded that the best controlled studies showed a clear pattern, in which the outcome does not rely upon needle location or even needle insertion, and since "these variables are those that define acupuncture, the only sensible conclusion is that acupuncture does not work." according to the us nih national cancer institute, a review of 17,922 patients reported that real acupuncture relieved muscle and joint pain, caused by aromatase inhibitors, much better than sham acupuncture. regarding cancer patients, the review hypothesized that acupuncture may cause physical responses in nerve cells, the pituitary gland, and the brain – releasing proteins, hormones, and chemicals that are proposed to affect blood pressure, body temperature, immune activity, and endorphin release. a 2012 meta-analysis concluded that the mechanisms of acupuncture "are clinically relevant, but that an important part of these total effects is not due to issues considered to be crucial by most acupuncturists, such as the correct location of points and depth of needling ... ... associated with more potent placebo or context effects". commenting on this meta-analysis, both edzard ernst and david colquhoun said the results were of negligible clinical significance. a 2011 overview of cochrane reviews found evidence that suggests acupuncture is effective for some but not all kinds of pain. a 2010 systematic review found that there is evidence "that acupuncture provides a short-term clinically relevant effect when compared with a waiting list control or when acupuncture is added to another intervention" in the treatment of chronic low back pain. two review articles discussing the effectiveness of acupuncture, from 2008 and 2009, have concluded that there is not enough evidence to conclude that it is effective beyond the placebo effect. acupuncture is generally safe when administered using clean needle technique (cnt). although serious adverse effects are rare, acupuncture is not without risk. severe adverse effects, including very rarely death (5 case reports), have been reported. tui na an example of a traditional chinese medicine used in tui na tui na (推拿) is a form of massage, based on the assumptions of tcm, from which shiatsu is thought to have evolved. techniques employed may include thumb presses, rubbing, percussion, and assisted stretching. qigong qìgōng (气功; 氣功) is a tcm system of exercise and meditation that combines regulated breathing, slow movement, and focused awareness, purportedly to cultivate and balance qi. one branch of qigong is qigong massage, in which the practitioner combines massage techniques with awareness of the acupuncture channels and points. qi is air, breath, energy, or primordial life source that is neither matter or spirit. while gong is a skillful movement, work, or exercise of the qi. forms nei gong: introspective and meditative wai gong: external energy and motion dong gong: dynamic or active jing gong: tranquil or passive other therapies cupping main article: cupping therapy acupuncture and moxibustion after cupping in japan cupping (拔罐; báguàn) is a type of chinese massage, consisting of placing several glass "cups" (open spheres) on the body. a match is lit and placed inside the cup and then removed before placing the cup against the skin. as the air in the cup is heated, it expands, and after placing in the skin, cools, creating lower pressure inside the cup that allows the cup to stick to the skin via suction. when combined with massage oil, the cups can be slid around the back, offering "reverse-pressure massage". gua sha gua sha gua sha (刮痧; guāshā) is abrading the skin with pieces of smooth jade, bone, animal tusks or horns or smooth stones; until red spots then bruising cover the area to which it is done. it is believed that this treatment is for almost any ailment. the red spots and bruising take three to ten days to heal, there is often some soreness in the area that has been treated. die-da diē-dǎ (跌打) or dit da, is a traditional chinese bone-setting technique, usually practiced by martial artists who know aspects of chinese medicine that apply to the treatment of trauma and injuries such as bone fractures, sprains, and bruises. some of these specialists may also use or recommend other disciplines of chinese medical therapies if serious injury is involved. such practice of bone-setting (正骨; 整骨) is not common in the west. chinese food therapy the concepts yin and yang are associated with different classes of foods, and tradition considers it important to consume them in a balanced fashion. regulations many governments have enacted laws to regulate tcm practice. australia from 1 july 2012 chinese medicine practitioners must be registered under the national registration and accreditation scheme with the chinese medicine board of australia and meet the board's registration standards, to practice in australia. canada tcm is regulated in five provinces in canada: alberta, british columbia, ontario, quebec, and newfoundland & labrador. china (mainland) the national administration of traditional chinese medicine was created in 1949, which then absorbed existing tcm management in 1986 with major changes in 1998. china's national people's congress standing committee passed the country's first law on tcm in 2016, which came into effect on 1 july 2017. the new law standardized tcm certifications by requiring tcm practitioners to (i) pass exams administered by provincial-level tcm authorities, and (ii) obtain recommendations from two certified practitioners. tcm products and services can be advertised only with approval from the local tcm authority. hong kong during british rule, chinese medicine practitioners in hong kong were not recognized as "medical doctors", which means they could not issue prescription drugs, give injections, etc. however, tcm practitioners could register and operate tcm as "herbalists". the chinese medicine council of hong kong was established in 1999. it regulates the compounds and professional standards for tcm practitioners. all tcm practitioners in hong kong are required to register with the council. the eligibility for registration includes a recognised 5-year university degree of tcm, a 30-week minimum supervised clinical internship, and passing the licensing exam. macau the portuguese macau government seldom interfered in the affairs of chinese society, including with regard to regulations on the practice of tcm. there were a few tcm pharmacies in macau during the colonial period. in 1994, the portuguese macau government published decree-law no. 53/94/m that officially started to regulate the tcm market. after the sovereign handover, the macau s.a.r. government also published regulations on the practice of tcm. in 2000, macau university of science and technology and nanjing university of traditional chinese medicine established the macau college of traditional chinese medicine to offer a degree course in chinese medicine. in macau, the legitimacy of chinese medicine is not built upon "miracle making". instead, it is achieved through a celebration of cultural tradition rejuvenated with discourses of nationalism and modernity, and through the mutual constructions of medical references between doctors and patients. in 2022, a new law regulating tcm, law no. 11/2021, came into effect. the same law also repealed decree-law no. 53/94/m. indonesia the chinese traditional medicine at one of chinese traditional medicine shop at jagalan road, surabaya, indonesia. all traditional medicines, including tcm, are regulated by indonesian minister of health regulation of 2013 on traditional medicine. traditional medicine license (surat izin pengobatan tradisional – sipt) is granted to the practitioners whose methods are recognized as safe and may benefit health. the tcm clinics are registered but there is no explicit regulation for it. the only tcm method which is accepted by medical logic and is empirically proofed is acupuncture. the acupuncturists can get sipt and participate in health care facilities. japan seirogan, a type of antidiarrhoeal drug in japan developed based on kanpo medicine theory main articles: kampo and kampo list korea korea institute of oriental medicine under the medical service act(의료법/醫療法), an oriental medical doctor, whose obligation is to administer oriental medical treatment and provide guidance for health based on oriental medicine, shall be treated in the same manner as a medical doctor or dentist. the korea institute of oriental medicine is the top research center of tcm in korea. malaysia the traditional and complementary medicine bill was passed by parliament in 2012 establishing the traditional and complementary medicine council to register and regulate traditional and complementary medicine practitioners, including tcm practitioners as well as other traditional and complementary medicine practitioners such as those in traditional malay medicine and traditional indian medicine. netherlands the logo of the dutch association of traditional chinese medicine (or 中 zhong - nederlandse vereniging voor traditionele chinese geneeskunde), the largest of the professional organisations that is recognised by private health insurance companies in the netherlands. there are no specific regulations in the netherlands on tcm; tcm is neither prohibited nor recognised by the government of the netherlands. chinese herbs as well as chinese herbal products that are used in tcm are classified as foods and food supplements, and these chinese herbs can be imported into the netherlands as well as marketed as such without any type registration or notification to the government. despite its status, some private health insurance companies reimburse a certain amount of annual costs for acupuncture treatments, this depends on one's insurance policy, as not all insurance policies cover it, and if the acupuncture practitioner is or is not a member of one of the professional organisations that are recognised by private health insurance companies. the recognized professional organizations include the nederlandse vereniging voor acupunctuur (nva), nederlandse artsen acupunctuur vereniging (naav), zhong, (nederlandse vereniging voor traditionele chinese geneeskunde), nederlandse beroepsvereniging chinese geneeswijzen yi