meta-analysis
The literature of homeopathy is littered with papers that are weirdly hilarious. A recent example of this genre is an article by Indian authors published in the ‘INTERNATIONAL JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE’ entitled Homeopathy in chronic disease management: a critical review of the evidence. Here is its abstract:
Homeopathy remains one of the most widely practiced complementary and alternative medicine (CAM) modalities worldwide, particularly among individuals with chronic non-communicable diseases (NCDs) who seek safe, holistic, and personalized therapeutic options. Despite its global popularity, controversy continues regarding its mechanisms of action and clinical effectiveness. This review critically evaluates the current evidence on the role of homeopathy in chronic disease management. A comprehensive review of randomized controlled trials (RCTs), systematic reviews, and meta-analyses published between 2000 and 2025 was conducted. Studies were included if they examined homeopathic interventions in chronic conditions such as asthma, arthritis, type 2 diabetes mellitus, depression, chronic pain, and fibromyalgia. Data were synthesized thematically to assess efficacy, mechanistic plausibility, methodological quality, and safety outcomes. Mechanistic hypotheses suggest that hormesis, nanoparticle-mediated signaling, immune modulation, and neuropsychological or psychosocial mechanisms may contribute to the therapeutic effects of homeopathy. Meta-analytic evidence demonstrates modest but statistically significant improvements in subjective measures such as pain, fatigue, and quality of life across several chronic diseases, with standardized mean differences ranging from 0.18 to 0.25. However, objective clinical outcomes, including spirometry and HbA1c, rarely show consistent benefit. Methodological challenges, including small sample sizes, heterogeneous interventions, limited follow-up durations, and a high risk of bias, continue to constrain the reliability of existing findings. Importantly, homeopathy exhibits a favorable safety profile, with no serious adverse events reported across chronic disease studies. Current evidence indicates that homeopathy may provide modest adjunctive benefits for symptom relief and improved patient satisfaction among individuals with chronic illnesses, although its specific therapeutic mechanisms remain uncertain. Integration of homeopathy into evidence-based, patient-centered chronic disease management frameworks may enhance holistic care. Future research should emphasize large-scale, multicenter randomized trials with standardized outcome measures and mechanistic endpoints to better define clinical relevance and biological plausibility.
The lead author of this paper earns his living in the Department of Materia Medica, NatoreHomeo Medical College, Natore, Bangladesh. Thus, we might be surprised by the critical tone of this paper. However, having a closer look at it, we soon find that, under a thin veneer of critical assessment, the paper is a prime attempt of white-washing the established evidence. Let me explain; the authors claim that:
- “Mechanistic hypotheses suggest that hormesis, nanoparticle-mediated signaling, immune modulation, and neuropsychological or psychosocial mechanisms may contribute to the therapeutic effects of homeopathy.” Do the authors really suggest that all of these vague theories are true? Why not decide which one constitutes the actual mode of action? Why not tell the truth and state clearly that none of them are remotely plausible, none would explain how homeopathy works, and none is accepted by anyone outside the cult of homeopathy?
- ” Meta-analytic evidence demonstrates modest but statistically significant improvements in subjective measures such as pain, fatigue, and quality of life across several chronic diseases, with standardized mean differences ranging from 0.18 to 0.25. ” Do the authors not see that the meta-analyses demonstrating such outcomes are invariably done by overtly biased homeopath? Do they really not know that independent scientists are unable to confirm such findings?
- “Homeopathy exhibits a favorable safety profile…” Are the authors not aware that using homeopathy (or any other ineffective therapy) to treat serious conditions at best prolongs the suffering of patients and at worst hastens their death?
- “Homeopathy may provide modest adjunctive benefits for symptom relief…” Do the authors know that this statement is firstly untrue and secondly contradicts Hahnemann’s teaching (he called doctors who employed homeopathy as an add-on therapy “traitors” and insisted that homeopathy was not a symptomatic treatment but a causal cure of disease)?
Understanding that this is what homeopaths call a ‘CRITICAL’ review might be helpful: it explains, I think, why they they feel that true critical assessments are nothing but brutal and cynical destructions of their beautiful fantasies.
Low back pain (LBP) is a significant public health issue due to its high prevalence and associated disability burden. Clinical practice guidelines recommend non-pharmacological/non-surgical interventions for managing pain and function in people with LBP. This overview of Cochrane review is aimed ato providing accessible, high-quality evidence on the effects of non-pharmacological and non-surgical interventions for people with LBP and to highlight areas of remaining uncertainty and gaps in the evidence regarding the effects of these interventions for people with LBP.
the team searched the Cochrane Database of Systematic Reviews from inception to 15 April 2023, to identify Cochrane reviews of randomised controlled trials testing the effect of non-pharmacological/non-surgical interventions, unrestricted by language. Major outcomes were pain intensity, function and safety. Two authors independently assessed eligibility, extracted data and assessed the quality of the reviews using AMSTAR 2 (A MeaSurement Tool to Assess Systematic Reviews) and the certainty of the evidence using GRADE. The primary comparison was placebo/sham.
A total of 31 Cochrane reviews were included of 644 trials that randomised 97,183 adults with LBP. The team had high confidence in the findings of 19 reviews, moderate confidence in the findings of two reviews, and low confidence in the findings of 10 reviews. They present results for non-pharmacological/non-surgical interventions compared to placebo/sham or no treatment/usual care at short-term (≤ three months) follow-up. Placebo/sham comparisons Acute/subacute LBP Compared to placebo, there is probably no difference in function (at one-week follow-up) for spinal manipulation (standardised mean difference (SMD) -0.08, 95% confidence interval (CI) -0.37 to 0.21; 2 trials, 205 participants; moderate-certainty evidence). Data for safety were reported only for heated back wrap. Compared to placebo, heated back wrap may result in skin pinkness (6/128 participants versus 1/130; 2 trials; low-certainty evidence). Chronic LBP Compared to sham acupuncture, acupuncture probably provides a small improvement in function (SMD -0.38, 95% CI -0.69 to -0.07; 3 trials, 957 participants; moderate-certainty evidence). Compared to sham traction, there is probably no difference in pain intensity for traction (0 to 100 scale, mean difference (MD) -4, 95% CI -17.7 to 9.7; 1 trial, 60 participants; moderate-certainty evidence). Data for safety were reported only for acupuncture. There may be no difference between acupuncture and sham acupuncture for safety outcomes (risk ratio (RR) 0.68, 95% CI 0.42 to 1.10; I2 = 0%; 4 trials, 465 participants; low-certainty evidence). No treatment/usual care comparisons Acute/subacute LBP Compared to advice to rest, advice to stay active probably provides a small reduction in pain intensity (SMD -0.22, 95% CI -0.02 to -0.41; 2 trials, 401 participants; moderate-certainty evidence). Compared to advice to rest, advice to stay active probably provides a small improvement in function (SMD -0.29, 95% CI -0.09 to -0.49; 2 trials, 400 participants; moderate-certainty evidence). Data for safety were reported only for massage. There may be no difference between massage and usual care for safety (risk difference 0, 95% CI -0.07 to 0.07; 1 trial, 51 participants; low-certainty evidence). Chronic LBP Compared to no treatment, acupuncture probably provides a medium reduction in pain intensity (0 to 100 scale, mean difference (MD) -10.1, 95% CI -16.8 to -3.4; 3 trials, 144 participants; moderate-certainty evidence), and a small improvement in function (SMD -0.39, 95% CI -0.72 to -0.06; 3 trials, 144 participants; moderate-certainty evidence). Compared to usual care, acupuncture probably provides a small improvement in function (MD 9.4, 95% CI 6.15 to 12.65; 1 trial, 734 participants; moderate-certainty evidence). Compared to no treatment/usual care, exercise therapies probably provide a small to medium reduction in pain intensity (0 to 100 scale, MD -15.2, 95% CI -18.3 to -12.2; 35 trials, 2746 participants; moderate-certainty evidence), and probably provide a small improvement in function (0 to 100 scale, MD -6.8, 95% CI -8.3 to -5.3; 38 trials, 2942 participants; moderate-certainty evidence). Compared to usual care, multidisciplinary therapies probably provide a medium reduction in pain intensity (SMD -0.55, 95% CI -0.83 to -0.28; 9 trials, 879 participants; moderate-certainty evidence), and probably provide a small improvement in function (SMD -0.41, 95% CI -0.62 to -0.19; 9 trials, 939 participants; moderate-certainty evidence). Compared to no treatment, psychological therapies using operant approaches probably provide a small reduction in pain intensity (SMD -0.43, 95% CI -0.75 to -0.11; 3 trials, 153 participants; moderate-certainty evidence). Compared to usual care, psychological therapies (including progressive muscle relaxation and behavioural approaches) probably provide a small reduction in pain intensity (0 to 100 scale, MD -5.18, 95% CI -9.79 to -0.57; 2 trials, 330 participants; moderate-certainty evidence), but there is probably no difference in function (SMD -0.2, 95% CI -0.41 to 0.02; 2 trials, 330 participants; moderate-certainty evidence). It is uncertain whether there is a difference between non-pharmacological/non-surgical interventions and no treatment/usual care for safety (very low-certainty evidence).
The authors concluded that spinal manipulation probably makes no difference to function compared to placebo for people with acute/subacute LBP. Acupuncture probably improves function slightly for people with chronic LBP, compared to sham acupuncture. There is probably no difference between traction and sham traction for pain intensity in people with chronic LBP. Compared to advice to rest, advice to stay active probably reduces pain intensity slightly and improves function slightly for people with acute LBP. Acupuncture probably reduces pain intensity, and improves function slightly for people with chronic LBP, compared to no treatment. Acupuncture probably improves function slightly for people with chronic LBP, compared to usual care. Exercise therapies probably reduce pain intensity, and improve function slightly for people with chronic LBP, compared to no treatment/usual care. Multidisciplinary therapies probably reduce pain intensity, and improve function slightly for people with chronic LBP, compared to usual care. Compared to usual care, psychological therapies probably reduce pain intensity slightly, but probably make no difference to function for people with chronic LBP.
The findings of this overview might surprise some chiropractors, however, it did not surprise me at all*. I have stated more often than I care to remember that, for LBP, we currently have no approach that is truly convincing. One form of so-called alternative medicine (SCAM) seems to be roughly as effective (or ineffective) as the next. Where they might differ is safety and cost. On both of these measures chiropractic spinal manipulation is less convincing than some of the other options available, as we have discussed ad nauseam on this blog.
So, in a nutshell, the message to LBP patients can be put simply: stay away from chiros, keep active and, if you insist, use whatever other form of SCAM that you fancy, that is safe and inexpensive.
PS
*I was, however, surprised that the authors had low confidence in the findings of 10 of the 31 reviews. Cochrane reviews should be the most reliable evidence available to date!!!
Aging trajectories are influenced by modifiable risk factors, and prior evidence has hinted that mult-ilingualism may have protective potential. However, reliance on suboptimal health markers, small samples, inadequate confounder control and a focus on clinical cohorts led to mixed findings and limited applicability to healthy populations.
With this analysis, researchers developed biobehavioral age gaps, quantifying delayed or accelerated aging in 86,149 participants across 27 European countries. National surveys provided individual-level positive (functional ability, education, cognition) and adverse (cardiometabolic conditions, female sex, sensory impairments) factors, while country-level multi-lingualism served as an aggregate exposure.
Biobehavioral factors predicted age (R2 = 0.24, r = 0.49, root mean squared error = 8.61), with positive factors linked to delayed aging and adverse factors to accelerated aging. Multi-lingualism emerged as a protective factor in cross-sectional (odds ratio = 0.46) and longitudinal (relative risk = 0.70) analyses. Mono-lingualism increased risk of accelerated aging (odds ratio = 2.11; relative risk = 1.43). The effects persisted after adjusting for linguistic, physical, social and sociopolitical exposomes.
The authors concluded that these results underscore the protective role of multi-lingualism and its broad applicability for global health initiatives.
Research into aging is understandably active. Thus plenty of factors have been idenfified that might slow down the process. Here is a quick summary.
Factors That Delay Aging
- Healthy Diet: Consuming a diet rich in fruits, vegetables, whole grains, nuts, legumes, fish, and lean proteins, while limiting red and processed meats, saturated fats, and added sugars.
- Calorie restriction: reducing total calorie intake while maintaining nutrient density, and intermittent fasting have shown promise in promoting longevity in some studies.
- Regular Physical Activity: Engaging in moderate to vigorous physical activity (e.g., brisk walking, strength training) consistently. This helps preserve muscle mass, bone density, and cardiovascular function.
- Maintaining a Healthy Weight: Avoiding obesity and excessive body fat reduces strain on organs and limits chronic inflammation.
- Optimal Cardiovascular Health: Actively managing and maintaining healthy blood pressure, cholesterol, and blood sugar levels.
- Quitting Smoking/Avoiding Tobacco Use: Completely abstaining from all forms of tobacco.
- Moderate Alcohol Consumption: Limiting alcohol intake or abstaining altogether.
- Quality Sleep: Getting sufficient, restorative sleep (typically 7-9 hours per night) with a consistent sleep schedule.
- Stress Management: Utilizing techniques like meditation or therapy to effectively manage stress and anxiety.
- Strong Social Connections: Nurturing healthy relationships and avoiding loneliness, which is linked to chronic stress.
- Life Purpose/Mental Stimulation: Having a sense of meaning or purpose and engaging in activities that challenge the brain (e.g., learning new skills).
- So-called alternative medicine (SCAM)? The evidence is mixed and often unconvincing. The most effective SCAMs for delaying aging might be a healthy lifestyle, the use dietary supplements based on sound evidence, as well as relaxation therapies where appropriate.
As you see, multi-lingualism, as suggested by the above paper, does not even feature in the list. Yet, the concept of cognitive reserve can explain why two people with similar age-related brain changes (like volume loss or plaque buildup) can have different cognitive abilities and patterns of aging. A higher cognitive reserve acts as a buffer against aging; specifically it can:
- Build Cognitive Reserve: Engaging in intellectually challenging activities throughout life, such as higher education, complex occupations, and continuous learning, creates a more resilient and flexible network of neural pathways. This reserve allows the brain to compensate for damage and maintain function longer.
- Promote Neuroplasticity: Learning new, complex skills—like another language, playing a musical instrument, or taking challenging courses—stimulates the creation of new neural connections and enhances neuroplasticity.
- Reduce Risk of Cognitive Decline: High levels of mental engagement lowers the risk of cognitive decline in older age.
So, the new study adds to and affirms the already existing knowledge: speaking several languages is likely to slow the aging process that we are all facing – a finding that, I have to admit, suits me fine!
- The authors claim to evaluate OMT for managing headaches associated with musculoskeletal dysfunction. Yet few of the trials were specifically aimed at this aim.
- Comparator treatment included sham manipulation, waitlist or no treatment, treatment as usual, a different type of OMT technique or protocol that was not the same as the experimental intervention, or any standard of care intervention, such as exercise therapy or medication. Most of these do not allow conclusions about specific effects of OMT.
- There was no attempt to control for placebo effects which might be significant in the case of OMT.
- In general, the methodological quality of the primary studies was low.
- There are too few studies to adequately assess the multitude of different OMT techniques.
- The fact that multiple forms of headache exist is not adequately addressed.
Yes, the authors try to be cautious in their conclusions and admit that the evidence is weak. Yet, I simply do not see enough compelling evidence to agree with them that the data are even suggestive of a positive effect.
Changes in the vaccine advisory process in the United States have disrupted immunization guidance, which reinforces the need for independent evidence review to inform decisions regarding immunization for respiratory viruses during the 2025-2026 season.
The researchers conducted a systematic review of U.S.-licensed immunizations against coronavirus disease 2019 (Covid-19), respiratory syncytial virus (RSV), and influenza. They searched databases on PubMed/MEDLINE, Embase, and Web of Science for updates of the most recent review by the Advisory Committee on Immunization Practices (ACIP) Evidence-to-Recommendations for each disease, which was performed during the 2023-2024 period. Outcomes included vaccine efficacy and effectiveness against hospitalization, other clinical end points, and safety.
Of 17,263 identified references, 511 studies met the inclusion criteria. Covid-19 mRNA vaccines against the XBB.1.5 subvariant had pooled vaccine effectiveness against hospitalization of 46% (95% confidence interval [CI], 34 to 55; from cohort studies) and 50% (95% CI, 43 to 57; from case-control studies) among adults and 37% (95% CI, 29 to 44) among immunocompromised adults. In a case-control study, vaccines against the KP.2 subvariant showed an effectiveness of 68% (95% CI, 42 to 82). Maternal RSV vaccination (for infant protection), nirsevimab for infants, and RSV vaccines in adults who were 60 years of age or older showed vaccine effectiveness of 68% or more against hospitalization. Influenza vaccination had a pooled vaccine effectiveness of 48% (95% CI, 39 to 55) in adults between the ages of 18 and 64 years and 67% (95% CI, 58 to 75) in children against hospitalization. Safety profiles were consistent with previous evaluations. The diagnosis of myocarditis associated with Covid-19 vaccines occurred at rates of 1.3 to 3.1 per 100,000 doses in male adolescents, with lower risk associated with longer dosing intervals. The RSVPreF vaccine was associated with 18.2 excess cases of Guillain-Barré syndrome per million doses in older adults; a significant association with preterm birth was not observed when the vaccine was administered at 32 to 36 weeks’ gestation.
The authors concluded that the evidence supports the safety and effectiveness of immunizations against Covid-19, RSV, and influenza during the 2025-2026 season.
On this blog, we have a surprising amount of commentators who seem unconvinced about the benefits of vaccinations, particularly the COVID vaccinations. Therefore, I thought that this recent article might help these confused people to better understand the current evidence.
In contrast to the self-appointed ‘experts’ claiming that vaccinations do more harm than good, the authors of this excellent paper come from the most reputable institutions in the US:
- 1Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA.
- 2Department of Medicine, Division of Infectious Diseases, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY.
- 3Department of Pediatrics, Mass General Brigham for Children and Harvard Medical School, Boston.
- 4Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston.
- 5Department of Medicine (Infectious Diseases), University of Pennsylvania Perelman School of Medicine, Philadelphia.
- 6Center for Infectious Disease Research and Policy, University of Minnesota, Minneapolis.
- 7Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield, WI.
- 8Harvard Medical School, Boston.
- 9Massachusetts General Hospital, Boston.
- 10Department of Epidemiology, Biostatistics, and Occupational Health, School of Population and Global Health, McGill University, Montreal.
- 11Division of Infectious Diseases, Brown University Health and Warren Alpert Medical School of Brown University, Providence, RI.
- 12Division of General Internal Medicine and Infectious Disease, Massachusetts General Hospital, Harvard Medical School, Boston.
- 13Division of Infectious Diseases, Massachusetts General Hospital, Boston.
Will this new paper convince many anti-vaxers? I sure hope so but somehow I also have my doubts.
Shingles or herpes zoster (HZ) is a neurotropic virus that causes a painful and hard to treat illness. Evidence is accumulating that HZ vaccinations might lower the risk of dementia. This effect is surprising but well-documented; here are 3 recent meta-analyses:
An international team of scientists aimed to evaluate the association of HZ infection, protective effects of antiviral treatment or vaccination on dementia. Systematic searches of PubMed, MEDLINE, EMBASE, Scopus, Web of Science, CINAHL, and Cochrane CENTRAL was performed from January 1, 1996, to October 31, 2024. Observational studies evaluating HZ infection, antivirals, or vaccination and dementia risk were selected. Risk of bias was examined with the Newcastle-Ottawa scale. A random-effects meta-analysis was performed, with the rate ratio (RR) and corresponding 95% confidence intervals (CIs) being pooled for dementia. Presence of heterogeneity was assessed with I2, and differences by study-level characteristics were estimated using subgroup meta-analysis and meta-regression.
Eighteen studies (N = 9.4 million) were included. Infection was associated with elevated risk of dementia (RR 1.14; 95% CI: 1.04, 1.25, I2 = 98%); this remained significant in the sensitivity analysis when the two case-control studies were removed (RR 1.17; 95% CI: 1.06, 1.30, I2 = 98%). Subgroup analysis based on sex, age, study population, bias scores, type of dementia or HZO did not show statistically significant differences in risk. Treatment with antivirals showed a small effect (RR 0.84; 95% CI: 0.71, 0.99, I2 = 73%), but prophylaxis with HZ vaccination was associated with a significantly lower risk (RR 0.68; 95% CI: 0.56, 0.83, I2 = 99%).
The authors concluded that there is a slightly raised dementia risk after HZ infection and reduced risks after antiviral treatment and prevention with vaccination. However, results should be interpreted with caution due to significant heterogeneity in pooled analyses.
Previous studies have reported a decreased risk of dementia with herpes zoster vaccination. Given this background, this systematic review and meta-analysis aimed to investigate the association between herpes zoster vaccination and the risk of dementia. An Indian/American team searched five databases until November 2023 for case-control, cross-sectional, or cohort studies investigating the association of herpes zoster vaccination and dementia. Odds ratios and 95% confidence intervals (95% CIs) were pooled in the meta-analysis. Meta-regression, subgroup, and sensitivity analysis were also conducted. The researchers evaluated a total of five studies (one cross-sectional, one case-control, and four cohort studies) that included a total number of 103,615 patients who were vaccinated with herpes zoster vaccine. All the studies were of high quality, ranging from 7 to 9. Due to the high heterogeneity (I2 = 100%, p < .00001) observed in our study, a random effect model was used for the analysis. The pooled odds ratio was 0.84 (95% CI: 0.50, 1.43), p (overall effect) = .53), indicating that herpes zoster vaccination reduces the risk of dementia.
The authors concluded that herpes zoster vaccination is associated with a reduction of the risk of dementia. More epidemiological studies are needed to confirm the association.
Herpes zoster (HZ) infection may increase the risk of dementia, that causes a heavy socioeconomic burden. However, the epidemiological evidence between HZ vaccination and the risk of dementia remains inconclusive. This meta-analysis was conducted to investigate the effect of HZ vaccination on the onset of dementia. The researchers searched PubMed, EMBASE, Web of Science, Science Direct, and Scopus for cohort studies assessing the association between HZ vaccination and dementia risk up to 20th January 2025. Hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled adopting a random-effect model. Four eligible studies were included in the systematic review and five retrospective cohort studies in the meta-analysis. Among 14,493,383 dementia-free participants at baseline, 427,309 dementia cases occurred during 36-95 months of follow-up. All studies were of high quality. Pooled analysis of adjusted HRs indicated that HZ vaccination could reduce dementia risk by 29% (HR = 0.71, 95% CI: 0.66-0.76, I2 = 97.15%). Subgroup analyses revealed heterogeneity linked to definitions of dementia, exposure measurements, vaccination doses, deprivation index, and region. The results were stable in the sensitivity analyses, and no publication bias was found.
The authors concluded that HZ vaccination was notably related to a reduced risk of dementia. More mechanistic studies and epidemiological studies are warranted.
_______________
The effect seems powerful and faily consistent across different studies. But how can this be? Australian neuroscientists have suggested that subclinical zooster virus reactivation might act as a renewable peripheral immune stressor, amplifying microglial priming in aging brains. Shingles vaccination may suppress this viral reservoir, reducing cumulative inflammatory tone.
Whatever the mechanism, the news that zoster vaccination might strongly reduce the dementia risk is hugely encouraging. It could also, I hope, have the effect that the dangerous anti-vaccination attitude currently fuelled by the incompetent US govenment will be getting a little less popular.
PS
Needless to say that these vaccinations also reliably prevent shingles!
So please, do consider getting vaccinated.
This meta-analysis evaluated and compared the safety and efficacy of spinal manipulation, mobilization, and massage for the management of cervicogenic headache (CGH). Comprehensive searches were conducted in Cochrane, Embase, PubMed, and ClinicalTrials.gov to identify studies investigating the effects of manipulation, mobilization, and massage on pain, disability, and physical function in patients with CGH. Key outcomes included pain severity (visual analog scale, VAS), Neck Disability Index (NDI), Flexion-Rotation Test (FRT), and Headache Disability Inventory (HDI) at various follow-up timepoints.
Fourteen studies totaling 1,297 CGH patients were included. Standard pairwise meta-analysis revealed that sustained natural apophyseal glides (SNAG*) mobilization produced significantly greater improvements compared to non-SNAG interventions in VAS (MD = 1.73, 95%CI: 1.05, 2.40), NDI (MD = 8.55, 95%CI: 2.73, 14.37), FRT (MD = -7.22, 95%CI: -9.38, -5.07), and HDI (MD = 9.29, 95%CI: 3.64, 14.95), with benefits maintained over time. Network meta-analysis showed that for VAS improvement, the surface under the cumulative ranking curve (SUCRA) probabilities were: cervical spine manipulation (CSM, 98.9%), mobilization (67.3%), exercise (21.0%), and massage (12.8%). For NDI, the SUCRA scores were: CSM (82.2%), mobilization (57.2%), exercise (6.7%), and massage (53.9%). CSM exhibited significantly greater VAS reductions compared to exercise, massage, and mobilization, while mobilization was superior to exercise and massage for VAS. For NDI, CSM was significantly better than exercise, but no other between-group differences were observed.
The authors concluded that, in patients with CGH, SNAG mobilization can significantly improve pain and function, with benefits maintained in the long-term. Additionally, CSM may be the most effective short-term intervention for reducing pain and disability compared to mobilization, massage, and exercise, although clinician expertise appears to be an important factor.
The authors note that both components of this study exhibited substantial heterogeneity, with variability in the frequency, duration, and nature of spinal interventions across studies. This lack of standardization complicates the translation of findings to clinical practice. Additionally, while the network meta-analysis allowed for comparative evaluation of several manual therapy modalities, the large differences between sham/control groups precluded the inclusion of SNAG, thereby limiting the comprehensiveness of the analysis.
They also admit that The small sample sizes and potential selection biases in the primary studies significantly limit the ability to generalize their findings to the broader CGH patient population. While the studies provide important insights into the effectiveness of manual therapy interventions, their conclusions should be interpreted cautiously. Larger, more diverse studies with more robust sampling strategies would help improve the external validity and reliability of the findings, allowing for more confident recommendations that can be applied to the wider CGH population in clinical settings.
I agree with these critical thoughts and wonder why the authors nonetheless formulated their conclusions so definitively. In my view, there are not enough reliable data for arriving at such firm conclusions. Furthermore, it is unclear how thay assessed the safety of the various interventions. Considering the well-documented risks of CSM, I would certainly not name it as the manual therapy of first choice.
*The SNAG technique involves the application of graded mobilization along the treatment plane of the selected cervical facet joint, from the mid-range to the end-range, with the joint position maintained.
This review aimed to evaluate the effectiveness of homeopathic treatments for respiratory infections, particularly upper respiratory tract infections (URTIs) like pharyngitis caused by Streptococcus pyogenes. It seeks to determine how well homeopathy can alleviate symptoms, reduce the duration of the illness, decrease the need for antibiotics, and improve overall patient outcomes.
To evaluate the effectiveness of homeopathy in treating respiratory infections, the review incorporated observational studies, randomized controlled trials (RCTs), systematic reviews, and in vitro research. Relevant studies were identified through searches in databases like Google Scholar, PubMed, AYUSH, and various homeopathic journals. The research considered included evaluations of homeopathy alone or alongside conventional treatments for upper respiratory tract infections (URTIs) in both children and adults. Studies with small sample sizes, incomplete data, duplicates, or content that could not be retrieved were excluded to ensure reliability.
The findings suggest that Atropa Belladonna 12C and other homeopathic remedies exhibit antibacterial effects against Streptococcus pyogenes in laboratory settings. Clinical studies indicate that homeopathy may help reduce fever, lessen symptom severity, and decrease the need for antibiotics in cases of upper respiratory infections (URTIs). For instance, in a study focused on recurrent pharyngitis, 93.33% of patients treated with homeopathy reported improvement, compared to only 33.34% in the biochemic group. Additionally, the EPI3 Cohort Study revealed a reduction in antibiotic use, although it did not show significant differences in the progression of the disease, according to some systematic reviews. While homeopathy appears to hold promise, further research is necessary to confirm its long-term effectiveness.
The authors conculded that research suggests that homoeopathy could serve as a helpful complementary treatment for respiratory infections, potentially reducing the reliance on antibiotics and enhancing symptom relief. However, further comprehensive studies are necessary to confirm its effectiveness and establish standardized treatment protocols. Integrating homeopathy into public health strategies may offer an additional approach to managing respiratory infections in both children and adults.
This review is a perfect model for people who want to know how NOT to conduct a meaningful review:
- Its aim is diffuse.
- Its methodology is vague.
- It includes anything from in-vitro experiments to clinical trials.
- It does not have a ‘results’ section but provides details of the primary studies in the ‘discussion’ section.
- It does not even attempt to evaluate the methodological quality of the primary studies which, in most cases, is dismal.
- It draws conclusions that are not based on sound data.
What emerges, once one has managed to obtain a clear picture of the carefully obfuscated evidence, is quite simple: there are no reliable studies to show that homeopathy is effective in treating respiratory infections. In view of this, I need to correct the conclusions of this review as follows:
Research shows that homeopathy as a treatment of respiratory infections is not supported by the evidence of reliable clinical trials. Its use should therefore be discouraged.
This, by the way, would also be more in line with the Cochrane review on the subject:
Background: Acute respiratory tract infections (ARTIs) are common and may lead to complications. Most children experience between three and six ARTIs annually. Although most infections are self-limiting, symptoms can be distressing. Many treatments are used to control symptoms and shorten illness duration. Most treatments have minimal benefit and may lead to adverse events. Oral homeopathic medicinal products could play a role in childhood ARTI management if evidence for their effectiveness is established. This is an update of a review first published in 2018.
Objectives: To assess the effectiveness and safety of oral homeopathic medicinal products compared with placebo or conventional therapy to prevent and treat ARTIs in children.
Search methods: We searched CENTRAL (2022, Issue 3), including the Cochrane Acute Respiratory Infections Specialised Register, MEDLINE (1946 to 16 March 2022), Embase (2010 to 16 March 2022), CINAHL (1981 to 16 March 2022), AMED (1985 to 16 March 2022), CAMbase (searched 16 March 2022), and British Homeopathic Library (searched 26 June 2013 – no longer operating). We also searched the WHO ICTRP and ClinicalTrials.gov (16 March 2022), checked references, and contacted study authors to identify additional studies.
Selection criteria: We included double-blind randomised controlled trials (RCTs) or double-blind cluster-RCTs comparing oral homeopathy medicinal products with identical placebo or self-selected conventional treatments to prevent or treat ARTIs in children aged 0 to 16 years.
Data collection and analysis: We used standard methodological procedures expected by Cochrane.
Main results: In this 2022 update, we identified three new RCTs involving 251 children, for a total of 11 included RCTs with 1813 children receiving oral homeopathic medicinal products or a control treatment (placebo or conventional treatment) for ARTIs. All studies focused on upper respiratory tract infections (URTIs), with only one study including some lower respiratory tract infections (LRTIs). Six treatment studies examined the effect on URTI recovery, and five studies investigated the effect on preventing URTIs after one to four months of treatment. Two treatment and three prevention studies involved homeopaths individualising treatment. The other studies used predetermined, non-individualised treatments. All studies involved highly diluted homeopathic medicinal products, with dilutions ranging from 1 x 10-4 to 1 x 10-200. We identified several limitations to the included studies, in particular methodological inconsistencies and high attrition rates, failure to conduct intention-to-treat analysis, selective reporting, and apparent protocol deviations. We assessed three studies as at high risk of bias in at least one domain, and many studies had additional domains with unclear risk of bias. Four studies received funding from homeopathy manufacturers; one study support from a non-government organisation; two studies government support; one study was co-sponsored by a university; and three studies did not report funding support. Methodological inconsistencies and significant clinical and statistical heterogeneity precluded robust quantitative meta-analysis. Only four outcomes were common to more than one study and could be combined for analysis. Odds ratios (OR) were generally small with wide confidence intervals (CI), and the contributing studies found conflicting effects, so there was little certainty that the efficacy of the intervention could be ascertained. All studies assessed as at low risk of bias showed no benefit from oral homeopathic medicinal products, whilst trials at unclear or high risk of bias reported beneficial effects. For the comparison of individualised homeopathy versus placebo or usual care for the prevention of ARTIs, two trials reported on disease severity; due to heterogeneity the data were not combined, but neither study demonstrated a clinically significant difference. We combined data from two trials for the outcome need for antibiotics (OR 0.79, 95% CI 0.35 to 1.76; low-certainty evidence). For the comparison of non-individualised homeopathy versus placebo or usual care for the prevention of ARTIs, only the outcome recurrence of ARTI was reported by more than one trial; data from three studies were combined for this outcome (OR 0.60, 95% CI 0.21 to 1.72; low-certainty evidence). For the comparison of both individualised and non-individualised homeopathy versus placebo or usual care for the treatment of ARTIs, two studies provided data on short-term cure (OR 1.31, 95% CI 0.09 to 19.54) and long-term cure (OR 1.01, 95% CI 0.10 to 9.96; very low-certainty evidence). The studies demonstrated an opposite direction of effect for both outcomes. Six studies reported on disease severity but were not combined as they used different scoring systems and scales. Three studies reported adverse events (OR 0.79, 95% CI 0.16 to 4.03; low-certainty evidence).
Authors’ conclusions: Pooling of five prevention and six treatment studies did not show any consistent benefit of homeopathic medicinal products compared to placebo on ARTI recurrence or cure rates in children. We assessed the certainty of the evidence as low to very low for the majority of outcomes. We found no evidence to support the efficacy of homeopathic medicinal products for ARTIs in children. Adverse events were poorly reported, and we could not draw conclusions regarding safety.
The moral of this long story might be this:
Cochrane reviews are more reliable than papers published in the International Journal on Science and Technology by homeopaths from the Department of Practice of Medicine, Bharati Vidyapeeth (Deemed to be University), and the Homoeopathic Medical College and Hospital, Pune- Satara Road, Maharashtra, India
When Harald Walach et al first published it, I did report about their paper entitled “Treatment effects in pharmacological clinical randomized controlled trials are mainly due to placebo”. The objective of their analysis was to determine what contributes to the size of the placebo effect in clinical drug trials by meta-regressions of randomized placebo-controlled clinical trials.
Walach and his co-authors concluded that the high correlation of r= .73 between placebo improvement and treatment improvement rates is genuine and not explainable by study or disease characteristics. We conclude from our data that the placebo-effect is the major driver of treatment effects in clinical trials that alone explains 69% of the variance. This leaves only limited space for effects due to pharmacological substances. Context effects are more important than pharmacological ones in the conditions studied by us.
At the time, I called this SLOPPY SCIENCE and explained:
- The authors lumped together trials of various drugs as though they are a homogeneous entity in terms of effectiveness beyond placebo (which, of course, they are not).
- The placebo response is the measured improvement of a patient in a clinical trial after receiving a sham treatment. Yet, the authors claim “the placebo response in clinical trials has four components: regression to the mean (RTM), measurement artefacts, natural tendency (NT) of the disease, and the genuine placebo effect”. This is nonsense, and I even fear that the authors know it.
- The paper’s ‘highlight’ claims that contextual factors like expectations and doctor-patient interactions drive healing. Yet, these phenomena are seperate from the placebo-effect and were not the subject of this investigation.
- Correlation is not causation.
Now RETRACTION WATCH have published interesting news about Walach’s article:
… Stephen Rhodes, a researcher at University Hospitals Cleveland Medical Center in Ohio, criticized the study in a letter to the editor in February, citing a “number of errors that lead to some sweeping conclusions.” In the letter, Rhodes wrote those leaps “reflect a misunderstanding of what a ‘treatment effect’ is,” noting that in a placebo-controlled trial, the measure can’t be “due to placebo.”
We asked Gideon Meyerowitz-Katz, a sleuth and research fellow at the University of Wollongong in Australia, to take a look at the paper. Meyerowitz-Katz called the work “bizarre” and told us the results seem to indicate “simply being in a clinical trial is the main component of healing.” The studies included in the analysis had “very low average treatment effects,” meaning they didn’t show a huge benefit for the interventions tested. The clinical trials included had another issue: one was retracted in 2018 after journal editors realized all its participants had been enrolled and randomized on the same day. “I do not think that a meta-analysis which includes work retracted nearly a decade ago can be relied on as evidence,” Meyerowitz-Katz said. When he attempted to replicate the methods, Meyerowitz-Katz wasn’t able to do so. The researchers claimed to have taken one of the formulas from a previous paper; however, the referenced paper used a regression model, and the formula was not listed, he said. Meyerowitz-Katz also pointed out a potential undisclosed conflict of interest. Walach runs the Change Health Science Institute, which promotes “homeopathy and various COVID-19 conspiracy theories,” he said.
Walach, in response to Meyerowitz-Katz’s comments, called the term “conspiracy theory” “an analytically void terminology, because it is dependent on the political mainstream view, which is in turn dependent on political power.” He did not respond to any of Meyerowitz-Katz’s critiques of the paper.
Meyerowitz-Katz touched on many of the same issues Rhodes had raised in his letter. Rhodes questioned if the results really suggest there is “limited space for effects due to pharmacological substances,” quoting from the original paper. He also wrote by weighing clinical trials by study size rather than standard deviation, the researchers are “throwing information away.”
The researchers responded to Rhodes in their own letter to the editor, conceding they should have used “treatment response” rather than “treatment effect” in the title “to avoid confusion.” The authors also argued they had demonstrated “whenever a treatment is very effective, so is the improvement in the placebo group and vice versa.”
Retraction Watch sent questions to the Journal of Clinical Epidemiology, including the above critiques of the paper. Andrea Tricco, the co-editor-in-chief of the publication, told us the journal was investigating the concerns and was “treating this as a matter of highest urgency.” Stefan Schmidt, the corresponding author of the paper, told us his group has been asked to give “a detailed reply within 30 days.”
PS
I think it is only fair to add this note by RETRACTION WATCH:
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This cross-sectional meta-epidemiological study investigated the patient-reported acupuncture-related adverse events (A-AEs) in acupuncture randomised controlled trials (RCTs). All RCTs were included that used acupuncture as the intervention group to obtain the efficacy and/or safety of acupuncture therapy and that based the acupuncture therapy on Traditional Medicine theory.
The researchers assessed
- (1) the general characteristics of acupuncture RCTs;
- (2) the general characteristics of PROs;
- (3) the reporting scores of PROs by the Extension of Consolidated Standards of Reporting Trials of Patient-Reported Outcomes (CONSORT PRO Extension);
- (4) the general characteristic of A-AEs; (5) the incidence of A-AEs.
They included 476 RCTs; 296 (62.2%) used PROs as study outcomes, 272 (57.1%) reported safety outcomes. The Visual Analogue Scale (149, 23.7%) and the Pittsburgh Sleep Quality Index (42, 6.7%) were the most common PROs reported. The reporting of PROs was incomplete, with sufficiently reporting scores ranging from 2.7% to 97.6% across the CONSORT PRO Extension.
164 studies reported A-AEs, of which 141 reported specific details. The OR for the incidence of AEs in the acupuncture group compared to the control group was 1.434 (95% CI 1.148 to 1.793). The researchers identified 1277 reports of A-AEs, predominantly tissue injury (eg, haematoma, bleeding), irritation (eg, pain, post-acupuncture discomfort), with no reports of serious A-AEs. The reporting of A-AEs lacked details on the acquisition methods (15.5%), occurrence time (5.5%), A-AEs’ treatment (18.1%) and A-AEs’ recovery (19.7%). Studies that reported funding, registry information, acupuncturist qualifications and non-significant primary outcomes were associated with the A-AEs’ reporting, and the difference was statistically significant (p≤0.05).
The authors concluded that their study found that the reporting of PROs and A-AEs was insufficient in acupuncture RCTs. Future studies should clarify the clinical significance of using PROs as outcomes and report AEs comprehensively to provide patients with sufficient information on the benefits and harms of acupuncture treatments.
If you have followed my blog for any length of time, you will have seen numerous studies that show how poor the reporting of AEs is in trials of acupuncture and other forms of so-called alternative medicine (SCAM). This is not just regrettable, it is unethical, dangerous and amounts to scientific misconduct.
Based on such flawed evidence SCAM promoters claim that their treatments are quite safe. But because of the very inadequate reporting this assumption might well be wrong. Thus consumers are systematically being misled into making wrong, and in a worst case scenaario fatal, therapeutic decisions.
Imagine what scandal it would generate, if we found that studies of pharmaceuticals were systematically hiding AEs by simply not monitoring and reporting them!
