systematic review
The objective of this paper, as stated by its authors, was to develop an evidence-based clinical practice guideline (CPG) through a broad-based consensus process on best practices for chiropractic management of patients with chronic musculoskeletal (MSK) pain.
Using systematic reviews identified in an initial literature search, a steering committee of experts in research and management of patients with chronic MSK pain drafted a set of recommendations. Additional supportive literature was identified to supplement gaps in the evidence base. A multidisciplinary panel of experienced practitioners and educators rated the recommendations through a formal Delphi consensus process using the RAND Corporation/University of California, Los Angeles, methodology.
The Delphi process was conducted January–February 2020. The 62-member Delphi panel reached consensus on chiropractic management of five common chronic MSK pain conditions:
- low-back pain (LBP),
- neck pain,
- tension headache,
- osteoarthritis (knee and hip),
- fibromyalgia.
Recommendations were made for non-pharmacological treatments, including:
- acupuncture,
- spinal manipulation/mobilization,
- other manual therapy;
- low-level laser (LLL);
- interferential current;
- exercise, including yoga;
- mind–body interventions, including mindfulness meditation and cognitive behavior therapy (CBT);
- lifestyle modifications such as diet and tobacco cessation.
Recommendations covered many aspects of the clinical encounter, from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral. Appropriate referral and comanagement were emphasized.
Therapeutic recommendations for low back pain:
- Consider multiple approaches. Both active and passive, and both physical and mind–body interventions should be considered in the management plan. The following are recommended, based on current evidence.
- Exercise
- Yoga/qigong (which may also be considered “mind–body” interventions)
- Lifestyle advice to stay active; avoid sitting; manage weight if obese; and quit smoking
- Spinal manipulation/mobilization
- Massage
- Acupuncture
- LLL therapy
- Transcutaneous electrical nerve stimulation (TENS) or interferential current may be beneficial as part of a multimodal approach, at the beginning of treatment to assist the patient in becoming or remaining active.
- Combined active and passive: multidisciplinary rehabilitation
- CBT
- Mindfulness-based stress reduction
Therapeutic recommendations for neck pain:
- Consider multiple approaches. Both active and passive, and both physical and mind–body interventions should be considered in the management plan for maximum therapeutic effect. The following are recommended, based on current evidence.
- Exercise (range of motion and strengthening).
- Exercise combined with manipulation/mobilization.
- Spinal manipulation and mobilization
- Massage
- Low-level laser
- Acupuncture
- These modalities may be added as part of a multimodal treatment plan, especially at the beginning, to assist the patient in becoming or remaining active:
- Transcutaneous nerve stimulation (TENS), traction, ultrasound, and interferential current.
- Yoga
- Qigong
Therapeutic recommendations for tension headache:
- Consider multiple approaches. Both active and passive, and both physical and mind–body interventions should be considered in the management plan for maximum therapeutic effect. The following are recommended, based on current evidence:
- Reassurance that TTH does not indicate presence of a disease.
- Advice to avoid triggers.
- Exercise (aerobic).
- Spinal manipulation
- Acupuncture
- Cold packs or menthol gels
- Combined active and passive
- CBT
- Relaxation therapy
- Biofeedback
- Mindfulness Meditation
Therapeutic recommendations for knee osteoarthritis:
- Consider multiple approaches. Both active and passive, and both physical and mind–body interventions should be considered in the management plan. The following are recommended, based on current evidence:
- Exercise
- Manual therapy
- Ultrasound
- Acupuncture, using “high dose” (greater treatment frequency, at least 3 × week)
- LLL therapy
Therapeutic recommendations for hip osteoarthritis:
- Consider multiple approaches. Both active and passive, and both physical and mind–body interventions should be considered in the management plan. The following are recommended, based on current evidence6
- Exercise
- Manual therapy
Therapeutic recommendations for fibromyagia:
- Consider multiple approaches. Both active and passive, and both physical and mind–body interventions should be considered in the management plan. The following are recommended, based on current evidence:
- Exercise (aerobic and strengthening)
- Advice on healthy lifestyle
- Education on the condition
- Spinal manipulation
- Myofascial release
- Acupuncture
- LLL therapy
- multidisciplinary rehabilitation
- CBT
- mindfulness meditation
- yoga
- Tai chi,
- Qigong
The authors concluded that these evidence-based recommendations for a variety of conservative treatment approaches to the management of common chronic MSK pain conditions may advance consistency of care, foster collaboration between provider groups, and thereby improve patient outcomes.
This paper is an excellent example of a pseudo-scientific process resulting in unreliable outcomes.
- The Delphi process was conducted some 4 years ago
- Because of the truly weird inclusion criteria, the findings are based essentially on just 3 systematic reviews.
- Anyone who has ever tried to conduct a consensus excercise knows that the outcome will almost entirely depend on who is chosen to sit on the panel. So, all you have to do to obtain pro-chiro recommendations is to select a few pro-chiro ‘experts’ who then write the recommendations!
- A “best practices for chiropractic management” may sound reasonable but, looking at the therapeutic recommendation, one easily realizes that the authors cast their nets so wide that the result has little to do with what differentiates chiropractic from Physiotherapists or osteopaths.
It is therefore not surprising that the recommendations are laughably unreliable: can, for instance, anyone explain to me why “advice on healthy lifestyle and education on the condition” are recommended for fibromyalgia but not for any other condition?
This paper is, in my view, chiropractic pseudo-science at its most ridiculous!
All it really does is it tries to legitimise all sorts of therapies as part of the chiropractic toolbox. My advice to patients is to:
- consult a physio if you need exercise therapy or LLL or manual therapy or ultrasound or interferential current or TENS or cold packs or massage;
- consult a clinical psychologist if you need CBT, or mindfulness, biofeedback;
- consult a doctor if you want rehab or education or lifestyle advice or reassurance;
- etc. etc.
And please avoid chiropractors who pretend they can do all of the above, while merely wanting to manipulate your neck.
Attention Deficit Hyperactivity Disorder (ADHD) is a common neurodevelopmental condition affecting children
and adults, characterized by symptoms of inattention, hyperactivity, and impulsivity. Despite the effectiveness of conventional treatments, such as stimulants, side effects drive interest in alternative therapies like homeopathy. This systematic review was aimed at determining the effectiveness of homeopathy as a treatment for ADHD.
A comprehensive search of PubMed, SCOPUS, and Google Scholar was conducted to identify clinical studies evaluating homeopathic treatments for ADHD. After applying selection criteria, eight studies were reviewed, consisting of randomized controlled trials, comparative studies, randomized open-label Pilot study, and clinical trials, were included in the final review.
The results suggest that some homeopathic treatments showed potential in reducing ADHD symptoms, particularly inattention and hyperactivity.
The authors concluded that homeopathy, particularly individualized treatment, shows promise as an adjunct or alternative treatment for ADHD, especially for those children whose caregivers seek alternatives to stimulant medications. Studies report that homeopathic treatment can significantly improve ADHD symptoms in some children, particularly when the correct remedy is identified. However, the evidence is mixed, with several studies showing improvements that may be attributable to the consultation process rather than the remedy itself. Given the increasing interest in Complementary and Alternative Medicine (CAM) among parents of children with ADHD, homeopathy may provide a valuable therapeutic option. Nevertheless, larger, more rigorous trials are required to confirm these findings and establish clear guidelines for its use in clinical practice. The potential for homeopathy to serve as an adjunct to conventional treatments, especially for younger patients or those intolerant to stimulants, remains an area worthy of further exploration.
What journal publishes such misleading drivel? It’s the African Journal of biomedical Research. No, I also had never heard of it! And who are the authors of this paper, their titles and affiliations? Here they are:
- Professor & HOD, Department of Anatomy, Dr. D.Y. Patil Homoeopathic Medical College & Research Centre, Dr. D.Y. Patil Vidyapeeth (Deemed to be University), Pimpri, Pune, Maharashtra, India,
- Professor & HOD, Department of Homoeopathic Pharmacy, Dr. D.Y. Patil Homoeopathic Medical College &
Research Centre, Dr. D.Y. Patil Vidyapeeth (Deemed to be University), Pimpri, Pune, Maharashtra, India, - Department of Homoeopathic Pharmacy, Dr. D.Y. Patil Homoeopathic Medical College & Research Centre, Dr. D.Y. Patil Vidyapeeth (Deemed to be University), Pimpri, Pune, Maharashtra, India,
- Department of Homoeopathic Pharmacy, Dr. D.Y. Patil Homoeopathic Medical College & Research Centre, Dr. D.Y. Patil Vidyapeeth (Deemed to be University), Pimpri, Pune, Maharashtra, India,
- Principal, Professor & HOD, Department of Forensic Medicine and Toxicology, Dr. D.Y. Patil Homoeopathic
Medical College & Research Centre, Dr. D.Y. Patil Vidyapeeth (Deemed to be University), Pimpri, Pune,
Maharashtra, India.
Five guys with the same name?
No, one chap with 5 rather pomopous titles!
And what is wrong with this ‘systematic review’?
Everything!
It has almost none of the qualities that render a paper a systematic review. Foremost, it does not account for the quality of the primary studies – the most reliable show no effect!
Therefore, I’d like to re-phrase and shorten the conclusions as follows:
There is no reliable evidence to shoe that homeopathy is effective for ADHD.
This update of a systematic review evaluated the effectiveness of spinal manipulations as a treatment for migraine headaches.
Amed, Embase, MEDLINE, CINAHL, Mantis, Index to Chiropractic Literature, and Cochrane Central were searched from inception to September 2023. Randomized clinical trials (RCTs) investigating spinal manipulations (performed by various healthcare professionals including physiotherapists, osteopaths, and chiropractors) for treating migraine headaches in human subjects were considered. Other types of manipulative therapy, i.e., cranial, visceral, and soft tissue were excluded. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the certainty of evidence.
Three more RCTs were published since our first review; amounting to a total of 6 studies with 645 migraineurs meeting the inclusion criteria. Meta-analysis of six trials showed that, compared with various controls (placebo, drug therapy, usual care), SMT (with or without usual care) has no superior effect on migraine intensity/severity measured with a range of instruments (standardized mean difference [SMD] − 0.22, 95% confidence intervals [CI] − 0.65 to 0.21, very low certainty evidence), migraine duration (SMD − 0.10; 95% CI − 0.33 to 0.12, 4 trials, low certainty evidence), or emotional quality of life (SMD − 14.47; 95% CI − 31.59 to 2.66, 2 trials, low certainty evidence) at post-intervention. A meta-analysis of two trials showed that compared with various controls, SMT (with or without usual care) increased the risk of adverse effects (risk ratio [RR] 2.06; 95% CI 1.24 to 3.41, numbers needed to harm = 6; very low certainty evidence). The main reasons for downgrading the evidence were study limitations (studies judged to be at an unclear or high risk of bias), inconsistency (for pain intensity/severity), imprecision (small sizes and wide confidence intervals around effect estimates) and indirectness (methodological and clinical heterogeneity of populations, interventions, and comparators).
We cocluded that the effectiveness of SMT for the treatment of migraines remains unproven. Future, larger, more rigorous, and independently conducted studies might reduce the existing uncertainties.
The only people who might be surprised by these conclusions are chiropractors who continue to advertise and use SMT to treat migraines. Here are a few texts by chiropractors (many including impressive imagery) that I copied from ‘X’ just now (within less that 5 minutes) to back up this last statement:
- So many people are suffering with Dizziness and migraines and do not know what to do. Upper Cervical Care is excellent at realigning the upper neck to restore proper blood flow and nerve function to get you feeling better!
- Headache & Migraine Relief! Occipital Lift Chiropractic Adjustment
- Are migraines affecting your quality of life? Discover effective chiropractic migraine relief at…
- Neck Pain, Migraine & Headache Relief Chiropractic Cracks
- Migraine Miracle: Watch How Chiropractic Magic Erases Shoulder Pain! Y-Strap Adjustments Unveiled
- Tired of letting migraines control your life? By addressing underlying issues and promoting spinal health, chiropractors can help reduce the frequency and severity of migraines. Ready to experience the benefits of chiropractic for migraine relief?
- Did you know these conditions can be treated by a chiropractor? Subluxation, Back Pain, Chronic Pain, Herniated Disc, Migraine Headaches, Neck Pain, Sciatica, and Sports Injuries.
- When a migraine comes on, there is not much you can do to stop it except wait it out. However, here are some holistic and non-invasive tips and tricks to prevent onset. Check out that last one! In addition to the other tips, chiropractic care may prevent migraines in your future!
Evidence-based chiropractic?
MY FOOT!
Dry needling (DN) is a treatment used by various healthcare practitioners, including physical therapists, physicians, and chiropractors. It involves the use of either solid filiform needles or hollow-core hypodermic needles for therapy of muscle pain, including pain related to myofascial pain syndrome. DN is mainly used to treat myofascial trigger points, but it is also used to target connective tissue, neural ailments, and muscular ailments. There is conflicting evidence regarding the effectiveness of DN for any condition.
Orofacial pain (OFP) typically has a musculoskeletal, dental, neural, or sinogenic origin. Our systematic review was aimed at evaluating the evidence base for the effectiveness of DN for OFP.
We searched Medline, Cochrane Central, and Web of Science (from their respective inceptions to February 2024) for RCTs evaluating the effectiveness of DN in patients with OFP. Studies with patients suffering from cervicogenic or tension type headaches as well as observational studies were excluded. Primary outcomes were pain intensity and severity; secondary outcomes were disability, quality of life, and adverse effects (AEs). The review adhered to the methods described by in the Cochrane Handbook.
Twenty-four RCTs with a total of 1,318 patients suffering from OFP could be included. Most had an unclear or high risk of bias, and the quality of the evidence ranged from very low to low for all comparisons and outcomes. A meta-analysis suggested that, compared with usual care alone, DN + usual care had no effect on pain intensity (visual analogue scale) (standardized mean difference = −1.89, 95% confidence intervals −5.81 to 2.02, very low certainty evidence) at follow-ups of up to 6 weeks. Only 6 RCTs (25%) mentioned AEs, and none of them reported that AEs had occurred. The remaining 18 (75%) studies failed to report AEs.
We concluded that DN cannot be considered as an effective treatment option for OFP. This is due to the uncertainties of the available evidence. We believe that larger, rigorous, and better reported trials with more homogeneous comparators might potentially reduce the current uncertainties. Such trials should strictly adhere to the classifications provided by the International Headache Society and published in the International Classification of Orofacial Pain.
Yet again, I need to stress that the vast majority od RCTs failed to mention AEs. When will the last (pseudo-) researcher have learnt that the non-reporting of AEs is a violation of research ethics?
Guest post by Catherine de Jong
Academic circles have reacted with surprise to the announcement on 12 November of the appointment of chiropractor Sidney Rubinstein as endowed professor at the Vrije Universiteit Amsterdam. The website of the Dutch Chiropractors Association (NCA) states:
“On 1 August 2024, Mr. Sidney Rubinstein was appointed professor by special appointment at the chair “Optimizing Management of Musculoskeletal Health” at the Vrije Universiteit in Amsterdam. In addition to his work as a chiropractor in his own practice, Rubinstein has been working at the Vrije Universiteit for a long time. In addition to treating patients, he has always focused on research and development within chiropractic and musculoskeletal (MSK) disorders.”
Chiropractic is an alternative method of treatment. There is no scientific evidence for clinically relevant positive treatment outcomes. For that reason, chiropractic is not mentioned as a treatment option in the guidelines of general practitioners and medical specialists in the Netherlands. Both the profession and the education are not recognized in the Netherlands. On the website of the NVAO (Dutch-Flemish Academic Organization, www.nvao.net), chiropractic does not appear as an accredited program. There is now plenty of research, especially case reports, on the damage that treatment by a chiropractor can cause, such as cerebral infarctions due to arterial dissection of carotid arteries due to cracking of the neck by chiropractors.
On June 20, 2008, the website of Medisch Contact (magazine of KNMG, Dutch Society of Medical Doctors) stated: “First Dutch chiropractor gets his PhD: Sidney Rubinstein will be the first chiropractor in the Netherlands to obtain a PhD today. Rubinstein states that most of the side effects of chiropractic are harmless and temporary.”
This dissertation, for which Sidney Rubinstein obtained his doctorate at VU Amsterdam, was substandard and was criticized in a letter sent to the same journal. The subsequent correspondence with, among others, the supervisor can be read here. In short, a dissertation that VU Amsterdam cannot be proud of.
The Cochrane database contains two reviews published by Rubinstein on chiropractic, or Spinal Manipulative Therapy (SMT) for acute and chronic back pain, respectively. The conclusion was the same in both cases: In summary, SMT appears to be no better or worse than other existing therapies for patients with acute/chronic low‐back pain. In a 2013 update (Spinal manipulative therapy for acute low back pain: an update of the Cochrane review. Spine 2013; 38(3): E158-77), Rubinstein comes to the same conclusion: SMT is no more effective for acute low back pain than inert interventions, sham SMT or as adjunct therapy. SMT also seems to be no better than other recommended therapies. Rubinstein himself has concluded years ago that chiropractic or SMT has no greater effect than other treatments (like standard physiotherapy), but still it needs to be researched again and again?
At the end of the news item on the NCA’s website, the truth is revealed: the NCA subsidizes half of the chair! The members of this organization (there are now more than 500 chiropractors in the Netherlands) have diligently raised the money for this chair. Since its foundation in 1896 by the grocer/magnetizer D.D. Palmer, chiropractic has had every chance to prove its usefulness, but it has not succeeded. That Rubinstein can change that situation is, of course, extremely unlikely.
This appointment is therefore in fact a political publicity stunt for a still pointless alternative treatment. It will do both the practice of Sidney Rubinstein and that of other chiropractors a lot of good that there is now a professor of chiropractic in the Netherlands.
The other half of the chair is paid for by the university. This means that public money that could have been better spent is now going to be wasted on research into an alternative treatment that we already know is useless, by a researcher who has already shown that there is no added value of treatment by a chiropractor.
A substandard dissertation and a purchased chair, but Sidney Rubinstein can call himself a professor. With the appointment of chiropractor Sidney Rubinstein as endowed professor at VU Amsterdam, the university is jeopardizing its good name and contributing to the unjustified elevation of Sidney Rubenstein’s status and his pointless method of treatment, chiropractic.
Can this appointment really be reconciled with the scientific norms and values that VU Amsterdam wants to uphold?
Spanish colleagues and I just published an article entitled “Is Osteopathic Manipulative Treatment Clinically Superior to Sham or Placebo for Patients with Neck or Low-Back Pain? A Systematic Review with Meta-Analysis”. Here is its abstract:
The aim of this systematic review and meta-analysis was to compare whether osteopathic manipulative treatment (OMT) for somatic dysfunctions was more effective than sham or placebo interventions in improving pain intensity, disability, and quality of life for patients with neck pain (NP) or low-back pain (LBP). Methods: A systematic review and meta-analysis was carried out. Searches were conducted in PubMed, Physiotherapy Evidence Database, Cochrane Library, and Web of Science from inception to September 2024. Studies applying a pragmatic intervention based on the diagnosis of somatic dysfunctions in patients with NP or LBP were included. The methodological quality was assessed with the PEDro scale. The quantitative synthesis was performed using random-effect meta-analysis calculating the standardized mean difference (SMD) with RevMan 5.4. The certainty of evidence was evaluated using GRADEPro. Results: Nine studies were included in the qualitative synthesis, and most of them showed no superior effect of OMTs compared to sham or placebo in any clinical outcome. The quantitative synthesis reported no statistically significant differences for pain intensity (SMD = −0.15; −0.38, 0.08; seven studies; 1173 patients) or disability (SMD = −0.09; −0.25, 0.08; six studies; 1153 patients). The certainty of evidence was downgraded to moderate, low, or very low. Conclusions: The findings of this study reveal that OMT is not superior to sham or placebo for improving pain, disability, and quality of life in patients with NP or LBP.
As always, it seems important to stress that our review has several limitations. Firstly, the searches were conducted in the most relevant databases; however, some studies not indexed in these sources may have been missed. Secondly, the diverse NP and LBP diagnosis, as well as the lack of data reported by some studies, complicates the interpretation of the results and may weaken our conclusion. Thirdly, the primary studies pragmatically applied interventions based on diagnoses of various somatic dysfunctions, resulting in a high degree of heterogeneity among the treatments applied.
Despite these limitations, it is fair to say, I think, that OMT is not nearlly as solidly supported by reliable evidence as most osteopaths try to make us believe. In essence, this means that, if you suffer from NP or LBP, you best concult a proper doctor or physiotherapist.
Chiropractic is a complementary medicine that has been growing increasingly in different countries over recent decades. It addresses the prevention, diagnosis and treatment of the neuromusculoskeletal system disorders and their effects on the whole body health.
This review aimed to evaluate the effectiveness of chiropractic in the treatment of different diseases. To gather data, scientific electronic databases, such as Cochrane, Medline, Google Scholar, and Scirus were searched and all systematic reviews in the field of chiropractic were obtained. Reviews were included if they were specifically concerned with the effectiveness of chiropractic treatment, included evidence from at least one clinical trial, included randomized studies and focused on a specific disease. The articles were excluded if:
- – they were concerned with a combination of chiropractic and other treatments (not specifically chiropractic treatment);
- – they lacked at least one clinical trial;
- – they lacked at least one randomized study;
- – and they studied chiropractic in the treatment of multiple diseases.
The research data including the article’s first author’s name, type of disease, intervention type, number and types of research used, meta-analysis, number of participants, and overall results of the study, were extracted, studied and analyzed.
Totally, 23 chiropractic systematic reviews were found, and 11 articles met the defined criteria. The results showed the influence of chiropractic on improvement of neck pain, shoulder and neck trigger points, and sport injuries. In the cases of asthma, infant colic, autism spectrum disorder, gastrointestinal problems, fibromyalgia, back pain and carpal tunnel syndrome, there was no conclusive scientific evidence. There is heterogeneity in some of the studies and also limited number of clinical trials in the assessed systematic reviews. Thus, conducting comprehensive studies based on more reliable study designs are highly recommended.
The authors stressed that three points should be emphasized. Firstly, there is a discrepancy between the development of chiropractic in different countries of the world and the quality and quantity of studies regarding the effectiveness and safety of chiropractic in treatment of diseases. Secondly, some of the systematic reviews regarding the effectiveness of chiropractic in treatment of diseases had a minimum quality of research methodology and were not useful for evaluation. Some of the excluded articles are examples of this problem. Finally, a limited number of studies (11 systematic review articles and 10 diseases) had the required criteria and were assessed in the study.
Assessment and analysis of the studies showed the impact of chiropractic on improvement of some upper extremity conditions including shoulder and neck trigger points, neck pain and sport injuries. In the case of asthma, infant colic and other studied diseases, further clinical trials with larger sample sizes and high quality research methodology are recommended.
So, is chiroprctic of proven effectiveness for any disease?
The conditions for which there is tentatively positive evidence (btw: most rely on my research!!!) are arguably not diseases but symptoms of undelying conditions. Therefore, the answer to my question above is:
NO.
Cupping is a from of so-called alternative medicine (SCAM) that has featured already many times on this blog, e.g.:
- Wet cupping in the management of cervical spondylosis? No!
- The effectiveness of cupping therapy for low back pain
- Cupping: “the propagation of ancient, scientifically unsound techniques that may cause more harm than benefit”
- Cupping therapy for non-specific chronic low back pain
- Cupping for Olympic swimmers. Or: why breaking your shoulder is not necessarily good for writing a successful book
- Wet cupping and dry humour
- Cupping for athletes: rubbish trials, rubbish review, rubbish journal
- The future of cupping: it’s bright, profitable and vacuous
Now a new and interesting paper has been published on the subject
This review aimed to investigate the effectiveness of cupping therapy on low back pain (LBP). Medline, Embase, Scopus and WANFANG databases were searched for relevant cupping RCTs on low back pain articles up to 2023. A complementary search was manually made on 27 September for update screening. Full-text English and Chinese articles on all ethnic adults with LBP of cupping management were included in this study. Studies looking at acute low back pain only were excluded. Two independent reviewers screened and extracted data, with any disagreement resolved through consensus by a third reviewer. The methodological quality of the included studies was evaluated independently by two reviewers using an adapted tool. Change-from-baseline outcomes were treated as continuous variables and calculated according to the Cochrane Handbook. Data were extracted and pooled into the meta-analysis by Review Manager software (version 5.4, Nordic Cochrane Centre).
Eleven trials involving 921 participants were included (6 on dry and 5 on wet cupping). Five studies were assessed as being at low risk of bias, and six studies were of acceptable quality. High-quality evidence demonstrated cupping significantly improves pain at 2-8 weeks endpoint intervention (d=1.09, 95% CI: [0.35-1.83], p = 0.004). There was no continuous pain improvement observed at one month (d=0.11, 95% CI: [-1.02-1.23], p = 0.85) and 3-6 months (d=0.39, 95% CI: [-0.09-0.87], p = 0.11). Dry cupping did not improve pain (d=1.06, 95% CI: [-0.34, 2.45], p = 0.14) compared with wet cupping (d=1.5, 95% CI: [0.39-2.6], p = 0.008) at the endpoint intervention. There was no evidence indicating the association between pain reduction and different types of cupping (p = 0.2). Moderate- to low-quality evidence showed that cupping did not reduce chronic low back pain (d=0.74, 95% CI: [-0.67-2.15], p = 0.30) and non-specific chronic low back pain (d=0.27, 95% CI: [-1.69-2.24], p = 0.78) at the endpoint intervention. Cupping on acupoints showed a significant improvement in pain (d=1.29, 95% CI: [0.63-1.94], p < 0.01) compared with the lower back area (d=0.35, 95% CI: [-0.29-0.99], p = 0.29). A potential association between pain reduction and different cupping locations (p = 0.05) was found. Meta-analysis showed a significant effect on pain improvement compared to medication therapy (n = 8; d=1.8 [95% CI: 1.22 – 2.39], p < 0.001) and usual care (n = 5; d=1.07 [95% CI: 0.21- 1.93], p = 0.01). Two studies demonstrated that cupping significantly mediated sensory and emotional pain immediately, after 24 h, and 2 weeks post-intervention (d= 5.49, 95% CI [4.13-6.84], p < 0.001). Moderate evidence suggested that cupping improved disability at the 1-6 months follow-up (d=0.67, 95% CI: [0.06-1.28], p = 0.03). There was no immediate effect observed at the 2-8 weeks endpoint (d=0.40, 95% CI: [-0.51-1.30], p = 0.39). A high degree of heterogeneity was noted in the subgroup analysis (I2 >50%).
The authors concluded that high- to moderate-quality evidence indicates that cupping significantly improves pain and disability. The effectiveness of cupping for LBP varies based on treatment durations, cupping types, treatment locations, and LBP classifications. Cupping demonstrated a superior and sustained effect on pain reduction compared with medication and usual care. The notable heterogeneity among studies raises concerns about the certainty of these findings. Further research should be designed with a standardized cupping manipulation that specifies treatment sessions, frequency, cupping types, and treatment locations. The actual therapeutic effects of cupping could be confirmed by using objective pain assessments. Studies with at least six- to twelve-month follow-ups are needed to investigate the long-term efficacy of cupping in managing LBP.
A crucial point here is that only 3 of the included studies were ‘patient-blind’, i.e. tried to control for placebo effects by using a sham procedure:
- The first of these used leaking vaccum cups that failed to create sucction. This would therefore not have resulted in the typical circular hematoma. In other words, patients were easily de-blinded.
- The second trial compared two different wet cupping techniques which involved different procedures. This would have been easily identifiable by the patients. In other words, patients were easily de-blinded.
- The third (which showed no effectiveness of cupping) supposedly patient-blind study used a similar method as the first. In other words, patients were easily de-blinded.
In addition, we ought to remember that in no study was it possible to blind the therapists. Thus there is a danger of verbal or non-verbal communications impacting on the outcomes.
In my view, it follows that the effectiveness of cupping is far lass certain than the authors of this paper try to make us believe.
Uterine fibroids are a common gynaecological condition often impacting quality of life. While conventional treatment options exist, there is growing interest in so-called alternative Medicine (SCAM) such as homeopathy. The objective of this review paper was to assess the effectiveness of homeopathic medicines in treating uterine fibroids through the analysis of recent clinical trials and observational studies, aiming to provide insights into the potential role of homeopathy as a SCAM for uterine fibroids.
A thorough search of databases such as PubMed, Google Scholar, Scopus, and pertinent medical journals was undertaken to locate recent studies on the efficacy of homeopathic medicines for uterine fibroids. Only studies meeting predefined inclusion criteria, including randomized controlled trials, prospective observational studies, and systematic reviews, were included in the review process.
Recent studies investigating the efficacy of homeopathic medicines in treating uterine fibroids consistently demonstrated positive outcomes, including symptom alleviation, reduction in fibroid size, and improved quality of life. Various remedies showed effectiveness across various potencies. Symptom severity scales, including the Visual Analogue Scale (VAS), Numerical Rating Scale (NRS), and Verbal Multidimensional Scoring System (VMSS), were utilized to assess pelvic pain, menstrual bleeding, and discomfort. Quality of life measures like the WHOQOL-BREF scale provided insights into overall well-being.
The authors concluded that the collective findings from these studies provide robust evidence supporting the efficacy and safety of homeopathic medicines in the management of uterine fibroids. By employing individualized treatment approaches tailored to patient-specific symptoms and characteristics, homeopathy offers a holistic and personalized approach to addressing fibroids and improving the quality of life for affected individuals. Overall, these studies provide robust evidence supporting the efficacy and safety of homeopathic medicines in treating uterine fibroids.
This is a very odd paper:
- The authors call it a “comprehensive review”, a term that is next to meaningless.
- It certainly is not a systematic review.
- The reason for merely including “recent studies” is unclear; it also makes a mockery of the attribute “comprehensive”.
- The reason for including observational studies, however, seems to be very clear: it is an age-old trick to generate a false-positive result.
- There was no assessment of the quality of the primary studies.
- In total, there were just 6 primary studies none of which was anywhere near to being rigorous.
- The authors never even investigated the safety of homeopathic remedies, yet they draw firm conclusions about it.
My conclusion is that this “comprehensive review” is comprehensive example of how to comprehensively mislead with comprehensively dishonest research. And why would anyone set out to do such a thing? Perhaps the authors’ affiliation provide some hints:
- Department of Homoeopathic Pharmacy,
- Homoeopathic Medical College & Research Centre.
The American Society of Clinical Oncology (ASCO) and the Society for Integrative Oncology have collaborated to develop guidelines for the application of integrative approaches in the management of:
- anxiety,
- depression,
- fatigue,
- use of cannabinoids and cannabis in patients with cancer.
These guidelines provide evidence-based recommendations to improve outcomes and quality of life by enhancing conventional cancer treatment with integrative modalities.
All studies that informed the guideline recommendations were reviewed by an Expert Panel which was made up of a patient advocate, an ASCO methodologist, oncology providers, and integrative medicine experts. Panel members reviewed each trial for quality of evidence, determined a grade quality assessment label, and concluded strength of recommendations.
The findings show:
- Strong recommendations for management of cancer fatigue during treatment were given to both in-person or web-based mindfulness-based stress reduction, mindfulness-based cognitive therapy, and tai chi or qigong.
- Strong recommendations for management of cancer fatigue after cancer treatment were given to mindfulness-based programs.
- Clinicians should recommend against using cannabis or cannabinoids as a cancer-directed treatment unless within the context of a clinical trial.
- The recommended modalities for managing anxiety included Mindfulness-Based Interventions (MBIs), yoga, hypnosis, relaxation therapies, music therapy, reflexology, acupuncture, tai chi, and lavender essential oils.
- The strongest recommendation in the guideline is that MBIs should be offered to people with cancer, both during active treatment and post-treatment, to address depression.
The authors concluded that the evidence for integrative interventions in cancer care is growing, with research now supporting benefits of integrative interventions across the cancer care continuum.
I am sorry, but I find these guidelines of poor quality and totally inadequate for the purpose of providing responsible guidance to cancer patients and carers. Here are some of my reasons:
- I know that this is a petty point, particularly for me as a non-native English speaker, but what on earth is an INTEGRATIVE THERAPY? I know integrative care or integrative medicine, but what could possibly be integrative with a therapy?
- I can vouch for the fact that the assertion “all studies that informed the guideline recommendations were reviewed” is NOT true. The authors seem to have selected the studies they wanted. Crucially, they do not reveal their selection criteria. I have the impression that they selected positive studies and omitted those that were negative.
- The panel of experts conducting the research should be mentioned; one can put together a panel to show just about anything simply by choosing the right individuals.
- The authors claim that they assessed the quality of the evidence, yet they fail to tell us what it was. I know that many of the trials are of low quality and their results therefore less than reliable. And guidance based on poor-quality studies is misguidance.
- The guidelines say nothing about the risks of the various treatments. In my view, this would be essential for any decent guideline. I know that some of the mentioned therapies are not free of adverse effects.
- They also say nothing about the absolute and relative effect sizes of the treatments they recommend. Such information would ne necessary for making informed decisions about the optimal therapeutic choices.
- The entire guideline is bar any critical thinking.
Overall, these guidelines provide more an exercise in promotion of dubious therapies than a reliable guide for cancer patients and their carers. The ASCO and the Society for Integrative Oncology should be ashamed to have given their names to such a poor-quality document.
