systematic review
How often have we heard the claim from proponents of alternative medicine that one strength of their approach is disease prevention (see for instance my previous post or this, this and this) and that conventional medicine neglects prevention almost completely? Such claims annoy me because they are demonstrably false.
I know, to some readers, this may seem like a bold statement; let me therefore try to justify it.
- So far, I have seen no good evidence that any alternative therapy might be effective in preventing any disease.
- Practically everything we know today about disease prevention originates from conventional medicine and science.
- There are thousands of papers that address prevention and, as far as I can see, they all originate from the realm of conventional medicine. Below is a list of just 7 recent reviews on the subject.
This paper is an update of the evidence for exercise as a prevention of heart failure. It concluded that exercise provides protective benefit in preventing HF (primary prevention). With HF present: exercise improvement with training provides benefits in HF (secondary prevention). The prediction of future in HF patients: exercise impairment, as a leading characteristic of HF, is used as a prognostic factor.
The aim of this review was to update evidence for the US Preventive Services Task Force on the benefits and harms of hormone therapy in reducing risks for chronic conditions. The authors found that hormone therapy for the primary prevention of chronic conditions in menopausal women is associated with some beneficial effects but also with a substantial increase of risks for harms. The available evidence regarding benefits and harms of early initiation of hormone therapy is inconclusive.
This paper reviewed the evidence for Implantable Cardiac Defibrillators (ICDs). The authors stated that individuals with stable ischemic heart disease (no recent myocardial infarction), especially those with inducible arrhythmias, seem to derive the highest mortality benefit from prophylactic ICD use.
These authors investigated whether neuromuscular and proprioceptive training is effective in preventing knee and anterior cruciate ligament (ACL) injuries. They concluded that neuromuscular and proprioceptive training appeared to decrease the incidence of injury to the knee and specifically the AC.
Other researchers summarized current evidence about real-world studies on apixaban for stroke prevention in atrial fibrillation. They concluded that the use of apixaban in real-life is associated with an overall similar effectiveness in reducing stroke and any thromboembolic events when compared with warfarin. A better safety profile was found with apixaban compared with warfarin, dabigatran, and rivaroxaban.
Finally, a review assessed the evidence of blood pressure (BP) lowering treatments as a means of reducing cardiovascular morbidity and mortality. The authors concluded that primary preventive BP lowering is associated with reduced risk for death and CVD if baseline SBP is 140 mm Hg or higher. At lower BP levels, treatment is not associated with any benefit in primary prevention but might offer additional protection in patients with CHD.
Testing preventative treatments is, of course, far from easy. Ideally, one would want to do an RCT, but often this is not possible, for instance, because the sample size would need to be prohibitively huge and the observation period prohibitively long (think of cholesterol-lowering for reducing cardiovascular risks, or smoking cessation for preventing cancer). Thus we rely frequently on other types of investigations such as epidemiological studies. This type of research is, however, rarely undertaken in alternative medicine, and when it does cover subjects related to this area, it is almost never done by proponents of alternative medicine.
The long and short of all this is depressingly simple: the often-heard claim that alternative medicine is strong on prevention is quite simply false. Proponents of alternative medicine like to talk about prevention (presumably because it is good for business), but when it comes to applying prevention and showing that their preventative interventions are effective, all this talk turns out to be little more than hot air.
I am sure – even hope – that some readers will disagree, and I look forward to their evidence proving me wrong.
The common cold is a perfect condition for providers of alternative medicine:
- it is prevalent (good money to be earned),
- it is not normally dangerous,
- it nevertheless reduces quality of life and thus patients look for a treatment,
- there probably is not a single alternative therapy that does not claim to be effective for it,
- it is gone after about a week, treated or not.
But is there an alternative therapy that does actually work? An article by the Cochrane Collaboration provides an excellent overview. It includes conventional as well as alternative treatments; here I have merely copied the passages related to the latter:
VITAMIN C
There was great excitement in the 1970s when Linus Pauling, (a Nobel laureate twice over), concluded from placebo-controlled trials that Vitamin C could prevent and alleviate the common cold. Further research followed and a Cochrane review, published in 2013, found 29 clinical trials, involving 11,306 participants. Unfortunately, the review did not confirm Pauling’s findings. Taking regular Vitamin C did not reduce the incidence of colds in the general population, although there was a modest reduction in the duration and severity of symptoms. The only people who appeared to derive some benefit were those who undertook short bursts of extreme exercise, such as marathon runners and skiers. In this group the risk of getting a cold was halved.
Trials looking at taking high dose Vitamin C at the onset of cold symptoms showed no consistent effect on the duration and severity of symptoms and more research is needed to clarify these findings.
ECHINACEA
Echinacea is widely used in Europe and North America for common colds. A Cochrane review (2014) showed that some Echinacea products may be more effective than placebo in treating colds but the overall evidence for clinically relevant effects was weak. There was some evidence of a small preventative effect.
INHALATIONS
Inhaled steam has been used for decades (see earlier reference to my childhood humiliation!) thinking that it helps drain away mucus more effectively and possibly destroys the cold virus. A Cochrane review (2017) of six trials with 387 participants showed no consistent benefit for this intervention.
GARLIC
A single trial with 146 participants showed that taking garlic every day for three months might prevent occurrences of the common cold but the evidence was of low quality and more research is needed to validate this finding. (Cochrane review 2014.)
END OF QUOTE
The article obviously focuses only on such therapies for which Cochrane reviews have been published. What about other treatments? As I already mentioned, if we believe the promoters of alternative medicine, the list is long. But fortunately, we do not believe them and want to see the evidence.
HOMEOPATHY
Unsurprisingly, the evidence is not good. One of my posts even expressed the fear that it might involve scientific misconduct.
CHIROPRACTIC
Yes, some chiropractors claim that their manipulations are effective for the common cold. But, as with almost all of their claims, this cannot be taken seriously; the assumption is bogus.
CHINESE HERBAL MEDICINES
A systematic review concluded that their use for common cold is not supported by robust evidence.
SAUNA
Ages ago, I published a small study with promising results:
Twenty-five volunteers were submitted to sauna bathing, with 25 controls abstaining from this or comparable procedures. In both groups the frequency, duration and severity of common colds were recorded for six months. There were significantly fewer episodes of common cold in the sauna group. This was found particularly during the last three months of the study period when the incidence was roughly halved compared to controls. The mean duration and average severity of common colds did not differ significantly between the groups. It is concluded that regular sauna bathing probably reduces the incidence of common colds, but further studies are needed to prove this.
Sadly, the findings were never replicated.
MY CONCLUSION
Grin and bear it!
(That is the cold as well as the myriad of false claims made by enthusiasts of alternative medicine)
This overview by researchers from that Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, UK, was aimed at summarising the current best evidence on treatment options for 5 common musculoskeletal pain presentations: back, neck, shoulder, knee and multi-site pain. Reviews and studies of treatments were considered of the following therapeutic options: self-management advice and education, exercise therapy, manual therapy, pharmacological interventions (oral and topical analgesics, local injections), aids and devices, other treatments (ultrasound, TENS, laser, acupuncture, ice / hot packs) and psychosocial interventions (such as cognitive-behavioural therapy and pain-coping skills).
Here are the findings for those treatments most relevant in alternative medicine (it is interesting that most alternative medicines were not even considered because of lack of evidence and that the team of researchers can hardly be accused of an anti-alternative medicine bias, since its senior author has a track record of publishing results favourable to alternative medicine):
EXERCISE
Current evidence shows significant positive effects in favour of exercise on pain, function, quality of life and work related outcomes in the short and long-term for all the musculoskeletal pain presentations (compared to no exercise or other control) but the evidence regarding optimal content or delivery of exercise in each case is inconclusive.
ACUPUNCTURE
The evidence from a good quality individual patient data meta-analysis suggests that acupuncture may be effective for short-term relief of back pain and knee pain with medium summary effect sizes respectively compared with usual care or no acupuncture. However, effects on function were reported to be minimal and not maintained at longer-term follow-up. Similarly for neck and shoulder pain, acupuncture was only found to be effective for short-term (immediately post-treatment and at short-term follow-up) symptom relief compared to placebo.
MANUAL THERAPY
Current evidence regarding manual therapy is beset by heterogeneity. Due to paucity of high quality evidence, it is uncertain whether the efficacy of manual therapy might be different for different patient subgroups or influenced by the type and experience of professional delivering the therapy. On the whole, the available evidence suggests that manual therapy may offer some beneficial effects on pain and function, but it may not be superior to other non-pharmacological treatments (e.g. exercise) for patients with acute or chronic musculoskeletal pain.
Overall. the authors concluded that the best available evidence shows that patients with musculoskeletal pain problems in primary care can be managed effectively with non-pharmacological treatments such as self-management advice, exercise therapy, and psychosocial interventions. Pharmacological interventions such as corticosteroid injections (for knee and shoulder pain) were shown to be effective treatment options for the short-term relief of musculoskeletal pain and may be used in addition to non-pharmacological treatments. NSAIDs and opioids also offer short-term benefit for musculoskeletal pain, but the potential for adverse effects must be considered. Furthermore, the optimal treatment intensity, methods of application, amount of clinical contact, and type of provider or setting, are unclear for most treatment options.
These findings confirm what we have pointed out many times before on this blog. There is very little that alternative therapies have to offer for musculoskeletal pain. Whenever it is possible, I would recommend exercise therapy initiated by a physiotherapist; it is inexpensive, safe, and at least as effective as acupuncture or chiropractic or osteopathy.
Practitioners of alternative medicine will, of course, not like this solution.
Acupuncturists may not be that bothered by such evidence: their focus is not necessarily on musculoskeletal but on a range of other conditions (with usually little evidence, I hasten to add).
But for chiropractors and osteopaths, this is much more serious, in my view. Of course, some of them also claim to be able to treat a plethora of non-musculoskeletal conditions (but there the evidence is even worse than for musculoskeletal pain, and therefore this type of practice is clearly unethical). And those who see themselves as musculoskeletal specialists have to either accept the evidence that shows little benefit and considerable risk of spinal manipulation, or go in a state of denial.
In the former case, the logical conclusion is to look for another job.
In the latter case, the only conclusion is that their practice is not ethical.
The ‘Dr Rath Foundation’ just published a truly wonderful (full of wonders) article about me. I want to publicly congratulate the author: he got my name right [but sadly not much more]. Here is the opening passage of the article which I encourage everyone to read in full [the numbers in square brackets refer to my comments below].
Professor Edzard Ernst: A Career Built On Discrediting Natural Health Science? [1]
Professor Edzard Ernst, a retired German [2] physician and academic, has recently [3] become a prominent advocate of plans that could potentially outlaw [4] the entire profession of naturopathic doctors [5] in Germany. Promoting the nonsensical idea that naturopathic medicine somehow poses a risk to public health, Ernst attacks its practitioners as supposedly having been educated in “nonsense” [6]. Tellingly, however, given that he himself has seemingly not published even so much as one completely original scientific trial of his own [7], Ernst’s apparent attempts to discredit natural healthcare approaches are largely reliant instead on his analysis or review of handpicked negative studies carried out by others [8].
- When I was appointed at Exeter to research alternative medicine in 1993, I had already been a full professor at Hannover, Germany and subsequently at Vienna, Austria. If anything, coming to Exeter was a big step down in terms of ‘career’, salary, number of co-workers etc. (full details in my memoir)
- I am German-born, became an Austrian citizen in 1990, and since 2000 I am a British national.
- I have been critical about the German ‘Heilpraktiker’ for more than 20 years.
- This refers to the recent ‘Muensteraner Memorandum’ which is the work of an entire team of multidisciplinary experts and advocates reforming this profession.
- ‘Heilpraktiker’ are certainly not doctors; they have no academic or medical background.
- This is correct, and I stand by my statement that educating people in vitalism and other long-obsolete concepts is pure nonsense.
- Since I am researching alternative medicine, I have conducted and published about 40 ‘scientific trials’, and before that time (1993) I have published about the same number again in various other fields.
- This refers to systematic reviews which, by definition, include all the studies available on a defines research question, regardless of their conclusion (their aim is to minimise random and selection biases) .
I hope you agree that these are a lot of mistakes (or are these even lies?) in just a short paragraph.
Now you probably ask: who is Dr Rath?
Many reader of this blog will have heard of him. This is what the Guardian had to say about this man:
Matthias Rath, the vitamin campaigner accused of endangering thousands of lives in South Africa by promoting his pills while denouncing conventional medicines as toxic and dangerous, has dropped a year-long libel action against the Guardian and been ordered to pay costs.
A qualified doctor who is thought to have made millions selling nutritional supplements around the globe through his website empire, Rath claimed his pills could reverse the course of Aids and distributed them free in South Africa, where campaigners, who have won a hard-fought battle to persuade the government to roll out free Aids drugs to keep millions alive, believe Rath’s activities led to deaths.
The Dr Rath Foundation focuses its promotional activities on eight countries – the US, the UK, Germany, the Netherlands, South Africa, Spain, France and Russia – claiming that his micronutrient products will cure not just Aids, but cancer, heart disease, strokes and other illnesses…
I am sure you now understand why I am rather proud of being defamed by this source!
Dr Peter Fisher (I have mentioned him several times before, see for instance here, here and here) claimed in his recent editorial (Fisher P, Homeopathy and intellectual honesty, Homeopathy (2017) – not yet available on Medline) that 43 systematic reviews of homeopathy have so far been published, and stated that “of these 21 were clearly or tentatively positive and 9 inconclusive”. In my book, this would mean that the majority of systematic reviews fail to be clearly positive. But Fisher seems to view this mini-statistic as a proof of homeopathy’s efficacy.
As evidence for his statement, Fisher cites this article from his own journal (‘Homeopathy’). However, the paper actually says this: “A total of 36 condition-specific systematic reviews have been identified in the peer-reviewed literature: 16 of them reported positive, or tentatively positive, conclusions about homeopathy’s clinical effectiveness; the other 20 were negative or non-conclusive.”
Odd?
Confused by this contradiction, I try to dig deeper. Medline provides currently 66 hits when searching systematic reviews of homeopathy. But this figure includes papers that are not really systematic reviews and excludes some relevant articles that are not Medline-listed.
The NHMRC report which Fisher also cites (see below) considered 57 systematic reviews of homeopathy. In his editorial, Fisher stated that the NHMRC report “seems to have missed some systematic reviews of homeopathy”. This can only mean that Fisher knows of more than 57 reviews. Why then does he claim that there are just 43?
Odd?
Yes, but Fisher’s editorial seems odd in several other ways as well.
- He accuses the NHMRC-authors of ‘malpractice’.
- He finds ‘shocking evidence of bias’.
- He alleges that the EASAC-report ‘cherry-picks evidence’.
- He accuses the EASAC-authors of ‘abuse of authority’.
Definitely odd!
Why does Dr Peter Fisher go this far, why is he so very aggressive?
I know Peter quite well. He is usually a fairly calm and collected sort of person who is not prone to irrational outbursts. This behaviour is therefore out of character.
So, why?
The only explanation that I have for his strange behaviour is that he feels cornered, has run out of rational arguments, and senses that homeopathy is now on its last leg.
What do you think?
The British press recently reported that a retired bank manager (John Lawler, aged 80) died after visiting a chiropractor in York. This tragic case was published in multiple articles, most recently in THE SUN. Personally, I find this regrettable – not the fact that the press warns consumers of chiropractic, but the tone and content of the articles.
Let me explain this by citing the one in THE SUN of today. Here is the critical bit that concerns me:
Ezvard Ernst, Emeritus Professor of Complementary Medicine at Exeter University, published a study showing at least 26 people had died as a result. He said: “The evidence is not in favour of chiropractic treatments. Nobody knows how many have suffered severe complications or died.” Edvard Ernst, Professor of Complementary Medicine, says many have suffered complications or died from chiropractors treatments… A study from Exeter University shows at least 26 people have died as a result of treatment.
And what is wrong with this?
The answer is lots:
- My first name is consistently misspelled (a triviality, I agree).
- I am once named as Emeritus Professor and once as Professor of Complementary Medicine. The latter is wrong (another triviality, perhaps, but some of my more demented critics have regularly accused me of carrying wrong titles)
- The mention of 26 deaths after chiropractic treatments is problematic and arguably misleading (see below).
- Our ‘study’ was not a study but a systematic review (another triviality?).
Now you probably think I am being pedantic, but I feel that the article is regrettable not so much by what it says but by what it fails to say. To understand this better, I will below copy my emails to the journalist who asked for help in researching this article.
- My email of 17/10 answering all 7 of the journalist’s specific questions:
- 1. Why are you sceptical of chiropractic?
- I have researched the subject for more than 2 decades, and I know that the evidence is not in favour of chiropractic
- 2. How many people do you believe have died in Britain as a result of being treated by a chiropractor? If it’s not possible to say, can you estimate?
- nobody knows how many patients have suffered severe complications or deaths. there is no system to monitor such events that is comparable to the post-marketing surveillance of conventional medicine. we did some research and found that the under-reporting of cases of severe complications was close to 100% in the UK.
- 3. What is so dangerous about chiropractic? Is there a particular physical treatment than endangers life?
- manipulations that involve rotation and over-extension of the upper spine can lead to a vertebral artery breaking up. this causes a stroke which sometimes is fatal.
- 4. Is the industry well regulated?
- UK chiropractors are regulated by the General Chiropractic Council. it is debatable whether they are fit for purpose (see here:http://edzardernst.com/2015/02/the-uk-general-chiropractic-council-fit-for-purpose/)
- 5. Should we be suspicious of claims that chiropractic can cure things like IBS and autism?
- such claims are not based on good evidence and therefore misleading and unethical. sadly, however, they are prevalent.
- 6. Who trains chiropractors?
- there are numerous colleges that specialise in that activity.
- 7. Is it true Prince Charles is to blame for the rise in popularity/prominence of chiropractic?
- I am not sure. certainly he has been promoting all sorts of unproven treatments for decades.
- My email of 18/10 answering 3 further specific questions
- 1. Would you actively discourage anyone from being treated by a chiropractor?
yes, anyone I feel responsible for
2. Are older people particularly at risk or could one wrong move affect anyone?
older people are at higher risk of bone fractures and might also have more brittle arteries prone to dissection
3. If someone has, say, a bad back or stiff neck what treatment would you recommend instead of chiropractic?
I realise every case is different, but you are sceptical of all complementary treatments (as I understand it) so what would you suggest instead?
I would normally consider therapeutic exercises and recommend seeing a good physio. - 3. My email of 23/10 replying to his request for specific UK cases
- the only thing I can offer is this 2001 paper
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1297923/
- where we discovered 35 cases seen by UK neurologists within the preceding year. the truly amazing finding here was that NONE of them had been reported anywhere before. this means under-reporting was exactly 100%.
END OF QUOTES
I think that makes it quite obvious that much relevant information never made it into the final article. I also know that several other experts provided even more information than I did which never appeared.
The most important issues, I think, are firstly the lack of a monitoring system for adverse events, secondly the level of under-reporting and thirdly the 50% rate of mild to moderate adverse-effects. Without making these issues amply clear, lay readers cannot possibly make any sense of the 26 deaths. More importantly, chiropractors will now be able to respond by claiming: 26 deaths compare very favourably with the millions of fatalities caused by conventional medicine. In the end, the message that will remain in the heads of many consumers is this: CONVENTIONAL MEDICINE IS MUCH MORE DANGEROUS THAN CHIROPRACTIC!!! (The 1st comment making this erroneous point has already been published: Don’t be stupid Andy. You wanna discuss how many deaths occur due to medication side effects and drug interactions? There is a reason chiros have the lowest malpractice rates.)
Don’t get me wrong, I am not accusing the author of the SUN-article. For all I know, he has filed a very thoughtful and complete piece. It might have been shortened by the editor who may also have been the one adding the picture of the US starlet with her silicone boobs. But I am accusing THE SUN of missing a chance to publish something that might have had the chance of being a meaningful contribution to public health.
Perhaps you still think this is all quite trivial. Yet, after having experienced this sort of thing dozens, if not hundreds of times, I disagree.
Gastro-oesophageal reflux disease (GORD) is a common, benign condition. It can be treated by changing eating habits or drugs. Many alternative therapies are also on offer, for instance, acupuncture. But does it work? Let’s find out.
The objective of this meta-analysis was to explore the effectiveness of acupuncture for the treatment of gastro-oesophageal reflux disease (GORD). Four English and four Chinese databases were searched through June 2016. Randomised controlled trials investigating the effectiveness of manual acupuncture or electroacupuncture (MA/EA) for GORD versus or as an adjunct to Western medicine (WM) were selected.
A total of 12 trials involving 1235 patients were included. The results demonstrated that patients receiving MA/EA combined with WM had a superior global symptom improvement compared with those receiving WM alone with no significant heterogeneity. Recurrence rates of those receiving MA/EA alone were lower than those receiving WM with low heterogeneity, while global symptom improvement (six studies) and symptom scores (three studies) were similar. Descriptive analyses suggested that acupuncture also improves quality of life in patients with GORD.
The authors concluded that this meta-analysis suggests that acupuncture is an effective and safe treatment for GORD. However, due to the small sample size and poor methodological quality of the included trials, further studies are required to validate our conclusions.
I am glad the authors used the verb ‘suggest’ in their conclusions. In fact, even this cautious terminology is too strong, in my view. Here are 9 reasons why:
- The hypothesis that acupuncture is effective for GORD lacks plausibility.
- All the studies were of poor or very poor methodological quality.
- All but one were from China, and we know that all acupuncture trials from this country are positive, thus casting serious doubt on their validity.
- Six trials had the infamous ‘A+B versus B’ design which never generates a negative result.
- There was evidence of publication bias, i. e. negative trials had disappeared and were thus not included in the meta-analysis.
- None of the trials made an attempt to control for placebo effects by using a sham-control procedure.
- None used patient-blinding.
- The safety of a therapy cannot be assessed on the basis of 12 trials
- Seven studies failed to report adverse effects, thus violating research ethics.
Considering these facts, I think that a different conclusion would have been more appropriate: this meta-analysis provides no good evidence for the assumption that acupuncture is an effective and safe treatment for GORD.
Reiki has been on my mind repeatedly (see for instance here, here, here and here). It is one of those treatments that are too crazy for words and too implausible to mention. Yet a new paper firmly claims that it is more than a placebo.
This review evaluated clinical studies of Reiki to determine whether there is evidence for Reiki providing more than just a placebo effect. The available English-language literature of Reiki was reviewed, specifically for
- peer-reviewed clinical studies,
- studies with more than 20 participants in the Reiki treatment arm,
- studies controlling for a placebo effect.
Of the 13 suitable studies,
- 8 demonstrated Reiki being more effective than placebo,
- 4 found no difference but had questionable statistical resolving power,
- one provided clear evidence for not providing benefit.
The author concluded that these studies provide reasonably strong support for Reiki being more effective than placebo. From the information currently available, Reiki is a safe and gentle “complementary” therapy that activates the parasympathetic nervous system to heal body and mind. It has potential for broader use in management of chronic health conditions, and possibly in postoperative recovery. Research is needed to optimize the delivery of Reiki.
These are truly fantastic findings! Reiki is more than a placebo – would have thought so? Who would have predicted that something as implausible as Reiki would one day be shown to work?
Now let’s start re-writing the textbooks of physics and therapeutics and research how we can optimize the delivery of Reiki.
Hold on – not so quick! Here are a few reasons why we might be sceptical about the validity of this review:
- It was published in one of the worst journals of alternative medicine.
- The author claimed to include just clinical trials but ended up including non-clinical studies and animal studies.
- Four trials were not double-blind.
- There was no critical assessment of the studies methodological quality.
- The many flaws of the primary studies were not mentioned in this review.
- Papers not published in English were omitted.
- The author who declared no conflict of interest has this affiliation: “Australasian Usui Reiki Association, Oakleigh, Victoria, Australia”.
I think we can postpone the re-writing of textbooks for a little while yet.
Mastitis is a common disease in dairies. Numerous non-antimicrobial drugs and treatment strategies have been recommended for this condition. Homeopaths in particular have long claimed that their highly diluted remedies are an effective option, and I have reported repeatedly about the evidence – see here, here, and here, for instance. Even though it is far from positive, evangelic homeopaths like our friend Dana Ullman or naïve quackery-fans like Prince Charles claim that it is “as effective as antibiotics, the mastitis treatment of choice”.
So, who is right?
I am biased, homeopaths insist.
Ullman is a joke, any rational thinker must admit.
Prince Charles? … no comment.
What we need is an independent body to look at the data.
A new systematic review did exactly that. Its authors are highly respected and come from institutions that are not likely to promote bogus claims:
- Département de Sciences Cliniques, Faculté de Médecine Vétérinaire, Université de Montréal, Canada
- Département de Sciences Cliniques, Faculté de Médecine Vétérinaire, Université de Montréal, Canada
- Canadian Bovine Mastitis and Milk Quality Research Network, Canada
- Canadian Bovine Mastitis and Milk Quality Research Network, Canada
- Sherbrooke Research and Development Centre, Agriculture and Agri-Food Canada
- Canadian Bovine Mastitis and Milk Quality Research Network, Canada
- Département de Pathologie et Microbiologie, Faculté de Médecine Vétérinaire, Université de Montreal, Canada.
It was performed with studies written in English or French selected from CAB Abstracts, PubMed, and Web of Science. All treatments other than conventional antimicrobials for clinical mastitis during lactation were retained. Only studies comparing the treatment under investigation to a negative or positive control, or both, were included. Outcomes evaluated were clinical and bacteriological cure rates and milk production. Selection of the study, data extraction, and assessment of risk of bias was performed by 3 reviewers. Assessment of risk of bias was evaluated using the Cochrane Collaboration tool for systematic review of interventions.
A total of 2,451 manuscripts were first identified and 39 manuscripts corresponding to 41 studies were included. Among these, 22 were clinical trials, 18 were experimental studies, and one was an observational study. The treatments evaluated were conventional anti-inflammatory drugs (n = 14), oxytocin with or without frequent milk out (n = 5), biologics (n = 9), homeopathy (n = 5), botanicals (n = 4), probiotics (n = 2), and other alternative products (n = 2). All trials had at least one unclear or high risk of bias. Most trials (n = 13) did not observe significant differences in clinical or bacteriological cure rates in comparison with negative or positive controls. Few studies evaluated the effect of treatment on milk yield. In general, the power of the different studies was very low, thus precluding conclusions on non-inferiority or non-superiority of the treatments investigated. No evidence-based recommendations could be given for the use of an alternative or non-antimicrobial conventional treatment for clinical mastitis.
The authors concluded that homeopathic treatments are not efficient for management of clinical mastitis.
Will this finally stop homeopaths from claiming that their placebos work for mastitis?
I would not count on it!
Insomnia is a ‘gold standard’ indication for alternative therapies of all types. In fact, it is difficult to find a single of these treatments that are not being touted for this indication. Consequently, it has become a nice little earner for alternative therapists (hence ‘gold standard’).
But how good is the evidence suggesting that any alternative therapy is effective for insomnia?
Whenever I have discussed this issue on my blog, the conclusion was that the evidence is less than convincing or even negative. Similarly, whenever I conducted proper systematic reviews in this area, the evidence turned out to be weak or negative. Here are four of the conclusions we drew at the time:
- The evidence for acupuncture as a treatment of insomnia is plagued by important limitations, e.g. the poor quality of most primary studies and some systematic reviews. Those that are sensitive to such limitations, fail to arrive at a positive verdict about the effectiveness of acupuncture.
- We conclude that, because of the paucity and of the poor quality of the data, the evidence for the effectiveness of auricular acupuncture for the symptomatic treatment of insomnia is limited. Further, rigorously designed trials are warranted to confirm these results.
- The evidence for valerian as a treatment for insomnia is inconclusive.
- Evidence from RCTs does not show homeopathy to be an effective treatment for insomnia and sleep-related disorders. (FACT, 2011, 16:195-99)
“But this ERNST fellow cannot be trusted, he is not objective!”, I hear some of my detractors shout.
But is he really?
Would an independent, high-level panel of experts arrive at more positive conclusions?
Let’s find out!
This European guideline for the diagnosis and treatment of insomnia recently provided recommendations for the management of adult patients with insomnia. The guideline is based on a systematic review of relevant meta-analyses published till June 2016. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to grade the evidence and guide recommendations.
The findings and recommendations are as follows:
- Cognitive behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (strong recommendation, high-quality evidence).
- A pharmacological intervention can be offered if cognitive behavioural therapy for insomnia is not sufficiently effective or not available. Benzodiazepines, benzodiazepine receptor agonists and some antidepressants are effective in the short-term treatment of insomnia (≤4 weeks; weak recommendation, moderate-quality evidence). Antihistamines, antipsychotics, melatonin and phytotherapeutics are not recommended for insomnia treatment (strong to weak recommendations, low- to very-low-quality evidence).
- Light therapy and exercise need to be further evaluated to judge their usefulness in the treatment of insomnia (weak recommendation, low-quality evidence).
- Complementary and alternative treatments (e.g. homeopathy, acupuncture) are not recommended for insomnia treatment (weak recommendation, very-low-quality evidence).
I think, I can rest my case.
