Evidence Based Medicine and CAM: A Review


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Evidence Based Medicine and CAM: A Review

  1. 1. ArticleEvidence Based Medicine and CAM: A ReviewDominick M. Maino, OD, MEd, FAAO, FCOVD-AProfessor of Pediatrics/Binocular Vision, Illinois College of OptometryAbstract The use of evidence based medicine to support A review of the supporting evidence for various the approaches we use for patient care is consideredlevels of research regarding complementary and the Gold Standard by which all diagnostic andalternative medicine that has randomized clinical therapeutic interventions are judged. However, eventrials (RTCs) available and information from the medicine has misgivings about only using evidencedCochrane Reviews are presented. The complementary based medicine when helping patients achieve theirand alternative medicine (CAM) areas reviewed health outcomes. David Hunter, MD, PhD, in hisinclude acupuncture, Chiropractic care, various article, Do We Need Evidence for Everything?, stateddiets, and the use of supplements; as well as, aroma that “There is no randomized, controlled trial supportingtherapy and several other non-allopathic therapeutic the contention that evidence-based research is beneficialinterventions. Overall, many CAM interventions … Systemic reviews have severe limitations of scope anddo not have randomized clinical trials that support reach … real patients bring with them an abundance oftheir use and even those RCTs that are available messy heterogeneity.” 1 Maino has noted medicine will,often have study design and other research related at times, selectively support evidence based medicineproblems as noted by the Cochrane Reviews. Some when it fits their belief systems and to discount thecritics note that there are no randomized, controlled research when it does not.2 Medicine also frequentlytrials in support of the belief that evidence-based uses interventions that do not have clear, unambiguousresearch is beneficial. They also note that these trials evidence based support to aid their patients.3often exhibit severe limitations of scope and that our A review of the supporting evidence for variouspatients bring with them a great deal of heterogeneity. levels of research regarding complementary andIf we had such research available to us, however, this alternative medicine that uses randomized clinicalwould at least begin the process of discovering which trials (RTCs) and the Cochrane Reviews is presented.CAM therapies can be utilized for those patients most The Cochrane Collaboration offers “… systematiclikely to benefit from these alternative approaches to reviews of primary research in human health care andhealth care. health policy, and are internationally recognized as the highest standard in evidence-based health care. They Keywords: clinical trials, Cochrane reviews, investigate the effects of interventions for prevention,complementary and alternative medicine, double treatment and rehabilitation. They also assess the accuracyblind, prospective, placebo controlled, randomized of a diagnostic test for a given condition in a specific patient group and setting. 4 As you might expect, the ”Correspondence regarding this article should be emailed to dmaino@ico.edu evidenced based medicine supporting the use of bothor sent to Dominick M. Maino, OD, MEd, Illinois College of Optometry, conventional and complementary and alternative3241 S. Michigan Ave., Chicago, IL 60616. All statements are theauthor’s personal opinion and may not reflect the opinions of the College medicine varies.of Optometrists in Vision Development, Optometry & Vision Development Several CAM therapies have not been reviewedor any institution or organization to which the author may be affiliated. by the Cochrane Collaboration Group. ThesePermission to use reprints of this article must be obtained from the editor. non-traditional interventions not reviewed by theCopyright 2012 College of Optometrists in Vision Development. OVD isindexed in the Directory of Open Access Journals. Online access is available Cochrane Collaboration Group include the Totalat http://www.covd.org. Load Theory, craniosacral therapy, reflex integration, detoxification (other than for drugs and alcoholMaino D. Evidence based medicine and CAM: a review. Optom VisDev 2012;43(1):13-17 abuse), as well as, Son-Rise, the Developmental Individual Relationship-Based (DIR) Model, andVolume 43/Number 1/2012 13
  2. 2. the Relationship Development Intervention (RDI) in the short-term),19 and tension headaches (suggestsPrograms. The fact that Cochrane has not reviewed that acupuncture could be a valuable option).20 Itthese therapies does not necessarily detract from should be noted that a randomized controlled trial oftheir value. It does usually mean that there are few patching vs acupuncture for anisometropic amblyopiaif any randomized, placebo controlled clinical trials in children from 7 to 12 years of age found thatavailable. The disadvantages of RCTs have been acupuncture was just as effective for anisometropicdiscussed in several papers and include limitations amblyopia when compared to patching and was alsoof external validity, high costs and the extensive time statistically superior.21required to complete the research.5,6,7,8 At least twopapers suggested that observational studies produced Chiropracticsimilar results.9,10 Chiropractic interventions showed slightly improved pain and disability outcomes in the shortAcupuncture term and pain in the medium term for acute and Acupuncture has been used to relieve any number subacute low-back pain.22 There is also some low qualityof human ailments and has been practiced in various evidence that neck manipulation provides more painAsian countries for millennia. Although few unwanted relief for those with acute/chronic neck pain.23side effects have been reported, its implementationby qualified practitioners is required. In traditional DietChinese medicine the body is in balance with two Research supporting gluten and/or casein free dietsopposing forces. These forces are yin (a cold, slow, as an effective intervention for persons with autismor passive principle,) and yang (a hot, excited, or are lacking. There is also little research concerning theactive principle). Any imbalance of these forces leads possible unwanted side effects of such diets.24to a blockage in the flow of qi (vital energy) and adiseased state. This blockage can be relieved by using Supplementsacupuncture.11 Supplementation with antioxidants and zinc may A systematic review of 4 randomized controlled be of benefit for those with AMD.25 Creatine use hastrials evaluating the efficacy and safety of acupuncture shown an increase in muscle strength in muscularwas completed. It was noted that these studies had dystrophies with activities of daily living improvinglow methodological quality and had many dissimilar as well.26 Ginseng appears to have beneficial effectsvariables and outcome measures. Because of the small on cognition, behavior and one’s quality of life.27 Thenumber of studies available for review and their low use of melatonin can be effective for dementia-relatedmethodological quality, no conclusions could be psychopathologic behavior problems28 while vitamindrawn regarding efficacy and safety.12 Several other D3 appears to decrease mortality in elderly womenanomalies that showed little evidenced based research who are in institutions and require dependent care.29to support the use of acupuncture included attention DHEA supplementation has not been shown to retarddeficit hyperactivity disorder,13 glaucoma14 and aging and/or age-associated cognitive impairment,stroke rehabilitation, (5 trials were identified, all of however.30poor quality).15 The use of vitamin B6 for improving autistic Acupuncture does seem somewhat effective for behaviors is not supported31 nor is the use of folate acidlow back pain (when added to conventional therapies, to improve the psychological or learning capabilities,it relieves pain and improves function better than the behavior or social performance of those with Fragileconventional therapies alone),16 smoking cessation (It X syndrome.32 Vitamin B12 has not been shown aswas noted that acupuncture may be better than doing being effective for improving cognitive function.33nothing. There is evidence to support that acupuncturemight have an effect greater than placebo),17 migraine Other CAMprevention (Patients receiving acupuncture reported An aroma therapy clinical trial showed a significantmore improvement. The studies reviewed suggest effect on measures of agitation and neuropsychiatricthat migraine patients benefit from acupuncture),18 symptoms.34 Although the trials were small and ofchronic neck pain (Those … with chronic neck pain poor quality, a Chinese herbal mixture, Zemaphyte,had better pain relief immediately after treatment and improved erythema, surface damage to the skin,14 Optometry & Vision Development
  3. 3. sleep disturbance and itching.35 Light therapy appears attention deficit hyperactivity disorder.53 Thereto have a modest positive effect for non-seasonal appears to be little evidence that light therapy isdepression.36 effective for managing cognitive, sleep, functional, Research concerning massage therapy used to behavioral, or psychiatric disturbances associated withpromote growth and development in pre-term babies dementia.54 Trials that support the use of meditationshowed that the children gained more weight each therapy for those with attentional issues or anxiety-day, spent less time in the hospital, had slightly better related conditions appear to be inadequate at thisscores on developmental tests and fewer postnatal time as well.55,56complications.37 While the use of probiotics added toinfant meals appeared to prevent infant eczema, with Conclusionat least one study suggesting the benefit could persist CAM therapies are just now being considered forup to four years of age.38 validation using evidenced based medicine criteria. It has been found that music therapy reduced Bias on both sides of the questions involving CAMpain by up to 50% in some patients and decreased therapy by clinicians, researchers, editors, publishersthe need for morphine-like analgesics.39 It also appears and authors must be considered when reviewing theto improve walking skills of those with acquired brain value of any published research.57 Only by maintaininginjury, was superior to placebo therapy for improving an open but skeptical approach to all aspects of patientverbal and gestural communicative skills of those diagnosis and treatment do we ensure the very best forwith autism and may be of use for the treatment of the patients under our care. Pragmatically, however, itdepression, as well.40,41,42 According to at least one is also important to recognize the importance of theCochrane review, however, listening therapies such clinician’s insights and experience to supplement thisas auditory integration continues to be practiced research based approach.despite evidence that shows it to be an experimental If we wait for the publication of clinical trialstreatment at best.43 before we institute therapeutic interventions for our The use of Omega-3 fish oils have been patients, our patients may not be able to benefit andrecommended for the treatment of several health even worse, suffer needless pain and loss of function.problems or for their prevention. Some research We must use all the tools within our treatmentsuggests that risk of Alzheimer’s disease is significantly toolbox that are appropriate. We must use our clinicalreduced among those with higher levels of fish and intuition and insights, as well as science, when makingOmega 3 PUFA consumption. Unfortunately, the lives of our patients better. First and foremost, asthese studies were not randomized clinical trials.44 Hippocrates58 noted: “Primum non nocerum” or weIndividuals with cystic fibrosis45 demonstrated positive should do no harm.outcomes. The use of Omega-3s did not appear tobe effective for treating individuals with Crohn’s Referencesdisease,46 the maintenance of remission in ulcerative Note: URLs are functional hyperlinks to internet addresses.colitis,47 or with cardiovascular disease.­ 48 1. Hunter D. Do We Need Evidence for Everything? American Orthop J St. John’s wort has been used for centuries for the 2010;60;59-62.treatment of depression. Cochrane states that extracts 2. Maino D, Mistakes were made (Yes by you!). Optom Vis Dev 2011;42(2):66- 69. Available from http://goo.gl/wluqm. Last accessed 8-11tested in clinical trials were superior to placebo, 3. Maino D. The number of placebo controlled, double blind, prospective,similarly effective as standard antidepressants, and and randomized strabismus surgery outcome clinical trials: none! Optomhad fewer side effects than these antidepressants. Vis Dev 2011;42(3):134-136.Unfortunately, it was also noted that St. Johns Wort 4. The Cochrane Collaboration available at http://www.cochrane.org/ cochrane-reviews accessed 8-11could compromise other medications taken by 5. Sanson-Fisher RW, Bonevski B, Green LW, D’Este C. Limitations ofpatients, so caution should always be used.49 There the randomized controlled trial in evaluating population-based healthappears to be little to no evidence that cannabinoids interventions. 2007 Am J Prev Med 33 (2): 155–61use has any affect on the symptoms/behaviors 6. Black N. Why we need observational studies to evaluate the effectiveness of health care. BMJ 1996;312 (7040): 1215–8.associated with dementia,50 Tourette syndrome,51 or 7. Rothwell PM . External validity of randomized controlled trials: “toschizophrenia.52 whom do the results of this trial apply?”. 2005 Lancet 365 (9453): 82–93. Homeopathy does not appear to be effective doi:10.1016/S0140-6736(04)17670-8for the treatment of the symptoms associated withVolume 43/Number 1/2012 15
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