Evidence-Based Medicine for Student Health Services
Robert J. Flaherty, MD
Swingle Student Health Service
Montana State University
Bozeman, MT 59717
Alternative/Complementary Medicine
http://www.montana.edu/wwwebm/Alternative.htm
 
Acupuncture Hypnotherapy Vitamin Therapies
Biofeedback Manipulative Medicine Other Therapies
Herbal Medicine Nutritional Therapy Patient Education
Homeopathy Spirituality/Prayer  
     
General Information

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Specific Conditions/Diseases

 
Acupuncture 
Acupuncture can alleviate dental pain, but important questions remain,  such as the optimal acupuncture technique and its relative efficacy compared with conventional methods of analgesia.
  • Caveats
    • Age group studied: Unknown
    • Type/size: Systematic review/meta-analysis (16 studies, 3 uncontrolled)
    • Population characteristics: Unknown
    • Outcome measures: Pain relief
  • Citations
P6 acupuncture seems to be an effective anti-emetic technique, except when administered under anesthesia.  A limited amount of high-quality evidence suggests that real acupuncture is more effective than sham acupuncture for improving symptoms of patients with fibromyalgia. However, because  this conclusion is based on a single high-quality study, further high-quality randomized trials are needed to provide more robust data on effectiveness. 
.  It is not yet possible to make any recommendations to patients, their physicians or acupuncturists about the practice of acupuncture in the treatment of asthma on the basis of the data currently reported.  Acupuncture has not been shown to be effective in relieving the symptoms of menopause.
  • Caveats
    • Age group studied: Unknown
    • Type/size: Systematic literature review (85 studies of alternative therapies, not all on this topic and few well controlled)
    • Population characteristics: Unknown
    • Outcome measures: Relief of symptoms
  • Citations
While acupuncture for smoking cessation appears promising there is insufficient evidence at present to recommend it as an effective form of therapy.
  • Caveats
    • Age group studied: Variable
    • Type/size: Meta-analysis of 26 RCTs (8268 patients)
    • Population characteristics: Variable
    • Outcome measures: Smoking cessation at 1,3, 6 and 12 months, as defined by self-reporting, validated by expired CO<5ppm or validated by two significant others nominated by the subject
  • Citations
Claims that acupuncture is efficacious as a therapy for smoking, heroin and alcohol addictions are not supported by results from sound clinical research. The efficacy of acupuncture in the treatment of chronic pain remains doubtful.  No clear picture emerges to show that acupuncture or acupressure is effective in reducing appetite or body weight.
  • Caveats
    • Age group studied: Unknown
    • Type/size: Systematic review of 4 RCTs (270 participants)
    • Population characteristics: Two trials involved obese volunteers, one trial involved volunteers and one trial involved obese women
    • Outcome measures: Body weight reduction; appetite
  • Citations
There is no evidence for the effectiveness of acupuncture, among other modalities, in the treatment of non-specific acute and chronic low back pain.



Biofeedback
Thermal biofeedback and interventions combining biofeedback and progressive muscle relaxation seem to be significantly more efficacious than other behavioral treatment modalities for migraine headache.

Further well designed studies are needed before biofeedback can be recommended as a treatment for anismus (inabilty to expell stools). 
  • Caveats
    • Age group studied: Adults and children
    • Type/size: Meta-analysis (11 studies = 137 patients)
    • Population characteristics: Patients with anismus diagnosed using electromyography, manometry, defecography and colon transit time
    • Outcome measures: Subjectly perceived success; number of defacations following biofeedback, laxative use and symptoms of constipation
  • Citations
The efficacy of biofeedback therapy in the rehabilitation of cerebrovascular disease has not been established.  For the treatnemt of low back pain, electromyographic biofeedback is no more effective than waiting list, placebo, or other conservative treatments. 



Herbal Medicine/Food Supplements
There is some evidence, albeit somewhat inconclusive, for the effectiveness of the following herbs:

  • Evening primrose for atopic dermatitis
  • Feverfew for migraine
  • Ginger for hyperemesis gravidarum and post-op nausea
  • Ginko biloba for dementia and tinnitus 
  • Horse chestnut seed for chronic venous insufficiency
  • Korean ginseng for flu vaccine immune response
  • Milk thistle for liver disease
  • St. John's wort for depression 
  • Saw palmetto for prostatic hyperplasia 
  • Zemaphyte (ten herbs) for atopic eczema 
Glucosamine (500mg tid) is better than placebo and as effective as NSAIDs in the treatment of arthritis.  There is evidence that extracts of hypericum (St. John's Wort) are more effective than placebo, and as effective as maprotiline, imipramine or amitryptiline, for the treatment of mild and moderately severe depressive disorders.  A garlic powder preparation may be of some clinical use in subjects with mild hypertension. 300 mL of a cranberry juice cocktail every day reduces bacteriuria and pyuria and prevents UTI in high risk groups.  Blueberry juice may have a similar effect.  Evidence from published trials suggests that Echinacea may be beneficial for the early treatment of acute upper respiratory infections (URIs). There is very little evidence supporting the prolonged use of Echinacea for the prevention of URIs.  Herbal remedies, vitamin E and evening primrose oil have not been shown to be effective in relieving the symptoms of menopause. However, phytoestrogens in soya flour, although physiologically weaker than human estrogen, have been shown to be effective in relieving symptoms of menopause.
  • Caveats
    • Age group studied: Unknown
    • Type/size: Systematic literature review (85 studies of alternative therapies, not all on this topic and few well controlled)
    • Population characteristics: Unknown
    • Outcome measures: Relief of symptoms
  • Citations
Further studies of greater sample size are required before firm conclusions regarding the role of calcium, magnesium and vitamin E for the treatment of premenstrual syndrome can be drawn. Likewise, further evaluation of evening primrose oil may be needed before dismissing it as a potential form of treatment. It is becoming clear that vitamin B6 is not an effective form of PMS treatment despite its widespread use. It is difficult to offer recommendations confidently based on the current literature on non-prescription treatment of PMS.  There is no anti-diabetic phytomedicine, including opuntia streptacantha, myrcia uniflora, Bauhiniab and garlic, that can be recommended for clinical use at the present time. The issue needs to be investigated in more detail preferably through randomised controlled trials.
  • Caveats
    • Age group studied: Unknown
    • Type/size: Qualitative review of 3 RCTs (~80 patients)
    • Population characteristics: Healthy volunteers and patients with NIDDM
    • Outcome measures: Glucose and insulin levels
  • Citations
Garlic as a therapy for the treatment of peripheral arterial occlusive disease cannot be recommended. 
  • Caveats
    • Age group studied: Unknown
    • Type/size: Systematic review of one RCT (32 patients)
    • Population characteristics: Unknown
    • Outcome measures: Pain-free walking distance
  • Citations
Zinc salts lozenges do not reduce the duration of common colds.



Homeopathy
Evidence from clinical trials of homeopathy is generally positive, particularly for duration of obstetric delivery, for improvement of nasal symptoms from pollinosis, pain from ankle sprains and postoperative ileus. Homeopathy does not appear to be effective for asthma, sinusitis, prevention of influenza or postoperative infections or symptoms of menopause. However, many of the trials are of low methodologic quality. 

The clinical effects of homeopathy do not appear to be completely due to placebo. However, there is  insufficient evidence that homeopathy is clearly efficacious for any single clinical condition. The claim that homeopathic arnica montana is efficacious beyond a placebo effect is not supported by rigorous clinical trials. 



Hypnotherapy 
Hypnotherapy leads to dramatic improvements in a high proportion of patients with poorly controlled Irritable Bowel Syndrome, and these improvements are maintained in the medium term

  • Caveats
    • Age group studied: Unknown
    • Type/size: Narrative review of 13 studies (442 patients)
    • Population characteristics: People with irritable bowel syndrome or unspecified problems of the gastrointestinal tract
    • Outcome measures: Patient assessed scores of abdominal pain, physician assessed pain, abdominal distension, abnormality of bowel habit, general well-being, anorectal manometry, diary card scores of disease severity, Spielberger Trait Anxiety Inventory Scores, and consultation rates
  • Citations
Hypnotherapy for smoking cessation has not been shown to have a greater effect on six month quit rates than other interventions or no treatment.
  • Caveats
    • Age group studied: Unknown
    • Type/size: Systematic review of 9 RCTs
    • Population characteristics: Unknown
    • Outcome measures: Abstinence from smoking at 6-12 months post-treatment
  • Citations



Manipulative Medicine
In the treatment of non-specific acute and chronic low back pain, therapies evaluated and lacking evidence of effectiveness include physiotherapy, acupuncture, osteopathy, chiropractic, and spinal manipulations.

There is insufficient data from quality RCTs to support the effectiveness of manipulation in the treatment of acute cervical pain or headaches.  Chiropractic has not been shown to be effective in relieving the symptoms of menopause.
  • Caveats
    • Age group studied: Unknown
    • Type/size: Systematic literature review (85 studies of alternative therapies, not all on this topic and few well controlled)
    • Population characteristics: Unknown
    • Outcome measures: Relief of symptoms
  • Citations
Massage seems to have some potential as a therapy for low back pain, but the evidence is weak. More investigations of this subject are urgently needed.  Twenty-one experienced therapeutic touch (TT) practitioners were unable to detect the investigator's "energy field." Their failure to substantiate TT's most fundamental claim is unrefuted evidence that the claims of TT are groundless and that further professional use is unjustified. 



Nutritional Therapy 
Eating more than four servings of whole grain food a week reduces the chance of many cancers by about 40%. 

The efficacy of s-adenosyl-l-methionine (SAMe) in treating depressive syndromes and disorders is superior with that of placebo and comparable to that of standard tricyclic antidepressants. Since SAMe is a naturally occurring compound with relatively few side-effects, it is a potentially important treatment for depression.



Spirituality/Prayer 
There is no evidence which either upholds or refutes the effect of intercessory prayer on the outcomes studied in the available trials. 

  • Caveats
    • Age group studied: Unknown
    • Type/size: Systematic review of 3 studies (459 patients)
    • Population characteristics: Any person with a physical or mental health problem
    • Outcome measures: Achievment of desired goals among recipients, care-givers (such as families), and those praying, death, illness, quality of life of recipients and care-givers
  • Citations



Vitamin Therapies 
Vitamin C, in doses of a gram or more per day, showed a consistently beneficial but generally modest therapeutic effect on duration of URI symptoms (a little less than 0.5 of a symptom day per URI episode).

  • Caveats
    • Age group: Adults
    • Type/size: Meta-analysis (30 trials)
    • Outcome measure: Duration of symptoms
    • Best dosage is not clear
Vitamin C (500mg per day for 50 days) was associated with a lower risk of reflex sympathetic dystrophy after wrist  fractures. Number needed to treat=7.
  • Caveats
    • Age group: Adults
    • Type/size: RCT of 123 patients (127 fractures)
    • Population characteristics: ER patients
    • Outcome measure: Occurance of RSD
Epidemiological data suggest that high levels of intake of vitamin E that are sustained for two or more years are associated with a reduced risk for fatal and nonfatal cardiovascular disease. Use of beta-carotene or vitamin C is less clearly associated with a reduced risk. Limitations of the epidemiological evidence, such as the differences in health behavior and dietary intake, may explain much of the observed reduction in risk. The randomised trials suggest that no anti-oxidant beneficially affects total mortality or mortality from cardiovascular disease. The trials were not specifically designed to assess fatal and nonfatal cardiovascular disease outcomes and probably used sub-optimal doses of vitamin E. The current evidence does not support the routine use of antioxidant vitamins as prevention against cardiovascular disease.  Given the low cost of riboflavin and the apparent lack of side effects, high dose riboflavin (400mg/d) prophylaxis seems to be worth trying for patients with two or more migraine headaches per month. Vitamin E (400-1600IU/d) is a safe, well-tolerated compound that may provide some modest beneficial effects in patients suffering from neuroleptic-induced tardive dyskinesia.  The current literature does not support a definite indication for the use of vitamin C in asthma and allergy.
  • Caveats
    • Age group studied: Unknown
    • Type/size: Narrative review of 24 studies (>255 patients)
    • Population characteristics: Unknown
    • Outcome measures: Scurvy, incidence of asthma, plasma ascorbic acid levels, skin sensitivity, exercise-induced bronchospasm, severity and frequency of asthma attacks, methacholine challenge, airway tone, bronchoconstriction, cellular immunity, leukocyte function, histamine bronchoprovocation, pulmonary function
  • Citations
Vitamin B6 is not an effective form of PMS treatment despite its widespread use.  Vitamin E has not been shown to be effective in relieving the symptoms of menopause. 
  • Caveats
    • Age group studied: Unknown
    • Type/size: Systematic literature review (85 studies of alternative therapies, not all on this topic and few well controlled)
    • Population characteristics: Unknown
    • Outcome measures: Relief of symptoms
  • Citations



Other Therapies 
No evidence is cited.


Patient Education and Other Resources
The following patient education materials are consistent with the available evidence:

Rev. 2/20/03

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This Web site developed and maintained by Robert J. Flaherty, MD.
Comments, additions and corrections are encouraged.