Massage for mechanical neck disorders.

BACKGROUND: Mechanical neck disorders (MND) are common, disabling and costly. Massage is a commonly used modality for the treatment of neck pain. OBJECTIVES: To assess the effects of massage on pain, function, patient satisfaction and cost of care in adults with neck pain. To document adverse effects of treatment. SEARCH STRATEGY: Cochrane CENTRAL, MEDLINE, EMBASE, MANTIS, CINAHL, and ICL databases were electronically searched, without language restriction, from their inception to September 2004 SELECTION CRITERIA: Studies using random or quasi-random assignment were included. DATA COLLECTION AND ANALYSIS: Two reviewers independently conducted citation identification, study selection, data abstraction and methodological quality assessment. Using a random-effects model, we calculated the relative risk and standardized mean difference. MAIN RESULTS: Nineteen trials met the inclusion criteria. Overall, the methodological quality was low, with 12/19 assessed as low-quality studies. Trials could not be statistically pooled because of heterogeneity in treatment and control groups. Therefore, a levels-of-evidence approach was used to synthesize results. Assessment of the clinical applicability of the trials showed that the participant characteristics were well reported, but neither the descriptions of the massage intervention nor the credentials or experience of the massage professionals were well reported. Six trials examined massage as a stand-alone treatment. The results were inconsistent. Of the 14 trials that used massage as part of a multimodal intervention, none were designed such that the relative contribution of massage could be ascertained. Therefore, the role of massage in multimodal treatments remains unclear. AUTHORS' CONCLUSIONS: No recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain. Pilot studies are needed to characterize massage treatment (frequency, duration, number of sessions, and massage technique) and establish the optimal treatment to be used in subsequent larger trials that examine the effect of massage as either a stand-alone treatment or part of a multimodal intervention. For multimodal interventions, factorial designs are needed to determine the relative contribution of massage. Future reports of trials should improve reporting of the concealment of allocation, blinding of outcome assessor, adverse events and massage characteristics. Standards of reporting for massage interventions, similar to CONSORT, are needed. Both short- and long-term follow-up are needed.

Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting.

BACKGROUND: There have been recent advances in chemotherapy-induced nausea and vomiting using 5-HT(3) inhibitors and dexamethasone. However, many still experience these symptoms, and expert panels encourage additional methods to reduce these symptoms. OBJECTIVES: The objective was to assess the effectiveness of acupuncture-point stimulation on acute and delayed chemotherapy-induced nausea and vomiting in cancer patients. SEARCH STRATEGY: We searched MEDLINE, EMBASE, PsycLIT, MANTIS, Science Citation Index, CCTR (Cochrane Controlled Trials Registry), Cochrane Complementary Medicine Field Trials Register, Cochrane Pain, Palliative Care and Supportive Care Specialized Register, Cochrane Cancer Specialized Register, and conference abstracts. SELECTION CRITERIA: Randomized trials of acupuncture-point stimulation by any method (needles, electrical stimulation, magnets, or acupressure) and assessing chemotherapy-induced nausea or vomiting, or both. DATA COLLECTION AND ANALYSIS: Data were provided by investigators of the original trials and pooled using a fixed effect model. Relative risks were calculated on dichotomous data. Standardized mean differences were calculated for nausea severity. Weighted mean differences were calculated for number of emetic episodes. MAIN RESULTS: Eleven trials (N = 1247) were pooled. Overall, acupuncture-point stimulation of all methods combined reduced the incidence of acute vomiting (RR = 0.82; 95% confidence interval 0.69 to 0.99; P = 0.04), but not acute or delayed nausea severity compared to control. By modality, stimulation with needles reduced proportion of acute vomiting (RR = 0.74; 95% confidence interval 0.58 to 0.94; P = 0.01), but not acute nausea severity. Electroacupuncture reduced the proportion of acute vomiting (RR = 0.76; 95% confidence interval 0.60 to 0.97; P = 0.02), but manual acupuncture did not; delayed symptoms for acupuncture were not reported. Acupressure reduced mean acute nausea severity (SMD = -0.19; 95% confidence interval -0.37 to -0.01; P = 0.04) but not acute vomiting or delayed symptoms. Noninvasive electrostimulation showed no benefit for any outcome. All trials used concomitant pharmacologic antiemetics, and all, except electroacupuncture trials, used state-of-the-art antiemetics. AUTHORS' CONCLUSIONS: This review complements data on post-operative nausea and vomiting suggesting a biologic effect of acupuncture-point stimulation. Electroacupuncture has demonstrated benefit for chemotherapy-induced acute vomiting, but studies combining electroacupuncture with state-of-the-art antiemetics and in patients with refractory symptoms are needed to determine clinical relevance. Self-administered acupressure appears to have a protective effect for acute nausea and can readily be taught to patients though studies did not involve placebo control. Noninvasive electrostimulation appears unlikely to have a clinically relevant impact when patients are given state-of-the-art pharmacologic antiemetic therapy.

Prophylactic mastectomy for the prevention of breast cancer.

BACKGROUND: Breast cancer is the most common cancer and the second most common cause of cancer-related death among North American and Western European women. Recent progress in understanding the genetic basis of breast cancer, along with rising incidence rates, have resulted in increased interest in prophylactic mastectomy as a method of preventing breast cancer, particularly in those with familial susceptibility. OBJECTIVES: The primary objective was to determine whether prophylactic mastectomy reduces death from any cause in women who have never had breast cancer and in women who have a history of breast cancer in one breast. The secondary objective was to examine the effect of prophylactic mastectomy on other endpoints including breast cancer incidence, breast cancer mortality, disease-free survival, physical morbidity, and psychosocial outcomes. SEARCH STRATEGY: Electronic searches were performed in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Cancerlit, and the Science Citation Index. SELECTION CRITERIA: Inclusion criteria were studies in English of any design type including randomized or nonrandomized controlled trials, cohort studies, case-control studies, and case series with at least ten participants. Participants included women at risk for breast cancer in at least one breast. Interventions included all types of mastectomy performed for the purpose of preventing breast cancer, including subcutaneous mastectomy, total or simple mastectomy, modified radical mastectomy, and radical mastectomy. DATA COLLECTION AND ANALYSIS: Information on patients, interventions, methods, and results were extracted by at least two independent reviewers. Methodological quality was assessed based on how well each study minimized potential selection bias, performance bias, detection bias, and attrition bias. Data for each study were summarized descriptively; quantitative meta-analysis was not feasible due to heterogeneity of study designs and insufficient reporting. Data were analyzed separately for bilateral prophylactic mastectomy (BPM) and contralateral prophylactic mastectomy (CPM). MAIN RESULTS: Twenty-three studies, including more than 4,000 patients, met inclusion criteria. No randomized or nonrandomized controlled trials were found. Most studies were either case series or cohort studies. All studies had methodological limitations, with the most common source of potential bias being systematic differences between the intervention and comparison groups that could potentially be associated with a particular outcome. Thirteen studies assessed the effectiveness of BPM. No study assessed all-cause mortality after BPM. All studies reporting on incidence of breast cancer and disease-specific mortality reported reductions after BPM. Nine studies assessed psychosocial measures; most reported high levels of satisfaction with the decision to have prophylactic mastectomy (PM) but more variable satisfaction with cosmetic results. Only one study assessed satisfaction with the psychological support provided by healthcare personnel during risk counseling and showed that more women were dissatisfied than satisfied with the support they received in the healthcare setting. Worry over breast cancer was significantly reduced after BPM when compared both to baseline worry levels and to the groups who opted for surveillance rather than BPM. Three studies reported body image/feelings of femininity outcomes, and all reported that a substantial minority (about 20%) reported BPM had adverse effects on those domains. Six studies assessed contralateral prophylactic mastectomy. Studies consistently reported reductions in contralateral incidence of breast cancer but were inconsistent about improvements in disease-specific survival. Only one study attempted to control for multiple differences between intervention groups, and this study showed no overall survival advantage for CPM at 15 years. Two case series were exclusively focused on adverse events from prophylactic mastectomy with reconstruction, and both reported rates of unanticipated re-operations from 30% to 49%. REVIEWERS' CONCLUSIONS: While published observational studies demonstrated that BPM was effective in reducing both the incidence of, and death from, breast cancer, more rigorous prospective studies (ideally randomized trials) are needed. The studies need to be of sufficient duration and make better attempts to control for selection biases to arrive at better estimates of risk reduction. The state of the science is far from exact in predicting who will get or who will die from breast cancer. By one estimate, most of the women deemed high risk by family history (but not necessarily BRCA 1 or 2 mutation carriers) who underwent these procedures would not have died from breast cancer, even without prophylactic surgery. Therefore, women need to understand that this procedure should be considered only among those at very high risk of the disease. For women who had already been diagnosed with a primary tumor, the data were particularly lacking for indications for contralateral prophylactic mastectomy. While it appeared that contralateral mastectomy may reduce the incidence of cancer in the contralateral breast, there was insufficient evidence about whether, and for whom, CPM actually improved survival. Physical morbidity is not uncommon following PM, and many women underwent unanticipated re-operations (usually due to problems with reconstruction); however, these data need to be updated to reflect changes in surgical procedures and reconstruction. Regarding psychosocial outcomes, women generally reported satisfaction with their decisions to have PM but reported satisfaction less consistently for cosmetic outcomes, with diminished satisfaction often due to surgical complications. Therefore, physical morbidity and post-operative surgical complications were areas that should be considered when deciding about PM. With regard to emotional well-being, most women recovered well postoperatively, reporting reduced cancer worry and showing reduced psychological morbidity from their baseline measures; exceptions also have been noted. Of the psychosocial outcomes measured, body image and feelings of femininity were the most adversely affected.

Quality of Cochrane reviews: assessment of sample from 1998.

OBJECTIVE: To assess the quality of Cochrane reviews. DESIGN: Ten methodologists affiliated with the Cochrane Collaboration independently examined, in a semistructured way, the quality of reviews first published in 1998. Each review was assessed by two people; if one of them noted any major problems, they agreed on a common assessment. Predominant types of problem were categorised. SETTING: Cyberspace collaboration coordinated from the Nordic Cochrane Centre. STUDIES: All 53 reviews first published in issue 4 of the Cochrane Library in 1998. MAIN OUTCOME MEASURE: Proportion of reviews with various types of major problem. RESULTS: No problems or only minor ones were found in most reviews. Major problems were identified in 15 reviews (29%). The evidence did not fully support the conclusion in nine reviews (17%), the conduct or reporting was unsatisfactory in 12 reviews (23%), and stylistic problems were identified in 12 reviews (23%). The problematic conclusions all gave too favourable a picture of the experimental intervention. CONCLUSIONS: Cochrane reviews have previously been shown to be of higher quality and less biased on average than other systematic reviews, but improvement is always possible. The Cochrane Collaboration has taken steps to improve editorial processes and the quality of its reviews. Meanwhile, the Cochrane Library remains a key source of evidence about the effects of healthcare interventions. Its users should interpret reviews cautiously, particularly those with conclusions favouring experimental interventions and those with many typographical errors.

Acupuncture for osteoarthritis of the knee: a systematic review.

OBJECTIVE: To evaluate trials of acupuncture for osteoarthritis (OA) of the knee, to assess the methodologic quality of the trials and determine whether low-quality trials are associated with positive outcomes, to document adverse effects, to identify patient or treatment characteristics associated with positive response, and to identify areas of future research. METHODS: Eight databases and 62 conference abstract series were searched. Randomized or quasi-randomized trials of all languages were included and evaluated for methodologic quality using the Jadad scale. Outcomes were pain, function, global improvement, and imaging. Data could not be pooled; therefore, a best-evidence synthesis was performed to determine the strength of evidence by control group. The adequacy of the acupuncture procedure was assessed by 2 acupuncturists trained in treating OA and blinded to study results. RESULTS: Seven trials representing 393 patients with knee OA were identified. For pain and function, there was limited evidence that acupuncture is more effective than being on a waiting list for treatment or having treatment as usual. For pain, there was strong evidence that real acupuncture is more effective than sham acupuncture; however, for function, there was inconclusive evidence that real acupuncture is more effective than sham acupuncture. There was insufficient evidence to determine whether the efficacy of acupuncture is similar to that of other treatments. CONCLUSION: The existing evidence suggests that acupuncture may play a role in the treatment of knee OA. Future research should define an optimal acupuncture treatment, measure quality of life, and assess acupuncture combined with other modalities.

¿Es eficaz la acupuntura para el tratamiento de dolor crónico? una revisión sistemática / Is acupuncture effective for the management of chronic pain? A systematic review

El dolor es la principal queja del millón estimado de consumidores americanos que recurren a la acupuntura todos los años. Aunque la mayoría de las clínicas para el dolor crónico ofrecen servicios de acupuntura, su eficacia en el tratamiento del dolor crónico sigue sin conocerse. Con esta revisión se pretendía evaluar la eficacia de la acupuntura como tratamiento del dolor crónico dentro del contexto de la calidad metodológica de los estudios. La búsqueda se realizó en MEDLINE (1966-99), dos bases de datos sobre medicina alternativa, 69 actas de congresos y las bibliografías de otros artículos y revisiones. Los criterios de inclusión de los ensayos fueron los siguientes: diseño aleatorio, poblaciones con dolor desde hacía más de tres meses, uso de agujas en lugar de electrodos de superficie, y publicados en inglés. Se extrajeron los datos de dos revisiones independientes utilizando un instrumento validado. Las discrepancias entre diferentes observadores se resolvieron por discusión. Cincuenta y un estudios cumplieron los criterios de inclusión. Su heterogeneidad clínica imposibilitó la agregación estadística. Los resultados fueron positivos en 21 estudios, negativos en 3 y neutrales en 27. Las tres cuartas partes de los estudios recibieron una puntuación baja en calidad y se observó una asociación significativa entre los estudios de baja calidad y unos resultados positivos (p = 0,05). Los estudios de alta calidad se agruparon según su diseño utilizando la acupuntura simulada como grupo de control, donde el riesgo de errores falsos negativos (tipo II) es alto como consecuencia de los grandes tamaños de muestra requeridos. Seis o más tratamientos de acupuntura se asociaron significativamente a unos resultados positivos (p = 0,03), incluso después de ajustar dichos resultados para tener en cuenta la calidad del estudio. Concluimos que existen evidencias limitadas de que la acupuntura es más eficaz que no realizar ningún tratamiento para el dolor crónico; y evidencias poco convincentes de la mayor eficacia de la acupuntura frente al placebo, la acupuntura simulada o el tratamiento tradicional. No obstante, hemos observado una relación importante entre la metodología de los estudios y sus resultados, que debería orientar la futura investigación (AU)

Reviewing the reviews. How strong is the evidence? How clear are the conclusions?

OBJECTIVES: The objectives of this paper were: a) to determine what can be learned from conclusions of systematic reviews about the evidence base of medicine; and b) to determine whether two readers draw similar conclusions from the same review, and whether these match the authors' conclusions. METHODS: Three methodologists (two per review) rated 160 Cochrane systematic reviews (issue 1, 1998) using pre-established conclusion categories. Disagreements were resolved by discussion to arrive at a consensual score for each review. Reviews' authors were asked to use the same categories to designate the intended conclusion. Interrater agreements were calculated. RESULTS: Interrater agreement between two readers was 0.68 and 0.72, and between readers and authors, 0.32. The largest categories assigned by methodologists were "positive effect" (22.5%), "insufficient evidence" (21.3%), and "evidence of no effect" (20.0%). The largest categories assigned by authors were "insufficient evidence" (32.4%), "possibly positive" (28.6%), and "positive effect" (26.7%). CONCLUSIONS: The number of reviews indicating that the modern biomedical interventions show either no effect or insufficient evidence is surprisingly high. Interrater disagreements suggest a surprising degree of subjective interpretation involved in systematic reviews. Where patterns of disagreement emerged between authors and readers, authors tended to be more optimistic in their conclusions than the readers. Policy implications are discussed.

Mind-body therapies for the treatment of fibromyalgia. A systematic review.

OBJECTIVE: To assess the effectiveness of mind-body therapy (MBT) for fibromyalgia syndrome (FM) by systematically reviewing randomized/quasirandomized controlled trials using methods recommended by the Cochrane Collaboration. METHODS: Nine electronic databases, 69 conference proceedings, and several citation lists were searched for relevant trials in any language. Eligible trials were scored for methodological quality using a validated instrument. Information on major outcomes was extracted. Insufficient data reporting prevented statistical pooling, therefore a best-evidence synthesis was performed. RESULTS: Thirteen trials involving 802 subjects were included. Seven trials received a high methodological score. Compared to waiting list/treatment as usual, there is strong evidence that MBT is more effective for self-efficacy, limited evidence for quality of life, inconclusive evidence for all other outcomes. There is limited evidence that MBT is more effective than placebo (for pain and global improvement); inconclusive evidence that MBT is more effective than physiotherapy, psychotherapy, or education/attention control for all outcomes; strong evidence that moderate/high intensity exercise is more effective than MBT (for pain and function). There is moderate evidence that MBT plus exercise (MBT+E) is more effective than waiting list/treatment as usual (for self-efficacy and quality of life); limited evidence that MBT+E is more effective than education/attention control; inconclusive for other outcomes. There is inconclusive evidence for MBT+E vs other active treatments for all outcomes. Longterm within-groups results show greatest benefit for MBT+E. CONCLUSION: MBT is more effective for some clinical outcomes compared to waiting list/treatment as usual or placebo. Compared to active treatments, results are largely inconclusive, except for moderate/high intensity exercise, where results favor the latter. Further research needs to focus on the synergistic effects of MBT plus exercise and/or plus antidepressants.

The evidence for acupuncture as a treatment for rheumatologic conditions.

Individuals with rheumatic disorders, particularly those with more severe, chronic conditions, are likely to be frequent users of complementary and alternative medical therapies. Although large-scale clinical trials have yet to be conducted, there is moderately strong evidence that acupuncture may be effective for treating both osteoarthritis and fibromyalgia. The utility of acupuncture in treating rheumatoid arthritis has not been demonstrated in large, randomized controlled trials. Physicians who treat patients with rheumatic conditions should become knowledgeable about the literature on both the effectiveness of acupuncture for these conditions as well as its potential to cause adverse side effects in particular patient groups.

Is acupuncture effective in the treatment of fibromyalgia?

BACKGROUND: We conducted this study to assess the effectiveness of acupuncture in the treatment of fibromyalgia syndrome (FMS), report any adverse effects, and generate hypotheses for future investigation. METHODS: We searched MEDLINE, EMBASE, Manual Therapy Information System, the Cochrane registry, the University of Maryland Complementary and Alternative Medicine in Pain, the Centralized Information Service for Complementary Medicine, and the National Institutes of Health Office of Alternative Medicine databases for the key words "acupuncture" and "fibromyalgia." Conference abstracts, citation lists, and letters supplemented the search. We selected all randomized or quasi-randomized controlled trials, or cohort studies of patients with FMS who were treated with acupuncture. Methodologic quality, sample characteristics, type of acupuncture treatment, and outcomes were extracted. Statistical pooling was not performed because of the differences in control groups. RESULTS: Seven studies (3 randomized controlled trials and 4 cohort studies) were included; only one was of high methodologic quality. The high-quality study suggests that real acupuncture is more effective than sham acupuncture for relieving pain, increasing pain thresholds, improving global ratings, and reducing morning stiffness of FMS, but the duration of benefit following the acupuncture treatment series is not known. Some patients report no benefit, and a few report an exacerbation of FMS-related pain. Lower-quality studies were consistent with these findings. Booster doses of acupuncture to maintain benefit once regular treatments have stopped have been described anecdotally but not investigated in controlled trials. CONCLUSIONS: The limited amount of high-quality evidence suggests that real acupuncture is more effective than sham acupuncture for improving symptoms of patients with FMS. 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.

Elemental signatures of human diets from the Georgia Bight.

Multielement analysis was performed on bone samples extracted from the femora of 39 adults from three mortuary sites (Johns Mound, Santa Catalina de Guale, and Santa Catalina de Guale de Santa Maria) and time periods (late preagricultural, early contact, and late contact) in the Georgia Bight. This study was used to investigate whether elemental analysis would support or contradict other lines of data regarding diets and dietary change previously generated for the region. The data are in agreement with an earlier interpretation, based on stable isotopes, that dietary maize increases through time but fails to support the idea that marine resources decreased in importance. Rather, it appears that the wild plant food component of the diets decreases as maize increases in importance; throughout the sequence, marine resources comprise a significant portion of the diets.