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Evidence Based Medicine and CAM: A Review

Dominick M. Maino, OD, MEd, FAAO, FCOVD-A
Professor of Pediatrics/Binocular Vision, Illinois College of Optometry

Abstract The use of evidence based medicine to support

A review of the supporting evidence for various the approaches we use for patient care is considered
levels of research regarding complementary and the Gold Standard by which all diagnostic and
alternative medicine that has randomized clinical therapeutic interventions are judged. However, even
trials (RTCs) available and information from the medicine has misgivings about only using evidenced
Cochrane Reviews are presented. The complementary based medicine when helping patients achieve their
and alternative medicine (CAM) areas reviewed health outcomes. David Hunter, MD, PhD, in his
include acupuncture, Chiropractic care, various article, Do We Need Evidence for Everything?, stated
diets, and the use of supplements; as well as, aroma that “There is no randomized, controlled trial supporting
therapy and several other non-allopathic therapeutic the contention that evidence-based research is beneficial
interventions. Overall, many CAM interventions … Systemic reviews have severe limitations of scope and
do not have randomized clinical trials that support reach … real patients bring with them an abundance of
their 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 medicine
problems as noted by the Cochrane Reviews. Some when it fits their belief systems and to discount the
critics note that there are no randomized, controlled research when it does not.2 Medicine also frequently
trials in support of the belief that evidence-based uses interventions that do not have clear, unambiguous
research is beneficial. They also note that these trials evidence based support to aid their patients.3
often exhibit severe limitations of scope and that our A review of the supporting evidence for various
patients bring with them a great deal of heterogeneity. levels of research regarding complementary and
If we had such research available to us, however, this alternative medicine that uses randomized clinical
would 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 “… systematic
likely to benefit from these alternative approaches to reviews of primary research in human health care and
health 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 accuracy
blind, 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 evidenced based medicine supporting the use of both
or sent to Dominick M. Maino, OD, MEd, Illinois College of Optometry,
conventional and complementary and alternative
3241 S. Michigan Ave., Chicago, IL 60616. All statements are the
author’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 reviewed
or any institution or organization to which the author may be affiliated. by the Cochrane Collaboration Group. These
Permission to use reprints of this article must be obtained from the editor.
non-traditional interventions not reviewed by the
Copyright 2012 College of Optometrists in Vision Development. OVD is
indexed in the Directory of Open Access Journals. Online access is available Cochrane Collaboration Group include the Total
at Load Theory, craniosacral therapy, reflex integration,
detoxification (other than for drugs and alcohol
Maino D. Evidence based medicine and CAM: a review. Optom Vis
Dev 2012;43(1):13-17 abuse), as well as, Son-Rise, the Developmental
Individual Relationship-Based (DIR) Model, and
Volume 43/Number 1/2012 13
the Relationship Development Intervention (RDI) in the short-term),19 and tension headaches (suggests
Programs. The fact that Cochrane has not reviewed that acupuncture could be a valuable option).20 It
these therapies does not necessarily detract from should be noted that a randomized controlled trial of
their value. It does usually mean that there are few patching vs acupuncture for anisometropic amblyopia
if any randomized, placebo controlled clinical trials in children from 7 to 12 years of age found that
available. The disadvantages of RCTs have been acupuncture was just as effective for anisometropic
discussed in several papers and include limitations amblyopia when compared to patching and was also
of external validity, high costs and the extensive time statistically superior.21
required to complete the research.5,6,7,8 At least two
papers suggested that observational studies produced Chiropractic
similar results.9,10 Chiropractic interventions showed slightly
improved pain and disability outcomes in the short
Acupuncture 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 quality
of human ailments and has been practiced in various evidence that neck manipulation provides more pain
Asian countries for millennia. Although few unwanted relief for those with acute/chronic neck pain.23
side effects have been reported, its implementation
by qualified practitioners is required. In traditional Diet
Chinese medicine the body is in balance with two Research supporting gluten and/or casein free diets
opposing forces. These forces are yin (a cold, slow, as an effective intervention for persons with autism
or passive principle,) and yang (a hot, excited, or are lacking. There is also little research concerning the
active principle). Any imbalance of these forces leads possible unwanted side effects of such diets.24
to a blockage in the flow of qi (vital energy) and a
diseased state. This blockage can be relieved by using Supplements
acupuncture.11 Supplementation with antioxidants and zinc may
A systematic review of 4 randomized controlled be of benefit for those with AMD.25 Creatine use has
trials evaluating the efficacy and safety of acupuncture shown an increase in muscle strength in muscular
was completed. It was noted that these studies had dystrophies with activities of daily living improving
low methodological quality and had many dissimilar as well.26 Ginseng appears to have beneficial effects
variables and outcome measures. Because of the small on cognition, behavior and one’s quality of life.27 The
number of studies available for review and their low use of melatonin can be effective for dementia-related
methodological quality, no conclusions could be psychopathologic behavior problems28 while vitamin
drawn regarding efficacy and safety.12 Several other D3 appears to decrease mortality in elderly women
anomalies that showed little evidenced based research who are in institutions and require dependent care.29
to support the use of acupuncture included attention DHEA supplementation has not been shown to retard
deficit hyperactivity disorder,13 glaucoma14 and aging and/or age-associated cognitive impairment,
stroke rehabilitation, (5 trials were identified, all of however.30
poor 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 acid
low 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 Fragile
conventional therapies alone),16 smoking cessation (It X syndrome.32 Vitamin B12 has not been shown as
was noted that acupuncture may be better than doing being effective for improving cognitive function.33
nothing. There is evidence to support that acupuncture
might have an effect greater than placebo),17 migraine Other CAM
prevention (Patients receiving acupuncture reported An aroma therapy clinical trial showed a significant
more improvement. The studies reviewed suggest effect on measures of agitation and neuropsychiatric
that migraine patients benefit from acupuncture),18 symptoms.34 Although the trials were small and of
chronic 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
sleep disturbance and itching.35 Light therapy appears attention deficit hyperactivity disorder.53 There
to have a modest positive effect for non-seasonal appears to be little evidence that light therapy is
depression.36 effective for managing cognitive, sleep, functional,
Research concerning massage therapy used to behavioral, or psychiatric disturbances associated with
promote growth and development in pre-term babies dementia.54 Trials that support the use of meditation
showed 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 this
scores on developmental tests and fewer postnatal time as well.55,56
complications.37 While the use of probiotics added to
infant meals appeared to prevent infant eczema, with Conclusion
at least one study suggesting the benefit could persist CAM therapies are just now being considered for
up 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 CAM
pain by up to 50% in some patients and decreased therapy by clinicians, researchers, editors, publishers
the need for morphine-like analgesics.39 It also appears and authors must be considered when reviewing the
to improve walking skills of those with acquired brain value of any published research.57 Only by maintaining
injury, was superior to placebo therapy for improving an open but skeptical approach to all aspects of patient
verbal and gestural communicative skills of those diagnosis and treatment do we ensure the very best for
with autism and may be of use for the treatment of the patients under our care. Pragmatically, however, it
depression, as well.40,41,42 According to at least one is also important to recognize the importance of the
Cochrane review, however, listening therapies such clinician’s insights and experience to supplement this
as 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 trials
treatment 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 and
recommended 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 treatment
suggests that risk of Alzheimer’s disease is significantly toolbox that are appropriate. We must use our clinical
reduced among those with higher levels of fish and intuition and insights, as well as science, when making
Omega 3 PUFA consumption. Unfortunately, the lives of our patients better. First and foremost, as
these studies were not randomized clinical trials.44 Hippocrates58 noted: “Primum non nocerum” or we
Individuals with cystic fibrosis45 demonstrated positive should do no harm.
outcomes. The use of Omega-3s did not appear to
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Volume 43/Number 1/2012 17

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