International Journal of Epidemiology 2002;31:272-273
© International Epidemiological Association 2002
Book Review |
The Desktop Guide to Complementary and Alternative Medicine
E Ernst, MH Pittler, C Stevinson, A White (eds). London: Harcourt, 2001, pp.444, £24.95 (+ CD-ROM), ISBN 0-7234-3207-4.
A friend from Australia e-mailed me: ‘Help, I’ve got to write a patient handbook on stroke and we need a section on complementary therapies. I've checked Cochrane Library but that was no help and BMJ's Clinical Effectiveness had nothing'. I just happened to have this book sitting on my desk. Turning to 347, I found some useful information—a list of synonyms (particularly helpful for a lay audience), a definition of stroke, and a summary stating that no specific form of CAM (complementary and alternative medicines) was widely used in the West, but in the East acupuncture and Chinese herbs were widely used. An ‘in press’ review of nine trials of acupuncture was cited, presumably done by the editors, which demonstrates benefits, but in placebo-controlled trials the effects were less marked, suggesting acupuncture works via non-specific effects rather than as a direct consequence of the needling. On meditation, the evidence of effects on blood pressure is curiously incomplete, missing a systematic review1 and a very well-known, seminal paper demonstrating reductions in mortality attributed to meditation.2
The search strategies are described in general in an opening chapter and the overall MEDLINE search for specific CAM is given but separate searches for the condition-specific topics covered in the main text are not stated. Consequently, it is impossible to decide whether, in the case of the meditation and blood pressure review, the search was inadequate or whether the studies were found but rejected on explicit grounds.
No estimates of the size of treatment effects are given, and the summary table simply gives the weight of evidence graded from one to three balls and an arrow showing the ‘direction of evidence’. Serious safety concerns are also highlighted which fits with the overall recommendation: '... it may be a matter of personal preference and individual judgement whether to use the various CAM therapies available'. The review is perfectly clear on the benefits of allopathic medicine in stroke: ‘the single factor known to improve the outcome after stroke is admission to a specialist stroke unit’. But no reference is given to this evidence, nor is it clear who wrote the section.
The book is organized into four main sections: methods and how to use it; evidence for specific therapies; conditions in which specific therapies may be useful; and general topics including ‘Why Patients Use CAM’ ‘Economic Issues in CAM’. A CD-ROM is also provided. The condition-specific section is eclectic in its choice of topics. You will find no section on angina or high blood pressure, despite both being common and, in the case of the latter, a considerable amount of ambiguous evidence exists that could be usefully summarized for the physician and patient.
The editors compared their evidence with the opinions found in several leading textbooks of CAM and were surprised by the broad range of CAM treatments recommended for many conditions, and by the lack of agreement between experts. There is, of course, a similar situation of lack of agreement in the use of many allopathic treatments and it is precisely because of the likelihood of biased appraisal that systematic reviewing has developed its rigorous methodology.
This book provides an enormous resource but it is quite unclear why this work is separate from The Cochrane Library. You will find no index entry for The Cochrane Library or Collaboration. Systematic reviews of some of the interventions examined are available here—for example the effects of prayer, exercise, diet and music have all been examined and published as Cochrane reviews. It would be more valuable to examine the evidence using the well-documented Cochrane principles and methods that promote collaboration, avoid duplication of effort, and capitalize on the energy and enthusiasm of a wide range of people to conduct and maintain reviews. I hope the authors' work on CAM treatments will be actively incorporated into The Cochrane Library. This need not stop their work on CAM treatments—for which there is a massive public market— being published in more attractive and user-friendly formats for different audiences.
References
1
Ebrahim S, Davey Smith G. Lowering blood pressure: a systematic review of sustained effects of non-pharmacological interventions. J Public Health Med 1998;20:441–48.
2 Patel C, Marmot M, Terry D, Carruthers M, Hunt B. Trial of relaxation in reducing coronary risk: four year follow up. Br Med J 1985;290:1103–06.
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