Abstract
—Holger Cramer, PhD, Editor-in-Chief, Journal of Integrative and Complementary Medicine
Acupuncture for Polycystic Ovary Syndrome
Polycystic ovary syndrome (PCOS) is a common hormonal disorder that can cause irregular periods and infertility. Acupuncture has been proposed to improve ovulation and fertility outcomes in women with PCOS. This review assessed randomized trials in women with PCOS comparing acupuncture or electroacupuncture with sham acupuncture, no treatment, exercise, relaxation, clomiphene, or Diane-35, and measuring live birth, ovulation, pregnancy, menstrual regularity, miscarriage, and adverse events. Nine trials involving 1606 women were included, with most follow-up periods around 12 weeks and only one large trial (1000 women) reporting live birth and multiple pregnancy. Compared with sham acupuncture, acupuncture may result in little or no difference in live birth, multiple pregnancy, ovulation, clinical pregnancy, or miscarriage rates (low-certainty evidence). Adverse events were probably more common with acupuncture and included dizziness, nausea, bruising, insomnia, abdominal pain, skin rashes, vaginal bleeding, and fatigue. Evidence comparing acupuncture with exercise, relaxation, clomiphene, or Diane-35 was uncertain for most outcomes. The authors concluded that there is no clear evidence that acupuncture improves fertility outcomes in women with PCOS. Larger, well-designed trials with consistent outcome reporting are needed to determine its effectiveness and safety.
Riboflavin Supplements for Blood Pressure Lowering in Adults
High blood pressure is a major risk factor for heart disease and stroke, contributing substantially to global morbidity and mortality. Riboflavin (vitamin B2) supplements have been proposed as a potential treatment to lower blood pressure. This review evaluated randomized controlled trials comparing oral riboflavin supplements with placebo in people with hypertension, assessing effects on systolic and diastolic blood pressure and adverse events. Four trials involving 374 participants were included. The evidence is very uncertain about the effect of riboflavin on systolic blood pressure (3 studies, 320 participants) and diastolic blood pressure (2 studies, 271 participants). Reported changes were small and not clearly clinically meaningful. No trials reported changes in antihypertensive medication use. One small study reported adverse events, with little to no difference between riboflavin and control groups (low-certainty evidence). Overall, the certainty of the evidence was very low due to small study sizes, incomplete reporting, and high study risk of bias. The authors concluded that it remains unclear whether riboflavin lowers blood pressure and recommended large, well-designed trials to provide more reliable evidence.
Manual Therapy with Exercise for Neck Pain
Neck pain can be disabling. Manual therapy (hands-on techniques to mobilize or manipulate soft tissues, joints, or nerves) and exercise (strengthening, stretching, motor control, cardiovascular, or mind–body) individually have evidence of effectiveness for the treatment of neck pain. This review evaluated the benefits and risks of manual therapy combined with exercise for the treatment of neck pain in adults. Nine randomized controlled trials involving 694 participants (76% female, mean age 46 years) were included, conducted across North America, Europe, Central Asia, East Asia, and the Pacific. Studies primarily included participants with chronic neck pain. Compared with attention control or placebo, manual therapy with exercise may show little to no reduction in pain but moderate improvement in function (low-certainty evidence). Compared with no treatment, manual therapy with exercise may result in a large reduction in pain, moderate functional improvement, and large gains in quality of life, with a slightly increased risk of non-serious transient adverse events such as soreness or headache (low-certainty evidence). Larger studies with better reporting of interventions and outcomes are needed, particularly for acute and subacute neck pain.
Acupuncture for Insomnia in People with Cancer
Insomnia is common in people with cancer and can worsen physical and psychological well-being, making effective treatment important. Acupuncture has been proposed as a non-drug therapy to improve sleep. This review assessed randomized trials in people with cancer comparing acupuncture with sham acupuncture, inactive control, or cognitive behavioral therapy for insomnia (CBT-I), measuring insomnia severity, sleep quality, sleep diary outcomes, and adverse events. Five studies involving 402 participants, mostly women with breast cancer, were included. Compared with sham acupuncture, acupuncture may have little to no effect on insomnia severity or sleep quality and may increase adverse events; however, all evidence was uncertain. Compared with inactive control, acupuncture may slightly reduce insomnia severity and improve sleep quality, but adverse events may be more frequent; however, all evidence was uncertain. Compared with CBT-I, acupuncture is probably less effective in improving insomnia severity, sleep quality, sleep onset latency, and sleep efficiency, although there may be no difference in adverse events. The authors conclude that improvements in acupuncture trial conduct and reporting are needed, and in the meantime the overall uncertainty in the evidence indicates that the choice to use acupuncture might be informed by patient values and preferences.
Calcium Supplementation During Pregnancy for Preventing Hypertensive Disorders and Related Problems
High blood pressure during pregnancy is a leading cause of maternal and neonatal morbidity and mortality, with pre-eclampsia being the most severe complication. This Cochrane review evaluated whether oral calcium supplementation can prevent these hypertensive disorders. The review included 10 randomized controlled trials involving 37,504 pregnant women and comparing calcium supplements to a placebo or different dosages of calcium. Studies were conducted in both high-income and low-income countries. Results from the largest trials provide high-certainty evidence that there is little or no difference in the risk of developing pre-eclampsia with calcium supplementation and placebo. Similarly, high-certainty evidence indicates that calcium does not significantly reduce the risk of perinatal loss or preterm delivery before 37 weeks. The evidence regarding maternal death and specific adverse events is uncertain because of the rarity of these outcomes in the study populations. There is also low- to high-certainty evidence of little or no difference between low-dose (500 mg) and high-dose (1500 mg) calcium regimens in pre-eclampsia, preterm delivery before 37 weeks, perinatal loss, and stillbirth. The authors conclude that further research into calcium supplementation for hypertensive disorders is unlikely to change the current evidence and suggest that future research efforts should instead focus on alternative interventions to prevent pregnancy-related hypertensive disorders.
Cannabis‐Based Medicines for Chronic Neuropathic Pain in Adults
Neuropathic pain, which arises from nervous system damage, is difficult to treat. Cannabis-based products, including plant-derived or synthetic tetrahydrocannabinol (THC) and cannabidiol (CBD), are increasingly proposed as potential therapies. This review evaluated the efficacy and safety of THC-dominant, CBD-dominant, and balanced THC/CBD medicines compared with placebo or active comparators in adults with chronic central or peripheral neuropathic pain. The review included 21 randomized controlled trials (2,187 participants) with study durations ranging from 2 to 26 weeks. There is no clear evidence that THC-dominant or CBD-dominant medicines provide at least 50% pain relief compared with placebo. While balanced THC/CBD medicines may slightly increase the likelihood of achieving 30% pain relief, the clinical importance of this effect is uncertain. THC-dominant products may increase the risk of adverse events related to the nervous system, such as dizziness, and THC/CBD medicines may lead to higher withdrawal rates due to side effects. Evidence across all outcomes is low to very low certainty due to small sample sizes and risk of bias. The authors conclude that robust evidence for the benefit of cannabis-based medicine is currently lacking, and future research should prioritize larger, well-designed trials that include participants with comorbidities to better define clinical usefulness.
Exercise for Depression
Depression is a common and disabling mental health condition affecting over 100 million people worldwide. Exercise has been proposed as an alternative or adjunct treatment for adults with depression. This review included 73 randomized controlled trials (4985 adults with depression) comparing exercise with no treatment, psychological therapy, or antidepressant medication. Compared with no treatment or control (57 trials, 2189 participants), exercise may produce a large reduction in depressive symptoms (SMD −0.67), although the effect size is smaller in higher-quality trials. Long-term effects are very uncertain. There is probably little or no difference in depression symptoms with exercise compared with psychological therapy, and there may be little or no difference in depression symptoms with exercise compared with pharmacological treatment. Treatment acceptability was similar across groups, and quality-of-life findings were inconsistent. Adverse events with exercise were not common and typically involved musculoskeletal problems or worsening depression; medication-related harms included diarrhea, sexual dysfunction, and fatigue. The authors conclude that exercise may be moderately effective compared with no treatment but appears similarly effective to psychological or pharmacological therapies. They recommend improving trial quality, clarifying which exercise types work best for different individuals, and examining long-term outcomes.
Spinal Manipulative Therapy for Adults with Chronic Low Back Pain
Chronic low back pain, defined as pain lasting longer than 12 weeks, is a common and disabling disorder. Spinal manipulative therapy (SMT) is a hands-on treatment involving gentle movements or quick controlled pushes delivered by chiropractors, manual therapists, and osteopaths to improve spinal motion and reduce pain. This review included 76 randomized controlled trials (11,866 predominantly middle-aged participants with chronic low back pain) comparing SMT to sham SMT, no treatment, or other conservative interventions. Compared with sham SMT, SMT may result in a small reduction in pain and a medium improvement in function at one month of follow-up, although the evidence is of very low certainty. Compared with no treatment, SMT may produce a moderate reduction in pain and a large improvement in function, although the evidence is of low to very low certainty. When SMT is compared with other conservative treatments, there may be little or no difference in pain and a small improvement in function, although the evidence is of low certainty. Adverse events were reported in less than half the studies and included muscle soreness and temporary increases in pain. No serious harms were reported. The authors conclude that SMT may be as effective as other conservative interventions, which supports the inclusion of SMT in guidelines.