Introduction

The conditions described in this chapter are disorders that often present in CAM practice. The format for each of these conditions is the same – it begins with a general description of the disorder, which is followed by a representative case of that condition. Each case is structured around the six stages of DeFCAM, including rapport, clinical assessment, CAM diagnosis, planning, application and review. Most of these stages are self-explanatory, except for the application stage. In keeping with the need for rigour and transparency in evidence-based practice, the methodology of the application section is described below.

Methodology

The application section in each of the 10 cases in this chapter identifies a wide range of dietary, lifestyle, nutritional, herbal and other modalities or interventions pertinent to CAM practice. To ensure that the content of this section was applicable to – or at least reflected – that used in CAM practice, several sources of information had to be reviewed. The first stage of the review consisted of a systematic search of the general CAM literature, specifically, a search of traditional and evidence-based texts on CAM, herbal medicine, nutrition, naturopathy, traditional Chinese medicine, chiropractic, osteopathy, homeopathy, mind–body medicine, aromatherapy, massage and reflexology. CAM texts were reviewed for content relevant to each of the 10 conditions presented. A systematic search of several online bibliographic databases (e.g. the Cochrane Library, CAM on PubMED, MEDLINE) was also performed to identify additional interventions. To locate the required information the search terms consisted of different combinations of conditions and CAM modalities. All interventions listed more than once in the general texts and/or bibliographic databases were considered potential treatments for the relevant condition.

A systematic search of the bibliographic databases was then performed to find the best available evidence of effectiveness for each potential intervention. The search strategy included all common and scientific names for the intervention and all alternative names for the condition. Treatments for which clinical evidence was available (i.e. level I to level IV evidence), were included in the application section. The evidence for these interventions was also appraised for quality.

To assess the quality of evidence, every eligible intervention was graded according to the hierarchy of evidence (Table 9.1), strength of evidence (Table 9.2) and direction of evidence (Table 9.3). A summary of each of these quality measures was provided for each intervention for which clinical evidence was available.

Table 9.1 The hierarchy of evidence

Level I	Systematic reviews
Level II	Well-designed randomised controlled trials
Level III-1	Pseudorandomised controlled trials
Level III-2	Comparative studies with concurrent controls, such as cohort studies, case-control studies or interrupted time series studies
Level III-3	Comparative studies without concurrent controls, such as a historical control study, two or more single-arm studies or interrupted time series without a parallel control group
Level IV	Case series with post-test or pre-test/post-test outcomes; uncontrolled open label study
Level V	Expert opinion or panel consensus
Level VI	Traditional evidence

Adapted from National Health and Medical Research Council (NHMRC 1999) and the Centre for Evidence-Based Medicine 2001 ^1,²

Table 9.2 Strength of evidence

Grade	Strength of evidence	Definition
A	Excellent	Evidence: multiple level I or II studies with low risk of bias Consistency: all studies are consistent Clinical impact: very large Generalisability: the client matches the population studied Applicability: findings are directly applicable to the CAM practice setting
B	Good	Evidence: one or two level II studies with low risk of bias, or multiple level III studies with low risk of bias Consistency: most studies are consistent Clinical impact: considerable Generalisability: the client is similar to the population studied Applicability: findings are applicable to the CAM practice setting with few caveats
C	Satisfactory	Evidence: level I or II studies with moderate risk of bias, or level III studies with low risk of bias Consistency: there is some inconsistency Clinical impact: modest Generalisability: the client is different from the population studied, but the relationship between the two is clinically sensible Applicability: findings are probably applicable to the CAM practice setting with several caveats
D	Poor	Evidence: level IV studies, level V or VI evidence, or level I to III studies with high risk of bias Consistency: evidence is inconsistent Clinical impact: small Generalisability: the client is different from the population studied, and the relationship between the two is not clinically sensible Applicability: findings are not applicable to the CAM practice setting

Adapted from NHMRC 2009 ³

Table 9.3 Direction of evidence

+	Positive evidence – intervention is more effective than the placebo or comparative agent
o	Neutral evidence – intervention is as effective or no different than the placebo or comparative agent
–	Negative evidence – intervention is less effective than the placebo or comparative agent

Interventions that demonstrated good to excellent evidence of effectiveness for the pertinent disorder (such as levels I, II or III-1, strength A or B and direction +), and were most compatible with the particular needs of the presenting case, that is, they targeted the planned goals, expected outcomes and CAM diagnoses, were listed as primary treatments in the CAM prescription. Interventions that addressed unmet needs of the presenting case but demonstrated lower levels of evidence (including levels III-2 or III-3 and strength C) were listed as secondary treatments.

< div class='tao-gold-member'>

Only gold members can continue reading. Log In or Register to continue