ObjectivesThe aim of this systematic review update was to determine the average effect of massage for adults with neck pain (NP) contrasted against another standard treatment.MethodsRandomised controlled trials comparing massage to standard treatments were included; placebo/no treatment comparisons were excluded. Databases were searched (CENTRAL, MEDLINE, EMBASE, CINAHL, ICL, trial registries) from inception to Oct-1-2023. We used the standard Cochrane methodological procedures: rated Risk of Bias 1.0, abstracted mean differences (MD), meta-analysed data, and rated the level of certainty (GRADE).ResultsWe included 42 studies (2656 participants; 67% high RoB) contrasted against 10 unique treatments. Trials studied ages 18–70, 70% female, and mean pain severity 52 Visual Analogue Scale (VAS). Very-low to moderate-certainty evidence for pain (MD VAS 0–100, 95% CI) at ≤12 weeks follow-up follows. The pre-stated minimal important difference margin was 10 VAS points. Massage was.Massage may not increase risks of minor adverse events: RR 0.37 (95%CI 0.22 to 0.61).ConclusionFor subacute-chronic NP, pain reduction varied by comparison. The evidence was limited by imprecision and high RoB. Focused planning for adequately dosed longer-term trials is needed.

BACKGROUND:Massage is widely used for neck pain, but its effectiveness remains unclear. OBJECTIVES:To assess the benefits and harms of massage compared to placebo or sham, no treatment or exercise as an adjuvant to the same co-intervention for acute to chronic persisting neck pain in adults with or without radiculopathy, including whiplash-associated disorders and cervicogenic headache. SEARCH METHODS:We searched multiple databases (CENTRAL, MEDLINE, EMBASE, CINAHL, Index to Chiropractic Literature, trial registries) to 1 October 2023. SELECTION CRITERIA:We included randomised controlled trials (RCTs) comparing any type of massage with sham or placebo, no treatment or wait-list, or massage as an adjuvant treatment, in adults with acute, subacute or chronic neck pain. DATA COLLECTION AND ANALYSIS:We used the standard methodological procedures expected by Cochrane. We transformed outcomes to standardise the direction of the effect (a smaller score is better). We used a partially contextualised approach relative to identified thresholds to report the effect size as slight-small, moderate or large-substantive. MAIN RESULTS:We included 33 studies (1994 participants analysed). Selection (82%) and detection bias (94%) were common; multiple trials had unclear allocation concealment, utilised a placebo that may not be credible and did not test whether blinding to the placebo was effective. Massage was compared with placebo (n = 10) or no treatment (n = 8), or assessed as an adjuvant to the same co-treatment (n = 15). The trials studied adults aged 18 to 70 years, 70% female, with mean pain severity of 51.8 (standard deviation (SD) 14.1) on a visual analogue scale (0 to 100). Neck pain was subacute-chronic and classified as non-specific neck pain (85%, including n = 1 whiplash), radiculopathy (6%) or cervicogenic headache (9%). Trials were conducted in outpatient settings in Asia (n = 11), America (n = 5), Africa (n = 1), Europe (n = 12) and the Middle East (n = 4). Trials received research funding (15%) from research institutes. We report the main results for the comparison of massage versus placebo. Low-certainty evidence indicates that massage probably results in little to no difference in pain, function-disability and health-related quality of life when compared against a placebo for subacute-chronic neck pain at up to 12 weeks follow-up. It may slightly improve participant-reported treatment success. Subgroup analysis by dose showed a clinically important difference favouring a high dose (≥ 8 sessions over four weeks for ≥ 30 minutes duration). There is very low-certainty evidence for total adverse events. Data on patient satisfaction and serious adverse events were not available. Pain was a mean of 20.55 points with placebo and improved by 3.43 points with massage (95% confidence interval (CI) 8.16 better to 1.29 worse) on a 0 to 100 scale, where a lower score indicates less pain (8 studies, 403 participants; I2 = 39%). We downgraded the evidence to low-certainty due to indirectness; most trials in the placebo comparison used suboptimal massage doses (only single sessions). Selection, performance and detection bias were evident as multiple trials had unclear allocation concealment, utilised a placebo that may not be credible and did not test whether blinding was effective, respectively. Function-disability was a mean of 30.90 points with placebo and improved by 9.69 points with massage (95% CI 17.57 better to 1.81 better) on the Neck Disability Index 0 to 100, where a lower score indicates better function (2 studies, 68 participants; I2 = 0%). We downgraded the evidence to low-certainty due to imprecision (the wide CI represents slight to moderate benefit that does not rule in or rule out a clinically important change) and risk of selection, performance and detection biases. Participant-reported treatment success was a mean of 3.1 points with placebo and improved by 0.80 points with massage (95% CI 1.39 better to 0.21 better) on a Global Improvement 1 to 7 scale, where a lower score indicates very much improved (1 study, 54 participants). We downgraded the evidence to low-certainty due to imprecision (single study with a wide CI that does not rule in or rule out a clinically important change) and risk of performance as well as detection bias. Health-related quality of life was a mean of 43.2 points with placebo and improved by 5.30 points with massage (95% CI 8.24 better to 2.36 better) on the SF-12 (physical) 0 to 100 scale, where 0 indicates the lowest level of health (1 study, 54 participants). We downgraded the evidence once for imprecision (a single small study) and risk of performance and detection bias. We are uncertain whether massage results in increased total adverse events, such as treatment soreness, sweating or low blood pressure (RR 0.99, 95% CI 0.08 to 11.55; 2 studies, 175 participants; I2 = 77%). We downgraded the evidence to very low-certainty due to unexplained inconsistency, risk of performance and detection bias, and imprecision (the CI was extremely wide and the total number of events was very small, i.e < 200 events). AUTHORS' CONCLUSIONS:The contribution of massage to the management of neck pain remains uncertain given the predominance of low-certainty evidence in this field. For subacute and chronic neck pain (closest to 12 weeks follow-up), massage may result in a little or no difference in improving pain, function-disability, health-related quality of life and participant-reported treatment success when compared to a placebo. Inadequate reporting on adverse events precluded analysis. Focused planning for larger, adequately dosed, well-designed trials is needed.

BackgroundMore than one in five patients who undergo treatment for breast cancer will develop breast cancer-related lymphedema (BCRL). BCRL can occur as a result of breast cancer surgery and/or radiation therapy. BCRL can negatively impact comfort, function, and quality of life (QoL). Manual lymphatic drainage (MLD), a type of hands-on therapy, is frequently used for BCRL and often as part of complex decongestive therapy (CDT). CDT is a fourfold conservative treatment which includes MLD, compression therapy (consisting of compression bandages, compression sleeves, or other types of compression garments), skin care, and lymph-reducing exercises (LREs). Phase 1 of CDT is to reduce swelling; Phase 2 is to maintain the reduced swelling.ObjectivesTo assess the efficacy and safety of MLD in treating BCRL.Search methodsWe searched Medline, EMBASE, CENTRAL, WHO ICTRP (World Health Organization's International Clinical Trial Registry Platform), and Cochrane Breast Cancer Group's Specialised Register from root to 24May 2013. No language restrictions were applied.Selection criteriaWe included randomized controlled trials (RCTs) or quasi-RCTs of women with BCRL. The intervention was MLD. The primary outcomes were (1) volumetric changes, (2) adverse events. Secondary outcomes were (1) function, (2) subjective sensations, (3) QoL, (4) cost of care.Data collection and analysisWe collected data on three volumetric outcomes. (1) LE (lymphedema) volume was defined as the amount of excess fluid left in the arm after treatment, calculated as volume in mL of affected arm post-treatment minus unaffected arm post-treatment. (2) Volume reduction was defined as the amount of fluid reduction in mL from before to after treatment calculated as the pretreatment LE volume of the affected arm minus the post-treatment LE volume of the affected arm. (3) Per cent reduction was defined as the proportion of fluid reduced relative to the baseline excess volume, calculated as volume reduction divided by baseline LE volume multiplied by 100. We entered trial data into ReviewManger 5.2 (RevMan), pooled data using a fixed-effect model, and analyzed continuous data as mean differences (MDs) with 95% confidence intervals (CIs). We also explored subgroups to determine whether mild BCRL compared to moderate or severe BCRL, and BCRL less than a year compared to more than a year was associated with a better response to MLD.Main resultsSix trials were included. Based on similar designs, trials clustered in three categories.(1) MLD + standard physiotherapy versus standard physiotherapy (one trial) showed significant improvements in both groups from baseline but no significant between-groups differences for per cent reduction.(2) MLD + compression bandaging versus compression bandaging (two trials) showed significant per cent reductions of 30% to 38.6% for compression bandaging alone, and an additional 7.11% reduction forMLD (MD7.11%, 95% CI 1.75% to 12.47%; two RCTs; 83 participants). Volume reduction was borderline significant (P = 0.06). LE volume was not significant. Subgroup analyses was significant showing that participants with mild-to-moderate BCRL were better responders to MLD than were moderate-to-severe participants.(3) MLD+ compression therapy versus nonMLDtreatment + compression therapy (three trials) were too varied to pool. One of the trials compared compression sleeve plus MLD to compression sleeve plus pneumatic pump. Volume reduction was statistically significant favoringMLD (MD 47.00 mL, 95% CI 15.25 mL to 78.75 mL; 1 RCT; 24 participants), per cent reduction was borderline significant (P= 0.07), and LE volume was not significant. A second trial compared compression sleeve plus MLD to compression sleeve plus selfadministered simple lymphatic drainage (SLD), and was significant forMLD for LE volume (MD -230.00 mL, 95% CI -450.84 mL to -9.16 mL; 1 RCT; 31 participants) but not for volume reduction or per cent reduction. A third trial of MLD + compression bandaging versus SLD + compression bandaging was not significant (P = 0.10) for per cent reduction, the only outcome measured (MD 11.80%, 95% CI -2.47% to 26.07%, 28 participants).MLD was well tolerated and safe in all trials.Two trials measured function as range of motion with conflicting results. One trial reported significant within-groups gains for both groups, but no between-groups differences. The other trial reported there were no significant within-groups gains and did not report between-groups results. One trial measured strength and reported no significant changes in either group.Two trials measured QoL, but results were not usable because one trial did not report any results, and the other trial did not report between-groups results.Four trials measured sensations such as pain and heaviness. Overall, the sensations were significantly reduced in both groups over baseline, but with no between-groups differences. No trials reported cost of care.Trials were small ranging from 24 to 45 participants. Most trials appeared to randomize participants adequately. However, in four trials the person measuring the swelling knew what treatment the participants were receiving, and this could have biased results.Authors' conclusionsMLD is safe and may offer additional benefit to compression bandaging for swelling reduction. Compared to individuals with moderate to-severe BCRL, those with mild-to-moderate BCRL may be the ones who benefit from adding MLD to an intensive course of treatment with compression bandaging. This finding, however, needs to be confirmed by randomized data.In trials where MLD and sleeve were compared with a nonMLD treatment and sleeve, volumetric outcomes were inconsistent within the same trial. Research is needed to identify themost clinically meaningful volumetric measurement, to incorporate newer technologies in LE assessment, and to assess other clinically relevant outcomes such as fibrotic tissue formation.Findings were contradictory for function (range of motion), and inconclusive for quality of life.For symptoms such as pain and heaviness, 60% to 80% of participants reported feeling better regardless of which treatment they received.One-year follow-up suggests that once swelling had been reduced, participants were likely to keep their swelling down if they continued to use a custom-made sleeve.

STUDY DESIGN:Systematic review. OBJECTIVE:To assess the effects of massage on pain, function, patient satisfaction, cost of care, and adverse events in adults with neck pain. SUMMARY OF BACKGROUND DATA:Neck pain is common, disabling, and costly. Massage is a commonly used modality for the treatment of neck pain. METHODS:We searched several databases without language restriction from their inception to September 2004. We included randomized and quasirandomized trials. Two reviewers independently identified studies, abstracted data, and assessed quality. We calculated the relative risks and standardized mean differences on primary outcomes. 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. RESULTS:Overall, 19 trials were included, with 12/19 receiving low-quality scores. Descriptions of the massage intervention, massage professional's credentials, or experience were frequently missing. Six trials examined massage as a stand-alone treatment. The results were inconclusive. Results were also inconclusive in 14 trials that used massage as part of a multimodal intervention because none were designed such that the relative contribution of massage could be ascertained. 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 Consolidated Standards of Reporting Trials, are needed. Both short and long-term follow-up are needed.

Massage is an increasingly popular complementary and alternative medicine modality used for a variety of conditions. Cochrane massage reviews are a gold mine of observations regarding the methodologic issues inherent in massage trials and have raised important questions, which can be used to guide future research. Among the research issues raised in Cochrane reviews are questions about combination trials, practitioner qualifications, adequate doses, and appropriate control groups. This article summarizes these key research issues.

questionnaires designed to assess knowledge of heart failure (HF) patients and (2) to identify the most applicable questionnaire to assess knowledge of HF patients. Methods: A literature search of electronic databases was conducted from database inception to March 2014. Eligible articles included studies describing the development and psychometric testing of questionnaires designed to assess HF patients’ knowledge. Outcomes were based on the quality criteria for measurement properties of health status questionnaires. Articles were considered for inclusion by 2 authors independently. Results: Overall, 12 articles were included, of which 4 (33.33%) were considered ‘‘good’’ quality. Twelve original English-language instruments were identified. Content validity was described in 10 studies and presented positive ratings in all of them (83.33%); internal consistency in 10 studies and positive ratings in 5 (41.66%); construct validity in 5 and positive ratings in 4 (33.33%); responsiveness in 3 and positive ratings in 2 (16.66%); and reproducibility and floor effects in 1 with positive ratings. Based on our criteria, the Atlanta HF Knowledge Test was identified as the most applicable questionnaire to assess knowledge of HF patients. Conclusion: Psychometric properties of questionnaires assessing HF patients’ knowledge are poorly described in the literature. Although we identified the Atlanta HF Knowledge Test as the most promising instrument, it has methodological limitations. We recommend the researchers to use the questionnaire that best serves their research question and context.

BACKGROUND The prevalence of mechanical neck disorders (MND) is known to be both a hindrance to individuals and costly to society. As such, massage is widely used as a form of treatment for MND. OBJECTIVES To assess the effects of massage on pain, function, patient satisfaction, global perceived effect, adverse effects and cost of care in adults with neck pain versus any comparison at immediate post-treatment to long-term follow-up. SEARCH METHODS We searched The Cochrane Library (CENTRAL), MEDLINE, EMBASE, MANTIS, CINAHL, and ICL databases from date of inception to 4 Feburary 2012. SELECTION CRITERIA Studies using random assignment were included. DATA COLLECTION AND ANALYSIS Two review authors independently conducted citation identification, study selection, data abstraction and methodological quality assessment. Using a random-effects model, we calculated the risk ratio and standardised mean difference. MAIN RESULTS Fifteen trials met the inclusion criteria. The overall methodology of all the trials assessed was either low or very low GRADE level. None of the trials were of strong to moderate GRADE level. The results showed very low level evidence that certain massage techniques (traditional Chinese massage, classical and modified strain/counter strain technique) may have been more effective than control or placebo treatment in improving function and tenderness. There was very low level evidence that massage may have been more beneficial than education in the short term for pain bothersomeness. Along with that, there was low level evidence that ischaemic compression and passive stretch may have been more effective in combination rather than individually for pain reduction. The clinical applicability assessment showed that only 4/15 trials adequately described the massage technique. The majority of the trials assessed outcomes at immediate post-treatment, which is not an adequate time to assess clinical change. Due to the limitations in the quality of existing studies, we were unable to make any firm statement to guide clinical practice. We noted that only four of the 15 studies reported side effects. All four studies reported post-treatment pain as a side effect and one study (Irnich 2001) showed that 22% of the participants experienced low blood pressure following treatment. AUTHORS' CONCLUSIONS No recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain.As a stand-alone treatment, massage for MND was found to provide an immediate or short-term effectiveness or both in pain and tenderness. Additionally, future research is needed in order to assess the long-term effects of treatment and treatments provided on more than one occasion.

BACKGROUND:In 1998, the National Institutes of Health Consensus Statement on Acupuncture concluded that promising results have emerged showing the efficacy of acupuncture in adult postoperative and chemotherapy induced nausea and vomiting. The acupuncture point, P6 had been the point used in most of the trials.OBJECTIVES:To summarize Cochrane systematic reviews assessing P6 stimulation for nausea and vomiting.RESULTS:Reviews were found on postoperative sickness, chemotherapy-induced nausea and vomiting, and pregnancy-related nausea and vomiting. Results for postoperative nausea and vomiting show the most consistent results with 26 trials and more than 3000 patients showing the superiority of real P6 stimulation over sham for both adults and children and for both nausea and vomiting. Pooled data of trials including different antiemetics showed that P6 stimulation seems to be superior to antiemetic medication for nausea and equivalent for vomiting. P6 stimulation was similarly effective across the different methods of stimulation, both invasive or noninvasive. Results for chemotherapy-induced nausea and vomiting showed 11 trials and over 1200 patients. Electroacupuncture, but not manual acupuncture, was beneficial for first-day vomiting. Acupressure was effective for first-day nausea but not vomiting. Wristwatch-like electrical devices were not effective for any outcome. Results for pregnancy-related nausea and vomiting comprised six trials and approximately 1150 patients. Results were mixed with some trials showing positive and other trials equivocal results with no favor to a certain kind of method.CONCLUSIONS:P6 stimulation may be beneficial for various conditions involving nausea and vomiting. The added value to modern antiemetics remains unclear. In patients on chemotherapy, future research should focus on patients for whom the problems are refractory. The next steps in research should include investigating whether acupuncture points added to P6 or individualizing treatment based on a Traditional Chinese Medicine diagnosis increases treatment effectiveness. It would also be worthwhile to identify predictors of response across the different conditions so that the individual patients can optimize acupuncture point therapy.

The objective of this overview is to summarize existing knowledge about the effects of acupuncture-point stimulation on nausea and vomiting. Systematic reviews on postoperative nausea and vomiting, chemotherapy-induced nausea and vomiting, and pregnancy-related nausea and vomiting exist. Several randomised trials, but no reviews, exist for motion sickness. For postoperative nausea and vomiting, results from 26 trials showed acupuncture-point stimulation was effective for both nausea and vomiting. For chemotherapy-induced nausea and vomiting, results of 11 trials differed according to modality with acupressure appearing effective for first-day nausea, electroacupuncture appearing effective for first-day vomiting, and noninvasive electrostimulation appearing no more effective than placebo for any outcome. For pregnancy-related nausea and vomiting, results were mixed. Experimental studies showed effects of P6-stimulation on gastric myoelectrical activity, vagal modulation and cerebellar vestibular activities in functional magnetic resonance imaging. There is good clinical evidence from more than 40 randomised controlled trials that acupuncture has some effect in preventing or attenuating nausea and vomiting. A growing number of experimental studies suggest mechanisms of action.

Background There have been recent advances in chemotherapy-induced nausea and vomiting using 5-HT3 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.

BackgroundSystematic reviewers generally evaluate randomized controlled trials (RCTs) based on the published reports. We evaluated whether the description of methods in the published reports is an accurate and complete reflection of study procedures used.MethodsThe authors of 51 RCTs included in a systematic review of acupuncture for chronic pain were sent a brief survey that included questions related to the following three important study quality dimensions: (1) generation of allocation sequence, (2) allocation concealment, and (3) blinding of outcomes assessor.ResultsWe received 35 of 51 responses for an overall response rate of 68.6%. Of 35 studies described as randomized in published reports, associated survey responses indicated that four actually used quasi-randomized methods. Among published reports with missing information on these quality dimensions, 27 of 32 studies used adequate methods for the generation of allocation sequence, 13 of 34 used adequate allocation concealment and 2 of 10 were blinded, according to survey responses. Survey responses generally confirmed information about randomization and blinding already described in investigators' RCT publications.ConclusionSurveying RCT investigators uncovered some information about study quality dimensions not described in published reports.

My name is Jeanette, and I am a middle-aged adult learner. There is a liberating confession in saying this, much like someone must feel walking into an AA meeting and saying, “I am so-and-so, and I am an alcoholic.” The confession is this: I do not learn in the same way that I learned in my 20s and 30s. In my youth, I, like all the other 20-somethings, got through college on rote memorization and use of mnemonic devices. The 12 cranial nerves were memorized with “On old Olympus' towering top, a Finn and German viewed a hop.” The bones of the wrist were memorized with the mnemonic, “Never lower Tillie's panties; mother might come home.” But now I am middle aged, and memorization is not my strong suit anymore. If you ask me to name the bones of the wrist, I can tell you that the ‘N’ stands for navicular, and the “L” stands for lunate. If you press me for the “T” and the “P” bones, I can only tell you apologetically that they are “Tillie's panties.” So, how does an adult learner learn new material if not by rote memorization, and how does this apply to what I learned in LBSC775? Creating a thesaurus without knowing the discipline well is like trying to navigate in a foreign country without speaking the language – you can quickly drown in a sea of words. When my friends Bella and Yakov immigrated to the United States from Russia, they told me their greatest culture shock was city driving. Yakov would drive, and Bella would try desperately to read all the signs to him. There were so many signs! Yard signs! Campaign signs! Advertisements on billboards! Street signs! Stop signs! Lost dog signs tacked to telephone poles. Lacking a cultural “filter,” Bella described the anguish of having every word look equally important. Selective perception is important in driving and in thesaurus development. You have to know your discipline well enough (or recruit experts who do know the discipline well enough) to know what, on your list of hundreds of terms, is not important enough to keep. You also have to know your topic well enough to discuss it at the elemental concept level. When we were developing the spirituality and health thesaurus, Dr. Soergel pressed us: “Can you have nonreligious spirituality?” What an apparently odd concept, yet not from an elemental concept point of view! “Can you have nonspiritual meditation? Nonspiritual yoga practice?” Good scope notes are like Map Quest driving directions – they tell you exactly what to do. Bad scope notes are like getting driving directions from the 16-year old at the service station who smoked up before he came to work – they will leave you going in circles for hours and may never get you where you want to go. By the end of the first night, I had already had several valuable epiphanies. I never knew that there was a difference between a scope note and a definition, the former being much more of an evolving work in progress and written with an eye toward helping indexers, and the latter being a more succinct point of reference. My only experience with scope notes up to that point had been MeSH, (the National Library of Medicine's Medical Subject Headings) and the MeSH examples had seemed like definitions. Similarly, when I saw the American Psychological Association (APA) Thesaurus scope notes, I still could not see what the difference was between a scope note and a definition. The epiphany came when I laid eyes on the Dewey Decimal Classification (www.oclc.org/dewey) later in the course. For me, it was love at first sight. I was enamored of the care that the authors of the scope notes had put into anticipating where indexers might get confused and providing explicit road signs at just those junctures. These are the model for scope notes written with an eye to the indexers and cataloguers. When choosing how to display related terms (RTs), you will need to decide between the thrift store approach and the Nordstrom approach. If you've ever shopped at a thrift store for clothes, you know that most thrift stores seem to take the same equally dreadful approach to clothing displays. Clothes are crammed as tightly as they can be on a rack and often arranged by color instead of size. As we reviewed various thesauri in class and analyzed their lists of related terms (RTs), I couldn't help but think of those crammed clothing racks. Some thesauri such as that for the Education Resources Information Clearinghouse (ERIC) (www.eric.ed.gov/ or http://searcheric.org/) and the APA Thesaurus are quite generous in providing RTs, but some users will find the resultant 12–15 alphabetized RTs under the descriptor about as functional as clothes arranged according to color. A more user-friendly approach is the Nordstrom approach – showcase the most important items using special display features such as putting them at the top of the list and bolding them or using an asterisk. Nordstrom teaches an important lesson: People like pre-selected options especially when they are in a hurry. Relying on frequency analysis as the sole way to identify terms is as useful as relying on the evening paper to identify important world events: some topics will be mentioned ad nauseum, others not even once. I went into this course believing that there was something inherently noble and righteous about frequency analysis. Perhaps the greatest epiphany on that first night was rethinking the relative value of the study participants that we had enrolled in a survey in order to generate search terms. Prior to the first night, I had been thinking that our 60 study participants would be the pivotal, central source of information for indexing terms. That first night, I learned that thesaurus development regularly relies on a variety of other sources – from textbooks to specialized dictionaries to other thesauri – and I began to get a sense of the enormity of the task. A frequency analysis of the study participants' responses simply would not be adequate. That night, upon returning home, I looked at the 700+ page hardback Handbook of Religion and Health with new eyes. Right there in the index was a wealth of information on terms and their interrelationships. Nearly an hour passed as I sat lost in the pages of the index of that book. As a result of that first class, I began to view the study participants and the resultant frequency analysis as icing on the cake with perhaps the greatest contribution being not the breadth of terms needed but the ascertainment of preferred terms. Which terms out of a group of equivalent terms did participants use most frequently to capture a particular concept? This selection would be the likely candidate for the preferred term. Creating a thesaurus is like doing a vaccination program in a developing country. You will always have those trips up the Andes on a donkey. Having a background in pubic health, I always go back to lessons learned there. Vaccination programs in developing countries possess a kind of universal truth – you can use 60% of your resources vaccinating 90% of the kids and then use the other 40% of your resources climbing the mountains of the Andes to vaccinate the other 10%. Don't expect that expenditure of energy will be evenly spread over all pieces of the schema. Some will require the trip up the Andes. Some tree structures in our schema, such as health conditions or mental disorders, could be easily modified from existing hierarchies such as MeSH or the DSM IV (the Diagnostic and Statistical Manual of Mental Disorders), respectively. These pieces were the equivalent of vaccinating 90% of the kids. However, other structures, such as how to categorize all the Protestant denominations, were a real trip up the Andes. Coincidentally, while I was working on this part of the schema, Dr. Soergel reminded us that we should be keeping track of our time spent on the thesaurus so that we have some idea how to estimate time on future projects. Thus, I was extremely aware while walking out of the Eisenhower Library at 2 a.m. that I had been there for three hours holed away in the religious history section trying to find one meaningful way to classify the plethora of Protestant denominations. I had not found one meaningful classification system, but I had read far more than I ever wanted to know about Martin Luther, John Knox and John Calvin. I probably spent an additional three hours searching the Web for classification systems. Some classifications used a liberal, moderate or conservative delineation. Others classified the denominations according to the time in history when they occurred, for instance, Reformation Era, Pietistic Era. There always seemed to be a couple of subgroups that didn't fit nicely anywhere. The temptation to alphabetize and be done with it once and for all became overwhelming, but then I would think of all those clothes on the thrift store rack arranged by color, and I would talk myself out of alphabetizing. Wei Ching (my project companion) and I had several conversations about which system to use. I can surely understand why thesaurus developers choose to alphabetize rather than go through the arduous process of assigning meaningful proximity to the descriptors. We finally opted for the liberal-to-conservative classification because that is what was used the most. However, in our indexing pilot study, I found that I didn't know where to index “Baptist” because the liberal-to-conservative gradient had placed northern Baptists in one compartment and southern Baptists in another. More refinement to this part of the schema still needs to happen. We need another trip up the Andes. Creating a thesaurus is like doing horticulture; sometimes only a hybrid will do. Creating a thesaurus is like building a swimming pool. It depends on your endusers. If the pool is for toddlers, you don't need a 12-foot depth. This license to create a hybrid is part of thesaurus development. It made more sense to classify the Protestant denominations as mentioned above. However, when it came to non-Christian religions, we were persuaded to use a modification of the Dewey system, which classifies them according to geography of origin, so the Indic religions are classified together, and the African religions are classified together. The Abrahamic religions are classified together as coming from the Middle East. When one looks at the classification schema, it makes sense. One would probably not suggest that the country of origin most meaningfully classifies all those Protestant subgroups. Yet, the other religions do naturally classify that way, so we had to create a hybrid of two concepts to get the pieces to fit. Creating a thesaurus is like building a swimming pool. It depends on your end-users. If the pool is for toddlers, you don't need a 12-foot depth. If a swimming pool were being created for Olympic divers, you would opt for depth. If the pool were being built for toddlers, you would opt for shallowness. If the pool were going to serve a variety of populations, you would create sections of appropriate depth and breadth to meet the needs of all users. The night Dr. Soergel explained breadth and depth being dependent on the purpose of the thesaurus, I had another epiphany. As he explained it, even the Harvard Business Thesaurus has a shallow section on health because it is needed for breadth, but the depth of that health section needs to be nowhere near the depth experienced in MeSH. Similarly, MeSH has a shallow section on economics that is not nearly to the depth of the Harvard Business Thesaurus but is adequate to represent the overlap of economics and medicine. The depth of respective sections should be determined by their use. Creating a thesaurus is like doing marriage counseling. You have to give equal time and credibility to both sides. In building a thesaurus, there are some terms that are marked terms. This distinction was another learning point for me. Marked terms show a polarity, like one pole of the magnet or one side of the coin. To be fair to the concept, which is really a concept on a continuum, you must show both anchor points. “Hope” is a marked term. It must be shown adjacent to “Hopelessness.” Emotional states are marked terms. For every happiness, there is a sadness. Personality traits are marked terms. For every introversion, there is an extroversion. For every shyness, there is a gregariousness. Creating a thesaurus without doing semantic factoring is like trying to put together furniture from Ikea without following the instructions. You will get interesting configurations, but you will not save time. From the start of the course, I felt a sense of urgency with trying to get everything done. How could we possibly have time to do semantic factoring when we were looking at a list of hundreds of terms? After we received our first output file from TermMaster, the thesaurus software, I began sorting and sorting terms. I assigned a code to things I could not sort, and I ended up with 30 pages of “unsortables.” At my first meeting with Wei Ching I expressed how stuck I was. With her fine-tipped pencil, she began to draw semantic factors. It was as if a fog was clearing up. I could see the elemental concepts emerge under the tip of her pencil. Things never seemed that hard again. Each time I would get stuck trying to sort, I would think of Wei Ching's philosophy: When in doubt, do semantic factoring. The AOD (Alcohol and Other Drugs) Thesaurus (http://etoh.niaaa.nih.gov/AODVoll/Aodthome.htm) exemplifies a nicely semantically factored thesaurus. Creating a thesaurus is like attending Alcoholics Anonymous. Sometimes you need the support of the group. Other times, you need one buddy you can call on at any time. At the beginning of the course, Dr. Soergel highly suggested that we work in groups. Having never developed a thesaurus, I could not grasp the gravity of what he was saying. Over the course of thesaurus development, I found having a colleague to talk things over with was the best thing. Moreover, I was grateful for the smallness of our class and class time devoted to discussing our projects. Wei Ching and I would save all our mutual questions to present to the class. I can still remember the day that Mary Catherine suggested using “Abrahamic religions” for Judaism, Christianity and Islam. Then there was the day that Dr. Soergel suggested putting Theosophy, Sufism and Babism close to Islam to infer their connection through proximity, but not to put them as subsets of Islam because that might be disputed by some. Then there was the day that Tamar suggested that rather than my interviewing 10 journalists to get their lists of suggested terms, I might want to peruse the New York Times index and the Washington Post index to see what terms they were using. The class discussions were like self-help sessions – go in with a problem, come out with at least one good solution. It would have been folly to try to do this task alone. Creating a thesaurus is like creating a questionnaire. If you don't disambiguate your terms, you will get “Yes,” “No” or “Not often enough,” written in the space next to “Sex.” Whenever I fill out a demographic form, and the term sex is used instead of gender, I am tempted to write something like “not enough” or simply “yes.” Ambiguity of terms invites mischief. The class discussions with the group developing the Judaica thesaurus were particularly interesting on this subject because they illustrated how important it was to disambiguate descriptors. One could not just use the term Spanish Judaica, for there is Judaica in the Spanish language, which is different from stories that take place in Spain, which are still different from stories about Spanish culture around the world. Interestingly, when creating the spirituality and health thesaurus, I thought we were disambiguating terms until we did the indexing pilot study. It became obvious to me that Born again could be a pregnancy and birth classification, so we changed the term to Religious born again. We had Conversion, which we realized could also mean conversion reaction, so we changed it to Religious conversion. The lesson here in selecting terms is to find creative ways to disambiguate them. Identical terms should not be used for two different concepts. Indexing articles is like trying to smell yourself. There's such a thing as getting so close to something that you lose your objectivity. We have a saying among several of us who write professionally for a living. When we are too close to our own work, we pass the manuscript off to an editor who has never seen it before. We send a note along saying, “I can't edit my own work; it's like trying to smell myself.” In our indexing pilot test, I indexed 150 abstracts in order to gather pilot data for our funders as well as to improve the thesaurus. I remember getting the feeling, after I had done about 20 abstracts, that the process was now going very well. However, when I looked at my indexing on the following day, I realized that the more articles I had done in a row, the worse my indexing had gotten. I had gotten too close to it, and my indexing had gotten sloppy. I had begun indexing based on terms used in the article instead of also indexing on the underlying concepts not explicitly stated. For example, in the sloppy stage, I might have indexed a study on prayer under “Prayer” but have been too mentally fatigued to see that I should have also indexed it under “Spiritual coping” since the article was about how terminally ill people use prayer to deal with their illnesses. A fresh mind is needed to see implicit concepts and not just explicit terms. I learned that I shouldn't index articles for more than an hour at a time without taking a break and doing something else that draws on another part of my brain. In short, mnemonics and rote memory aren't the only way to learn. I will never shop at a thrift store again without thinking of it as the most dreadful way to display RTs. I will never swim in a pool again without thinking of the shallow health section in the Harvard Business Thesaurus. Most of all, I will never be appalled that some odorous locker room does not offend the regular users, for I have learned that indexing is like a locker room – if you're in it long enough you just can't smell yourself anymore.

In the current issue of the Cochrane Library (Issue 3, 2004), there are more than 25 systematic reviews addressing the use of vitamins in the prevention or treatment of disease. Vitamins have been a mainstay of health since their discovery in the early 1900s, so a question arises as to when using vitamins is considered complementary as opposed to conventional medical practice. Complementary or alternative vitamin use encompasses those uses that are outside of accepted medical practice. The use of vitamin C to prevent scurvy is accepted medical practice. The use of vitamin C as a therapeutic adjunct to asthma is not. This paper summarizes 15 Cochrane systematic reviews on the complementary use of vitamins for an array of conditions including the common cold, Alzheimer's disease, asthma, chemotherapy-induced mucositis, and depression.

There are more than 20 completed Cochrane systematic reviews on botanical medicine presently published in the Cochrane Library. There are more than 40 that are planned or in progress. It is an opportune time to explore the information needs of readers of botanical systematic reviews and how those needs can be met better by Cochrane systematic reviews. It is proposed that Cochrane systematic reviews focus not only on efficacy but also on expanded safety and quality. Expanded safety refers not only to the occurrence of adverse events but also the contraindications for use such as drug-herb interactions or allergies to products. Quality pertains to whether or not there was a method of standardizing active ingredients in trials and methods for minimizing risks of contamination. Because there are no package inserts to accompany herbal products as there are for drugs, Cochrane systematic reviews offer the ideal forum to present this much-needed information on expanded safety and quality.

The Journal of Alternative and Complementary MedicineVol. 9, No. 6 Education, Initiatives, and Information ResourcesFrom the Five Blind Men to Cochrane Complementary Medicine Systematic ReviewsJeanette EzzoJeanette EzzoSearch for more papers by this authorPublished Online:5 Jul 2004https://doi.org/10.1089/107555303771952307AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byThe 13th International Cochrane Colloquium in Melbourne: An Invitation for Complementary and Alternative Medicine Researchers and Consumers Eric Manheimer and Brian Berman30 August 2005 | The Journal of Alternative and Complementary Medicine, Vol. 11, No. 4 Volume 9Issue 6Dec 2003 To cite this article:Jeanette Ezzo.From the Five Blind Men to Cochrane Complementary Medicine Systematic Reviews.The Journal of Alternative and Complementary Medicine.Dec 2003.969-972.http://doi.org/10.1089/107555303771952307Published in Volume: 9 Issue 6: July 5, 2004PDF download

The Journal of Alternative and Complementary MedicineVol. 9, No. 5 Guest EditorialShould Journals Devote Space to Trials with No Results?Jeanette EzzoJeanette EzzoSearch for more papers by this authorPublished Online:5 Jul 2004https://doi.org/10.1089/107555303322524436AboutSectionsPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail "Should Journals Devote Space to Trials with No Results?." , 9(5), pp. 611–612FiguresReferencesRelatedDetailsCited BySystematic Review and Meta-analysis in Clinical Practice10 February 2011Systematic Reviews and Meta-Analyses in SurgeryEfficacy and safety of acupuncture for chronic pain caused by gonarthrosis: A study protocol of an ongoing multi-centre randomised controlled clinical trial [ISRCTN27450856]24 March 2004 | BMC Complementary and Alternative Medicine, Vol. 4, No. 1Clinical Trials in Cancer Part II: Biomedical, Complementary, and Alternative Medicine: Significant Issues8 February 2007 | Clinical Journal of Oncology Nursing, Vol. 8, No. 6 Volume 9Issue 5Oct 2003 To cite this article:Jeanette Ezzo.Should Journals Devote Space to Trials with No Results?.The Journal of Alternative and Complementary Medicine.Oct 2003.611-612.http://doi.org/10.1089/107555303322524436Published in Volume: 9 Issue 5: July 5, 2004PDF download

Courses in complementary and alternative medicine (CAM) are increasing in medical schools in the United States and, currently, approximately two thirds of U.S. medical schools offer at least one such course. As these courses grow in popularity, however, concerns are also growing that these courses lack an evidence-based perspective. We propose that one interesting and easy way to bring an evidence-based perspective to the CAM classroom is to utilize the Cochrane Electronic Library (CLIB), which is available in many medical libraries, as a teaching tool. The CLIB currently houses more than 80 CAM-related, full-text systematic reviews and approximately 5000 CAM-related clinical trials, making it a Valued resource for people who seek CAM evidence. Moreover, the CLIB commitment to publishing reviews regardless of the results make it a resource where one can find reviews concluding there is strong evidence of benefit or no evidence of benefit. In addition to the access to CAM evidence which the CLIB provides, students can learn basic critical appraisal skills by learning the rationale behind Cochrane systematic reviews. A survey of CAM course directors, however, shows that almost one half of these directors have never used the CLIB. For those who have never used the CLIB, this editorial explains the four main databases within the CLIB and presents ideas for using them in CAM school courses.