Generation Maybe - Various - Plastic Bomb #95 (CD) download full album zip cd mp3 vinyl flac
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D D e1. Da Da D D Da D D e2 D e1 D D D Da D Redline Version Da Da Da. D e1 D D D D e1 D D D e1 D e1 D D D D D D De1. Redline Version D D D D e1 D e1 D D D Da Da D Even of so called eco disposables. Look up the Nappy Bill. Mothers are cutting back on basic necessities such as food, utilities, and childcare to buy diapers for their children. If you use disposables and disposable wipes such as food, utilities, and childcare to buy diapers for their children.
So, shaming mothers pretty much never works. Guess what? Our son hardly has diaper rash—EVER! Having two boys in 13 months also makes a difference. You are not taking in to account folks with multiple babies, a job or two, and a house hold to maintain—let alone the single mom. I am hearing you say that cloth diapering is easy.
Say that to a mom with two babies who both poop times a day. Do you really want to go there? My husband used to be a Scientist and I used to teach ecology programs; we both care about the environment a great deal, but we also care about our sanity and have limited time. Compassion and Understanding go a long, long way. I find neither in this post.
Good luck converting those in the disposable world. Sorry you feel shamed, but no where do I state that someone is a bad person for making the choices they make. In fact, I stuck very strictly to the facts and the national implications of those facts.
Mothers seem to choose to feel shamed by anyone these days who speaks to doing something that seems healthier or greener, even if all the other person did was speak to their own experience.
Either be confident in your choices or make new choices. Either way, you will have chosen to give up shame and the unnecessary defensiveness that goes with it. But there are good choices for the planet and bad ones. And anything that goes in the landfill when there is an alternative is not the best choice at all.
This post is mostly for all the folks who have no idea what is wrong with regular disposables, or who say—erroneously—that cloth uses so much water that it works out even with disposables. For everyone else, I am mostly preaching to the choir. That was my choice at the time, and sometimes it was challenging or inconvenient to make that choice, but I feel confident about it.
I switxhed to cloth diapers and did it properly and no problems at all. Very useful article. Really can helpful to understand the disadvantages of disposable diapers. Thank you. Very smartly written article. HUGE eye opener.
I just let my 1 year go diaper free for a few hours every day. Sometimes the whole day during summers. Just use an old cloth to clean up after him. Thanks for your post, however I usually disposable with cloth diaper inserts, I give my daughter used cloth diapers on day and disposable on night.
This make her has a good sleep. The tiny rock we live on is polluted enough, so I think using cloth diapers is definitely worth the effort. Now I have to think twice before changing one. After my wife and I had twins, I made an online calculator to help other new parents estimate diaper use and sizing over time:. I really love the statistical and informational content of this piece, however the sanctimonious tone it is given in and unfortunately the title will probably turn disposable users from reading and taking this piece to heart.
What about the impact on water? We live in California. I considered cloth diapers but we are in a drought as a state. It takes significantly more water to manufacture disposable diapers than it does to wash cloth diapers during the 3 or so years you use them with each child. That said, for home water use, the average top loading washing machine uses about gallons per load, and the average high efficiency machine uses gallons.
In the full cost accounting, an extra load of laundry can be easily justified if you are conserving elsewhere. And the cool thing about washing machines is that they can be easily retrofitted for greywater saving. Using simple tools, the pipe in the back of the machine that drains the water out of each load can be diverted to your yard, or to a barrel or cistern for future use in the yard or garden.
I am currently expecting my third child, and I used disposables with my previous two. I have always wanted to use cloth due to the environmental impact, but thanks to my humongous pile of laundry, I dismissed it without looking into it. I did a Google search to find out more about the health problems with disposables, as rashes had never been an issue with my boys. My goodness!! Thank you for this!
I will be sending it to all my family members who have objected to my plans to use cloth!! What are views on diaper services and may I use the picture of the one year of diapers. I agree that cloth is better all the way around. The image of a year of diapers is not mine.
The photo credit is on the article and you will need to contact her to get permission to use it. Services can have an economy of scale that can make washing the diapers even more efficient than washing at home, plus the ease of the service makes it convenient for more people to adopt cloth over plastic.
I would check with the service to see what their practices are and what they use to wash the diapers. Eco Disposable Diapers are best diapers. Just wanted to tell you that this article worked for me! Loving it! Thank you for your comment. These toxins are absorbed through the skin and by inhalation. The manufacture of plastic diapers also releases numerous toxins that are also harmful to everyone. The environmental pollution and its effects on human and planetary health should be reason enough to consider cloth diapering.
I also live in an area that when baby goes to daycare, he will HAVE to use disposables. Thanks in advance! A daycare cannot require you to use disposable diapers! As far as flushable liners, I made my own fleece liners to use when my baby gets a rash and they work wonders. I just bought a yard and a half of fleece and cut then into the same size as my inserts and surged around the outside.
I use one with every diaper and have never had a problem with a diaper rash since. Hey there. I recently came across this in another article. It is amazing what a people will use on the most important things in their lives, their kids. I mean come on! It is our babies we are putting these poison filled pampers on after-all. We are an organic cloth diaper service based out of Los Angeles, CA. I am writing a blog for our website and would love to reference this article.
Do I have your persmission? Yes, you may reference this article with a link back to this site. Thanks for spreading the word!! My husband and I decided to switch our son to cloth when we realized from day ONE that disposable made his rump chafe and bleed. Even after switching to cloth diapers we noticed his skin was always red and irritated.
I read on a blog to try cloth wipes so we did and BAM no more irritation, redness, or bleeding. My son is not only allergic to something in the disposable diaper but also the preservative MI that is found in wipes.
There are way too many benefits and our son is happier than ever. Generation Maybe - Various - Plastic Bomb #95 (CD) is not hard to do, you just have to find a diapers that works best for your family and life style and stick with it.
Good Luck! Hello, I am a student at UCMerced who is currently enrolled in sustainability science. I am writing a short paper on waste babies produce, and I was wondering if I could cite a couple of phrases from this article. Thank You! Sure, with proper source crediting and a link back to the article, please. Though do remember that bloggers are secondary sources of information.
My primary sources are in the links within the article and at the bottom of the post. Best to you!! I love the picture with the sposies vs 24 cloth diapers. Can I share that pic on FB? Do you have the original source for it?
Sharing is caring!! Compared to the dioxin exposure acquired via dietary sources which is what this study is aboutthis is true. Obviously you will get significantly more exposure from eating it than you would by having it near your mucous membranes. However, why would anyone want to have any dioxin at all anywhere near their bodies, or want it produced in the environment for any reason?
Although the no-diaper thing weirded me out a bit, haha. We use pocket diapers, and they are so easy, even my mom can use them! My hubby and I are huge supporters of cloth diapering! We have cloth diapered our daughter since the day she was born! Yep, right into cloth in the hospital.
In addition, I really love that we used one size cloth diapers for our daughter as we are buying even less cloth diapers this way, as opposed to buying a complete stash for each size. We also use a naturally derived free and clear detergent because we have sensitive skin and it is more earth friendly than the scented chemically detergents! When was this article originally posted? And if so, what are your thoughts on them? My opinion is it is nice to see more conscious diapers out there, but I still think cloth is the better option.
Still…WAY better than conventional disposables! My 2 kids are teens now, but we used cloth for them both. One thing I noticed was that they both potty trained pretty effortlessly not long after they turned 2. I think it was because I always changed them as soon as they were wet, so they never got used to sitting around in soiled diapers.
Love the article. Kudos for a well-written article and the long list of sources! Hi, I would just like to say that you did an amazing job with this article. I started using cloth when my son was 2 months old, and we have been extremely happy with cloth diapers.
I had no clue of ALL of the information that you provided in this article. Very insightful and frightening. Things might be different now. I used cloth diapers with my son now He went to a babysitter who was willing to use them.
When my daughter came along now18we needed to use a day care center. They would not allow cloth diapers, so on the days I worked, we had to do disposables. I hated them, but had no choice. Are day care centers today allowing cloth? Where I live, they all allow cloth if you are using the all-in-one cloth diapers that act just like disposables. They can fold the diaper and send home in a wetbag. So there may need to be some tweaking to the style of cloth diaper system used — but it CAN be done!
Many times if you introduce the conversation with the provider by bringing in an example diaper they are much more accepting of the idea. Also, when you point out they will only be changing the diaper, cleaning the child and putting the diaper home in a bag instead of putting a diaper in the trash — what is expected of them is hardly different from throwaways.
What a beautiful post! Choosing to use disposable diapers is not a choice that only affects your family it is choice that concerns every human on this planet. It is so irritating. Thank you for laying out why disposables hurt us all.
Thanks so much, Amy. I also have a doctorate in an environmental field and feel confident cloth is much better for the environment. However, I do feel that this article presents the worst case scenario of disposables vs. As a result, it comes across a little harsh and unlikely to convert many non-believers who take a reactionary stance. Prefolds work fabulously for us but some babies do terribly in cotton and need stay dry materials which are synthetic. Some babies, like mine, do terribly in synthetics.
It can be costly and time consuming to figure out what works. Still not as costly as sposies, and of course, you do need to figure out what works in terms of disposable brands. Of course, I like saving time by not having to run out to the store to buy disposables all the time, too, and the laundry savings of never having a leak or a blowout.
However, some folks do struggle with detergent build up, stripping, rashes, etc. I do want to add from an environmental perspective that the water used in oil production, particularly as we move from conventional oil to bitumen, shale oil, etc. There is no comparison with laundry water usage. Even so, water usage is not best understood through absolute numbers. Using excess water in a place with a water shortage is not the same as using it where there is an abundance.
The water used in oil production tends to drain ecologically vital wetlands, which can never be reclaimed. From a water standpoint alone, there is no comparison between cloth and sposies. Um, dioxin is discussed thoroughly in the middle of the article. Most cloth diapers are intentionally not bleached with chlorine bleach. If you should happen to find a cloth diaper that was made with chlorine-bleached cloth, any dioxins present are removable by washing, as is true of all bleached fabric.
This has come at the right time when iam single handedly advocating for massive sensitisation in mothers in uganda on how to dispose of diapesr and their associated dangers both to our babys lives and the environment atlarge,i would therefore like to take up this opportunity to call up some one who can jump on board and join me develop this proposal as a major consern.
I can be reached on my e-mail address :boarbase gmail. Iam so greatful with all the informative articles that i have read about both the disposal Diapers and cloth diapers and thank god this has come in the right time when iam single handledly advocating for mass sensitization about the dangers of disposaples diapers towards our health and the environment.
Kindly could someone come to my resque and we develop this proposal together to see that Africa at large is given knowledge about the dangers of disposal diapers please. I will be greatful if iam contacted on my e-mail address :boardbase gmail. I love you for this awesome post, Dawn! So jam-packed with awesome information! Thanks again for a wonderfully informative post! The way I potty trained my son. I turned him backward on the toilet.
He would have his little cars up on top of the tank, he was comfortable and never felt like he was going to fall in. I would turn the water on in the sink or put his little foot in a little pan of warm water, it worked every time and there was never a need for a deflecter at all.
Thanks for sharing, will definitely have to try this out! My son turned 40 this month. I remember very clearly that I had like 26 dozen cloth diapers of different kinds, some were thicker.
I would put 3 or so together and fold them to fit him at the time. I rinsed them in the toilet and kept them in a diaper pail with a solution of water and Stanley Degreaser, if anyone remembers Stanley products. When it came to washing them I would dump the entire contents into the washing machine, run it on the spin cycle and then turn it on to start the washing cycle.
I hung them on the clothes line and his diapers were always clean, white with no stains and smelled fresh. If the weather was bad I would hang them over a wooden rack that sat over the floor heater.
I used plastic pants over his diapers at night and if we were going somewhere otherwise from the time he was born it was just cloth diapers. Five years later when I had my daughter they had started making disposables but I used cloth with her also. I did use disposables when we traveled and that was it. That was their original purpose.
My babies never had diaper rash. First thing in the morning and after bowel movements they got what I call a butt bath in the sink. There were no wipes, they were cleaned with wash rags. I would just throw their sleeper up over their shoulder and lay them across my left arm and wash their bottom with soap and water, wrap a towel around them and go put a new diaper on them. To this day neither one likes to be dirty. As with anything to much of it is bad for you including disposable diapers.
If I was having babies now I would still do it the way I did then and be a proud mama. I hear women saying they are to busy and such well I worked and ran another business out of my house. Even at my age I still do not take any prescription drugs, I am into natural health. I think people should not listen to all the prescription ads on TV and think for themselves. I think doctors are great if you have a broken bone or such but I do not go them for my preventive health.
As with the diaper ads on TV, it is mind over matter and what is important to you. If it is important you will enjoy doing it. Both found statistically significant and clinically relevant short-term up to 3 months benefits of acupuncture over control for response, number of headache days and pain intensity. Long-term effects beyond 3 months were not investigated. Six trials compared acupuncture with a sham acupuncture intervention, and five of the six provided data for meta-analyses.
Small but statistically significant benefits of acupuncture over sham were found for response as well as for several other outcomes. Three of the four trials comparing acupuncture with physiotherapy, massage or relaxation had important methodological or reporting shortcomings. Their findings are difficult to interpret, but collectively suggest slightly better results for some outcomes in the control groups. In the previous version of this review, evidence in support of acupuncture for tension-type headache was considered insufficient.
Now, with six additional trials, the authors conclude that acupuncture could be a valuable non-pharmacological tool in patients with frequent episodic or chronic tension-type headaches. Patients with tension-type headache suffer from episodes of pain which is typically bilateral affects both sides of the headpressing or tightening in quality, mild to moderate in intensity, and which does not worsen with routine physical activity.
In most patients tension-type headache occurs infrequently and there is no need for further treatment beyond over-the-counter pain killers. In some patients, however, tension-type headache occurs on several days per month or even daily.
Acupuncture is a therapy in which thin needles are inserted into the skin at defined points; it originates from China. Acupuncture is used in many countries for tension-type headache prophylaxis - that is, to reduce the frequency and intensity of tension-type headaches. We reviewed 11 trials which investigated whether acupuncture is effective in the prophylaxis of tension-type headache.
Two large trials investigating whether adding acupuncture to basic care which usually involves only treating unbearable pain with pain killers found that those patients who received acupuncture had fewer headaches. Overall, these trials found slightly better effects in the patients receiving the true acupuncture intervention. Three of the four trials in which acupuncture was compared to physiotherapy, massage or relaxation had important methodological shortcomings. Their findings are difficult to interpret, but collectively suggest slightly better results for some outcomes with the latter therapies, Generation Maybe - Various - Plastic Bomb #95 (CD).
In conclusion, the available evidence suggests that acupuncture could be a valuable option for patients suffering from frequent tension-type headache. Patients with tension-type headache suffer from episodes of pain which is typically bilateral, pressing or tightening in quality and of mild to moderate intensity, and which does not worsen with routine physical activity IHS There is no nausea, but photophobia or phonophobia may be present.
Infrequent episodic tension-type headache episodes of headache lasting minutes to days which occur less than once per month has no important impact on individuals. If headaches occur on at least one day, but less than 15 days per month, this is classified as frequent episodic tension-type headache. In some patients this can evolve to chronic tension-type headache on 15 or more days per month. Tension-type headache should not be confused with migraine, which is characterized by recurrent attacks of mostly one-sided, severe headache, although some patients suffer from both types of headaches.
Tension-type headache is the most common type of primary headache, and the disability attributable to it is larger worldwide than that due to migraine Stovner Epidemiological studies report highly variable prevalences depending on case definition and country Stovner If headache episodes are not too frequent up to a maximum of 10 days per monthunbearable pain can be treated with analgesic drugs or non-steroidal anti-inflammatory drugs Pfaffenrath In patients with chronic tension-type headache, guidelines recommend antidepressants such as amitriptyline Pfaffenrath In addition to, or instead of drug therapy, behavioral interventions such as relaxation or biofeedback have been shown to be beneficial McCrory However, additional effective intervention tools with good tolerability are desirable.
Acupuncture in the context of this review is defined as the needling of specific points of the body. It is one of the most widely used complementary therapies in many countries Bodeker For example, according to a population-based survey in the year in the United States, 4.
A similar survey in Germany performed in the same year found that 8. Acupuncture was originally developed as part of Chinese medicine wherein the purpose of treatment is to bring the patient back to the state of equilibrium postulated to exist prior to illness Endres Some acupuncture practitioners have dispensed with these concepts and understand acupuncture in terms of conventional neurophysiology.
Acupuncture is often used as a intervention to reduce the frequency and intensity of headaches. For example, 9. Practitioners typically claim that a short course of treatment, such as 12 sessions over a 3-month period, can have a long-term impact on the frequency and intensity of headache episodes.
However, it is unclear to what extent these observations from experimental settings are relevant to the long-term effects reported by practitioners. As in many other clinical areas, the findings of controlled trials of acupuncture for tension-type and other headaches have not been conclusive in the past. In we published a first version of our review on acupuncture for idiopathic headache Melchartand in we published an updated version in The Cochrane Library Melchart However, the quality and the amount of evidence are not fully convincing.
Due to the increasing number of studies, and for clinical reasons, we decided to split our previous review on idiopathic headache into two separate reviews on migraine Linde and tension-type headache for the present update.
We included controlled trials in which allocation to treatment was explicitly randomized, and in which patients were followed up for at least 8 weeks after randomization. Trials in which a clearly inappropriate method of randomization for example, open alternation was used were excluded. Studies including patients with headaches of various types e. The treatments considered had to involve needle insertion at acupuncture points, pain points or trigger points, and had to be described as acupuncture.
Studies investigating other methods of stimulating acupuncture points without needle insertion for example, laser stimulation or transcutaneous electrical stimulation were excluded. Trials that only compared different forms of acupuncture were excluded. Studies were included if they reported at least one clinical outcome related to headache for example, response, frequency, pain intensity, headache scores, analgesic use.
Trials reporting only physiological or laboratory parameters were excluded, as were trials with outcome measurement periods of less than 8 weeks from randomization to final observation.
For our previous versions of the review on idiopathic headache Melchart ; Melchartwe used a very broad search strategy to identify as many references on acupuncture for headaches as possible, as we also aimed to identify non-randomized studies for an additional methodological investigation Linde The sources searched for the version of the review were:.
For the present update, detailed search strategies were developed for each database searched see Appendix 1. Detailed strategies for each database searched are provided in Appendix 1. In addition to the formal searches, one of the reviewers KL regularly checked last search 15 April all new entries in PubMed identified by a simple search combining acupuncture AND headache, checked available conference abstracts and asked researchers in the field about new studies.
All abstracts identified by the updated search were screened by one reviewer KLwho excluded those that were clearly irrelevant for example, studies focusing on other conditions, reviews, etc. Full texts of all remaining references were obtained and were again screened to exclude clearly irrelevant papers. All other articles and all trials included in our previous review of acupuncture for idiopathic headache were then formally checked by at least two reviewers for eligibility according to the above-mentioned selection criteria.
Disagreements were resolved by discussion. Information on patients, methods, interventions, outcomes and results was extracted independently by at least two reviewers using a specially designed form. In particular, we extracted exact diagnoses; headache classifications used; number and type of centres; age; sex; duration of disease; number of patients randomized, treated and analyzed; number of, and reasons for dropouts; duration of baseline, treatment and follow-up periods; details of acupuncture treatments such as selection of points; number, frequency and duration of sessions; achievement of Generation Maybe - Various - Plastic Bomb #95 (CD) an irradiating feeling considered to indicate effective needling ; number, training and experience of acupuncturists ; and details of control interventions sham technique, type and dosage of drugs.
For details regarding methodological issues and study results, see below. Where necessary, we sought additional information from the first or corresponding authors of the included studies. For the assessment of study quality, the new risk of bias approach for Cochrane reviews was used Higgins We used the following six separate criteria:.
In a first step, information relevant for making a judgment on a criterion was copied from the original publication into an assessment table. If additional information from study authors was available, this was also entered in the table, along with an indication that this was unpublished information. At least two reviewers independently made a judgment whether the risk of bias for each criterion was considered low, high or unclear.
For the operationalization of the first five criteria, we followed the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions Higgins Headache trials typically measure a multiplicity of headache outcomes at several time points using diaries, and there is a plethora of slightly different outcome measurement methods.
While a single primary endpoint is sometimes predefined, the overall pattern of a variety of outcomes is necessary to get a clinically interpretable picture. We considered trials as having a low risk of bias for this item if they reported Generation Maybe - Various - Plastic Bomb #95 (CD) results of the most relevant headache outcomes assessed typically a frequency measure, intensity, analgesic use and response for the most relevant time points end of treatment and, if done, follow-upand if the outcomes and time points reported made it unlikely that authors had picked them out because they were particularly favorable or unfavorable.
Trials that met all criteria, or all but one criterion, were considered to be of higher quality. Some trials had both blinded sham control groups and unblinded comparison groups receiving no prophylactic treatment or drug treatment. We also attempted to provide a crude estimate of the quality of acupuncture.
Two reviewers mostly GA and BB, or, for trials in which one of these reviewers was involved, AW who are trained in acupuncture and have several years of practical experience answered two questions. First, they were asked how they would treat the patients included in the study. The latter method was proposed by a member of the review team AW and has been used in a systematic review of clinical trials of acupuncture for back pain Ernst For the purposes of summarizing results, the included trials were categorized according to control groups: 1 comparisons with no acupuncture treatment of acute headaches only or routine care ; 2 comparisons with sham acupuncture interventions; and 3 comparisons with other treatments.
We defined four time windows for which we tried to extract and analyze study findings:. In all included studies acupuncture treatment started immediately or very soon after randomization. If more than one data point were available for a given time window, we used: for the first time window, preferably data closest to 8 weeks; for the second window, data closest to the 4 weeks after completion of treatment for example, if treatment lasted 8 weeks, data for weeks 9 to 12 ; for the third window, data closest to 6 months; and for the fourth window, data closest to 12 months.
We extracted data for the following outcomes:. In studies comparing acupuncture with other therapies, we used for the denominator the number of patients analyzed. If the number of responders regarding headache days was not available, we used global assessment measures by patients or physicians. Number of headache days means and standard deviations per 4-week period calculation of weighted mean differences. Headache intensity any measures available, extraction of means and standard deviations, calculation of standardized mean differences.
Frequency of analgesic use any continuous or rank measures available, extraction of means and standard deviations, calculation of standardized mean differences. Headache score any measures available, extraction of means and standard deviations, calculation of standardized mean differences. For continuous measures, we used, if available, the data from intention-to-treat analyses with missing values replaced; otherwise we used the presented data on available cases.
All these outcomes rely on patient reports, mainly collected in headache diaries. The main outcome measure was the proportion of responders for the 3- to 4-month window close to the end of the treatment cycle and a time point for which outcome data are often available.
Due to the variable study methods, pooled effect size estimates have to be interpreted with great caution. We did not pool findings from the studies for the other comparisons see Results for an explanation. See: Characteristics of included studies; Characteristics of excluded studies. In our previous review on idiopathic headache Melchartwe evaluated 26 trials that included participants with various types of headaches.
The search update identified a total of new references. Full reports for one tension-type headache trial Jena that was reported only as a published conference abstract at the time of completion of the literature search January were later identified through personal contacts with authors. Most of the references identified by the search update were excluded at the first screening step by one reviewer, as they were clearly irrelevant.
The most frequent reasons for exclusion at this level were: article was a review or a commentary; studies of non-headache conditions; studies in patients suffering from migraine; clearly non-randomized design; and investigation of an intervention which was not true acupuncture involving skin penetration. A total of 55 full-text papers were then formally assessed by at least two reviewers for eligibility.
Thirty-one studies reported in 34 publications did not meet the selection criteria see Characteristics of excluded studies.
The most frequent reason for exclusion was that patients did not suffer from tension-type headache, or that patients with mixed pain or mixed headaches had been included without presentation of a subgroup analysis for tension-type headache patients 13 trials. Other common reasons for exclusion were: post-randomization observation periods of less than 8 weeks 4 trials including 2 cross-over trials with less than 8 weeks per period ; doubts about whether allocation was randomized 3 trials ; and use of laser acupuncture no skin penetration; Generation Maybe - Various - Plastic Bomb #95 (CD) trials.
Eleven trials described in 21 publications including published protocols and papers reporting additional aspects such as treatment details or cost-effectiveness analyses met all selection criteria and were included in the review. The total number of study participants was We received additional data relevant for effect size calculation from the authors of four studies Endres ; Jena ; Karst ; Melchart In two trials, additional information were not needed White ; Whiteand for two older trials, we were unable to contact study authors Ahonen ; Tavola A total of patients with tension-type headache were included in the studies median 62, range 10 to The remaining trials either explicitly stated that they included both forms Endres ; Jena ; Karst ; Melchart or made no clear statement Ahonen ; Tavola ; Wylie All trials used a parallel-group design no cross-over trials.
In two trials acupuncture was compared to routine care Jena or treatment of acute headaches only Melchart Six trials used a sham control but the actual techniques varied. In three trials, non-acupuncture points were needled Endres ; Melchart ; Tavolawhile in the remaining three Karst ; White ; White non-skin-penetrating techniques were used see Characteristics of included studies for details. Wylie compared acupuncture with a combination of massage and relaxation.
There was no trial comparing acupuncture with prophylactic drug treatment. The largest study by far Jena used a quite unusual approach and has to be described in greater detail.
In this very large, highly pragmatic study, 15, headache patients recruited by more than physicians in Germany were included. A total of 11, patients not giving consent to randomization received up to 15 acupuncture treatments within 3 months and were followed for an additional 3 months. This was also the case for patients randomized to immediate acupuncture, while the remaining patients remained on routine care not further defined for 3 months and then received acupuncture.
The published analysis of this trial is on all randomized patients, but the authors provided us with unpublished results of subgroup analyses on the patients with tension-type headache. The large number of practitioners involved and the pragmatic approach make it likely that there is some diagnostic uncertainty whether all patients truly had tension-type headache.
The number of acupuncture sessions varied between 6 and In two trials White ; Whitebrief needling was used needles inserted for a few seconds only.
In trials using individualized strategies, assessments were difficult because of a lack of detail about the actual interventions used.
Post-randomization observation periods varied between 8 and 64 weeks. Apart from three trials Ahonen ; Carlsson ; Jenaall trials used diaries for the measurement of the most important headache outcomes. All but two trials Ahonen ; Jena included a baseline observation period before randomization.
The trials comparing acupuncture to other therapies rarely presented their findings in a manner allowing effect size calculation, while for trials comparing acupuncture with no acupuncture or sham acupuncture, effect size estimates could be calculated for the most relevant outcomes. The methodological quality of trials varied significantly.
Newer trials tended to be of higher quality than older trials. An adequate method of sequence generation was reported for six trials Endres ; Jena ; Karst ; Melchart ; White ; Whiteand an adequate method for allocation concealment for five Endres ; Jena ; Melchart ; White ; White Patients were blinded only in the six sham-controlled trials. The two trials comparing acupuncture to routine care only Jena or treatment of acute headaches only Melchart were unblinded but otherwise had a low risk of bias.
In both trials, patients received acupuncture 3 months after randomization waiting list conditionso it is only possible to assess short-term effects up to 3 months after start of the treatment.
We did not calculate pooled effect size estimates, as the two control groups and patient samples differed. The patients included in Melchart had much more frequent headaches at baseline mean Both studies found significant benefits of acupuncture over control for the outcomes responder rate Figure 1headache frequency Figure 2 and intensity Analysis 1. Effects were larger in the trial comparing acupuncture to acute treatment only Melchart than in the trial in which acupuncture was compared to Generation Maybe - Various - Plastic Bomb #95 (CD) care Jena Responder rate ratios were The differences between acupuncture and waiting list groups for number of headache days at 3 months were 6.
Only one trial measured analgesic use and a headache score Melchart ; there were significantly better results in the acupuncture groups Analysis 1. Forest plot of comparison: 1 Acupuncture vs.
The five interpretable trials Endres ; Karst ; Melchart ; Tavola ; White with sham comparisons all had comparably good quality despite some problems with attrition during long-term follow-up Karst ; White and some uncertainties regarding the details of randomization Karst ; Tavola Four trials had follow-up periods of about 6 months after randomization, and one more than 12 months Tavola Only one trial Endres found significant differences in regard to response Figure 3 and number of headache days per 4 weeks Figure 4 for the first three time windows.
There was little statistical heterogeneity; however, these analyses have limited power. In the time window 3 to 4 months after randomization, the pooled responder rate ratio main outcome measure was 1. Regarding headache intensity, a significant difference was found only at 5 to 6 months after randomization Analysis 2.
Three trials Karst ; Melchart ; Tavola reported data on frequency of analgesic use for the first two time windows Analysis 2. When these trials were pooled, there was a small, significant effect of acupuncture over sham controls standardized mean differences 0. Headache score data was measured in only two trials Analysis 2. Forest plot of comparison: 2 Acupuncture vs. For the three older trials Ahonen ; Carlsson ; Wyliethere are several methodological uncertainties see the relevant risk of bias assessmentsand reporting of results is insufficient.
This review identified two unblinded, but otherwise adequately performed, large studies Jena ; Melchart showing that adding acupuncture to routine care or treatment of acute headaches reduces the frequency of headaches in the short-term 3 months.
Long-term effects were not investigated. There are six trials comparing various acupuncture strategies with various sham interventions. Pooled analyses of the trials found a small but significant reduction of headache frequency over sham over a period of 6 months.
None of the four trials comparing acupuncture with physiotherapy, massage or exercise found a superiority of acupuncture, and for some outcomes better results were observed with a comparison therapy, but these mostly small and older trials of limited quality are difficult to interpret.
Acupuncture is a therapy which is applied in a variable manner in different countries and settings. For example, in Germany, where the three largest trials included in this review were performed, acupuncture is mainly provided by general practitioners and other physicians.
Their approach to acupuncture is based on the theories of traditional Chinese medicine, although the amount of training they receive in traditional Chinese medicine is limited Weidenhammer The trials included in this review come from a variety of countries and used a variety of study approaches.
However, as with other therapies for tension-type headache McCrorythe evidence base available is far from complete. Despite its frequency, tension-type headache is much less often investigated than migraine.
For the German setting, the two available large studies Jena ; Melchart clearly show clinically relevant short-term benefits of adding acupuncture to routine care. But it is unclear whether these findings can be extrapolated to other settings. It is also unclear whether patients with episodic and chronic tension-type headache respond in a different manner to acupuncture.
The meta-analyses on response, headache days per 4 weeks and intensity are heavily influenced by the large, rigorous trial by Endres For headache frequency response and headache days per 4 weeksthis trial found statistically significant benefits over sham acupuncture.
For example, patients who changed from one analgesic to another were reclassified as non-responders. While such massive reclassification might be worthwhile for certain reasons, it is very uncommon in trials on tension-type headache.
As our findings are based on a small number of albeit comparably well-done trials, they are not robust and have to be interpreted with caution. In our parallel review on migraine Lindewe found no clear effects of acupuncture interventions over sham treatment, but relevant effects over routine care and some significant effects over evidence-based prophylactic drug treatment.
We did not find any comparisons of acupuncture with prophylactic drug treatment. The trial by Endres was originally designed to include a third arm of patients randomized to amitriptyline, the currently most widely accepted therapy Diener However, as patients were unwilling to participate in a trial with the possibility of being randomized to amitriptyline, this arm was dropped after 1 year of very poor accrual. This suggests that patients ready to accept treatment with acupuncture and amitriptyline differ.
The question how acupuncture compares to other non-pharmacological treatments cannot be answered at present. The quality of clinical trials of acupuncture for headache has clearly improved since the previous version of our review. Methods for sequence generation, allocation concealment, handling of dropouts and withdrawals and reporting of findings were adequate in the majority of the recent trials.
Still, designing and performing clinical trials of acupuncture is a challenge, particularly with respect to blinding and selection of control interventions.
As all relevant headache outcomes have to be assessed by the patients themselves, reporting bias is possible in all trials comparing acupuncture to no treatment, routine, care, drug treatment or other therapies. We are confident that we have identified the existing large clinical trials relevant to our question, but we cannot rule out the possibility that there are additional small trials which are unpublished or published in sources not accessible by our search.
We have not systematically searched Chinese databases for this version of the review, but Chinese trials meeting our selection criteria might exist. The few Chinese trials identified through our literature search did not meet the inclusion criteria. There is considerable skepticism toward clinical trials from China because results reported in the past were almost exclusively positive Vickers However, the quality and number of randomized trials published in Chinese have improved over the last years Wangand it seems inadequate to neglect this evidence without examining it critically.
For the next update of this review we plan to include researchers and evidence from China to overcome this shortcoming. Three members of the review team were involved in at least one of the included trials. These trials were assessed by other members of the review team.
All reviewers are or were affiliated to a CAM complementary and alternative medicine research centre. Just before the submission of this review, another meta-analysis on acupuncture for tension-type headache was published Davis This review was restricted to sham-controlled trials, but included cross-over trials with observation periods shorter than 8 weeks per phase, which were excluded by us.
The main outcome measure was the number of headache days per month during treatment broadly comparable to our first time window and at long-term follow-up 20 to 25 weeks.
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