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Effectiveness and safety of moxibustion for primary insomnia: a systematic review and meta-analysis.BMC Complementary and Alternative... Jul 2016Primary insomnia is a widespread and refractory disease. Moxibustion therapy for insomnia shows some advantages compared with conventional therapies. This systematic... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Primary insomnia is a widespread and refractory disease. Moxibustion therapy for insomnia shows some advantages compared with conventional therapies. This systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to evaluate the effectiveness and safety of moxibustion therapy for insomnia.
METHODS
We conducted a comprehensive literature review of the CENTRAL, PubMed, EMBASE, Web of science, CNKI, VIP, and Wanfang Data databases from their inception to July 2015 for RCTs that compared moxibustion with western medications, oral Chinese medicine, or other methods of traditional Chinese medicine (TCM) in patients with primary insomnia. The primary outcome measure was effective rate and secondary outcome measure was adverse events. Data collection and analysis included risk of bias evaluation, meta-analysis, sensitivity analysis, publication bias and adverse events analysis according to corresponding criteria.
RESULTS
The study included 22 RCTs (1,971 patients). The quality of the studies was low. The overall meta-analysis demonstrated that moxibustion was more effective for insomnia than western medications, oral Chinese medicine and other TCM therapies (RR = 1.17, 95 % CI 1.12 to 1.23, P < 0.00001). Subgroup analyses demonstrated that moxibustion was more effective for insomnia than western medications (RR = 1.16, 95 % CI 1.09 to 1.24, P < 0.00001), oral Chinese medicine (RR = 1.11, 95 % CI 1.04 to 1.18, P = 0.002), and other TCM therapies (RR = 1.22, 95 % CI 1.15 to 1.30, P < 0.00001). There were no serious adverse effects associated with moxibustion therapy for insomnia, and the rate of adverse events was low.
CONCLUSION
It is difficult to get the conclusion regarding the effectiveness and safety of moxibustion for primary insomnia due to insufficient evidence, such as the high risk of bias in the included studies, small sample sizes, and few reports on adverse effects. Moxibustion should be considered as a novel therapeutic option for insomnia, and more rigorous clinical trials of moxibustion therapy for insomnia are needed to assess its effects.
Topics: Adult; Aged; Female; Humans; Male; Medicine, Chinese Traditional; Middle Aged; Moxibustion; Sleep Initiation and Maintenance Disorders
PubMed: 27411310
DOI: 10.1186/s12906-016-1179-9 -
PloS One 2015We performed a systematic review and meta-analysis of double-blind, randomized, placebo-controlled trials evaluating suvorexant for primary insomnia. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
We performed a systematic review and meta-analysis of double-blind, randomized, placebo-controlled trials evaluating suvorexant for primary insomnia.
METHODS
Relevant studies were identified through searches of PubMed, databases of the Cochrane Library, and PsycINFO citations through June 27, 2015. We performed a systematic review and meta-analysis of suvorexant trial efficacy and safety outcomes. The primary efficacy outcomes were either subjective total sleep time (sTST) or subjective time-to-sleep onset (sTSO) at 1 month. The secondary outcomes were other efficacy outcomes, discontinuation rate, and individual adverse events. The risk ratio, number-needed-to-treat/harm, and weighted mean difference (WMD) and 95% confidence intervals (CI) based on a random effects model were calculated.
RESULTS
The computerized literature database search initially yielded 48 results, from which 37 articles were excluded following a review of titles and abstracts and another eight review articles after full-text review. Thus, we identified 4 trials that included a total of 3,076 patients. Suvorexant was superior to placebo with regard to the two primary efficacy outcomes (sTST: WMD = -20.16, 95% CI = -25.01 to -15.30, 1889 patients, 3 trials, sTSO: WMD = -7.62, 95% CI = -11.03 to -4.21, 1889 patients, 3 trials) and was not different from placebo in trial discontinuations. Suvorexant caused a higher incidence than placebo of at least one side effects, abnormal dreams, somnolence, excessive daytime sleepiness/sedation, fatigue, dry mouth, and rebound insomnia.
CONCLUSIONS
Our analysis of published trial results suggests that suvorexant is effective in treating primary insomnia and is well-tolerated.
Topics: Azepines; Female; Humans; Male; Middle Aged; Randomized Controlled Trials as Topic; Sleep Aids, Pharmaceutical; Sleep Initiation and Maintenance Disorders; Treatment Outcome; Triazoles
PubMed: 26317363
DOI: 10.1371/journal.pone.0136910 -
Psychiatry Research Oct 2017No systematic reviews and meta-analyses on the use of Z-drug for schizophrenia are available. Randomized, placebo-controlled, or non-pharmacological... (Meta-Analysis)
Meta-Analysis Review
No systematic reviews and meta-analyses on the use of Z-drug for schizophrenia are available. Randomized, placebo-controlled, or non-pharmacological intervention-controlled trials published before 03/20/2017 were retrieved from major healthcare databases and clinical trial registries. A meta-analysis including only randomized, placebo-controlled trials was performed. Efficacy outcomes were measured as improvement in overall schizophrenia symptoms, total sleep time, and wake after sleep onset. Safety/acceptability outcomes were discontinuation rate and individual adverse events. Four trials [1 alpidem placebo-controlled study (n=66), 2 eszopiclone placebo-controlled studies (n=60), and 1 eszopiclone, shallow needling-controlled study (n=96)] were identified. The meta-analysis showed no significant differences in any outcome between pooled Z-drug and placebo treatment groups. For individual studies, alpidem was superior to placebo in improving the overall schizophrenia symptoms. One of the eszopiclone studies showed that eszopiclone was superior to placebo in improving the Insomnia Severity Index scores. Another eszopiclone study showed that eszopiclone did not differ from shallow needling therapy in improving both schizophrenia- and insomnia-related symptoms. Although this study failed to show significant benefits for the use of Z-drug in the treatment of schizophrenia, it showed that short-term use of eszopiclone is an acceptable method for treating persistent insomnia among these patients.
Topics: Adolescent; Adult; Aged; Clinical Trials as Topic; Eszopiclone; Female; Humans; Hypnotics and Sedatives; Imidazoles; Male; Middle Aged; Pyridines; Randomized Controlled Trials as Topic; Schizophrenia; Sleep; Sleep Initiation and Maintenance Disorders; Treatment Outcome; Young Adult
PubMed: 28686934
DOI: 10.1016/j.psychres.2017.06.063 -
Sleep Medicine Reviews Feb 2015Doxepin, a sedating tricyclic drug, at 3 mg and 6 mg doses was recently approved by the U.S. food and drug administration (FDA) for the treatment of insomnia. The... (Review)
Review
Doxepin, a sedating tricyclic drug, at 3 mg and 6 mg doses was recently approved by the U.S. food and drug administration (FDA) for the treatment of insomnia. The objective of this systematic review was to obtain a precise summary of the efficacy and safety of doxepin as a hypnotic. We searched key databases and trial registers up to March 2014 and contacted pharmaceutical companies and the FDA for unpublished data. A total of nine randomized placebo-controlled trials were analyzed. Six studies were on doxepin 1-6 mg/d, two on doxepin 25-300 mg/d, and one on ramelteon 8 mg and doxepin 3 mg combined. All low-dose studies were industry-sponsored. We found that low-dose doxepin had a small to medium effect size against placebo for sleep maintenance and sleep duration but not for sleep initiation at both immediate and short-term posttreatment. There was no significant next-day residual effect with low-dose doxepin. Headache and somnolence were the most common side effects. We concluded that low-dose doxepin for 1-2 nights appeared to be safe and effective in improving sleep. However, a clear conclusion on its short-term benefits and risks as well as withdrawal effects was not possible due to the small number of studies.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Dose-Response Relationship, Drug; Doxepin; Drug Therapy, Combination; Female; Humans; Indenes; Male; Middle Aged; Randomized Controlled Trials as Topic; Sleep Initiation and Maintenance Disorders; Treatment Outcome; United States; United States Food and Drug Administration; Young Adult
PubMed: 25047681
DOI: 10.1016/j.smrv.2014.06.001 -
Drug and Alcohol Dependence Dec 2017To determine the efficacy of behavioral and pharmacological interventions for insomnia among individuals with alcohol use disorder (AUD). (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To determine the efficacy of behavioral and pharmacological interventions for insomnia among individuals with alcohol use disorder (AUD).
PROCEDURES
Comprehensive literature searches of psychological, medical, and educational databases were conducted through October 2016. Eligible studies evaluated the efficacy of an insomnia intervention, included a comparison condition, sampled individuals with AUD and either insomnia disorder or complaints of insomnia, assessed sleep-related outcomes, and provided relevant statistics to calculate between-group effect sizes. Effect sizes were estimated for sleep quality, days of alcohol abstinence, and symptoms of depression. Type of intervention (behavioral versus pharmacological) was tested as a moderator of intervention efficacy.
MAIN FINDINGS
Nine studies met eligibility criteria and were included in the final review and meta-analysis. Random-effects models indicated that intervention participants reported greater improvements in sleep quality (d+=0.62, 95% CI=0.28, 0.97) and symptoms of depression (d+=0.52, 95% CI=0.06, 0.98) than control participants. Participants reported significantly greater improvements in sleep quality in response to behavioral (d+=1.20, 95% CI=0.70, 1.70) as opposed to pharmacological (d+=0.43, 95% CI=0.19, 0.67) interventions. Behavioral (d+=0.74, 95% CI=0.31, 1.18) and pharmacological (d+=0.08, 95% CI=-0.64, 0.78) interventions did not have significantly different effects on depressive symptoms. Neither behavioral nor pharmacological interventions improved rates of alcohol abstinence.
CONCLUSIONS
Insomnia interventions improve sleep quality and reduce symptoms of depression among individuals with comorbid AUD. Given the methodological weaknesses of studies reviewed, additional research is needed to determine the efficacy of insomnia treatment in improving rates of alcohol relapse within this population.
Topics: Adult; Alcoholism; Behavior Therapy; Depression; Female; Humans; Male; Middle Aged; Sleep; Sleep Aids, Pharmaceutical; Sleep Initiation and Maintenance Disorders; Treatment Outcome
PubMed: 29096290
DOI: 10.1016/j.drugalcdep.2017.09.029 -
Neural Plasticity 2016Measurement of sleep microarchitecture and neural oscillations is an increasingly popular technique for quantifying EEG sleep activity. Many studies have examined sleep... (Review)
Review
Measurement of sleep microarchitecture and neural oscillations is an increasingly popular technique for quantifying EEG sleep activity. Many studies have examined sleep spindle oscillations in sleep-disordered adults; however reviews of this literature are scarce. As such, our overarching aim was to critically review experimental studies examining sleep spindle activity between adults with and without different sleep disorders. Articles were obtained using a systematic methodology with a priori criteria. Thirty-seven studies meeting final inclusion criteria were reviewed, with studies grouped across three categories: insomnia, hypersomnias, and sleep-related movement disorders (including parasomnias). Studies of patients with insomnia and sleep-disordered breathing were more abundant relative to other diagnoses. All studies were cross-sectional. Studies were largely inconsistent regarding spindle activity differences between clinical and nonclinical groups, with some reporting greater or less activity, while many others reported no group differences. Stark inconsistencies in sample characteristics (e.g., age range and diagnostic criteria) and methods of analysis (e.g., spindle bandwidth selection, visual detection versus digital filtering, absolute versus relative spectral power, and NREM2 versus NREM3) suggest a need for greater use of event-based detection methods and increased research standardization. Hypotheses regarding the clinical and empirical implications of these findings, and suggestions for potential future studies, are also discussed.
Topics: Adolescent; Adult; Aged; Brain; Brain Waves; Bruxism; Disorders of Excessive Somnolence; Electroencephalography; Female; Humans; Male; Middle Aged; Parasomnias; Sleep Initiation and Maintenance Disorders; Sleep Stages; Sleep Wake Disorders; Young Adult
PubMed: 27034850
DOI: 10.1155/2016/7328725 -
The Cochrane Database of Systematic... Aug 2015Insomnia is a common sleep disorder in modern society. It causes reduced quality of life and is associated with impairments in physical and mental health. Listening to... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Insomnia is a common sleep disorder in modern society. It causes reduced quality of life and is associated with impairments in physical and mental health. Listening to music is widely used as a sleep aid, but it remains unclear if it can actually improve insomnia in adults.
OBJECTIVES
To assess the effects of listening to music on insomnia in adults and to assess the influence of specific variables that may moderate the effect.
SEARCH METHODS
We searched CENTRAL, PubMed, Embase, nine other databases and two trials registers in May 2015. In addition, we handsearched specific music therapy journals, reference lists of included studies, and contacted authors of published studies to identify additional studies eligible for inclusion, including any unpublished or ongoing trials.
SELECTION CRITERIA
Randomised controlled trials and quasi-randomised controlled trials that compared the effects of listening to music with no treatment or treatment-as-usual on sleep improvement in adults with insomnia.
DATA COLLECTION AND ANALYSIS
Two authors independently screened abstracts, selected studies, assessed risk of bias, and extracted data from all studies eligible for inclusion. Data on pre-defined outcome measures were subjected to meta-analyses when consistently reported by at least two studies. We undertook meta-analyses using both fixed-effect and random-effects models. Heterogeneity across included studies was assessed using the I² statistic.
MAIN RESULTS
We included six studies comprising a total of 314 participants. The studies examined the effect of listening to pre-recorded music daily, for 25 to 60 minutes, for a period of three days to five weeks.Based on the Grades of Recommendations, Assessment, Development and Evaluation (GRADE) approach, we judged the evidence from five studies that measured the effect of music listening on sleep quality to be of moderate quality. We judged the evidence from one study that examined other aspects of sleep (see below) to be of low quality. We downgraded the quality of the evidence mainly because of limitations in design or being the only published study. As regards risk of bias, most studies were at high risk of bias on at least one domain: one study was at high risk of selection bias and one was judged to be at unclear risk; six studies were at high risk of performance bias; three studies were at high risk of detection bias; one study was at high risk of attrition bias and was study was judged to be at unclear risk; two studies were judged to be at unclear risk of reporting bias; and four studies were at high risk of other bias.Five studies (N = 264) reporting on sleep quality as assessed by the Pittsburgh Sleep Quality Index (PSQI) were included in the meta-analysis. The results of a random-effects meta-analysis revealed an effect in favour of music listening (mean difference (MD) -2.80; 95% confidence interval (CI) -3.42 to -2.17; Z = 8.77, P < 0.00001; moderate-quality evidence). The size of the effect indicates an increase in sleep quality of the size of about one standard deviation in favour of the intervention compared to no treatment or treatment-as-usual.Only one study (N = 50; low-quality evidence) reported data on sleep onset latency, total sleep time, sleep interruption, and sleep efficiency. However, It found no evidence to suggest that the intervention benefited these outcomes. None of the included studies reported any adverse events.
AUTHORS' CONCLUSIONS
The findings of this review provide evidence that music may be effective for improving subjective sleep quality in adults with insomnia symptoms. The intervention is safe and easy to administer. More research is needed to establish the effect of listening to music on other aspects of sleep as well as the daytime consequences of insomnia.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Female; Humans; Male; Middle Aged; Music; Music Therapy; Randomized Controlled Trials as Topic; Sleep; Sleep Initiation and Maintenance Disorders; Time Factors
PubMed: 26270746
DOI: 10.1002/14651858.CD010459.pub2 -
Sleep Medicine Dec 2023Cognitive behavioral therapy for insomnia (CBT-I) as a first-line treatment may improve insomnia in pregnant women. The efficacy of the components, modalities, doses,... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Cognitive behavioral therapy for insomnia (CBT-I) as a first-line treatment may improve insomnia in pregnant women. The efficacy of the components, modalities, doses, and effectiveness of CBT-I in pregnant women at follow-up remains unclear.
OBJECTIVES
To assess the effectiveness of CBT-I in pregnant women and identify effective intervention components, modalities, and doses.
DESIGN
Systematic review and meta-analysis.
METHODS
Six English databases (PubMed, Embase, Cochrane Library, Web of Science, PsycINFO, CINAHL) and four Chinese databases (CNKI, WanFang Data, SinoMed, and CQVIP) were searched from inception to 10 January 2023. Randomized controlled trials (RCTs) on CBT-I in pregnant women with outcomes of insomnia severity measured by Insomnia Severity Index (ISI) or sleep quality measured by Pittsburgh Sleep Quality Index (PSQI). Two reviewers independently completed records selection, data extraction, and study quality assessment. The fixed-effect or random-effect model was used for pooled analyses. Subgroup analyses were conducted based on different delivery types and intervention duration. The GRADE approach was used to evaluate the certainty of the evidence. Narrative analyses were used when meta-analysis was not appropriate. Mean differences with 95% CIs of insomnia severity and sleep quality scores were the main outcomes (greater scores indicating greater severity).
RESULTS
Nine RCTs (N = 978) meeting the inclusion criteria were included. These trials included individual- (n = 6) or group-based (n = 3) interventions, which were conducted via face-to-face (n = 5), digital (n = 3) or telephone and e-mail (n = 1) formats. Six studies stated intervention components specific to pregnant women. CBT-I improved insomnia severity (MD = -2.69, 95% CI: -3.41 to -1.96, P < 0.001, high quality evidence; MD = -3.69, 95% CI: -5.91 to -1.47, P = 0.001, moderate quality evidence) and sleep quality (MD = -2.85, 95% CI: -4.73 to -0.97, P = 0.003, moderate quality evidence; MD = -1.88, 95% CI: -2.89 to -0.88, P < 0.001, moderate quality evidence) immediately after intervention (<1-month) and at short-term (≥1 month to <6 months) follow-up, respectively. Two RCTs reported no effectiveness on insomnia severity at medium-term (≥6 months to<12 months) follow-up. Only 1 RCT showed reduced insomnia severity at long-term (≥12 months) follow-up. One RCT reported no effectiveness in sleep quality at medium-term follow-up and effectiveness at long-term follow-up was not reported.
CONCLUSIONS
Pregnant women may benefit from CBT-I to improve short-term insomnia, but long-term effectiveness is unclear. Rigorous RCTs with long-term follow-ups are warranted.
Topics: Female; Pregnancy; Humans; Pregnant Women; Sleep Initiation and Maintenance Disorders; Cognitive Behavioral Therapy; Sleep Quality
PubMed: 37952481
DOI: 10.1016/j.sleep.2023.11.002 -
Sleep Medicine Jan 2021Repetitive transcranial magnetic stimulation (rTMS) might be a promising technique in treating insomnia. A comprehensive meta-analysis of the available literature is... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Repetitive transcranial magnetic stimulation (rTMS) might be a promising technique in treating insomnia. A comprehensive meta-analysis of the available literature is conducted to offer evidence.
OBJECTIVE
To evaluate the efficacy and safety of rTMS for insomnia, either as monotherapy or as a complementary strategy.
METHODS
CENTRAL, PubMed, EMBASE, PsycINFO, CINAHL, PEDro, CBM, CNKI, WANFANG, and VIP were searched from earliest record to August 2019. Randomized control trials (RCTs) published in English and Chinese examining effects of rTMS on patients with insomnia were included. Two authors independently completed the article selection, data extraction and rating. Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality of the included studies. The RevMan software was used for meta-analysis. The quality of the evidence was assessed by Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
RESULTS
A total of 36 trials from 28 eligible studies were included, involving a total of 2357 adult participants (mean age, 48.80 years; 45.33% males). Compared with sham rTMS, rTMS was associated with improved PSQI total score (SMD -2.31, 95% CI -2.95 to -1.66; Z = 7.01, P < 0.00001) and scores of seven subscales. Compared to other treatment, rTMS as an adjunct to other treatment was associated with improved PSQI total score (SMD -1.44, 95% CI -2.00 to -0.88; Z = 5.01, P < 0.00001), and may have effects on scores of seven subscales. Compared with other treatment, rTMS was associated with improved Pittsburgh sleep quality index (PSQI) total score (SMD -0.63, 95% CI -1.22 to -0.04; Z = 2.08, P = 0.04), and may have a better score in sleep latency, sleep disturbance and hypnotic using of seven subscales. In the three pair of comparisons, the results for polysomnography (PSG) outcomes were varied. In general, rTMS may improve sleep quality through increasing slow wave and rapid eye movement (REM) sleep. The rTMS group was more prone to headache than the sham or blank control group (RR 1.71, 95% CI 1.03 to 2.85; Z = 2.07, P = 0.04). No severe adverse events were reported. Reporting biases and low and very low grade of some evidences should be considered when interpreting the results of this meta-analysis.
CONCLUSIONS
Our findings indicate that rTMS may be a safe and effective option for insomnia. Further international, multicenter, high-quality RCTs with more objective, quality of life related and follow-up assessments are needed.
Topics: Adult; Female; Humans; Male; Middle Aged; Multicenter Studies as Topic; Quality of Life; Sleep Initiation and Maintenance Disorders; Transcranial Magnetic Stimulation; Treatment Outcome
PubMed: 32830052
DOI: 10.1016/j.sleep.2020.05.020 -
The Cochrane Database of Systematic... Apr 2015Telerehabilitation, an emerging method, extends rehabilitative care beyond the hospital, and facilitates multifaceted, often psychotherapeutic approaches to modern... (Review)
Review
BACKGROUND
Telerehabilitation, an emerging method, extends rehabilitative care beyond the hospital, and facilitates multifaceted, often psychotherapeutic approaches to modern management of patients using telecommunication technology at home or in the community. Although a wide range of telerehabilitation interventions are trialed in persons with multiple sclerosis (pwMS), evidence for their effectiveness is unclear.
OBJECTIVES
To investigate the effectiveness and safety of telerehabilitation intervention in pwMS for improved patient outcomes. Specifically, this review addresses the following questions: does telerehabilitation achieve better outcomes compared with traditional face-to-face intervention; and what types of telerehabilitation interventions are effective, in which setting and influence which specific outcomes (impairment, activity limitation and participation)?
SEARCH METHODS
We performed a literature search using the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Review Group Specialised Register( 9 July, 2014.) We handsearched the relevant journals and screened the reference lists of identified studies, and contacted authors for additional data.
SELECTION CRITERIA
Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) that reported telerehabilitation intervention/s in pwMS and compared them with some form of control intervention (such as lower level or different types of intervention, minimal intervention, waiting-list controls or no treatment (or usual care); interventions given in different settings) in adults with MS.
DATA COLLECTION AND ANALYSIS
Two review authors independently selected studies and extracted data. Three review authors assessed the methodological quality of studies using the GRADEpro software (GRADEpro 2008) for best-evidence synthesis. A meta-analysis was not possible due to marked methodological, clinical and statistical heterogeneity between included trials and between measurement tools used. Hence, we performed a best-evidence synthesis using a qualitative analysis.
MAIN RESULTS
Nine RCTs, one with two reports, (N = 531 participants, 469 included in analyses) investigated a variety of telerehabilitation interventions in adults with MS. The mean age of participants varied from 41 to 52 years (mean 46.5 years) and mean years since diagnosis from 7.7 to 19.0 years (mean 12.3 years). The majority of the participants were women (proportion ranging from 56% to 87%, mean 74%) and with a relapsing-remitting course of MS. These interventions were complex, with more than one rehabilitation component and included physical activity, educational, behavioural and symptom management programmes.All studies scored 'low' on the methodological quality assessment. Overall, the review found 'low-level' evidence for telerehabilitation interventions in reducing short-term disability and symptoms such as fatigue. There was also 'low-level' evidence supporting telerehabilitation in the longer term for improved functional activities, impairments (such as fatigue, pain, insomnia); and participation measured by quality of life and psychological outcomes. There were limited data on process evaluation (participants'/therapists' satisfaction) and no data available for cost effectiveness. There were no adverse events reported as a result of telerehabilitation interventions.
AUTHORS' CONCLUSIONS
There is currently limited evidence on the efficacy of telerehabilitation in improving functional activities, fatigue and quality of life in adults with MS. A range of telerehabilitation interventions might be an alternative method of delivering services in MS populations. There is insufficient evidence to support on what types of telerehabilitation interventions are effective, and in which setting. More robust trials are needed to build evidence for the clinical and cost effectiveness of these interventions.
Topics: Adult; Humans; Middle Aged; Multiple Sclerosis; Randomized Controlled Trials as Topic; Telemedicine; Treatment Outcome
PubMed: 25854331
DOI: 10.1002/14651858.CD010508.pub2