Innovative tools for quality assessment: integrated quality criteria for review of multiple study designs (ICROMS). Assessment of study quality for systematic reviews: a comparison of the Cochrane Collaboration Risk of Bias Tool and the Effective Public Health Practice Project Quality Assessment Tool: methodological research. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Examining the theory‐effectiveness hypothesis: A systematic review of systematic reviews What are the most effective behaviour change techniques to promote physical activity and/or reduce sedentary behaviour in inactive adults? A systematic review protocol Comparison of tools for assessing the methodological quality of primary and secondary studies in health technology assessment reports in Germany Risk of bias in randomised controlled trials of health behaviour change interventions: Evidence, practices and challenges Efficacy of postural and neck-stabilization exercises for persons with acute whiplash-associated disorders: a systematic review. Psychosocial determinants of fruit and vegetable intake in adult population: a systematic review Reducing patient delay with symptoms of acute coronary syndrome: a research protocol for a systematic review of previous interventions to investigate which behaviour change techniques are associated with effective interventions Energy balance-related behaviours associated with overweight and obesity in preschool children: a systematic review of prospective studies. Assessing the complexity of interventions within systematic reviews: development, content and use of a new tool (iCAT_SR) Using Guasha to treat musculoskeletal pain: A systematic review of controlled clinical trials Understanding effects in reviews of implementation interventions using the Theoretical Domains Framework [GRADE guidelines: 18. How ROBINS-I and other tools to assess risk of bias in nonrandomized studies should be used to rate the certainty of a body of evidence]. GRADE guidelines: 18. How ROBINS-I and other tools to assess risk of bias in nonrandomized studies should be used to rate the certainty of a body of evidence. [Psychological mechanisms in the transition from acute to chronic pain: over- or underrated?]. Structural brain alterations following adult non-CNS cancers: a systematic review of the neuroimaging literature The clinical effectiveness of different parenting programmes for children with conduct problems: a systematic review of randomised controlled trials Prevalence of spondylosis deformans in the feline spine and correlation with owner-perceived behavioural changes. Systematic review of cognitive behavioural therapy for the management of headaches and migraines in adults [Active music therapy for chronic pain: a prospective study]. Comparison of perioperative racemic methadone, levo-methadone and dextromoramide in cats using indicators of post-operative pain. Determinants of weight loss maintenance: a systematic review. A systematic review of school-based interventions targeting physical activity and sedentary behaviour among older adolescents Determinants of non‐compliance with Antiretroviral Therapy among adults living with HIV/AIDS: A Systematic Review Development and initial validation of the EDIN scale, a new tool for assessing prolonged pain in preterm infants Effectiveness of interventions to improve the public’s antimicrobial resistance awareness and behaviours associated with prudent use of antimicrobials: a systematic review Comparison of the efficacy of saline, local anesthetics, and steroids in epidural and facet joint injections for the management of spinal pain: A systematic review of randomized controlled trials How do systematic reviews incorporate risk of bias assessments into the synthesis of evidence? A methodological study PROBAST: A Tool to Assess the Risk of Bias and Applicability of Prediction Model Studies How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect? How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect? A general critical appraisal tool: an evaluation of construct validity. Overview of Systematic Reviews: Yoga as a Therapeutic Intervention for Adults with Acute and Chronic Health Conditions Relationship of orthopedic examination, goniometric measurements, and radiographic signs of degenerative joint disease in cats Evaluation of the Quality of Prognosis Studies in Systematic Reviews Assessing risk of bias in prevalence studies: modification of an existing tool and evidence of interrater agreement. Developmental and sex differences in somatosensory perception—a systematic comparison of 7- versus 14-year-olds using quantitative sensory testing The effectiveness of self‐management educational interventions for osteoarthritis of the knee Methodological quality of systematic reviews in subfertility: a comparison of Cochrane and non-Cochrane systematic reviews in assisted reproductive technologies. How useful are systematic reviews for informing palliative care practice? Survey of 25 Cochrane systematic reviews A comprehensive approach to rehabilitation interventions following breast cancer treatment - a systematic review of systematic reviews PROMIS PF CAT Outperforms the ODI and SF-36 Physical Function Domain in Spine Patients The effectiveness of music on pain among preterm infants in the neonatal intensive care unit: a systematic review Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews. Assessing baseline imbalance in randomised trials: implications for the Cochrane risk of bias tool. Effectiveness of workplace interventions in rehabilitating musculoskeletal disorders and preventing its consequences among workers with physical and sedentary employment: systematic review protocol A comparison of pain-assessment tools for use with elderly long-term-care residents. Psychosocial interventions for people with dementia: An overview and commentary on recent developments Quality improvement needed in quality improvement randomised trials: systematic review of interventions to improve care in diabetes Does Cryotherapy Improve Outcomes With Soft Tissue Injury? Plantar fasciitis – to jab or to support? A systematic review of the current best evidence Effectiveness of physical therapist administered spinal manipulation for the treatment of low back pain: a systematic review of the literature. Knowledge translation of the HELPinKIDS clinical practice guideline for managing childhood vaccination pain: usability and knowledge uptake of educational materials directed to new parents Developing a targeted, theory-informed implementation intervention using two theoretical frameworks to address health professional and organisational factors: a case study to improve the management of mild traumatic brain injury in the emergency department Behavioural interventions for type 2 diabetes: an evidence-based analysis. Effectiveness of education in evidence-based healthcare: the current state of outcome assessments and a framework for future evaluations. Healthcare professionals' intentions and behaviours: A systematic review of studies based on social cognitive theories Oxytocin increases recognition of masked emotional faces Identifying effective behavioural components of Intervention and Comparison group support provided in SMOKing cEssation (IC-SMOKE) interventions: a systematic review protocol Where do all the undergraduate and new graduate nurses go and why? A search for empirical research evidence.
OBJECTIVES With the aim to facilitate a more comprehensive review process in public health including patient safety , we established a tool that we have termed ICROMS ( Integrated quality Criteria for the Review Of Multiple Study design s ) , which unifies , integrates and refines current quality criteria for a large range of study design s including qualitative research . STUDY DESIGN Review , pilot testing and expert consensus . METHODS The tool is the result of an iterative four phase process over two years : 1 ) gathering of established criteria for assessing controlled , non-controlled and qualitative study design s ; 2 ) pilot testing of a first version in two systematic review s on behavioural change in infection prevention and control and in antibiotic prescribing ; 3 ) further refinement and adding of additional study design s in the context of the European Centre for Disease Prevention and Control funded project ' Systematic review and evidence -based guidance on organisation of hospital infection control programmes ' ( SIGHT ) ; 4 ) scrutiny by the pan-European expert panel of the SIGHT project , which had the objective of ensuring robustness of the systematic review . RESULTS ICROMS includes established quality criteria for r and omised studies , controlled before- and -after studies and interrupted time series , and incorporates criteria for non-controlled before- and -after studies , cohort studies and qualitative studies . The tool consists of two parts : 1 ) a list of quality criteria specific for each study design , as well as criteria applicable across all study design s by using a scoring system ; 2 ) a ' decision matrix ' , which specifies the robustness of the study by identifying minimum requirements according to the study type and the relevance of the study to the review question . The decision matrix directly determines inclusion or exclusion of a study in the review . ICROMS was applied to a series of systematic review s to test its feasibility and usefulness in the appraisal of multiple study design s. The tool was applicable across a wide range of study design s and outcome measures . CONCLUSION ICROMS is a comprehensive yet feasible appraisal of a large range of study design s to be included in systematic review s addressing behaviour change studies in patient safety and public health . The tool is sufficiently flexible to be applied to a variety of other domains in health-related research . Beyond its application to systematic review s , we envisage that ICROMS can have a positive effect on research ers to be more rigorous in their study design and more diligent in their reporting BACKGROUND The Cochrane Collaboration is strongly encouraging the use of a newly developed tool , the Cochrane Collaboration Risk of Bias Tool ( CCRBT ) , for all review groups . However , the psychometric properties of this tool to date have yet to be described . Thus , the objective of this study was to add information about psychometric properties of the CCRBT including inter-rater reliability and concurrent validity , in comparison with the Effective Public Health Practice Project Quality Assessment Tool ( EPHPP ) . METHODS Both tools were used to assess the method ological quality of 20 r and omized controlled trials included in our systematic review of the effectiveness of knowledge translation interventions  to improve the management of cancer pain . Each study assessment was completed independently by two review ers using each tool . We analysed the inter-rater reliability of each tool 's individual domains , as well as final grade assigned to each study . RESULTS The EPHPP had fair inter-rater agreement for individual domains and excellent agreement for the final grade . In contrast , the CCRBT had slight inter-rater agreement for individual domains and fair inter-rater agreement for final grade . Of interest , no agreement between the two tools was evident in their final grade assigned to each study . Although both tools were developed to assess ' quality of the evidence ' , they appear to measure different constructs . CONCLUSIONS Both tools performed quite differently when evaluating the risk of bias or method ological quality of studies in knowledge translation interventions for cancer pain . The newly introduced CCRBT assigned these studies a higher risk of bias . Its psychometric properties need to be more thoroughly vali date d , in a range of research fields , to underst and fully how to interpret results from its application For the current issue of the Journal , we asked Drs Anna Taddio and C Meghan McMurtry to comment on and put into context the Cochrane Review on psychological interventions for needle-related procedural pain and distress in children and adolescents ( 1 ) . Background This review is an up date d version of the original Cochrane review published in Issue 4 , 2006 . Needle-related procedures are a common source of pain and distress for children . Our previous review on this topic indicated that several psychological interventions were efficacious in managing paediatric needle pain including distraction , hypnosis and combined cognitive behavioural interventions . Considerable additional research in the area has been published since that time . Methods Search strategy Search es of the following data bases were conducted for relevant r and omized controlled trials ( RCTs ): Cochrane Central Register of Controlled Trials ( CENTRAL ) ; MEDLINE ; EMBASE ; PsycINFO ; the Cumulative Index to Nursing and Allied Health Literature ( CINAHL ) ; and Web of Science . Requests for relevant studies were also posted on various electronic list servers . An up date d search was conducted in March 2012 and again in March 2013 . Selection criteria Participants included children and adolescents two to 19 years of age undergoing needle-related procedures . Only RCTs with ≥5 participants in each study arm comparing a psychological intervention group with a control or comparison group were eligible for inclusion . Data analysis Two review authors extracted data and assessed trial quality , and a third author helped with data extraction and coding for one non-English study . Included studies were coded for quality using the Cochrane Risk of bias tool . St and ardized mean differences with 95 % CIs were calculated for all analyses using Review Manager version 5.2 . Results Thirty-nine trials with a total of 3394 participants were included . The most commonly studied needle-related procedures were veni-puncture , intravenous line insertion and immunization .  Studies included children two to 19 years of age , with the most evidence available for children < 12 years of age . Consistent with the original review , the most commonly studied psychological interventions for needle procedures were distraction , hypnosis and cognitive behavioural therapy ( CBT ) . The majority of included studies ( 19 of 39 ) examined distraction only . The additional studies from this review up date continued to provide strong evidence for the efficacy  of distraction and hypnosis . No evidence was available to support the efficacy of preparation and information , combined CBT ( ≥2 cognitive or behavioural strategies combined ) , parent coaching plus distraction , suggestion or virtual reality for reducing children ’s pain and distress . No conclusions could be drawn about interventions of memory alteration , parent positioning plus distraction , blowing out air or distraction plus suggestion because evidence was available from single studies only . In addition , the risk of bias scores indicated several domains with high or unclear bias scores ( eg , selection , detection and performance bias ) , suggesting that the method ological rigour and reporting of RCTs of psychological interventions continue to exhibit considerable room for improvement . Conclusions Overall , there is strong evidence supporting the efficacy of distraction and hypnosis for needle-related pain and distress in children and adolescents , with no evidence currently available for preparation and information or both , combined CBT , parent coaching plus distraction , suggestion or virtual reality . Additional research is needed to further assess interventions that have only been investigated in one RCT to date ( ie , memory alteration , parent positioning plus distraction , blowing out air and distraction plus suggestion ) . There are continuing issues with the quality of trials examining psychological interventions for needle-related pain and distress . The full text of the Cochrane Review is available in The Cochrane Library ( 1 ) PURPOSE Health interventions based on theory may be more effective than those that are not . This review of review s synthesizes all published r and omized controlled trial ( RCT ) meta-analytic evidence from the last decade to examine whether theory-based interventions were found to be associated with more effective  adult health behaviour change interventions . METHODS Systematic review s including meta-analyses were identified by search ing Medline , CINAHL , PsycINFO , and CDSR . A narrative synthesis was used to summarize and analyse the evidence . Only review s including RCTs of health behaviour change interventions with adults aged 18 + published from 2007 to 2017 were included . RESULTS Of 8,659 articles , nine systematic review s met inclusion criteria . The majority of review s ( n = 8) suggested no increased effectiveness for theory-based compared to non-theory-based interventions for effectiveness of outcomes relating to health behaviour . Less than half of the RCTs included in the review s reported the use of theory ( 85/183 ) . Two review s suggested interventions based on control theory , motivational interviewing , or self-determination theory were associated with greater effectiveness for physical activity and /or dietary interventions and outcomes . Method ological and reporting issues limit the conclusions . CONCLUSIONS Theory-based interventions as currently operationalized in systematic review s were not found to be more effective than non-theory-based interventions . Method ological and reporting issues at study and review level may not reflect the true utility of theory use within health behaviour interventions . The promotion of theory use may benefit from using a multifaceted argument , rather than a narrow focus of increased effectiveness . Statement of contribution What is already known on this subject ? Theory use is regularly promoted by cl aim ing that it will lead to more effective behaviour change interventions . Theory use has been frequently linked to effectiveness within systematic review s of behaviour change interventions . The theory-effectiveness hypothesis has not been systematic ally examined at the systematic review level . What does this study add ? Theory use as operationalized by systematic review authors was not associated with increased effectiveness within systematic review s examining r and omized controlled trials of behaviour change interventions in adults . Interventions based on control theory , motivational interviewing , or self-determination theory were associated with greater effectiveness for physical activity and /or dietary interventions and outcomes . Theory use should be promoted using a multifaceted argument , and assertions for increased effectiveness of theory-based interventions should only be used in domains where specific evidence exists to support this cl aim Introduction Large proportions of the population are not meeting recommended levels of physical activity and have increasingly sedentary lifestyles . Low levels of physical activity are predictive of poor health outcomes and time spent sedentary is related to a host of risk factors independently of physical activity levels . Building an evidence base of the best approaches to intervene in the lifestyles of inactive individuals is crucial in preventing long-term disease , disability and higher mortality rates . Methods and analysis Systematic search es will be conducted on all relevant data bases ( eg , PubMed , Scopus , CINAHL , PsycINFO ) . Studies will be included if they assess interventions aim ed at changing physical activity or sedentary behaviour levels in adults ( over 18 ) who are inactive and do not suffer from chronic conditions . Studies must also be r and omised controlled trials ( RCTs ) , have a primary outcome of physical activity or sedentary behaviour , and measure outcomes at least 6 months after intervention completion . Studies will be coded using the Behaviour Change Technique ( BCT ) taxonomy v1 and Template for Intervention Description and Replication ( TIDieR ) guidelines . 2 review ers will independently screen full-text articles and extract data on study characteristics , participants , BCTs , intervention features and outcome measures . Study quality will also be assessed independently by 2 review ers using the Cochrane risk of bias tool . A meta- analysis will be considered if there is sufficient homogeneity across outcomes . GRADE criteria will be used to assess quality of evidence . Dissemination This will be the first review to systematic ally appraise interventions aim ed at changing the physical activity or sedentary behaviour of inactive individuals using RCT design s with a 6-month follow-up post-intervention . This review will better inform intervention design ers targeting inactive population s and inform the design of a future complex intervention . Review registration number This protocol was registered with the International Prospect i ve Register of Systematic Review s ( PROSPERO ) on 17 October 2014 ( registration number : CRD42014014321 ) Health care policy background Findings from scientific studies form the basis for evidence -based health policy decisions . Scientific background Quality assessment s to evaluate the credibility of study results are an essential part of health technology assessment reports and systematic review s. Quality assessment tools ( QAT ) for assessing the study quality examine to what extent study results are systematic ally distorted by confounding or bias ( internal validity ) . The tools can be divided into checklists , scales and component ratings . Research questions What QAT are available to assess the quality of interventional studies or studies in the field of health economics , how do they differ from each other and what conclusions can be drawn from these results for quality assessment s ? Methods A systematic search of relevant data bases from 1988 onwards is done , supplemented by screening of the references , of the HTA reports of the German Agency for Health Technology Assessment ( DAHTA ) and an internet search . The selection of relevant literature , the data extraction and the quality assessment are carried out by two independent review ers . The substantive elements of the QAT are extracted using a modified criteria list consisting of items and domains specific to r and omized trials , observational studies , diagnostic studies , systematic review s and health economic studies . Based on the number of covered items and domains , more and less comprehensive QAT are distinguished . In order to exchange experiences regarding problems in the practical application of tools , a workshop is hosted . Results A total of eight systematic method ological review s is identified as well as 147 QAT : 15 for systematic review s , 80 for r and omized trials , 30 for observational studies , 17 for diagnostic studies and 22 for health economic studies . The tools vary considerably with regard to the content , the performance and quality of operationalisation . Some tools do not only include the items of internal validity but also the items of quality of reporting and external validity . No tool covers all elements or domains . Design -specific generic tools are presented , which cover most of the content criteria . Discussion The evaluation of QAT by using content criteria is difficult , because there is no scientific consensus on the necessary elements of internal validity , and not all of the generally accepted elements are based on empirical evidence . Comparing QAT with regard to contents neglects the operationalisation of the respective parameters , for which the quality and precision are important for transparency , replicability , the correct assessment and interrater reliability . QAT , which mix items on the quality of reporting and internal validity , should be avoided . Conclusions There are different , design -specific tools available which can be preferred for quality assessment , because of its wider coverage of substantive elements of internal validity . To minimise the subjectivity of the assessment , tools with a detailed and precise operationalisation of the individual elements should be applied . For health economic studies , tools should be developed and complemented with instructions , which define the appropriateness of the criteria . Further research is needed to identify study characteristics that influence the internal validity of studies The major strength of a r and omised controlled trial ( RCT ) is the degree to which it can establish a causal relationship between an experimental treatment and the outcome ( i.e. internal validity ) , as r and omisation should ensure that potential confounders are equally distributed over the treatment and control arms . Internal validity in RCTs can be threatened , however , by multiple sources of bias . For example , poor r and omisation procedures ( e.g. failure to conceal allocations until treatments have been assigned ) can lead to selection bias because more high-risk individuals are selected to receive the experimental treatment . There is a range of potential sources of bias in RCTs , and several well-known tools for assessing the risk of bias provide useful overviews of these sources and strategies for reducing them ( e.g. Guyatt et al. , 2011 ; Higgins , Altman , & Sterne , 2011 ) . These tools are also influential : trials scoring high on risk-of-bias assessment s should have a smaller chance on publication and – if published – to be included in ‘ best evidence ’ systematic review s ( Johnson , Low , & MacDonald , 2015 ) , and thus for their interventions to influence policy and practice . Systematic review s suggest that many health behaviour change ( HBC ) trials suffer from a moderate to high risk of bias ( e.g. Oberjé , de Kinderen , Evers , van Woerkum , & de Bruin , 2013 ; Poobalan , Aucott , Precious , Crombie , & Smith , 2009 ) ; more so than , for example , drug trials ( Crocetti , Amin , & Scherer , 2010 ) . Moreover , risk-of-bias scores have been found to explain heterogeneity in effect sizes , especially in trials with subjective outcome measures ( Savovic et al. , 2012 ; Wood et al. , 2008 ) . Since replication studies of HBC intervention evaluations are uncommon , invalid inferences due to bias may not be easily discovered and rectified . Despite these concerns , there has been little attention in the behaviour change intervention literature to the sources and consequences of bias in trials , and to strategies that may be effective in reducing the risk of bias . This paucity of research on risk of bias in HBC trial is in turn reflected in widely used instruments for assessing the risk of bias , such as the Cochrane risk-of-bias tool ( Higgins et al. , 2011 ) , which seems to be mostly based on evidence from non-behavioural trials . The objective of this special issue is to reflect on the evidence , practice s and challenges in relation to reducing the risk of bias in HBC trials . We hope that this special issue will both impact scientific practice ( i.e. enhancing the quality of HBC trial design , reporting and synthesis ) and have an agenda- setting effect ( i.e. inspire people to do empirical research into what sources of bias actually do affect HBC trials , what strategies are effective for mitigating these , and thus what criteria should be used for grading the quality of the evidence of HBC trials ) PURPOSE We systematic ally review ed r and omized and quasi-r and omized clinical trials in the literature to assess the efficacy of neck stabilization and postural exercises on pain , neck range of motion , and time off work in adults with acute whiplash-associated disorders . METHODS Electronic data bases , reference lists of relevant Cochrane review s , reference lists of studies selected for inclusion , and tables of contents of relevant journals were systematic ally search ed for r and omized and quasi-r and omized controlled trials . Two independent review ers selected studies for inclusion , assessed method ological quality , and extracted data . Because of the heterogeneity of the interventions , a qualitative synthesis was performed using " levels of evidence " as recommended by van Tulder et al. RESULTS Eight studies representing five clinical trials were selected for inclusion . Two trials were grade d as high quality , two as moderate quality , and one as low quality . Many of these studies had mixed results , demonstrating significant differences on some outcome measures but not on others . CONCLUSIONS There is moderate evidence to support the use of postural exercises for decreasing pain and time off work in the treatment of patients with acute whiplash-associated disorders . However , no evidence exists to support the use of postural exercises for increasing neck range of motion . There is conflicting evidence in support of neck stabilization exercises in the treatment of patients with acute whiplash-associated disorders Background Accumulating evidence suggests that fruit and vegetable intake ( FVI ) plays a protective role against major diseases . Despite this protective role and the obesity p and emic context , population s in Western countries usually eat far less than five servings of fruits and vegetables per day . In order to increase the efficiency of interventions , they should be tailored to the most important determinants or mediators of FVI . The objective was to systematic ally review social cognitive theory-based studies of FVI and to identify its main psychosocial determinants . Methods Published papers were systematic ally sought using Current Contents ( 2007 - 2009 ) and Medline , Embase , PsycINFO , Proquest and Thesis , as well as Cinhal ( 1980 - 2009 ) . Additional studies were identified by a manual search in the bibliographies . Search terms included fruit , vegetable , behaviour , intention , as well as names of specific theories . Only studies predicting FVI or intention to eat fruits and vegetables in the general population and using a social cognitive theory were included . Independent extraction of information was carried out by two persons using predefined data fields , including study quality criteria . Results A total of 23 studies were identified and included , 15 study ing only the determinants of FVI , seven study ing the determinants of FVI and intention and one study ing only the determinants of intention . All pooled analyses were based on r and om-effects models . The r and om-effect R2 observed for the prediction of FVI was 0.23 and it was 0.34 for the prediction of intention . Multicomponent theoretical frameworks and the theory of planned behaviour ( TPB ) were most often used . A number of method ological moderators influenced the efficacy of prediction of FVI . The most consistent variables predicting behaviour were habit , motivation and goals , beliefs about capabilities , knowledge and taste ; those explaining intention were beliefs about capabilities , beliefs about consequences and perceived social influences . Conclusions Our results suggest that the TPB and social cognitive theory ( SCT ) are the preferable social cognitive theories to predict behaviour and TPB to explain intention . Efficacy of prediction was nonetheless negatively affected by method ological factors such as the study design and the quality of psychosocial and behavioural measures Introduction Delay to presentation with symptoms of acute coronary syndrome ( ACS ) is common meaning many fail to achieve optimal benefit from treatments . Interventions have had variable success in reducing delay . Evidence suggests inclusion of behaviour change techniques ( BCTs ) may improve effectiveness of interventions but this has not yet been systematic ally evaluated . Data from other time-critical conditions may be relevant . Methods and analysis A systematic review will be undertaken to identify which BCTs are associated with effective interventions to reduce patient delay ( or prompt rapid help-seeking ) among people with time-critical conditions ( eg , chest pain , ACS , lumps , stroke , cancer and meningitis ) . A systematic search of a wide range of data bases ( including Cochrane Library , MEDLINE , EMBASE , CINAHL , PsycInfo ) and grey literature will be undertaken to identify all relevant intervention studies ( r and omised controlled trials , controlled clinical trials and cohort studies ) . Two independent review ers will screen abstract s to identify relevant studies , apply inclusion criteria to full papers , assess method ological quality and extract data . Primary outcome measure Change in patient decision time BCTs reported in each of the included studies will be categorised and presented according to the latest reliable taxonomy . Results of included studies will be synthesis ed , exploring relationships between inclusion of each BCT and effectiveness of the overall intervention . Where possible , means and SDs for differences in delay time will be calculated and combined within meta-analyses to derive a st and ardised mean difference and 95 % CI . Analysis of ( 1 ) all time-critical and ( 2 ) ACS-only interventions will be undertaken . Ethics and dissemination No ethical issues are anticipated . Results will be su bmi tted for publication in a relevant peer- review ed journal The current review aim ed to systematic ally identify dietary , physical activity and sedentary behaviours in preschool children ( 4 - 6 years of age ) that are prospect ively related to overweight or obesity later in childhood . Prospect i ve studies published between January 1990 and June 2010 were selected from search es in PubMed , EMBASE , PsycINFO , CINAHL and Cochrane Library . Studies examining the prospect i ve association between at least one relevant behaviour measured during preschool period ( children aged 4 - 6 years at baseline ) in relation to at least one anthropometric measurement at follow-up ( age < 18 years ) were included . Harvest plots were used to summarize the results and draw conclusions from the evidence . Of the 8,718 retrieved papers , 23 papers reporting on 15 different study sample s were included in this review . Strong evidence was found for an inverse association between total physical activity and overweight . Moderate evidence was observed for a positive association between television viewing and overweight . Because of the heterogeneity in the assessed dietary behaviours , insufficient evidence was found for an association between  dietary intake or specific dietary behaviours and overweight . These results suggest that interventions aim ing to prevent overweight among preschool children should focus on promotion of total physical activity and limitation of screen time and that further research is needed to establish whether and which dietary behaviours are important for obesity prevention in this age group . However , despite the lack of evidence for dietary behaviours from the present review , future interventions may already target specific dietary behaviours that are highly prevalent and for which there a clear rationale as well as preliminary evidence that these behaviours are associated with overweight Background Health interventions fall along a spectrum from simple to more complex . There is wide interest in methods for review ing ‘ complex interventions ’ , but few transparent approaches for assessing intervention complexity in systematic review s. Such assessment s may assist review authors in , for example , systematic ally describing interventions and developing logic models . This paper describes the development and application of the intervention Complexity Assessment Tool for Systematic Review s ( iCAT_SR ) , a new tool to assess and categorise levels of intervention complexity in systematic review s. Methods We developed the iCAT_SR by adapting and extending an existing complexity assessment tool for r and omized trials . We undertook this adaptation using a consensus approach in which possible complexity dimensions were circulated for feedback to a panel of method ologists with expertise in complex interventions and systematic review s. Based on these inputs , we developed a draft version of the tool . We then invited a second round of feedback from the panel and a wider group of systematic review ers . This informed further refinement of the tool . Results The tool comprises ten dimensions : ( 1 ) the number of active components in the intervention ; ( 2 ) the number of behaviours of recipients to which the intervention is directed ; ( 3 ) the range and number of organizational levels targeted by the intervention ; ( 4 ) the degree of tailoring intended or flexibility permitted across sites or individuals in applying or implementing the intervention ; ( 5 ) the level of skill required by those delivering the intervention ; ( 6 ) the level of skill required by those receiving the intervention ; ( 7 ) the degree of interaction between intervention components ; ( 8) the degree to which the effects of the intervention are context dependent ; ( 9 ) the degree to which the effects of the interventions are changed by recipient or provider factors ; ( 10 ) and the nature of the causal pathway between intervention and outcome . Dimensions 1–6 are considered ‘ core ’ dimensions . Dimensions 7–10 are optional and may not be useful for all interventions . Conclusions The iCAT_SR tool facilitates more in-depth , systematic assessment of the complexity of interventions in systematic review s and can assist in undertaking review s and interpreting review findings . Further testing of the tool is now needed Background Guasha is a therapeutic method for pain management using tools to scrape or rub the surface of the body to relieve blood stagnation . This study aims to systematic ally review the controlled clinical trials on the effectiveness of using Guasha to treat musculoskeletal pain . Methods We search ed 11 data bases ( without language restrictions ) : MEDLINE , Allied and Complementary Medicine ( AMED ) , EMBASE , Cumulative Index to Nursing and Allied Health Literature ( CINAHL ) , Korean Studies Information ( KSI ) , DBPIA , Korea Institute of Science and Technology Information ( KISTI ) , KoreaMed , Research Information Service System ( RISS ) , China National Knowledge Infrastructure ( CNKI ) and the Cochrane Library . The search strategy was Guasha ( OR scraping ) AND pain . Risk of bias was assessed with the Cochrane criteria ( i.e. sequence generation , blinding , incomplete outcome measures and allocation concealment ) . Results Five r and omized controlled trials ( RCTs ) and two controlled clinical trials ( CCTs ) were included in the present study . Two RCTs compared Guasha with acupuncture in terms of effectiveness , while the other trials compared Guasha with no treatment ( 1 trial ) , acupuncture ( 4 trials ) , herbal injection ( 1 trial ) and massage or electric current therapy ( 1 trial ) . While two RCTs suggested favorable effects of Guasha on pain reduction and response rate , the quality of these RCTs was poor . One CCT reported beneficial effects of Guasha on musculoskeletal pain but had low method ological quality . Conclusion Current evidence is insufficient to show that Guasha is effective in pain management . Further RCTs are warranted and method ological quality should be improved Background Behavioural theory can be used to better underst and the effects of behaviour change interventions targeting healthcare professional behaviour to improve quality of care . However , the explicit use of theory is rarely reported despite interventions inevitably involving at least an implicit idea of what factors to target to implement change . There is a quality of care gap in the post-fracture investigation ( bone mineral density ( BMD ) scanning ) and management ( bisphosphonate prescription ) of patients at risk of osteoporosis . We aim ed to use the Theoretical Domains Framework ( TDF ) within a systematic review of interventions to improve quality of care in post-fracture investigation . Our objectives were to explore which theoretical factors the interventions in the review may have been targeting and how this might be related to the size of the effect on rates of BMD scanning and osteoporosis treatment with bisphosphonate medication . Methods A behavioural scientist and a clinician independently coded TDF domains in intervention and control groups . Quantitative analyses explored the relationship between intervention effect size and total number of domains targeted , and as number of different domains targeted . Results Nine r and omised controlled trials ( RCTs ) ( 10 interventions ) were analysed . The five theoretical domains most frequently coded as being targeted by the interventions in the review included “ memory , attention and decision processes ” , “ knowledge ” , “ environmental context and re sources ” , “ social influences ” and “ beliefs about consequences ” . Each intervention targeted a combination of at least four of these five domains . Analyses identified an inverse relationship between both number of times and number of different domains coded and the effect size for BMD scanning but not for bisphosphonate prescription , suggesting that the more domains the intervention targeted , the lower the observed effect size . Conclusions When explicit use of theory to inform interventions is absent , it is possible to retrospectively identify the likely targeted factors using theoretical frameworks such as the TDF . In osteoporosis management , this suggested that several likely determinants of healthcare professional behaviour appear not yet to have been considered in implementation interventions . This approach may serve as a useful basis for using theory-based frameworks such as the TDF to retrospectively identify targeted factors within systematic review s of implementation interventions in other implementation context OBJECTIVE To provide guidance on how systematic review authors , guideline developers , and health technology assessment practitioners should approach the use of the risk of bias in  nonr and omized studies of interventions ( ROBINS-I ) tool as a part of GRADE 's certainty rating process . STUDY DESIGN AND SETTING The study design and setting comprised iterative discussion s , testing in systematic review s , and presentation at GRADE working group meetings with feedback from the GRADE working group . RESULTS We describe where to start the initial assessment of a body of evidence with the use of ROBINS-I and where one would anticipate the final rating would end up . The GRADE accounted for issues that mitigate concerns about confounding and selection bias by introducing the upgrading domains : large effects , dose-effect relations , and when plausible residual confounders or other biases increase certainty . They will need to be considered in an assessment of a body of evidence when using ROBINS-I. CONCLUSION The use of ROBINS-I in GRADE assessment s may allow for a better comparison of evidence from r and omized controlled trials ( RCTs ) and nonr and omized studies ( NRSs ) because they are placed on a common metric for risk of bias . Challenges remain , including appropriate presentation of evidence from RCTs and NRSs for decision-making and how to optimally integrate RCTs and NRSs in an evidence assessment OBJECTIVE To provide guidance on how systematic review authors , guideline developers , and health technology assessment practitioners should approach the use of the risk of bias in  nonr and omized studies of interventions ( ROBINS-I ) tool as a part of GRADE 's certainty rating process . STUDY DESIGN AND SETTING The study design and setting comprised iterative discussion s , testing in systematic review s , and presentation at GRADE working group meetings with feedback from the GRADE working group . RESULTS We describe where to start the initial assessment of a body of evidence with the use of ROBINS-I and where one would anticipate the final rating would end up . The GRADE accounted for issues that mitigate concerns about confounding and selection bias by introducing the upgrading domains : large effects , dose-effect relations , and when plausible residual confounders or other biases increase certainty . They will need to be considered in an assessment of a body of evidence when using ROBINS-I. CONCLUSIONS The use of ROBINS-I in GRADE assessment s may allow for a better comparison of evidence from r and omized controlled trials ( RCTs ) and nonr and omized studies ( NRSs ) because they are placed on a common metric for risk of bias . Challenges remain , including appropriate presentation of evidence from RCTs and NRSs for decision-making and how to optimally integrate RCTs and NRSs in an evidence assessment INTRODUCTION During the last 20 years a great number of studies have emphasized the potential role of psychological factors as relevant predictors for the first onset of back pain as well as for the development of chronic pain . The formulation of a biopsychosocial perspective of the etiology and chronicity of back pain was a natural consequence . Actual questions concern the relative impact of psychological risk factors in the process of chronicity of back pain compared to biomedical , social and occupational factors . METHODS Whereas several review articles regarding the role of psychological risk factors are available up to now , a recently published review conducted by Steven Linton was the first systematic analysis of well controlled prospect i ve studies published since 1967 . Using a grading system similar to that recommended for guidelines the author defined a level A evidence when at least two good- quality prospect i ve studies supported the prospect i ve power of a variable . Level B evidence had support from one prospect i ve study . Level C represented inconclusive data and level D indicated that no studies met the criteria . Based on a literature search of more than 900 studies , 37 good- quality prospect i ve studies were analysed in detail . RESULTS The results indicated level A evidence for the following interrelations : ( 1 ) Psychosocial variables , especially chronic distress in daily life , depression and work dissatisfaction were clearly associated with the onset of back and neck pain ( 2 ) . Psychological variables , especially chronic stress in daily life , work dissatisfaction , depression and pain-related cognitions and coping behaviour were clearly linked to the transition from acute to chronic pain and disability ( 3 ) . Psychological variables generally had more prospect i ve power than biomedical , social or objective occupational variables . Among the pain-related cognitions , catastrophizing and fear-avoidance-beliefs yielded the most empirical support . Among coping behaviour passive coping stretegies such as avoiding behaviour was most important . At least level B evidence has been shown for the counterpart of an extreme suppressive coping behaviour . Patients who tended to suppress or ignore pain in order to finish all activities they started , who were unable to integrate phases of passive relaxation into the daily routine displayed a high risk of chronicity of pain 6 months after an acute phase of pain . One international and two German good- quality prospect i ve studies have shown the predictive power of a maladaptive suppressive behaviour pattern . Based on the avoidance-endurance-model of pain chronification , both extreme and one-sided passive pain coping as well as one-sided suppressive coping modes were conceptualized as maladaptive due to the process of chronicity . We assume that extreme passive behaviour will lead to immobility and muscular atrophy . Neurophysiological processes of sensitization will further lead to the development of chronic pain . On the other h and , extreme suppressive behaviour will lead to an overuse of muscles and joints with a repetitive combination of muscular hyperactivity and pain . These repetitive pain experiences will also elicit neurophysiological processes of sensitization . ( 4 ) Psychosocial variables displayed more predictive power than biomedical or biomechanical factors . ( 5 ) Psychosocial factors may be used as predictors of the risk for developing long-term pain and disability . Mixed empirical evidence has been shown for the role of personality factors ( level C evidence ) and no support has been found for the idea of a " pain prone " personality disorder or for the role of sexual and physical abuse . DISCUSSION 20 years of research , several qualitative review s and a recently published systematic review of 37 good- quality prospect i ve studies regarding the role of psychological , biomedical , social and objective occupational factors in the process of chronicity of back pain revealed that psychological factors are significantly related to the onset of back pain as well as to the development of chronic pain . Furthermore , the psychological factors displayed more predictive power than biomedical or biomechanical variables . As a consequence for clinical practice , these psychological risk factors have to be considered as " yellow flags " if a back pain problem wo n't respond to medical treatment for more than four weeks . As a further consequence , special risk factor - based psychosocial interventions should be offered in addition to the medical treatment to patients with high psychological risk factors for the development of chronic pain . The efficacy of such an interdisciplinary care in the very early phases of back pain in order to prevent chronicity of pain and disability has been published recently by our group Abstract Background : Cancer and cancer treatments may impact the brain through several pathways leading to cognitive impairment . Neuroimaging evidence has begun to eluci date the neurobiological underpinnings of cancer-related cognitive impairment . The aim of this paper was to systematic ally review available literature on structural brain alterations following adult non- central nervous system ( CNS ) cancers and associated treatments . Methods : This review followed PRISMA guidelines and was registered in PROSPERO ( ID#107387 ) . Comprehensive search es were conducted in June 2018 using PubMed and Web of Science . Inclusion criteria were English peer- review ed journal articles of formal , controlled studies that examined structural neuroimaging outcomes in adult non-CNS cancer patients and survivors . Selected articles were assessed for quality and risk of bias using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies . Results : Thirty-six publications of prospect i ve and cross-sectional studies met inclusion criteria and were included . Structural brain alterations following cancer and its treatment were reported in a majority of the publications as evidence d by reduced global and local gray matter volumes , impaired white matter microstructural integrity , and brain network alterations . Structural alterations were most often evident when cancer-treated groups were compared with healthy controls , and more subtle when compared with cancer controls . Regarding the existence of pretreatment impairments , the evidence was equivocal . There was significant between- study heterogeneity in imaging analytical approaches and use of statistical adjustments . Over half reported associations with cognitive outcomes , though regions and associated cognitive domains were heterogeneous . Conclusions : Structural brain alterations following cancer and cancer treatments were reported in a majority of the review ed studies . However , the extent of observed alterations depended on the choice of comparison groups . Method ological issues exist that will need to be addressed systematic ally to ensure the validity of findings . Large-scale prospect i ve studies with extended assessment points are warranted to replicate and build upon initial findings Background Conduct problems are common , disabling and costly . The prognosis for children with conduct problems is poor , with outcomes in adulthood including criminal behaviour , alcoholism , drug abuse , domestic violence , child abuse and a range of psychiatric disorders . There has been a rapid expansion of group based parent-training programmes for the treatment of children with conduct problems  in a number of countries over the past 10 years . Existing review s of parent training have method ological limitations such as inclusion of non-r and omised studies , the absence of investigation for heterogeneity prior to meta- analysis or failure to report confidence intervals . The objective of the current study was to systematic ally review r and omised controlled trials of parenting programmes for the treatment of children with conduct problems .  Methods St and ard systematic review methods were followed including duplicate inclusion decisions , data extraction and quality assessment . Twenty electronic data bases from the fields of medicine , psychology , social science and education were comprehensively search ed for RCTs and systematic review s to February 2006 . Inclusion criteria were : r and omised controlled trial ; of structured , repeatable parenting programmes ; for parents/carers of children up to the age of 18 with a conduct problem ; and at least one measure of child behaviour . Meta- analysis and qualitative synthesis were used to summarise included studies . Results 57 RCTs were included . Studies were small with an average group size of 21 . Meta-analyses using both parent ( SMD -0.67 ; 95 % CI : -0.91 , -0.42 ) and independent ( SMD -0.44 ; 95 % CI : -0.66 , -0.23 ) reports of outcome showed significant differences favouring the intervention group . There was insufficient evidence to determine the relative effectiveness of different approaches to delivering parenting programmes . Conclusion Parenting programmes are an effective treatment for children with conduct problems . The relative effectiveness of different parenting programmes requires further research OBJECTIVES The primary objective was to determine the prevalence , spinal distribution , and association with the signalment of cats suffering from different grade s of feline spondylosis deformans ( spondylosis ) . The secondary objective was to document behavioural changes associated with spondylosis by owner observation . METHODS A cross-sectional study was performed to determine the prevalence of feline spondylosis ( group 1 ) . A prospect i ve study was performed to determine the association between radiographic abnormalities of the lumbosacral region ( L3-S1 ) and owner perceived behavioural changes based on a completed question naire ( group 2 ) . The radiographs were review ed using a grading system ( 0 - 3 ) for spondylosis . RESULTS The prevalence of spondylosis in group 1 was 39.4 % ( 158/402 ) . Cats with spondylosis were significantly older than cats without spondylosis ( p < 0.001 ) . The thoracic ( T ) vertebrae T4-T10 were most often affected by spondylosis , but spondylosis was most severe in the T10-S1 vertebrae . In group 2 , spondylosis of the lumbosacral region was significantly correlated with owner-reported behavioural changes , such as a decreased willingness to greet people and to being petted , increased aggressiveness , and a poor perceived quality of life ( p = 0.037 ) . CLINICAL SIGNIFICANCE This study found that feline spondylosis is common and that spondylosis of the lumbosacral region may be accompanied by behavioural changes Aim : This systematic review aim ed to establish if cognitive behavioural therapy ( CBT ) can reduce the physical symptoms of chronic headache and migraines in adults . Methods : Evidence from search es of eight data bases was systematic ally sought , appraised and synthesis ed . Screening of title and abstract s was conducted independently by two review ers . Full papers were screened , data extracted and quality assessed by one review er and checked by a second . Data were synthesis ed narratively by intervention due to the heterogeneity of the studies . The inclusion criteria specified r and omised controlled trials with CBT as an intervention in adults suffering from chronic headaches/migraines not associated with an underlying pathology/medication overuse .  CBT was judged on the basis of authors describing the intervention as CBT . The diagnosis of the condition had to be clinician verified . Studies had to include a comparator and employ headache/migraine-specific outcomes such as patient-reported headache days . Results : Out of 1126 screened titles and abstract s and 20 assessed full papers , 10 studies met the inclusion criteria of the review . Some studies combined CBT with another intervention , as well as employing varying numbers of comparators . CBT was statistically significantly more effective in improving some headaches-related outcomes in CBT comparisons with waiting lists ( three studies ) , in combination with relaxation compared with relaxation only ( three studies ) or antidepressant medication ( one study ) , with no statistically significant differences in three studies . Conclusions : The findings of this review were mixed , with some studies providing evidence in support of the suggestion that people experiencing headaches or migraines can benefit from CBT , and that CBT can reduce the physical symptoms of headache and migraines . However , methodology inadequacies in the evidence base make it difficult to draw any meaningful conclusions or to make any recommendations There are only few publications about the effect of music therapy on pain relief . The intention of this prospect i ve study is to demonstrate the influence of the Nordoff/Robbins method of active music therapy in a group of 12 patients with fibromyalgia , myofascial pain syndromes and polyarthritis on  pain reduction , life quality and coping . The clinical parameters of each patient were related to the observations in the audio- and video-documented music therapy setting s and to the self-reported changes in pain intensity and pain behaviour . There was a significant reduction of pain intensity and pain-related disability in the music group compared to a control group , but no change in the depression and anxiety score . The influence of music therapy could be even better demonstrated in the systematic analysis of the single cases by individual profiles . Active music therapy affects especially the communicative and emotional dimension of chronic pain . Psychophysiological and psychodynamic models are presented to explain the effectiveness of music therapy on pain reduction . Clinical studies on music therapy as well as on other " art therapies " should relate the analysis of clinical parameters to the descriptive-phenomenological documentation of the therapeutic process to demonstrate systematic ally the influence of music and art in the individual case OBJECTIVE To compare three opioid agonist drugs for perioperative analgesia in cats . STUDY DESIGN Prospect i ve , blind , controlled , r and omised trial . ANIMALS Ninety client-owned cats , weighing 3.1 ( 2.1 - 4.5 ) kg , aged 14.6 ( 6.0 - 84.0 ) months , were studied . METHODS Seventy-six cats , scheduled for ovariectomy , received either 0.6 mg kg(-1 ) racemic methadone , 0.3 mg kg(-1 ) levo-methadone , 0.05 mg kg(-1 ) dextromoramide or a saline placebo IM . Behaviour and body position were assessed and scored 20 minutes later by a single ' blinded ' observer . Anaesthesia was induced with propofol and maintained with halothane .  Heart rate ( HR ) , respiratory rate ( RR ) , Fe'CO2 and SpO2 were recorded during anaesthesia . Post-operatively , pain was categorised as absent , moderate or severe , on the basis of appearance , behaviour and response to palpation of the surgical wound ( pain score ) . Appearance , pain scores and physiological variables were monitored every 30 minutes , for a duration of 4 hours . Differences between time-dependent continuous variables were analysed using mixed models for repeated measurements . Differences in categorical , time-dependent variables were analysed using chi2-tests . Significance was set at p < or = 0.05 . RESULTS There were no significant changes in appearance after pre-anaesthetic medication . After surgery , there was no association between appearance and pain score with HR or RR . The assessment of pain depended on comparison with the placebo group , by comparing animals ' reactions to wound palpation . Sixteen of the 18 cats in the placebo group and 14 of the 19 cats in the dextromoramide group showed signs of moderate-to-severe pain after surgery . In the levo-methadone group ( n = 20 ) , one animal showed pain after 60 minutes and two after 120 minutes . One cat in the racemic methadone group ( n = 19 ) showed pain signs and behavioural changes at 60 minutes . Compared to the two methadone groups , ' rescue ' analgesia was required more often in cats treated with dextromoramide or saline . CONCLUSION AND CLINICAL RELEVANCE Dextromoramide ( 0.05 mg kg(-1 ) ) was ineffective , while racemic methadone ( 0.6 mg kg(-1 ) ) and levo-methadone ( 0.3 mg kg(-1 ) ) provided effective analgesia in cats following ovariectomy , without behavioural , respiratory or cardiovascular side effects BACKGROUND Discerning the determinants of weight loss maintenance is important in the planning of future interventions and policies regarding overweight and obesity . We have therefore systematic ally synthesized recent literature on determinants of weight loss maintenance for individuals with overweight and obesity . METHODS With the use of the Preferred Reporting Items for Systematic Review s and Meta-Analyses statement , prospect i ve studies were identified from search es in PubMed and PsycINFO from 2006 to 2016 . We included articles investigating adults with overweight and obesity undergoing weight loss without surgery or medication .  Included articles were scored on their method ological quality , and a best- evidence synthesis was applied to summarize the results . RESULTS Our search result ed in 8,222 articles of which 67 articles were selected . In total , 124 determinants were identified of which 5 were demographic , 59 were behavioural , 51 were psychological/cognitive and 9 were social and physical environmental determinants . We found consistent evidence that demographic determinants were not predictive of weight loss maintenance . Behavioural and cognitive determinants that promote a reduction in energy intake , an increase in energy expenditure and monitoring of this balance are predictive determinants . CONCLUSION This review identifies key determinants in weight loss maintenance . However , more research regarding cognitive and environmental determinants of weight loss maintenance is needed to advance our knowledge on determinants of weight loss maintenance ABSTRACT Lack of  physical activity  (  PA  ) and high levels of sedentary behaviour ( SB ) have been associated with health problems . This systematic review evaluates the effectiveness of school-based interventions to increase PA  and decrease SB  among 15–19-year-old adolescents , and examines whether intervention characteristics ( intervention length , delivery mode and intervention provider ) and intervention content ( i.e. behaviour change techniques , BCTs ) are related to intervention effectiveness . A systematic search of r and omised or cluster r and omised controlled trials with outcome measures of PA and /or SB rendered 10 results . Risk of bias was assessed using the Cochrane risk of bias tool . Intervention content was coded using Behaviour Change Technique Taxonomy v1 . Seven out of 10 studies reported significant increases in PA . Effects were generally small and short-term ( Cohen 's d ranged from 0.132 to 0.659 ) . Two out of four studies that measured SB reported significant reductions in SB . Interventions that increased PA  included a higher number of BCTs , specific BCTs ( e.g. , goal setting , action planning and self-monitoring ) , and were delivered by research staff . Intervention length and mode of delivery were unrelated to effectiveness . More studies are needed that evaluate long-term intervention effectiveness and target SBs among older adolescents Background Non‐compliance with Antiretroviral Therapy is a major public health concern and further challenged by interaction of various social and clinical obstacles . So ; near perfect pill taking is desirable in order to maximise its benefits . Objectives To systematic ally search , appraise and synthesis e the best available evidence on determinants of non‐compliance with Antiretroviral Therapy among adults living with HIV/AIDS and provide direction to future how to increase compliance with Antiretroviral Therapy . Inclusion criteria Types of participants The systematic review considered studies with 18 years and above year old adults living with HIV/AIDS . Focus of the review Determinants of non‐compliance with Antiretroviral Therapy among adults living with HIV/AIDS . Types of studies Quantitative study design s were considered for inclusion . Types of outcomes Socio‐economic , Health service , Psychosocial and behavioural and Clinical related outcomes . Search strategy English language articles published between January1997 and December 2011 were sought across major data bases . Method ological quality Method ological quality was assessed using Joanna Briggs Institute Meta Analysis of Statistical Assessment and Review Instrument critical appraisal tools . Data collection Data were extracted from papers included in the review by using a st and ardized data extraction tool . Data synthesis Meta‐ analysis was conducted using fixed and r and om effects model with mantel Haenszel method using Revman5 software . Heterogeneity between the studies was assessed using & khgr;2 test at a p‐value of < 0.05 . Summary statistics were expressed as adjusted odds ratio or adjusted risk ratio with 95 % confidence intervals at a p‐value of < 0.05 . Results Nine studies ( seven cross‐sectional , one cohort study and one case‐control study ) were included in the review . Results from meta analysis showed that white race adults living with HIV/AIDS  were 1.38 times more likely to non‐comply with Antiretroviral Therapy when compared with black adults living with HIV/ AIDS ( Adjusted Relative Risk=1.38 ; 95%CI=1.21 , 1.58 , p value<0.00001 ) .  Non‐depressed adults living with HIV/AIDS  were 1.77 times more likely to non‐comply with Antiretroviral Therapy when compared with depressed adults living with HIV/AIDS ( Adjusted Odds ratio = 1.77 ; 95%CI=1.17 , 2.69 , p value=0.007 ) . Substance non‐user adults living with HIV/ AIDS were 2.04 times more likely to non‐comply with Antiretroviral Therapy when compared with substance user adults living with HIV/ AIDS ( Adjusted Relative Risk = 2.04 ; 95%CI=1.51 , 2.74 , p value=<0.00001 ) . Adults living with HIV/ AIDS with baseline CD4 count ≥200cells/ml were 1.8 times more likely to non‐comply with Antiretroviral Therapy when compared with adults livings with HIV/ AIDS with baseline CD4 count ≥200cells/ml ( Adjusted Odds ratio=1.84 ; 95%CI=1.08 , 3.15 , p value=0.03 ) . Conclusion We found the base line CD4 count ≥200cells/ml , not being depressed ; not using substances and being white in race were associated with non‐compliance with Antiretroviral Therapy . Implication s for practice Behavioural change via counselling should be encouraged as a way to increase compliance . Reminders to take mediations regularly , on time , offering encouragement to keep going , helping to keep clinic appointments and providing emotional support for adults living with HIV/AIDS is important . Implication s for research Further research utilizing more robust experimental methods would help to further explore the findings of this review OBJECTIVE To develop and vali date a scale suitable for use in clinical practice as a tool for assessing prolonged pain in premature infants . METHODS Pain indicators identified by observation of preterm infants and selected by a panel of experts were used to develop the EDIN scale ( Échelle Douleur Inconfort Nouveau-Né , neonatal pain and discomfort scale ) . A cohort of preterm infants was studied prospect ively to determine construct validity , inter-rater reliability , and internal consistency of the scale . RESULTS The EDIN scale uses five behavioural indicators of prolonged pain : facial activity , body movements , quality of sleep , quality of contact with nurses , and consolability . The validation study included 76 preterm infants with a mean gestational age of 31.5 weeks .  Inter-rater reliability was acceptable , with a κ coefficient range of 0.59–0.74 . Internal consistency was high : Cronbach 's α coefficients calculated after deleting each item ranged from 0.86 to 0.94 . To establish construct validity , EDIN scores in two extreme situations ( pain and no pain ) were compared , and a significant difference was observed . CONCLUSIONS The validation data suggest that the EDIN is appropriate for assessing prolonged pain in preterm infants . Further studies are warranted to obtain further evidence of construct validity by comparing scores in less extreme situations Background A global antimicrobial resistance ( AMR ) awareness intervention targeting the general public has been prioritized . Objectives To evaluate the effectiveness of interventions that aim to change AMR awareness and subsequent stewardship behaviours amongst the public . Methods Five data bases were search ed between 2000 and 2016 for interventions to change the public 's AMR awareness and /or antimicrobial stewardship behaviours . Study design s meeting the Cochrane Effective Practice and Organization of Care ( EPOC ) criteria , non-controlled before- and -after studies and prospect i ve cohort studies were considered eligible . Participants recruited from healthcare setting s and studies measuring stewardship behaviours of healthcare professionals were excluded .  Quality of studies was assessed using EPOC risk of bias criteria . Data were extracted and synthesized narratively . Registration : PROSPERO international prospect i ve register of systematic review s ( PROSPERO 2016 : CRD42016050343 ) . Results Twenty studies were included in the review with nine meeting the EPOC criteria . The overall risk of bias was high . Nineteen studies were conducted in high-income countries .  Mass media interventions were most common ( n = 7 ) , followed by school-based ( n = 6 ) and printed material interventions ( n = 6 ) . Seventeen studies demonstrated a significant effect on changing knowledge , attitudes or the public 's antimicrobial stewardship behaviours . Analysis showed that interventions targeting schoolchildren and parents have notable potential , but for the general public the picture is less clear . Conclusions Our work provides an in-depth examination of the effectiveness of AMR interventions for the public . However , the studies were heterogeneous and the quality of evidence was poor . Well- design ed , experimental studies on behavioural outcomes of such interventions are required Background : The efficacy of epidural and facet joint injections has been assessed utilizing multiple solutions including saline , local anesthetic , steroids , and others . The responses to these various solutions have been variable and have not been systematic ally assessed with long-term follow-ups . Methods : R and omized trials utilizing a true active control design were included . The primary outcome measure was pain relief and the secondary outcome measure was functional improvement . The quality of each individual article was assessed by Cochrane review criteria , as well as the criteria developed by the American Society of Interventional Pain Physicians ( ASIPP ) for assessing interventional techniques . An evidence analysis was conducted based on the qualitative level of evidence ( Level I to IV ) . Results : A total of 31 trials met the inclusion criteria . There was Level I evidence that local anesthetic with steroids was effective in managing chronic spinal pain  based on multiple high- quality r and omized controlled trials . The evidence also showed that local anesthetic with steroids and local anesthetic alone were equally effective except in disc herniation , where the superiority of local anesthetic with steroids was demonstrated over local anesthetic alone . Conclusion : This systematic review showed equal efficacy for local anesthetic with steroids and local anesthetic alone in multiple spinal conditions except for disc herniation where the superiority of local anesthetic with steroids was seen over local anesthetic alone Background Systematic review s ( SRs ) are expected to critically appraise included studies and privilege those at lowest risk of bias ( RoB ) in the synthesis . This study examines if and how critical appraisal s inform the synthesis and interpretation of evidence in SRs . Methods All SRs published in March – May 2012 in 14 high-ranked medical journals and a sample from the Cochrane library were systematic ally assessed by two review ers to determine if and how : critical appraisal was conducted ; RoB was summarised at study , domain and review levels ; and RoB appraisal s informed the synthesis process . Results Of the 59 SRs studied , all except six ( 90 % ) conducted a critical appraisal of the included studies , with most using or adapting existing tools . Almost half of the SRs reported critical appraisal in a manner that did not allow readers to determine which studies included in a review were most robust . RoB assessment s were not incorporated into synthesis in one-third ( 20 ) of the SRs , with their consideration more likely when review s focused on r and omised controlled trials . Common methods for incorporating critical appraisal s into the synthesis process were sensitivity analysis , narrative discussion and exclusion of studies at high RoB. Nearly half of the review s which investigated multiple outcomes and carried out study -level RoB summaries did not consider the potential for RoB to vary across outcomes . Conclusions The conclusions of the SRs , published in major journals , are frequently uninformed by the critical appraisal process , even when conducted . This may be particularly problematic for SRs of public health topics that often draw on diverse study design Prediction relates to estimating the probability of something currently unknown . In the context of medical research , prediction typically concerns either diagnosis ( probability of a certain condition being present but not yet detected ) or prognosis ( probability of an outcome developing in the future ) ( 13 ) . Prognosis applies not only to sick persons or those with an established diagnosis but also to , for example , pregnant women at risk for diabetes ( 4 ) . Prediction research includes predictor finding studies , prediction model studies ( development , validation , and extending or updating ) , and prediction model impact studies ( 1 ) . Predictor finding studies ( also known as risk factor or prognostic factor studies ) aim to identify which predictors ( such as age , disease stage , or biomarkers ) independently contribute to the prediction of a diagnostic or prognostic outcome ( 1 , 5 ) . Prediction model studies aim to develop , vali date , or up date ( for example , extend ) a multivariable prediction model . A prediction model uses multiple predictors in combination to estimate probabilities to inform and often guide individual care ( 2 , 6 , 7 ) . These models can predict an individual 's probability of either currently having a particular outcome or disease ( diagnostic prediction model ) or having a particular outcome in the future ( prognostic prediction model ) . Both types of model are widely used in various medical domains and setting s ( 810 ) , as evidence d by the large number of models developed in cancer ( 11 , 12 ) , neurology ( 13 , 14 ) , and cardiovascular disease ( 15 ) . Prediction models are sometimes described as  risk prediction models , predictive models , prediction indices or rules , or risk scores ( 2 , 7 ) . An example is QRISK2 for predicting cardiovascular risk ( 16 ) . Prediction model impact studies evaluate the effect of using a model to guide patient care compared with not using such a model . They use a comparative design , such as a r and omized trial , to study the model 's effect on clinical decision making , patient outcomes , or costs of care ( 1 ) . Systematic review s have a key role in evidence -based medicine and the development of clinical guidelines ( 1719 ) . They are considered to provide the most reliable form of evidence for the effects of an intervention or diagnostic test ( 20 , 21 ) . Systematic review s of prediction models are a relatively new and evolving area but are increasingly undertaken to systematic ally identify , appraise , and summarize evidence on the performance of prediction models ( 1 , 6 , 22 ) . Assessing the quality of included studies is a crucial step in any systematic review ( 20 , 21 ) . The QUIPS ( Quality In Prognosis Studies ) tool has been developed to assess risk of bias ( ROB ) in predictor finding ( prognostic factor ) studies ( 23 ) . Research ers can use the revised Cochrane ROB Tool ( ROB 2.0 ) ( 24 ) to investigate the method ological quality of prediction model impact studies that use a r and omized comparative design , or ROBINS-I ( Risk Of Bias In Nonr and omized Studies of Interventions ) for those that use a nonr and omized comparative design ( 25 ) . As more prediction model studies and systematic review s of such studies are used as evidence for clinical guidance , a tool facilitating quality assessment for individual prediction model studies is urgently needed . We present PROBAST ( Prediction model Risk Of Bias ASsessment Tool ) , a tool to assess the ROB and concerns regarding the applicability of diagnostic and prognostic prediction model studies . PROBAST can be used to assess studies of model development and model validation , including those updating a prediction model ( Box 1 [ 26 ] ) . We refer to the accompanying explanation and elaboration document ( 27 ) , for detailed explanations of how to use PROBAST and how to judge ROB and applicability . Box 1 . Types of diagnostic and prognostic modeling studies or reports addressed by PROBAST . Adopted from the TRIPOD ( Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis ) and CHARMS ( CHecklist for critical Appraisal and data extraction for systematic Review s of prediction Modelling Studies ) guidance ( 7 , 26 ) . PROBAST = Prediction model Risk Of Bias ASsessment Tool . Methods : Development of PROBAST Development of PROBAST was based on a 4-stage approach for developing health research reporting guidelines : define the scope , review the evidence base , use a Web-based Delphi procedure , and refine the tool through piloting ( 28 ) . Guidelines explicitly aim ed at the development of quality assessment tools were not available at the time ( 29 ) . Development Stage 1 : Scope and Definitions A steering group of 9 experts in prediction model studies and development of quality assessment tools agreed on key features of the desired scope of PROBAST . A panel of 38 experts with different background s further refined the scope during the Web-based Delphi procedure . PROBAST was design ed mainly to assess primary studies included in a systematic review . The group agreed that PROBAST would assess both risk of bias and concerns regarding applicability of a study evaluating a multivariable prediction model to be used for individualized diagnosis or prognosis . A domain-based structure was adopted , similar to that used in other ROB tools , such as ROB 2.0 ( 24 ) , ROBINS-I ( 25 ) , QUADAS-2 ( Quality Assessment of Diagnostic Accuracy Studies 2 ) ( 30 ) , and ROBIS ( 31 ) . We agreed that PROBAST should cover primary studies that develop , vali date , or up date multivariable prediction models aim ing to make individualized predictions of a diagnostic or prognostic outcome ( Box 1 ) . Studies that use multivariable modeling techniques to identify predictors ( such as risk or prognostic factors ) associated with an outcome but do not attempt to develop , vali date , or up date a model for making individualized predictions are not covered by PROBAST ( 5 ) . Therefore , PROBAST is not intended for predictor finding studies or prediction model impact studies . Studies of diagnostic and prognostic models often use different terms for predictors and outcomes ( Box 2 ) . A multivariable prediction model is defined as any combination or equation of 2 or more predictors for estimating probability or risk for an individual ( 6 , 7 , 3234 ) . Box 2 . Differences between diagnostic and prognostic prediction model studies . PROBAST = Prediction model Risk Of Bias ASsessment Tool . Development Stage 2 : Review of Evidence We used the following 3 approaches to build an evidence base to inform the development of PROBAST : identifying relevant method ological review s in the area of prediction model research ( November 2012 to January 2013 ) , asking members of the steering group to identify relevant method ological studies ( January 2013 to March 2013 ) , and using the Delphi procedure to ask members of the wider group to identify additional evidence ( February 2012 to July 2014 ) . Identified literature was used to guide the scope and produce an initial list of signaling questions to consider for inclusion in PROBAST ( 1 , 2 , 57 , 26 , 3340 ) . We grouped signaling questions into common themes to identify possible domains . Additional literature provided as part of the Web-based surveys informed development of the explanation and elaboration document . Development Stage 3 : Web-Based Delphi Procedure We used a modified Delphi process to gain feedback and agreement on the scope , structure , and content of PROBAST . Web-based surveys were developed to gather structured feedback for each round . The 38-member Delphi group comprised method ological experts in prediction model research and development of quality assessment tools , experienced systematic review ers , commissioners , and representatives of reimbursement agencies . We included various stakeholders to ensure that the views of end users , method ological experts , and decision makers were represented . The Delphi process consisted of 7 rounds . Round 1 asked about the scope of the tool , and participants agreed to focus on prediction model studies and follow a domain-based structure . Round 2 aim ed to identify relevant domains and agree on which to include . The signaling questions for domains were refined in rounds 3 to 5 . Respondents used a 1-to-5 Likert scale to rate each proposed signaling question for inclusion . They could also suggest rephrasing , provide supporting evidence ( such as references to relevant studies ) , and suggest missing signaling questions . Round 6 refined the domains and introduced further optional guidance for using PROBAST . In the last round , participants received the agreed draft version of PROBAST and had the opportunity to provide any final feedback . Development Stage 4 : Piloting and Refining the Tool We held 6 workshops on PROBAST at consecutive annual Cochrane Colloquia ( Quebec , Canada , 2013 ; Hyderabad , India , 2014 ; Vienna , Austria , 2015 ; Seoul , South Korea , 2016 ; Cape Town , South Africa , 2017 ; and Edinburgh , United Kingdom , 2018 ) . We also held numerous consecutive workshops with MSc and PhD students ( for example , the master 's program in epidemiology at Utrecht University [ Utrecht , the Netherl and s ] and the Evidence -Based Health Care program at Oxford University [ Oxford , United Kingdom ] ) . In these workshops , we piloted the then-current version of PROBAST to gather feedback on practical issues associated with using the tool so that we could further refine and subsequently vali date it . Finally , more than 50 review groups have already piloted PROBAST versions , including the final version , in their review s. Topics included cancer , cardiology , endocrinology , pulmonology , and orthopedics . All feedback received from these initiatives was used to further inform the content and structure of PROBAST , wording of the signaling questions , and content of the guidance documents ( 27 ) . Results : The PROBAST Tool What Does PROBAST Assess ? PROBAST assesses both risk of bias and concerns regarding applicability of primary studies that developed or vali date d multivariable prediction models for diagnosis or prognosis ( Boxes 1 and 2 ) Background Across the developed world , we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision . Integrated care pathways ( ICPs ) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration . ICPs map out a patient 's journey , providing coordination of services for users . They aim to have : ' the right people , doing the right things , in the right order , at the right time , in the right place , with the right outcome ' . The value for ICPs in supporting the delivery of care across organisational boundaries , providing greater consistency in practice , improving service continuity and increasing collaboration has been advocated by many . However , there is little evidence to support their use , and the need for systematic evaluations in order to measure their effectiveness has been widely identified . A recent Cochrane review assessed the effects of ICPs on functional outcome , process of care , quality of life and hospitalisation costs of in patients with acute stroke , but did not specifically focus on service integration or its derivatives . To the best of our knowledge , no such systematic review of the literature exists . Objectives To systematic ally review all high‐ quality studies which have evaluated the impact of care pathway technologies on ' service integration ' and its derivatives in stroke care To examine how elements of service integration are defined in such studies To examine the type of evidence utilised to measure service integration To analyse the weight of evidence used to support cl aims about the effectiveness of ICPs on improving service integration To produce recommendations for ICP developers , users and evaluators . Inclusion criteria Types of participants The review focused on the care of adult patients who had suffered a stroke . It included the full spectrum of services ‐ acute care , rehabilitation and long‐term support ‐ in hospital and community setting s. Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest , defined for the purpose of this review as ' a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and st and ardise the outcome orientated care ' . Here ' multidisciplinary ' is taken to refer to the involvement of two or more disciplines . Types of outcomes Service integration ' was the outcome of interest however , this was defined and measured in the selected studies . Types of studies This review was concerned with how ' service integration ' was defined in evaluations of ICPs ; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on ' service integration ' . Studies that made an explicit link between ICPs and service integration were included in the review . Evidence generated from r and omised controlled trials , quasi‐experimental , qualitative and health economics research was sought . The search was limited to publications after 1980 , coinciding with the emergence of ICPs in the healthcare context . Assessment for inclusion of foreign papers was based on the English‐ language abstract , where available . These were included only if an English translation was available . Exclusion criteria This review excluded studies that : focused only on a single aspect of stroke care ( e.g. dysphasia ) evaluated ICPs as part of a wider program of service development did not make an explicit link between ICPs and service integration did not meet the definition of ICP utilised for the purpose s of the review focused exclusively on the outcomes of variance analysis Search strategy In order to avoid replication , the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Data base and the Cochrane Library were search ed to establish that no systematic review s existed and none were in progress . A three‐stage search strategy was then used to identify both published and unpublished studies ( see Appendix III ) . Data collection Our search strategy located 2123 papers , of which 39 were retrieved for further evaluation . We critically appraised seven papers , representing five studies . These were all evaluation studies and , as is typical in this field , comprised a range of study design s and data collection methods . Owing to the diversity of the study types included in the review , we developed a single‐ appraisal checklist and data ‐ extraction tool which could be applied to all research design s.32 The tool drew on the Joanna Briggs Institute ( JBI ) appraisal checklists for experimental studies and interpretive and critical research , and also incorporated specific information and issues which were relevant for our purpose s ( see Appendix VI ) . This extends the thinking outlined in Lyne et al.31 in which , drawing on Campbell and Stanley 's classic paper , the case is made for developing an appraisal tool which is applicable to all types of evaluation , irrespective of study design . In assessing the quality of the papers , we were sympathetic to the method ological challenges of evaluating complex interventions such as ICPs . We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare context s. In accordance with the aims of this particular review , we have included studies , which are method ologically weaker than is typical of many systematic review s because , in our view , in the absence of stronger evidence , they yield useful information . Data synthesis Given the heterogeneity of the included studies , meta‐ analysis and /or qualitative synthesis was not possible . A narrative summary of the study findings is presented . Results ICPs can be effective in ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner , although these improvements may reflect better documentation rather than actual changes in practice . ICPs can be effective in improving the documentation of rehabilitation goals , documentation of communication with patients , carers ( diagnosis , prognosis and follow‐up arrangements ) and documentation of notification of primary care physicians of discharge . However , this can create additional burdens of work for staff . Early studies of  ICP‐managed care in the acute stroke context have demonstrated reduced length of stay without any associated adverse effects on discharge destination , morbidity or mortality . These effects do not reach statistical significance , however , and may reflect wider changes in service provision and a general trend towards reduced length of hospital stay . While later studies in the acute and rehabilitation context s do not reveal any significant reduction in length of stay , they do report greater documented use of certain clinical interventions and assessment s , suggesting that ICPs can be effective in mobilising hospital re sources around the patient . ICPs implemented in the context of acute stroke care can be effective in reducing the occurrence of urinary tract infections , although we do not know whether this can be attributed to improved service integration . ICP management in stroke rehabilitation may not be flexible enough to meet diverse patient needs and can result in insufficient attention to higher‐level functioning and carer needs influencing perceptions of quality of life . ICP management may assist in clarifying role boundaries and a shared underst and ing of the work , but this can result in some members of the disciplinary team perceiving that their contribution is not appropriately reflected in the documentation . There is some evidence that ICPs may be effective in changing professional behaviours in the desired direction where there is scope for improvement , but in situations in which multidisciplinary working is effective , their positive effects may be limited . Furthermore , it is far from clear what the active ingredients of ICPs actually are . Kwan et al. suggest that it was the process of ICP development that had most impact on behaviours rather than the use of the artefact per se.20 None of the studies assessed the balance of costs and benefits of ICP use . Therefore , we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits . Conclusions Implication s for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care . This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of re sources around the patient without incurring additional increases in length of stay . ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable . Their value in the context of rehabilitation setting s in which recovery pathways are more variable is less clear . There is some evidence that ICPs may be effective in bringing about behavioural changes in context s where deficiencies in service provision have been identified . Their value in context s where inter‐professional working is well established is less clear . While earlier before and after studies show a reduction in length of stay in ICP‐managed care , this may reflect wider healthcare trends , and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced . There is some evidence to suggest that ICPs bring about improvements in documentation , but we do not know how far documented practice reflects actual practice . It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use . As none of the studies review ed included an economic evaluation , moreover , it remains unclear whether the benefits of ICPs UNLABELLED EXECUTIVE SUMMARY : BACKGROUND Across the developed world , we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision . Integrated care pathways ( ICPs ) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration . ICPs map out a patient 's journey , providing coordination of services for users . They aim to have : ' the right people , doing the right things , in the right order , at the right time , in the right place , with the right outcome ' . The value for ICPs in supporting the delivery of care across organisational boundaries , providing greater consistency in practice , improving service continuity and increasing collaboration has been advocated by many . However , there is little evidence to support their use , and the need for systematic evaluations in order to measure their effectiveness has been widely identified . A recent Cochrane review assessed the effects of ICPs on functional outcome , process of care , quality of life and hospitalisation costs of in patients with acute stroke , but did not specifically focus on service integration or its derivatives . To the best of our knowledge , no such systematic review of the literature exists . OBJECTIVES • To systematic ally review all high- quality studies which have evaluated the impact of care pathway technologies on ' service integration ' and its derivatives in stroke care • To examine how elements of service integration are defined in such studies • To examine the type of evidence utilised to measure service integration • To analyse the weight of evidence used to support cl aims about the effectiveness of ICPs on improving service integration • To produce recommendations for ICP developers , users and evaluators . INCLUSION CRITERIA Types of participants The review focused on the care of adult patients who had suffered a stroke . It included the full spectrum of services - acute care , rehabilitation and long-term support - in hospital and community setting s. Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest , defined for the purpose of this review as ' a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and st and ardise the outcome orientated care ' Here ' multidisciplinary ' is taken to refer to the involvement of two or more disciplines . Types of outcomes ' Service integration ' was the outcome of interest however , this was defined and measured in the selected studies . Types of studies This review was concerned with how ' service integration ' was defined in evaluations of ICPs ; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on ' service integration ' . Studies that made an explicit link between ICPs and service integration were included in the review . Evidence generated from r and omised controlled trials , quasi-experimental , qualitative and health economics research was sought . The search was limited to publications after 1980 , coinciding with the emergence of ICPs in the healthcare context . Assessment for inclusion of foreign papers was based on the English- language abstract , where available . These were included only if an English translation was available . EXCLUSION CRITERIA This review excluded studies that : • focused only on a single aspect of stroke care ( e.g. dysphasia ) • evaluated ICPs as part of a wider program of service development • did not make an explicit link between ICPs and service integration • did not meet the definition of ICP utilised for the purpose s of the review • focused exclusively on the outcomes of variance analysis SEARCH STRATEGY In order to avoid replication , the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Data base and the Cochrane Library were search ed to establish that no systematic review s existed and none were in progress . A three-stage search strategy was then used to identify both published and unpublished studies ( see Appendix III ) . DATA COLLECTION Our search strategy located 2123 papers , of which 39 were retrieved for further evaluation . We critically appraised seven papers , representing five studies . These were all evaluation studies and , as is typical in this field , comprised a range of study design s and data collection methods . Owing to the diversity of the study types included in the review , we developed a single- appraisal checklist and data - extraction tool which could be applied to all research design s.(32 ) The tool drew on the Joanna Briggs Institute ( JBI ) appraisal checklists for experimental studies and interpretive and critical research , and also incorporated specific information and issues which were relevant for our purpose s ( see Appendix VI ) . This extends the thinking outlined in Lyne et al.(31 ) in which , drawing on Campbell and Stanley 's classic paper , the case is made for developing an appraisal tool which is applicable to all types of evaluation , irrespective of study design . In assessing the quality of the papers , we were sympathetic to the method ological challenges of evaluating complex interventions such as ICPs . We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare context s. In accordance with the aims of this particular review , we have included studies , which are method ologically weaker than is typical of many systematic review s because , in our view , in the absence of stronger evidence , they yield useful information . DATA SYNTHESIS Given the heterogeneity of the included studies , meta- analysis and /or qualitative synthesis was not possible . A narrative summary of the study findings is presented . RESULTS 1 ICPs can be effective in ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner , although these improvements may reflect better documentation rather than actual changes in practice . 2 ICPs can be effective in improving the documentation of rehabilitation goals , documentation of communication with patients , carers ( diagnosis , prognosis and follow-up arrangements ) and documentation of notification of primary care physicians of discharge . However , this can create additional burdens of work for staff . 3 Early studies of ICP-managed care in the acute stroke context have demonstrated reduced length of stay without any associated adverse effects on discharge destination , morbidity or mortality . These effects do not reach statistical significance , however , and may reflect wider changes in service provision and a general trend towards reduced length of hospital stay . While later studies in the acute and rehabilitation context s do not reveal any significant reduction in length of stay , they do report greater documented use of certain clinical interventions and assessment s , suggesting that ICPs can be effective in mobilising hospital re sources around the patient . 4 ICPs implemented in the context of acute stroke care can be effective in reducing the occurrence of urinary tract infections , although we do not know whether this can be attributed to improved service integration . 5 ICP management in stroke rehabilitation may not be flexible enough to meet diverse patient needs and can result in insufficient attention to higher-level functioning and carer needs influencing perceptions of quality of life . 6 ICP management may assist in clarifying role boundaries and a shared underst and ing of the work , but this can result in some members of the disciplinary team perceiving that their contribution is not appropriately reflected in the documentation . 7 There is some evidence that ICPs may be effective in changing professional behaviours in the desired direction where there is scope for improvement , but in situations in which multidisciplinary working is effective , their positive effects may be limited . Furthermore , it is far from clear what the active ingredients of ICPs actually are . Kwan et al. suggest that it was the process of ICP development that had most impact on behaviours rather than the use of the artefact per se.(20 ) 8 None of the studies assessed the balance of costs and benefits of ICP  use . Therefore , we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits . CONCLUSIONS Implication s for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care . This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of re sources around the patient without incurring additional increases in length of stay .  ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable . Their value in the context of rehabilitation setting s in which recovery pathways are more variable is less clear . There is some evidence that ICPs may be effective in bringing about behavioural changes in context s where deficiencies in service provision have been identified . Their value in context s where inter-professional working is well established is less clear . While earlier before and after studies show a reduction in length of stay in ICP-managed care , this may reflect wider healthcare trends , and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced . There is some evidence to suggest that ICPs bring about improvements in documentation , but we do not know how far documented practice reflects actual practice . It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use . ( ABSTRACT TRUNCATED BACKGROUND Many critical appraisal tools ( CATs ) exist for which there is little or no information on development of the CAT , evaluation of validity , or testing reliability . The proposed CAT was developed based on a number of other CATs , general research methods theory , and reporting guidelines but requires further study to determine its effectiveness . OBJECTIVES To establish a scoring system and to evaluate the construct validity of the proposed critical appraisal tool before undertaking reliability testing . METHODS Data obtained from this exploratory study along with information on the design of the proposed CAT were combined to evaluate construct validity using the St and ards for educational and psychological testing which consist of five types of evidence : test content , response process , internal structure , relations to other variables , and consequences of testing . To obtain data for internal structure and relations to other variables , the proposed CAT was analysed against five alternative CATs . A r and om sample of 10 papers from six different research design s across the range of health related research were selected , giving a total sample size of 60 papers . RESULTS In all research design s , the proposed CAT had significant ( p<0.05 , two-tailed ) weak to moderate positive correlations ( Kendall 's τ 0.33 - 0.55 ) with the alternative CATs , except in the Preamble category . There were significant moderate to strong positive correlations in the quasi-experimental ( τ 0.70 - 1.00 ) , descriptive/exploratory/observational ( τ 0.72 - 1.00 ) , qualitative ( τ 0.74 - 0.81 ) , and systematic review ( τ 0.62 - 0.82 ) design s and to a lesser extent in the true experimental ( τ 0.68 - 0.70 ) design . There were no significant correlations in the single system research design s. CONCLUSIONS Based on the results obtained , the theory on which the proposed CAT was design ed , and the objective of the proposed CAT there was enough evidence to show that inferences made from scores obtained from the proposed CAT should be sound Objectives . Overview the quality , direction , and characteristics of yoga interventions for treatment of acute and chronic health conditions in adult population s. Methods . We search ed for systematic review s in 10 online data bases , bibliographic references , and h and - search es in  yoga-related  journals . Included review s satisfy Oxman criteria and specify yoga as a primary intervention in one or more r and omized controlled trials for treatment in adults . The AMSTAR tool and GRADE approach evaluated the method ological quality of review s and quality of evidence . Results . We identified 2202 titles , of which 41 full-text articles were assessed for eligibility and 26 systematic review s satisfied inclusion criteria . Thirteen systematic review s include quantitative data and six papers include meta- analysis . The quality of evidence is generally low . Sixteen different types of health conditions are included . Eleven review s show tendency towards positive effects of yoga intervention , 15 review s report unclear results , and no , review s report adverse effects of yoga . Yoga appears most effective for reducing symptoms in anxiety , depression , and pain . Conclusion . Although the quality of systematic review s is high , the quality of supporting evidence is low . Significant heterogeneity and variability in reporting interventions by type of yoga , setting s , and population characteristics limit the generalizability of results Background Available information suggests a mismatch between radiographic and orthopedic examination findings in cats with DJD . However , the extent of the discrepancy between clinical and radiographic signs of OA in companion animals has not been described in detail . This study aim ed to evaluate the relationship between orthopedic examination findings , joint goniometry  , and radiographic signs of DJD in 100 cats , in a prospect i ve observational design . Cat temperament , pain response to palpation , joint crepitus , effusion and thickening were grade d. Radiographs of appendicular joints and the axial skeleton were made under sedation . Joint motion was measured by use of a plastic goniometer before and after sedation . Associations between radiographic degenerative joint disease ( DJD ) and examination findings were assessed to determine sensitivity , specificity and likelihood estimations . Results Pain response to palpation was elicited in 0 - 67 % of the joints with DJD , with a specificity ranging from 62 - 99 % ; crepitus was detected in 0 - 56 % of the joints and its specificity varied between 87 and 99 % ; for effusion , values ranged between 6 and 38 % ( specificity , 82 - 100 % ) , and thickening , 0 - 59 % ( specificity , 74 - 99 % ) . Joints with DJD tended to have a decreased range of motion . The presence of pain increased the odds of having DJD in the elbow ( right : 5.5 ; left : 4.5 ) ; the presence of pain in the lower back increased the odds of spinal DJD being present ( 2.97 for lumbar ; 4.67 for lumbo-sacral ) . Conclusions Radiographic DJD can not be diagnosed with certainty using palpation or goniometry . However , negative findings tend to predict radiographically normal joints . Palpation and goniometry may be used as a tool to help to screen cats , mostly to rule out DJD Prognosis studies are investigations of future events or the evaluation of associations between risk factors and health outcomes in population s of patients ( 1 ) . The results of such studies improve our underst and ing of the clinical course of a disease and assist clinicians in making informed decisions about how best to manage patients . Prognostic research also informs the design of intervention studies by helping define subgroups of patients who may benefit from a new treatment and by providing necessary information about the natural history of a disorder ( 2 ) . There has recently been a rapid increase in the use of systematic review methods to synthesize the evidence on research questions related to prognosis . It is essential that investigators conducting systematic review s thoroughly appraise the method ologic quality of included studies to be confident that a study 's design , conduct , analysis , and interpretation have adequately reduced the opportunity for bias ( 3 , 4 ) . Caution is warranted , however , because inclusion of method ologically weak studies can threaten the internal validity of a systematic review ( 4 ) . This follows abundant empirical evidence that inadequate attention to biases can cause invalid results and inferences ( 5 - 9 ) . However , there is limited consensus on how to appraise the quality of prognosis studies ( 1 ) . A useful framework to assess bias in such studies follows the basic principles of epidemiologic research ( 10 , 11 ) . We focus on 6 areas of potential bias : study participation , study attrition , prognostic factor measurement , confounding measurement and account , outcome measurement , and analysis . The main objectives of our review of review s are to describe methods used to assess the quality of prognosis studies and to describe how well current practice s assess potential biases . Our secondary objective is to develop recommendations to guide future quality appraisal , both within single studies of prognostic factors and within systematic review s of the evidence . We hope this work facilitates future discussion and research on biases in prognosis studies and systematic review s. Methods Literature Search and Study Selection We identified systematic review s of prognosis studies by search ing MEDLINE ( 1966 to October 2005 ) using the search strategy recommended by McKibbon and colleagues ( 12 ) . This strategy combines broad search terms for systematic review s ( systematic review .mp ; meta- analysis .mp ) and a sensitive search strategy for prognosis studies ( cohort , incidence , mortality , follow-up studies , prognos * , predict * , or course ) . We also search ed the reference lists of included review s and method ologic papers to identify other relevant publications . We restricted our search to English- language publications . One review er conducted the search and selected the studies . Systematic review s , defined as review s of published studies with a comprehensive search and systematic selection , were included if they assessed the method ologic quality of the included studies by using 1 or more explicit criteria . We excluded studies if they were meta-analyses of independent patient data only , if their primary goal was to investigate the effectiveness of an intervention or specific diagnostic or screening tests , or if they included studies that were not done on humans . Data Extraction and Synthesis Individual items included in the quality assessment of the systematic review s were recorded as they were reported in the publication ( that is , the information that would be available to readers and future review ers ) . We review ed journal Web sites and contacted the authors of the systematic review s for additional information when authors made such an offer in their original papers . When review s assessed different study design s by using different sets of quality items , we extracted only those items used to assess cohort studies . We constructed a comprehensive list of distinct items that the review s used to assess the quality of their included studies . The full text of each review was screened . All items used by the review authors to assess the quality of studies were extracted into a computerized spreadsheet by 1 review er . Two experienced review ers , a clinical epidemiologist and an epidemiologist , independently synthesized the quality items extracted from the prognosis review s to determine how well the systematic review s assessed potential biases . We did this in 3 steps : 1 ) identified distinct concepts or domains addressed by the quality items ; 2 ) grouped each extracted quality item into the appropriate domain or domains ; and 3 ) identified the domains necessary to assess potential biases in prognosis studies . We then used this information to assess how well the review s ' quality assessment included items from the domains necessary to assess potential biases . After completing each of the first 3 steps , the review ers met to attempt to reach a consensus . The consensus process involved each review er presenting his or her observations and results , followed by discussion and debate . A third review er was available in cases of persistent disagreement or uncertainty . In the first step , all domains addressed by the quality items were identified . The first review er iteratively and progressively defined the domains as items were extracted from the included review s. The second review er defined domains from a r and om list of all extracted quality items . Limited guidance was provided to the review ers so that their assessment s and definitions of domains would be independent . The review ers agreed on a final set of domains that adequately and completely defined all of the extracted items . In the second step , review ers independently grouped each extracted item into the appropriate domains . Review ers considered each extracted item by asking , What is each particular quality item addressing ? or What are the review 's authors getting at with the particular quality assessment item ? . Items were grouped into the domain or domains that best represented the concepts being addressed . For example , the extracted items at least 80 % of the group originally identified was located for follow-up and follow-up was sufficiently complete or does n't jeopardize validity were each independently classified by both review ers as assessing the domain completeness of follow-up adequate , whereas the extracted item quantification and description of all subjects lost to follow-up was classified as assessing the domain completeness of follow-up described . In the third step , we identified the domains necessary to assess potential biases . Each review er considered the ability of the identified domains to adequately address , at least in part , 1 of the following 6 potential biases : 1 ) study participation , 2 ) study attrition , 3 ) prognostic factor measurement , 4 ) confounding measurement and account , 5 ) outcome measurement , and 6 ) analysis . Domains were considered to adequately address part of the framework if information garnered from that domain would inform the assessment of potential bias . For example , both review ers judged that the identified domain study population represents source population or population of interest assessed potential bias in a prognosis study , whereas the domain research question definition did not , although the latter is an important consideration in assessing the inclusion of studies in a systematic review . Finally , on the basis of our previous ratings , we looked at whether each review included items from the domains necessary to assess the 6 potential biases . We calculated the frequency of systematic review s by assessing each potential bias and the number of review s that adequately assessed bias overall . From this systematic synthesis , we developed recommendations for improving quality appraisal in future systematic review s of prognosis studies . We used Microsoft Access and Excel 2002 ( Microsoft Corp. , Redmond , Washington ) for data management and SAS for Windows , version 9.1 ( SAS Institute , Inc. , Cary , North Carolina ) for descriptive statistics . Role of the Funding Sources The funding sources , the Canadian Institutes of Health Research , the Canadian Chiropractic Research Foundation , the Ontario Chiropractic Association , and the Ontario Ministry of Health and Long Term Care , did not have a role in the collection , analysis , or interpretation of the data or in the decision to su bmi t the manuscript for publication . Results We identified 1384 potentially relevant articles . Figure 1 shows a flow chart of studies that were included and excluded . Figure 2 shows the number of review s identified by year of publication . We excluded 131 systematic review s of prognosis studies that did not seem to include any quality assessment of the included studies ; this represented 44 % of prognosis review s. We included 163 review s of prognosis studies in our analysis ( 13 - 175 ) . The most common topics were cancer ( 15 % ) , musculoskeletal disorders and rheumatology ( 13 % ) , cardiovascular ( 10 % ) , neurology ( 10 % ) , and obstetrics ( 10 % ) . Other review s included a wide range of health and health care topics . Sixty-three percent of the review s investigated the association between a specific prognostic factor and a particular outcome ; the remainder investigated multiple prognostic factors or models . The number of primary studies included in each systematic review ranged from 3 to 167 ( median , 18 [ interquartile range , 12 to 31 ] ) . A complete description of the included review s is available from the authors on request . Figure 1 . Flow diagram of inclusion and exclusion criteria of systematic review s. Figure 2 . Number of systematic review s of prognosis studies identified over time . Quality Items One hundred fifty-three review s provided adequate detail to allow extraction of quality items . Eight hundred eighty-two distinct quality items were extracted from the review s. Most review s developed their own set of quality items , with only a few applying criteria from previous review s. Most quality items OBJECTIVE In the course of performing systematic review s on the prevalence of low back and neck pain , we required a tool to assess the risk of study bias . Our objectives were to ( 1 ) modify an existing checklist and ( 2 ) test the final tool for interrater agreement . STUDY DESIGN AND SETTING The final tool consists of 10 items addressing four domains of bias plus a summary risk of bias assessment . Two research ers tested the interrater agreement of the tool by independently assessing 54 r and omly selected studies .  Interrater agreement overall and for each individual item was assessed using the proportion of agreement and Kappa statistic . RESULTS Raters found the tool easy to use , and there was high interrater agreement : overall agreement was 91 % and the Kappa statistic was 0.82 ( 95 % confidence interval : 0.76 , 0.86 ) . Agreement was almost perfect for the individual items on the tool and moderate for the summary assessment . CONCLUSION We have addressed a research gap by modifying and testing a tool to assess risk of study bias . Further research may be useful for assessing the applicability of the tool across different conditions Summary Quantitative sensory testing in 7‐ and 14‐year‐olds based on a priori sample size calculations revealed higher pain sensitivity in 7‐year‐olds , but no sex‐related differences and similar detection thresholds . ABSTRACT There are controversial discussion s regarding developmental‐ and sex‐related differences in somatosensory perception , which were found , eg , when comparing younger children ( 6–8 years ) , older children ( 9–12 years ) , and adolescents ( 13–16 years ) using quantitative sensory testing ( QST ) . The aim of our current study was to systematic ally assess the impact of age and sex using the QST protocol of the German Research Network on Neuropathic Pain ( DFNS ) . QST , including thermal and mechanical detection and pain thresholds , was assessed in 86 healthy 7‐year‐old children ( 42 girls and 44 boys ) and 87 healthy 14‐year‐old adolescents ( 43 girls and 44 boys ) . The sample size was calculated a priori to detect medium‐sized effects as found in the previous studies with adequate power . Developmental and sex differences were tested using univariate analysis of variance . Children were more sensitive to most pain stimuli , except cold pain stimuli , compared with adolescents , but did not differ in mechanical and thermal detection thresholds except in regard to cold stimuli . Sex had an impact only on warm detection , with girls being more sensitive . There were no interactions between age and sex . In conclusion , developmental changes during the puberty appear to influence pain perception , whereas sex effects in childhood are negligible . At present , it is not clear what brings about the differences between adult men and women that are apparent in epidemiological studies . Our results contradict the hypothesis that differences in peripheral nerve‐fiber functioning underlie sex effects Background Osteoarthritis ( OA ) is a common cause of pain and disability , and is the most common form of arthritis in the Western world . The most common joint to be affected is the knee . Pain and functional disability are common symptoms , which can lead to reduced quality of life and increase the risk of further morbidity . Current treatment aims to educate patients about the management of OA , reduce pain , improve function , decrease disability and reduce the progression of the disease . Education with clients has been described as a set of planned educational activities design ed to improve patients ' health behaviours and /or health status . The purpose of self‐education is to maintain or improve health , or , in some cases , to slow deterioration by increasing participant 's perception of self efficacy defined as an ability to control or manage various aspects of OA . To date , there is no systematic review of the literature undertaken to identify the effectiveness of self‐management educational activities for osteoarthritis of the knee . Objective The objective of this systematic review is to evaluate the effectiveness of  self‐management educational interventions on function and quality of life for adult subjects with OA of the knee . Search strategy A comprehensive search strategy was undertaken on data bases available from University of South Australia from their inception to January 2007 . Selection criteria R and omised controlled trials or clinical controlled trials were sought which evaluated any self management interventions for osteoarthritis knee . Critical appraisal of study quality was undertaken using Joanna Briggs Institute critical appraisal instruments . Data extraction was via the Joanna Briggs Institute st and ard data extraction form for evidence of effectiveness , and Review Manager Software was used to calculate comparative statistics . Results Thirteen trials were included in the review . Trials were clinical ly and method ologically heterogeneous . Pooled results indicate evidence of a beneficial effect from  self management strategies with reducing pain ( SMD ‐0.25 , 95%CI ‐0.36 to ‐0.13 , 11 trials 1379 participants ) . There was no effect on physical function ( SMD 0.13 , 95%CI ‐0.33 to ‐0.08 , eight trials , 1156 subjects ) . No beneficial effects were found from self management interventions with improving quality of life . We also found the exercise component of self management ( four trials ) demonstrated a benefit with reducing pain , improving function and quality of life . Exercise also offered a benefit over no exercise  . Overall method ological quality was moderate . Discussion Pooled results indicate evidence of a beneficial effect from self management strategies with reducing pain and improving function . Significant heterogeneity was found between trials . This was controlled for in the analysis but may be explained by heterogeneity in both the intervention and control group . The exercise component of self management programmes appears to contribute a significant benefit . Conclusion There is encouraging evidence of a small benefit from exercise in self management programs . Clear guidelines can not be provided for practice regarding the exercise content due to heterogeneity but overall benefit suggests this component should be emphasized and implemented in primary care self management programmes STUDY QUESTION Are there differences in the method ological quality of Cochrane systematic review s ( CRs ) and non-Cochrane systematic review s ( NCRs ) of assisted reproductive technologies ? SUMMARY ANSWER CRs on assisted reproduction are of higher method ological quality than similar review s published in other journals . WHAT IS KNOWN ALREADY The quality of systematic review s varies . STUDY DESIGN , SIZE AND DURATION This was a cross-sectional study of 30 CR and 30 NCR systematic review s that were r and omly selected from the eligible review s identified from a literature search for the years 2007 - 2011 . MATERIAL S , SETTING AND METHODS We extracted data on the reporting and method ological characteristics of the included systematic review s. We assessed the method ological quality of the review s using the 11-domain Measurement Tool to Assess the Method ological Quality of Systematic Review s ( AMSTAR ) tool and subsequently compared CR and NCR systematic review s. MAIN RESULTS AND THE ROLE OF CHANCE The AMSTAR quality assessment found that CRs were superior to NCRs . For 10 of 11 AMSTAR domains , the requirements were met in > 50 % of CRs , but only 4 of 11 domains showed requirements being met in > 50 % of NCRs . The strengths of CRs are the a priori study design , comprehensive literature search , explicit lists of included and excluded studies and assessment s of internal validity . Significant failings in the CRs were found in duplicate study selection and data extraction ( 67 % meeting requirements ) , assessment for publication bias ( 53 % meeting requirements ) and reporting of conflicts of interest ( 47 % meeting requirements ) . NCRs were more likely to contain method ological weaknesses as the majority of the domains showed < 40 % of review s meeting requirements , e.g. a priori study design ( 17 % ) , duplicate study selection and data extraction ( 17 % ) , assessment of study quality ( 27 % ) , study quality in the formulation of conclusions ( 23 % ) and reporting of conflict of interests ( 10 % ) . LIMITATIONS , REASONS FOR CAUTION The AMSTAR assessment can only judge what is reported by authors . Although two of the five authors are involved in the production of CRs , the risk of bias was reduced by not involving these authors in the assessment of the systematic review quality . WIDER IMPLICATION S OF THE FINDINGS Not all systematic review s are equal . The reader needs to consider the quality of the systematic review when they consider the results and the conclusions of a systematic review . STUDY FUNDING /COMPETING INTEREST(S ) There are no conflicts with any commercial organization . Funding was provided for the students by the summer studentship programme of the Faculty of Medical and Health Sciences of the University of Auckl and Background In contemporary medical research , r and omised controlled trials are seen as the gold st and ard for establishing treatment effects where it is ethical and practical to conduct them . In palliative care such trials are often impractical , unethical , or extremely difficult , with multiple method ological problems . We review the utility of Cochrane review s in informing palliative care practice . Methods Published review s in palliative care registered with the Cochrane Pain , Palliative and Supportive Care Group as of December 2007 were obtained from the Cochrane Data base of Systematic Review s , issue 1 , 2008 . We review ed the quality and quantity of primary studies available for each review , assessed the quality of the review process , and judged the strength of the evidence presented . There was no prior intention to perform any statistical analyses . Results 25 published systematic review s were identified . Numbers of included trials ranged from none to 54 . Within each review , included trials were heterogeneous with respect to patients , interventions , and outcomes , and the number of patients contributing to any single analysis was generally much lower than the total included in the review . A variety of tools were used to assess trial quality ; seven review s did not use this information to exclude low quality studies , weight analyses , or perform sensitivity analysis for effect of low quality . Authors indicated that there were frequently major problems with the primary studies , individually or in aggregate . Our judgment was that the review ing process was generally good in these review s , and that conclusions were limited by the number , size , quality and validity of the primary studies .We judged the evidence about 23 of the 25 interventions to be weak . Two review s had stronger evidence , but with limitations due to method ological heterogeneity or definition of outcomes . No review provided strong evidence of no effect . Conclusion Cochrane review s in palliative care are well performed , but fail to provide good evidence for clinical practice because the primary studies are few in number , small , clinical ly heterogeneous , and of poor quality and external validity . They are useful in highlighting the weakness of the evidence base and problems in performing trials in palliative care Background Breast cancer ( BC ) is the most common type of cancer in women worldwide . Post-treatment , patients suffer from side effects and have various rehabilitation needs , which means that individualization is fundamental for optimal rehabilitation . This systematic review ( SR ) of SRs aims to evaluate the current evidence on rehabilitation interventions in female patients following BC treatment . Methods Full-text SRs published in English from 2009 were search ed in Embase , PubMed , Cinahl Complete , PsycINFO , AMED , SCOPUS , and Cochrane Library . Inclusion criteria : SRs of r and omized or non-r and omized controlled trials investigating the effects of  rehabilitation interventions in women following BC treatment . All outcomes were considered . Method ological quality was evaluated using the AMSTAR 2 tool and interrater agreement was evaluated . Out of 1269 citations retrieved , 37 SRs were included . Results Five rehabilitation areas were identified : exercise and physical activity ( PA ) , complementary and alternative medicine ( CAM ) , yoga , lymphoedema treatment , and psychosocial interventions . The most solid evidence was found in exercise/PA and yoga . Exercise interventions improved outcomes such as shoulder mobility , lymphoedema , pain , fatigue and quality of life ( QoL ) . Effects of yoga were shown on QoL , anxiety , depression , sleep disturbance , fatigue and gastrointestinal symptoms . The effect of CAM was shown on nausea , pain , fatigue , anger and anxiety but these results need to be interpreted with caution because of low method ological quality in included studies in the SRs . Among the lymphoedema treatments , positive effects were seen for resistance training on volume reduction and muscle strength and psychosocial interventions such as cognitive behavioural therapy had positive effects on QoL , anxiety , depression and mood disturbance . Conclusions This SR of SRs show solid positive effects of exercise/PA and yoga for women following BC treatment , and provides extended knowledge of the effects of CAM , yoga , lymphoedema treatment and psychosocial interventions . It is evident that more than one intervention could have positive effects on a specific symptom and that the effects depend not only on intervention type but also on how and when the intervention is provided . The results can be used as a foundation for individualized rehabilitation and aid health care professionals in meeting patients ’ individual needs and preferences . Trial registration PROSPERO ( CRD42017060912 ) Study Design . The Oswestry Disability Index v2.0 ( ODI ) , SF36 Physical Function Domain ( SF-36 PFD ) , and PROMIS Physical Function CAT v1.2 ( PF CAT ) question naires were prospect ively collected from 1607 patients complaining of back or leg pain , visiting a university-based spine clinic . All question naires were collected electronically , using a tablet computer . Objective . The aim of this study was to compare the psychometric properties of the PROMIS PF CAT with the ODI and SF36 Physical Function Domain in the same patient population . Summary of Background Data . Evidence -based decision-making is improved by using high- quality patient-reported outcomes measures . Prior studies have revealed the shortcomings of the ODI and SF36 , commonly used in spine patients . The PROMIS Network has developed measures with excellent psychometric properties . The Physical Function domain , delivered by Computerized Adaptive Testing ( PF CAT ) , performs well in the spine patient population , though to- date direct comparisons with common measures have not been performed . Methods . St and ard Rasch analysis was performed to directly compare the psychometrics of the PF CAT , ODI , and SF36 PFD . Spearman correlations were computed to examine the correlations of the three instruments . Time required for administration was also recorded . Results . One thous and six hundred seven patients were administered all assessment s. The time required to answer all items in the PF CAT , ODI , and SF-36 PFD was 44 , 169 , and 99 seconds . The ceiling and floor effects were excellent for the PF CAT ( 0.81 % , 3.86 % ) , while the ceiling effects were marginal and floor effects quite poor for the ODI ( 6.91 % and 44.24 % ) and SF-36 PFD ( 5.97 % and 23.65 % ) . All instruments significantly correlated with each other . Conclusion . The PROMIS PF CAT outperforms the ODI and SF-36 PFD in the spine patient population and is highly correlated . It has better coverage , while taking less time to administer with fewer questions to answer . Level of Evidence : Review question / objective The objective of this review is to synthesize the best available evidence related to the effectiveness of music as pain relieving method among preterm infants during painful procedures in the neonatal intensive care unit . Review questions are : Among preterm infants in the neonatal intensive care unit , is music effective in reducing pain scores ? physiological pain indicators ? behavioural pain indicators ? hormonal pain indicators ? Background Patients and context Preterm infants ( i.e. babies born at or before 37 gestational weeks ) compose a patient group of the most vulnerable to pain . Infants treated in a neonatal intensive care unit ( NICU ) are exposed to a variety of painful procedures ( e.g. heel prick , iv cannula insertion , endotracheal suctioning ) and to environmental stress ( e.g. noise , light ) . Simons et al.1 , for example , described an average 14 + /‐ 4 painful procedures during the first 2 weeks of life within a period of 24 hours among 151 neonates . Many studies have shown that repeated and sustained pain can have direct and long‐term consequences on the neurological and behavior‐oriented development of the neonates during the rapid development phase of the central nervous system . Pain can cause detectable physiological , behavioral and hormonal changes2,3,4 and contribute to the altered development of the pain system during later childhood and adolescence3,4,50 . Instead , live music such as singing is excellent type of music when it is steady , constant , quiet , soothing and directed to the infants6 . Graven7 emphasizes that recorded sound should not replace human voice exposure in the NICU ; therefore , health care providers should provide ample opportunity for the infant to hear parent 's voices live , such as singing or humming , in interactions between the parent and the infant at the bedside . The AmericanAcademy of Pediatrics Committee on Environmental Health has recommended safe levels of sound8 , and these recommendations have been up date d by an expert team of practitioners . Recommendations specify that continuous sound should not exceed an hourly equivalent sound level of 50 A‐weighted decibels (dBA)7,8,9 , and music as an auditory stimulus not exceed 75 dB in NICU6,8,10 . If earphones or other devices are used , sound sources should be kept at reasonable distances from the infant 's ear , played for brief periods and at levels below 55 dB7 . Music listening can be initiated with or without the involvement of a music therapist . In this review , music can be implemented for premature infants by a music therapist or any health care providers and it will include both recorded and live music . Outcomes Regardless of the type of music , several studies have investigated the short term effects of music on preterm infants , including the improvement in physiological outcomes ( e.g. oxygen saturation , heart rate , respiratory rate , and blood pressure ) , as well as in behavioural state ( e.g. crying , facial expression , body movements ) and pain scores6,11,12,13 . For example , Chou et al. 6 showed that premature infants receiving recorded music , that was the combination of womb sounds and the mother singing , with endotracheal suctioning had significantly higher oxygen saturation than when they did not receive music . Butt & Kisilewsky12 compared recorded music involving both the vocal and instrumental version of Brahms lullaby versus no music , and found that infants older than 31 weeks demonstrated significant reduction in heart rate , behavioral state and pain . In the study of Arnon et al.11 the infants receiving live music , compared with infants receiving recorded music or no music , had significantly reduced heart rate and behavioral scores during the post‐intervention period . Live music comprised of a lullaby sang by the female voice with frame drum and an accompanying harp . The same music was played by a tape recorder . Live music showed significant benefits , whereas no statistically significant changes were found for the recorded music and control groups . Teckenberg‐Jansson et al.13 indicated that music therapy combined with kangaroo care  decreased the pulse , slowed down the respiration and increased the transcutaneous oxygen saturation in preterm infants . The musical instruments used were a lyre and a female human voice , which hummed or sang . There is evidence that music has also positive consequences on long‐term outcomes , including length of hospitalization , weight gain , and non‐nutritive sucking10,13,14,15 . For example , in the study of Caine16 the preterm infants received music stimulation which consisted of recorded vocal music ( including lullabies and children 's music ) and routine auditory stimulation . Exposure to the music stimulation had many positive effects on preterm infants , such as it increased daily average weight , formula and caloric intake , and significantly reduced total hospital stays and stress behaviors for the experimental group . In addition , according to Lubetzky et al.10 exposure to music by Mozart significantly lowered energy expenditure among healthy preterm infants . Hartling et al.17 have published a systematic review on the efficacy of music for medical indicators in term and preterm neonates . Nine r and omized trials ( 1989‐2006 ) were included . According to the results of this review music may have positive effects on physiological parameters and behavioral states , and may reduce pain and improve oral feeding rates among the premature infants . The effects of music were evaluated during medical procedures ( circumcision , heel prick ) and for other indicators . In addition , Cignacco et al.18 conducted a systematic literature review on the efficacy of non‐pharmacological interventions in the management of procedural pain in preterm and term neonates during the period from 1984 to 2004 . According to this review there was no clear evidence that the method of music could have a pain‐alleviating effect on neonates . In the Cochrane Library , one systematic review is also available up to year of 2011 concerning  non‐pharmacological  management of infants and young children ( preterm , neonate , older up to three years ) during procedural pain19 , but this review did not consider music as an intervention . To date , there is also one meta‐ analysis published by St and ley20 concerning the efficacy of music therapy  for premature infants during the period from 1950 to 1999 . It concluded that music was beneficial for many outcomes among the preterm infants in the NICU . However , the results of this review were limited by the poor method ological quality of the included studies , and unclear reporting on the phases of review . In our systematic review , studies published in 2000 and after will be considered for inclusion in the review . The number of the RCT 's concerning the effectiveness of music  among the preterm infants in NICU is especially increased during the last few years , and these studies have not included in the previous systematic review s and meta‐ analysis BACKGROUND Multiple sclerosis ( MS ) is a major cause of chronic , neurological disability , with a significant long-term disability burden , often requiring comprehensive rehabilitation . OBJECTIVES To systematic ally evaluate evidence from published Cochrane Review s of clinical trials to summarise the evidence regarding the effectiveness and safety of rehabilitation interventions for people with MS ( pwMS ) , to improve patient outcomes , and to highlight current gaps in knowledge . METHODS We search ed the Cochrane Data base of Systematic Review s up to December 2017 , to identify Cochrane Review s that assessed the effectiveness of organised rehabilitation interventions for pwMS . Two review ers independently assessed the quality of included review s , using the Revised Assessment of Multiple Systematic Review s ( R-AMSTAR ) tool , and the quality of the evidence for reported outcomes , using the GRADE framework . MAIN RESULTS Overall , we included 15 review s published in the Cochrane Library , comprising 164 r and omised controlled trials ( RCTs ) and four controlled clinical trials , with a total of 10,396 participants . The included review s evaluated a wide range of rehabilitation interventions , including : physical activity and exercise therapy , hyperbaric oxygen therapy ( HBOT ) , whole-body vibration , occupational therapy , cognitive and psychological interventions , nutritional and dietary supplements , vocational rehabilitation , information provision , telerehabilitation , and interventions for the management of spasticity . We assessed all review s to be of high to moderate method ological quality , based on R-AMSTAR criteria .Moderate- quality evidence suggested that physical therapeutic modalities ( exercise and physical activities ) improved functional outcomes ( mobility , muscular strength ) , reduced impairment ( fatigue ) , and improved participation ( quality of life ) . Moderate- quality evidence suggested that inpatient or outpatient multidisciplinary rehabilitation programmes led to longer-term gains at the levels of activity and participation , and interventions that provided information improved patient knowledge . Low-qualitty evidence suggested that neuropsychological interventions , symptom-management programmes ( spasticity ) , whole body vibration , and telerehabilitation improved some patient outcomes . Evidence for other rehabilitation modalities was inconclusive , due to lack of robust studies . AUTHORS ' CONCLUSIONS The evidence suggests that regular specialist evaluation and follow-up to assess the needs of patients with all types of MS for appropriate rehabilitation interventions may be of benefit , although the certainty of evidence varies across the different types of interventions evaluated by the review s. Structured , multidisciplinary rehabilitation programmes and physical therapy ( exercise or physical activities ) can improve functional outcomes ( mobility , muscle strength , aerobic capacity ) , and quality of life . Overall , the evidence for many rehabilitation interventions should be interpreted cautiously , as the majority of included review s did not include data from current studies . More studies , with appropriate design , which report the type and intensity of modalities and their cost-effectiveness are needed to address the current gaps in knowledge A key component of the Cochrane Collaboration 's risk of bias tool for critically evaluating r and omised trials is the consideration of whether baseline characteristics of the treatment groups being compared are systematic ally different . Considered under the domain of ' selection bias ' , this is currently evaluated by looking at the methods of r and omisation and specifically at the generation of the r and omised allocation sequence and the concealment of this sequence during the process of r and omisation . Assessment of the actual similarity of baseline variables across groups in demographic and clinical characteristics is seldom performed . Even when performed , the link with selection bias is sometimes not considered . Methods of r and omisation and allocation concealment are often poorly reported in published trials , yet baseline data tables are presented in a large majority of trial reports . In this article , we propose that assessment of trial baseline data should form a key and prominent part of selection bias judgements when using the risk of bias tool . We outline the possible benefits from using this approach , including reduced uncertainty in systematic review conclusions , reduced risk of chance findings being ascribed to treatment effects and better use of available evidence by a more considered approach to evaluating studies using imperfect r and omisation and allocation methods Background Musculoskeletal disorders ( MSDs ) are the leading cause of work disability and sickness absence worldwide . The prevalence of MSDs increases with age , consequently challenging sustainable employability among the growing ageing workforce . Knowledge of feasible and efficient workplace-based interventions to rehabilitate MSD or prevent its consequences is therefore warranted . This systematic review will evaluate the effectiveness of workplace-based interventions on MSDs and its consequences among adult workers with physical and sedentary work tasks , respectively . Methods We will search the following bibliographic data bases : PubMed ( including the data base ‘ MEDLINE ’ ) and Web of Science Core Collection ( including the data bases ‘ Science Citation Index Exp and ed ’ , ‘ Social Sciences Citation Index ’ and ‘ Arts & Humanities Citation Index ’ ) . Manual search es will also be performed . We will include r and omised controlled trials ( RCTs ) and non- RCTs reported in English in which ( 1 ) participants are adult workers with MSD , ( 2 ) interventions are aim ing at rehabilitating pain symptoms of MSD or preventing the consequences of MSD and ( 3 ) interventions are initiated and /or carried out at the workplace . The review will adhere to the ‘ Preferred Reporting Items for Systematic review s and Meta-Analyses ’ ( PRISMA ) guidelines for reporting systematic review s and the Institute for Work and Health ( IWH ) guidelines for workplace-based interventions . For the primary evaluation of the review , the quality assessment and evidence synthesis will conform to the IWH guidelines . Secondary evaluation will include a meta- analysis ( unless the included studies do not allow this due to heterogeneity ) and employ the risk of bias domains recommended by Cochrane along with the Grading of Recommendations , Assessment , Development and Evaluations ( GRADE ) approach on the studies with pain intensity as an outcome . Discussion This systematic review will provide knowledge on effective workplace-based interventions among physical and sedentary workers with MSD . RCTs are considered the most powerful experimental design in clinical trials , but solely including these may be too restrictive to underst and effective workplace-based interventions where r and omised and carefully controlled trials ( RCTs ) are not always possible . In order to maximize practical relevance , the selection process will , therefore , include both RCTs and non- RCTs and the quality assessment and evidence synthesis will conform to IWH guidelines focusing on developing practical guidelines for stakeholders . The result of this work will form the basis for industry-specific evidence -based recommendations on effective workplace-based interventions for rehabilitation of MSDs and its consequences that will later be operationalised into concrete and user-friendly practical tools for workplaces . Systematic review registration International Prospect i ve Register of Systematic Review s ( PROSPERO ) number CRD42018116752 The purpose of this study was to examine the psychometric properties ( test-retest and interrater reliability , criterion concurrent validity ) of 3 verbal pain- assessment tools ( Faces Pain Scale , Numerical Rating Scale , Present Pain Intensity Scale )  and a behavioural pain- assessment scale for use with an elderly population . The study used a repeated- measures design to examine the reliability and validity of the tools across 4 groups of participants with varying levels of cognitive impairment using a non-r and om stratified sample of 130 elderly long-term-care residents . The findings support the test-retest and interrater reliability of the  behavioural pain- assessment tool  across all levels of cognitive impairment , whereas the same measures of reliability for the verbal-report tools decreased with increasing cognitive impairment ; however , the majority of elderly with mild to moderate cognitive impairment were able to complete at least 1 of these tools . The findings are discussed in relation to their clinical and research implication An influential review in 2010 concluded that non-pharmacological multi-component interventions have positive effects on cognitive functioning , activities of daily living , behaviour and mood of people with dementia . Our aim here is to provide an up-to- date overview of research into psychosocial interventions and their impact on psychosocial outcomes . We focused on r and omised controlled trials , controlled studies and review s published between October 2008 and August 2015 , since the earlier review . The search of PsychInfo , Medline and the Cochrane data base of systematic review s yielded 61 relevant articles , organised into four themes echoing key phases of the care pathway : Living at home with dementia ( five review s , eight studies ) , carer interventions ( three review s , four studies ) , interventions in residential care ( 16 review s , 12 studies ) and end-of-life care ( three review s , two studies ) , along with an additional group spanning community and institutional setting s ( six review s , two studies ) . Community findings suggested that appointment of dementia specialists and attention to case management can produce positive outcomes ;  physical therapies , cognitive training and modified cognitive behaviour therapy also had a range of benefits . There was more limited evidence of positive benefits for people with dementia through interventions with family carers . Thirty-two articles focused on the management of ‘ behavioural symptoms ’ through a range of interventions all of which had some evidence of benefit . Also a range of multi-component and specific interventions had benefits for cognitive , emotional and behavioural well-being of people with dementia in residential setting s , as well as for quality of life . Overall , interventions tended to be short term with impact only measured in the short term . We recommend further research on interventions to promote living well in the community post-diagnosis and to address end-of-life care . Development of psychosocial interventions would benefit from moving beyond the focus on control of behaviours to focus on wider aspects of life for people with dementia Objective Despite the increasing numbers of published trials of quality improvement ( QI ) interventions in diabetes , little is known about the risk of bias in this literature . Design Secondary analysis of a systematic review . Data sources Medline , the Cochrane Effective Practice and Organisation of Care ( EPOC ) data base ( from inception to July 2010 ) and references of included studies . Eligibility criteria R and omised trials assessing 11 predefined QI strategies or financial incentives targeting health systems , healthcare professionals or patients to improve the management of adult out patients with diabetes . Analysis Risk of bias ( low , unclear or high ) was assessed for the 142 trials in the review across nine domains using the EPOC version of the Cochrane Risk of Bias Tool . We used Cochran-Armitage tests for trends to evaluate the improvement over time . Results There was no significant improvement over time in any of the risk of bias domains . Attrition bias ( loss to follow-up ) was the most common source of bias , with 24 trials ( 17 % ) having high risk of bias due to incomplete outcome data . Overall , 69 trials ( 49 % ) had at least one domain with high risk of bias . Inadequate reporting frequently hampered the risk of bias assessment : allocation sequence was unclear in 82 trials ( 58 % ) and allocation concealment was unclear in 78 trials ( 55 % ) . There were significant reductions neither in the proportions of studies at high risk of bias over time nor in the adequacy of reporting of risk of bias domains . Conclusions Nearly half of the included QI trials in this review were judged to have high risk of bias . Such trials have serious limitations that put the findings in question and therefore inhibit evidence -based QI . There is a need to limit the potential for bias when conducting QI trials and improve the quality of reporting of QI trials so that stakeholders have adequate evidence for implementation REFERENCE : Bleakley C , McDonough S , MacAuley D. The use of ice in the treatment of acute soft-tissue injury : a systematic review of r and omized controlled trials . Am J Sport Med . 2004 ; 32:251 - 261 . CLINICAL QUESTION : What is the clinical evidence base for cryotherapy use ? DATA SOURCES : Studies were identified by using a computer-based literature search on a total of 8 data bases : MEDLINE , Proquest , ISI Web of Science , Cumulative Index to Nursing and Allied Health ( CINAHL ) on Ovid , Allied and Complementary Medicine Data base ( AMED ) on Ovid , Cochrane Data base of Systematic Review s , Cochrane Data base of Abstract s of Review s of Effectiveness , and Cochrane Controlled Trials Register ( Central ) . This was supplemented with citation tracking of relevant primary and review articles . Search terms included surgery , orthopaedics , sports injury , soft tissue injury , sprains and strains , contusions , athletic injury , acute , compression , cryotherapy , ice , RICE , and cold . STUDY SELECTION : To be included in the review , each study had to fulfill the following conditions : be a r and omized , controlled trial of human subjects ; be published in English as a full paper ; include patients recovering from acute soft tissue or orthopaedic surgical interventions who received cryotherapy in inpatient , outpatient , or home-based treatment , in isolation or in combination with placebo or other therapies  ; provide comparisons with no treatment , placebo , a different mode or protocol of cryotherapy , or other physiotherapeutic interventions ; and have outcome measures that included function ( subjective or objective ) , pain , swelling , or range of motion . DATA EXTRACTION : The study population , interventions , outcomes , follow-up , and reported results of the assessed trials were extracted and tabulated . The primary outcome measures were pain , swelling , and range of motion . Only 2 groups reported adequate data for return to normal function . All eligible articles were rated for method ologic quality using the PEDro scale . The PEDro scale is a checklist that examines the believability ( internal validity ) and the interpretability of trial quality . The 11-item checklist yields a maximum score of 10 if all criteria are satisfied . The intraclass correlation coefficient and kappa values are similar to those reported for 3 other frequently used quality scales ( Chalmers Scale , Jadad Scale , and Maastricht List ) . Two review ers grade d the articles , a method that has been reported to be more reliable than one evaluator . MAIN RESULTS : Specific search criteria identified 55 articles for review , of which 22 were eligible r and omized , controlled clinical trials . The articles ' scores on the PEDro scale were low , ranging from 1 to 5 , with an average score of 3.4 . Five studies provided adequate information on the subjects ' baseline data , and only 3 studies concealed allocation during subject recruitment . No studies blinded their therapist 's administration of therapy , and just 1 study blinded subjects . Only 1 study included an intention-to-treat analysis . The average number of subjects in the studies was 66.7 ; however , only 1 group undertook a power analysis . The types of injuries varied widely ( eg , acute or surgical ) . No authors investigated subjects with muscle contusions or strains , and only 5 groups studied subjects with acute ligament sprains . The remaining 17 groups examined patients recovering from operative procedures ( anterior cruciate ligament repair , knee arthroscopy , lateral retinacular release , total knee and hip arthroplasties , and carpal tunnel release ) . Additionally , the mode of cryotherapy varied widely , as did the duration and frequency of cryotherapy application . The time period when cryotherapy was applied after injury ranged from immediately after injury to 1 to 3 days postinjury . Adequate information on the actual surface temperature of the cooling device was not provided in the selected studies . Most authors recorded outcome variables over short periods ( 1 week ) , with the longest reporting follow-ups of pain , swelling , and range of motion recorded at 4 weeks postinjury . Data in that study were insufficient to calculate effect size . Nine studies did not provide data of the key outcome measures , so individual study effect estimates could not be calculated . A total of 12 treatment comparisons were made . Ice submersion with simultaneous exercises was significantly more effective than heat and contrast therapy plus simultaneous exercises at reducing swelling .  Ice was reported to be no different from ice and low-frequency or high-frequency electric stimulation in effect on swelling , pain , and range of motion .  Ice alone seemed to be more effective than applying no form of cryotherapy after minor knee surgery in terms of pain , but no differences were reported for range of motion and girth . Continuous cryotherapy was associated with a significantly greater decrease in pain and wrist circumference after surgery than intermittent cryotherapy . Evidence was marginal that a single simultaneous treatment with ice and compression is no more effective than no  cryotherapy  after an ankle sprain . The authors reported ice to be no more effective than rehabilitation only with regard to pain , swelling , and range of motion .  Ice and compression seemed to be significantly more effective than ice alone in terms of decreasing pain . Additionally , ice , compression , and a placebo injection reduced pain more than a placebo injection alone . Lastly , in 8 studies , there seemed to be little difference in the effectiveness of ice and compression  compared with  compression alone . Only 2 of the 8 groups reported significant differences in favor of ice and compression . CONCLUSIONS : Based on the available evidence , cryotherapy seems to be effective in decreasing pain . In comparison with other rehabilitation techniques , the efficacy of cryotherapy has been question ed . The exact effect of cryotherapy on more frequently treated acute injuries ( eg , muscle strains and contusions ) has not been fully eluci date d. Additionally , the low method ologic quality of the available evidence is of concern . Many more high- quality studies are required to create evidence -based guidelines on the use of cryotherapy . These must focus on developing modes , duration s , and frequencies of ice application that will optimize outcomes after injury Background : Plantar fasciitis is a common condition routinely managed by podiatrists in the community and is widely treated conservatively . Two commonly used treatments for plantar fasciitis are customized functional foot orthoses and corticosteroid injections . While common to clinical practice , the evidence base underpinning these treatment strategies is unknown . Therefore , the aim of this systematic review was to assess the effectiveness and safety of customized functional foot orthoses and corticosteroid injections in the treatment of plantar fasciitis . Methods : A systematic literature search was conducted . Experimental studies , in English , from 1998 to 2010 were accepted for inclusion in this review . The PEDro quality assessment tool and the National Health and Medical Research Council ’s hierarchy of evidence were used to assess the quality of the included studies . Results : Six r and omized controlled trials which met the selection criteria were included in this review . Four reported on customized functional foot orthoses and 2 on corticosteroid injections . Current best available evidence highlights that both customized functional foot orthoses and corticosteroid injections can lead to a decrease in pain associated with plantar fasciitis . Additionally , customized functional foot orthoses may also provide an additional benefit in terms of increased functional ability in patients with plantar fasciitis .  Corticosteroid injections may have side effects , especially pain ( from the injection ) . Conclusion : Both customized functional foot orthoses and corticosteroid injections can lead to reduction in pain associated with plantar fasciitis . While customized functional foot orthoses may increase the functional outcomes in patients with plantar fasciitis , corticosteroid injections may have side effects ( especially pain as a result of the injection ) , which may limit its acceptability BACKGROUND CONTEXT Low back pain ( LBP ) is a prevalent disorder in society that has been associated with increased loss of work time and medical expenses . A common intervention for LBP is spinal manipulation , a technique that is not specific to one scope of practice or profession . PURPOSE The purpose of this systematic review was to examine the effectiveness of physical therapy spinal manipulations for the treatment of patients with low back pain . METHODS A search of the current literature was conducted using PubMed , CINAHL , SPORTD iscus , Pro Quest Nursing and Allied Health Source , Scopus , and Cochrane Controlled Trials Register . Studies were included if each involved : 1 ) individuals with LBP ; 2 ) spinal manipulations performed by physical therapists compared to any control group that did not receive manipulations ; 3 ) measurable clinical outcomes or efficiency of treatment measures , and 4 ) r and omized control trials . The quality of included articles was determined by two independent authors using the criteria developed and used by the Physiotherapy Evidence Data base ( PEDro ) . RESULTS Six r and omized control trials met the inclusion criteria of this systematic review . The most commonly used outcomes in these studies were some variation of pain rating scales and disability indexes . Notable results included varying degrees of effect sizes favoring physical therapy spinal manipulations and minimal adverse events result ing from this intervention . Additionally , the manipulation group in one study reported statistically significantly less medication use , health care utilization , and lost work time . CONCLUSION Based on the findings of this systematic review there is evidence to support the use of spinal manipulation by physical therapists in clinical practice . Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain Background Although numerous evidence -based and feasible interventions are available to treat pain from childhood vaccine injections , evidence indicates that children are not benefitting from this knowledge . Unrelieved vaccination pain puts children at risk for significant long-term harms including the development of needle fears and subsequent health care avoidance behaviours . Parents report that while they want to mitigate vaccination pain in their children , they lack knowledge about how to do so . An evidence -based clinical practice guideline for managing vaccination pain was recently developed in order to address this knowledge-to-care gap . Educational tools ( pamphlet and video ) for parents were included to facilitate knowledge transfer at the point of care . The objectives of this study were to evaluate usability and effectiveness in terms of knowledge acquisition from the pamphlet and video in parents of newly born infants . Methods Mixed methods design . Following heuristic usability evaluation of the pamphlet and video , parents of newborn infants review ed revised versions of both tools and participated in individual and group interviews and individual knowledge testing . The knowledge test comprised of 10 true/false questions about the effectiveness of various pain management interventions , and was administered at three time points : at baseline , after review of the pamphlet , and after review of the video . Results Three overarching themes were identified from the interviews regarding usability of these educational tools : receptivity to learning , accessibility to information , and validity of information . Parents ’  performance on the knowledge test improved ( p≤0.001 ) from the baseline phase to after review of the pamphlet , and again from the pamphlet review phase to after review of the video . Conclusions Using a robust testing process , we demonstrated usability and conceptual knowledge acquisition from a parent-directed educational pamphlet and video about management of vaccination pain . Future studies are planned to determine the impact of these educational tools when introduced in clinical setting s on parent behaviors during infant vaccinations Background Despite the availability of evidence -based guidelines for the management of mild traumatic brain injury in the emergency department ( ED ) , variations in practice exist . Interventions design ed to implement recommended behaviours can reduce this variation . Using theory to inform intervention development is advocated ; however , there is no consensus on how to select or apply theory . Integrative theoretical frameworks , based on syntheses of theories and theoretical constructs relevant to implementation , have the potential to assist in the intervention development process . This paper describes the process of applying two theoretical frameworks to investigate the factors influencing recommended behaviours and the choice of behaviour change techniques and modes of delivery for an implementation intervention . Methods A stepped approach was followed : ( i ) identification of locally applicable and actionable evidence -based recommendations as targets for change , ( ii ) selection and use of two theoretical frameworks for identifying barriers to and enablers of change ( Theoretical Domains Framework and Model of Diffusion of Innovations in Service Organisations ) and ( iii ) identification and operationalisation of intervention components ( behaviour change techniques and modes of delivery ) to address the barriers and enhance the enablers , informed by theory , evidence and feasibility/acceptability considerations . We illustrate this process in relation to one recommendation , prospect i ve assessment of post-traumatic amnesia ( PTA ) by ED staff using a vali date d tool . Results Four recommendations for managing mild traumatic brain injury were targeted with the intervention . The intervention targeting the PTA recommendation consisted of 14 behaviour change techniques and addressed 6 theoretical domains and 5 organisational domains . The mode of delivery was informed by six Cochrane review s. It was delivered via five intervention components : ( i ) local stakeholder meetings , ( ii ) identification of local opinion leader teams , ( iii ) a train-the-trainer workshop for appointed local opinion leaders , ( iv ) local training workshops for delivery by trained local opinion leaders and ( v ) provision of tools and material s to prompt recommended behaviours . Conclusions Two theoretical frameworks were used in a complementary manner to inform intervention development in managing mild traumatic brain injury in the ED . The effectiveness and cost-effectiveness of the developed intervention is being evaluated in a cluster r and omised trial , part of the Neurotrauma Evidence Translation ( NET ) program UNLABELLED In June 2008 , the Medical Advisory Secretariat began work on the Diabetes Strategy Evidence Project , an evidence -based review of the literature surrounding strategies for successful management and treatment of diabetes . This project came about when the Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the Ministry 's newly released Diabetes Strategy .After an initial review of the strategy and consultation with experts , the secretariat identified five key areas in which evidence was needed . Evidence -based analyses have been prepared for each of these five areas : insulin pumps , behavioural interventions , bariatric surgery , home telemonitoring , and community based care . For each area , an economic analysis was completed where appropriate and is described in a separate report . To review these titles within the Diabetes Strategy Evidence series , please visit the Medical Advisory Secretariat Web site , http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html,DIABETES STRATEGY EVIDENCE PLATFORM : Summary of Evidence -Based AnalysesContinuous Subcutaneous Insulin Infusion Pumps for Type 1 and Type 2 Adult Diabetics : An Evidence -Based Analysis Behavioural Interventions for Type 2 Diabetes : An Evidence -Based Analysis  BARIATRIC SURGERY FOR PEOPLE WITH DIABETES AND MORBID OBESITY : An Evidence -Based Summary Community-Based Care for the Management of Type 2 Diabetes : An Evidence -Based Analysis Home Telemonitoring for Type 2 Diabetes : An Evidence -Based Analysis Application of the Ontario Diabetes Economic Model ( ODEM ) to Determine the Cost-effectiveness and Budget Impact of Selected Type 2 Diabetes Interventions in Ontario OBJECTIVE The objective of this report is to determine whether behavioural interventions are effective in improving glycemic control in adults with type 2 diabetes . BACKGROUND Diabetes is a serious chronic condition affecting millions of people worldwide and is the sixth leading cause of death in Canada . In 2005 , an estimated 8.8 % of Ontario 's population had diabetes , representing more than 816,000 Ontarians . The direct health care cost of diabetes was $ 1.76 billion in the year 2000 and is projected to rise to a total cost of $ 3.14 billion by 2016 . Much of this cost arises from the serious long-term complications associated with the disease including : coronary heart disease , stroke , adult blindness , limb amputations and kidney disease . Type 2 diabetes accounts for 90 - 95 % of diabetes and while type 2 diabetes is more prevalent in people aged 40 years and older , prevalence in younger population s is increasing due to a rise in obesity and physical inactivity in children . Data from the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) has shown that tight glycemic control can significantly reduce the risk of developing serious complications in type 2 diabetics . Despite physicians ' and patients ' knowledge of the importance of glycemic control , Canadian data has shown that only 38 % of patients with diabetes have HbA1C levels in the optimal range of 7 % or less . This statistic highlights the complexities involved in the management of diabetes , which is characterized by extensive patient involvement in addition to the support provided by physicians . An enormous dem and is , therefore , placed on patients to self-manage the physical , emotional and psychological aspects of living with a chronic illness . Despite differences in individual needs to cope with diabetes , there is general agreement for the necessity of supportive programs for patient self-management . While traditional programs were didactic models with the goal of improving patients ' knowledge of their disease , current models focus on behavioural approaches aim ed at providing patients with the skills and strategies required to promote and change their behaviour . Several meta-analyses and systematic review s have demonstrated improved health outcomes with  self-management support programs in type 2 diabetics . They have all , however , either looked at a specific component of self-management support programs ( i.e. self-management education ) or have been conducted in specific population s. Most review s are also qualitative and do not clearly define the interventions of interest , making findings difficult to interpret . Moreover , heterogeneity in the interventions has led to conflicting evidence on the components of effective programs . There is thus much uncertainty regarding the optimal design and delivery of these programs by policymakers . EVIDENCE -BASED ANALYSIS OF EFFECTIVENESS : RESEARCH QUESTIONS Are behavioural interventions  effective in improving glycemic control in adults with type 2 diabetes?Is the effectiveness of the intervention impacted by intervention characteristics ( e.g. delivery of intervention , length of intervention , mode of instruction , interventionist etc . ) ? INCLUSION CRITERIA English Language Published between January 1996 to August 2008 Type 2 diabetic adult population ( > 18 years)R and omized controlled trials ( RCTs ) Systematic review s , or meta-analyses Describing a multi-faceted self-management support intervention as defined by the 2007 Self-Management Mapping Guide (1)Reporting outcomes of glycemic control ( HbA1c ) with extractable data Studies with a minimum of 6-month follow up EXCLUSION CRITERIA Studies with a control group other than usual care Studies with a sample size < 30 Studies without a clearly defined intervention OUTCOMES OF INTEREST PRIMARY OUTCOME glycemic control ( HbA1c ) SECONDARY OUTCOMES systolic blood pressure ( SBP ) control , lipid control , change in smoking status , weight change , quality of life , knowledge , self-efficacy , managing psychosocial aspects of diabetes , assessing dissatisfaction and readiness to change , and setting and achieving diabetes goals . SEARCH STRATEGY A search was performed in OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , EMBASE , the Cumulative Index to Nursing & Allied Health Literature ( CINAHL ) , The Cochrane Library , and the International Agency for Health Technology Assessment ( INAHTA ) for studies published between January 1996 and August 2008 . Abstract s were review ed by a single author and studies meeting the inclusion criteria outlined above were obtained . Data on population characteristics , glycemic control outcomes , and study design were extracted . Reference lists were also checked for relevant studies . The quality of the evidence was assessed as being either high , moderate , low , or very low according to the GRADE methodology . SUMMARY OF FINDINGS The search identified 638 citations published between 1996 and August 2008 , of which 12 met the inclusion criteria and one was a meta- analysis ( Gary et al. 2003 ) . The remaining 11 studies were RCTs ( 9 were used in the meta- analysis ) and only one was defined as small ( total sample size N=47 ) . SUMMARY OF PARTICIPANT DEMOGRAPHICS ACROSS STUDIES : A total of 2,549 participants were included in the 11 identified studies . The mean age of participants reported was approximately 58 years and the mean duration of diabetes was approximately 6 years . Most studies reported gender with a mean percentage of females of approximately 67 % . Of the eleven studies , two focused only on women and four included only Hispanic individuals . All studies evaluated type 2 diabetes patients exclusively . STUDY CHARACTERISTICS : The studies were conducted between 2002 and 2008 . Approximately six of 11 studies were carried out within the USA , with the remaining studies conducted in the UK , Sweden , and Israel ( sample size ranged from 47 to 824 participants ) . The quality of the studies ranged from moderate to low with four of the studies being of moderate quality and the remaining seven of low quality ( based on the Consort Checklist ) . Differences in quality were mainly due to method ological issues such as inadequate description of r and omization , sample size calculation allocation concealment , blinding and uncertainty of the use of intention-to-treat ( ITT ) analysis . Patients were recruited from several setting s : six studies from primary or general medical practice s , three studies from the community ( e.g. via advertisements ) , and two from outpatient diabetes clinics . A usual care control group was reported in nine of 11 of the studies and two studies reported some type of minimal diabetes care in addition to usual care for the control group . INTERVENTION CHARACTERISTICS : All of the interventions examined in the studies were mapped to the 2007 Self-management Mapping Guide . The interventions most often focused on problem solving , goal setting and encouraging participants to engage in activities that protect and promote health ( e.g. modifying behaviour , change in diet , and increase physical activity ) . All of the studies examined comprehensive interventions targeted at least two self-care topics ( e.g. diet , physical activity , blood glucose monitoring , foot care , etc . ) . Despite the homogeneity in the aims of the interventions , there was substantial clinical heterogeneity in other intervention characteristics such as duration , intensity , setting , mode of delivery ( group vs. individual ) , interventionist , and outcomes of interest ( discussed below ) . DURATION , INTENSITY AND MODE OF DELIVERY : Intervention duration s ranged from 2 days to 1 year , with many falling into the range of 6 to 10 weeks . The rest of the interventions fell into categories of ≤ 2 weeks ( 2 studies ) , 6 months ( 2 studies ) , or 1 year ( 3 studies ) . Intensity of the interventions varied widely from 6 hours over 2 days , to 52 hours over 1 year ; however , the majority consisted of interventions of 6 to 15 hours . Both individual and group sessions were used to deliver interventions . Group counselling was used in five studies as a mode of instruction , three studies used both individual and group sessions , and one study used individual sessions as its sole mode of instruction . ( ABSTRACT Background A discipline which critically looks at the evidence for practice should itself be critically examined . Credible evidence for the effectiveness of training in evidence -based healthcare ( EBHC ) is essential . We attempted to summarise the current knowledge on evaluating the effectiveness of training in EBHC while identifying the gaps . Methods A working group of EBHC teachers developed a conceptual framework of key areas of EBHC teaching and practice in need of evidence mapped to appropriate methods and outcomes . A literature search was conducted to review the current state of research in these key areas . Studies of training interventions that evaluated effectiveness by considering learner , patient or health system outcomes in terms of knowledge , skills , attitude , judgement , competence , decision-making , patient satisfaction , quality of life , clinical indicators or cost were included . There was no language restriction . Results Of 55 articles review ed , 15 met the inclusion criteria : six systematic review s , three r and omised controlled trials and six before-after studies . We found weak indications that undergraduate training in EBHC improves knowledge but not skills , and that clinical ly integrated postgraduate teaching improves both knowledge and skills . Two r and omised controlled trials reported no impact on attitudes or behaviour . One before-after study found a positive impact on decision-making , while another suggested change in learners ' behaviour and improved patient outcome . We found no studies assessing the impact of EBHC training on patient satisfaction , health-related quality of life , cost or population -level indicators of health . Conclusions Literature evaluating the effectiveness of training in EBHC has focused on short-term acquisition of knowledge and skills . Evaluation design s were method ologically weak , controlled trials appeared inadequately powered and systematic review s could not provide conclusive evidence owing to weakness of study design Background There is an important gap between the implication s of clinical research evidence and the routine clinical practice of healthcare professionals . Because individual decisions are often central to adoption of a clinical -related behaviour , more information about the cognitive mechanisms underlying behaviours is needed to improve behaviour change interventions targeting healthcare professionals . The aim of this study was to systematic ally review the published scientific literature about factors influencing health professionals ' behaviours based on social cognitive theories . These theories refer to theories where individual cognitions/thoughts are viewed as processes intervening between observable stimuli and responses in real world situations . Methods We search ed psycINFO , MEDLINE , EMBASE , CIHNAL , Index to theses , PROQUEST dissertations and theses and Current Contents for articles published in English only . We included studies that aim ed to predict healthcare professionals ' intentions and behaviours with a clear specification of relying on a social cognitive theory . Information on percent of explained variance ( R2 ) was used to compute the overall frequency-weighted mean R2 to evaluate the efficacy of prediction in several context s and according to different method ological aspects . The cognitive factors most consistently associated with prediction of healthcare professionals ' intention and behaviours were documented . Results Seventy eight studies met the inclusion criteria . Among these studies , 72 provided information on the determinants of intention and 16 prospect i ve studies provided information on the determinants of behaviour . The theory most often used as reference was the Theory of Reasoned Action ( TRA ) or its extension the Theory of Planned Behaviour ( TPB ) . An overall frequency-weighted mean R2 of 0.31 was observed for the prediction of behaviour ; 0.59 for the prediction of intention . A number of moderators influenced the efficacy of prediction ; frequency-weighted mean R2 varied from 0.001 to 0.58 for behaviour and 0.19 to 0.81 for intention . Conclusion Our results suggest that the TPB appears to be an appropriate theory to predict behaviour whereas other theories better capture the dynamic underlying intention . In addition , given the variations in efficacy of prediction , special care should be given to method ological issues , especially to better define the context of behaviour performance The neuropeptide oxytocin has been shown to improve many aspects of social cognitive functioning , including facial emotion recognition , and to promote social approach behaviour . In the present study , we investigated the modulatory effects of oxytocin on the recognition of briefly presented facial expressions . In order to diversify the degree of visual awareness for the facial stimuli , presentation duration was systematic ally varied . Fifty-six participants were administered intranasal oxytocin or a placebo in a double-blind , r and omized , between-subjects design . Participants viewed angry and happy target faces or neutral distractors for 18 , 35 , or 53 ms subsequently masked by neutral faces . Participants had to indicate the presence or absence of the briefly presented target face . Discrimination indices ( d ' ) showed that oxytocin generally enhanced detection accuracy of emotional stimuli . This effect was more pronounced for the recognition of happy faces . We provide evidence that a single dose of intranasally administered oxytocin enhances detection of briefly presented emotional stimuli . The possible role of stimulus valence and recognition difficulty is discussed Background Systematic review s of behaviour change interventions for  smoking cessation  vary in scope , quality , and applicability . The current review aims to generate more accurate and useful findings by ( 1 ) a detailed analysis of intervention elements that change behaviour ( i.e. behaviour change techniques ( BCTs ) ) and potential moderators of behaviour change ( i.e. other intervention and sample characteristics ) and ( 2 ) assessing and controlling for variability in support provided to comparison groups in smoking cessation trials . Methods A systematic review will be conducted of r and omized controlled trials of behaviour change interventions for smoking cessation in adults ( with or without pharmacological support ) , with a minimum follow-up of 6 months , published after 1995 . Eligible articles will be identified through the Cochrane Tobacco Addiction Group Specialized Register . Study authors will be asked for detailed descriptions of smoking cessation support provided to intervention and comparison groups . All data will be independently coded by two research ers . The BCT taxonomy v1 ( tailored to smoking cessation interventions ) and template for intervention description and replication criteria will be used to code intervention characteristics . Data collection will further include sample and trial characteristics and outcome data ( smoking cessation rates ) . Multilevel mixed-effects meta-regression models will be used to examine which BCTs and /or BCT clusters delivered to intervention and comparison groups explain smoking cessation rates in treatment arms ( and effect sizes ) and what key moderators of behaviour change are . Predicted effect sizes of each intervention will be computed assuming all interventions are compared against comparison groups receiving the same levels of behavioural support ( i.e. low , medium , and high levels ) . Multi-disciplinary advisory board members ( policymakers , health care providers , and (ex-)smokers ) will provide strategic input throughout the project to ensure the review ’s applicability to policy and practice . Discussion By capturing BCTs in intervention and comparison groups , this systematic review will provide more accurate estimates of the effectiveness of smoking cessation interventions , the most promising BCTs and /or BCT clusters associated with smoking cessation rates in intervention and comparison arms , and important moderators of behaviour change . The results could set new st and ards for conducting meta-analyses of behaviour change interventions and improve research , service delivery , and training in the area of smoking cessation . Systematic review registration PROSPERO OBJECTIVE To review the published scientific literature for studies quantifying or examining factors associated with the attrition of undergraduate nursing students in pre- registration programs and the retention of graduate nurses in the workforce . METHODS The following selection criteria were used to systematic ally search the literature : target population s were either students in pre- registration nursing programs or registered nurses in their graduate year ; the studies were to be primary observational or analytical ( cross-sectional , case-control or prospect i ve cohort studies ) in design ; and outcome measures were attrition in undergraduate programs and /or retention of graduates within the workforce . Three authors guided by a st and ardised procedure performed data extraction and quality assessment independently . Synthesis of the data appears in text and tabular format . Due to the heterogenic nature of the study methods , meta- analysis was not possible . RESULTS This review found only four studies that met all inclusion criteria . All four studies examined undergraduate attrition as an outcome with two studies reporting a range of 25 - 27 % attrition within the first year . No studies were found that quantified or examined retention of new graduates as an outcome measure . Only two of the four studies followed cohorts of students prospect ively and were able to provide a high level of evidence , although each of these studies was design ed to assess specific exposures as potential predictors of attrition , rather than assess actual factors associated with students leaving their program . CONCLUSION There is a paucity of research studies in the literature from which evidence quantifying attrition and retention and the reasons why students leave undergraduate nursing programs or new graduates leave the profession can be obtained . Clearly there is a need to systematic ally track undergraduates and new graduates to quantify and underst and attrition , retention and workforce choices within the nursing profession and begin to build this evidence -base
Studies were primarily related to the assessment of pain in relation to surgical procedures , and no clear distinction was made concerning the onset of acute and chronic pain .
The metrics used within the tools appeared to focus primarily on the sensory aspect of pain , with no study clearly discriminating between the sensory and affective components of pain .
Objectives The objectives were to review systematic ally the range of assessment tools used in cats to detect the behavioural expression of pain and the evidence of their quality ; and to examine behavioural metrics ( considering both the sensory and affective domains ) used to assess pain .