Effectiveness of exercise interventions on physical function in community-dwelling frail older people: an umbrella review of systematic reviews Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews. Physical activity, muscle function, falls and fractures Sarcopenia in ovarian cancer patients, oncologic outcomes revealing the importance of clinical nutrition: review of literature. Systematic Review: Inspiratory Muscle Training in Patients with Chronic Obstructive Pulmonary Disease: The State of the Evidence The Effect of Pelvic Floor Muscle Exercise on Female Sexual Function During Pregnancy and Postpartum: A Systematic Review. A systematic review of the effectiveness of eccentric strength training in the prevention of hamstring muscle strains in otherwise healthy individuals. Nutritional Intervention as a Preventive Approach for Cognitive-Related Outcomes in Cognitively Healthy Older Adults: A Systematic Review. The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews Exercise Interventions in Children with Cancer: A Review Physical Activity/Exercise and Type 2 Diabetes Nonpharmacological interventions to prevent type 2 diabetes in women diagnosed with gestational diabetes mellitus: a systematic overview Systematic reviews in public health: old chestnuts and new challenges. The effects of exercise and protein-energy supplements on body composition and muscle function in frail elderly individuals: a long-term controlled randomised study. Pelvic floor muscle training and adjunctive therapies for the treatment of stress urinary incontinence in women: a systematic review The effects of whey protein with or without carbohydrates on resistance training adaptations Summarizing systematic reviews: methodological development, conduct and reporting of an umbrella review approach Examining the theory‐effectiveness hypothesis: A systematic review of systematic reviews The effectiveness of interventions to reduce undernutrition and promote eating in older adults with dementia: A systematic review Exercise and Nutritional Supplementation on Community-Dwelling Elderly Japanese Women With Sarcopenic Obesity: A Randomized Controlled Trial. The Effects of Physical Activity on Health and Quality of Life in Adolescent Cancer Survivors: A Systematic Review Similar effects of leucine rich and regular dairy products on muscle mass and functions of older polymyalgia rheumatica patients: A randomized crossover trial Effects of high-intensity exercise and protein supplement on muscle mass in ADL dependent older people with and without malnutrition—A randomized controlled trial Handgrip strength does not represent an appropriate measure to evaluate changes in muscle strength during an exercise intervention program in frail older people. Efficiency and Contribution of Strategies for Finding Randomized Controlled Trials: A Case Study from a Systematic Review on Therapeutic Interventions of Chronic Depression Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Balancing the strengths of systematic and narrative reviews. Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: a randomized, double-blind, placebo-controlled trial. Whey protein, amino acids, and vitamin D supplementation with physical activity increases fat-free mass and strength, functionality, and quality of life and decreases inflammation in sarcopenic elderly. Mapping the Cochrane evidence for decision making in health care. The Effectiveness of Exercise Interventions for the Management of Frailty: A Systematic Review Dietetic guidelines: diet in secondary prevention of cardiovascular disease. Combining intra-dialytic exercise and nutritional supplementation in malnourished older haemodialysis patients: Towards better quality of life and autonomy. Home-based health promotion for older people with mild frailty: the HomeHealth intervention development and feasibility RCT. Identifying the content of home-based health behaviour change interventions for frail older people: a systematic review protocol Dietary and physical activity strategies to prevent type 2 diabetes in South Asian adults: protocol for a systematic review
Objectives : This umbrella review aim ed to determine the effectiveness of exercise interventions , alone or in combination with other interventions , in improving physical function in community-dwelling older people identified as pre-frail or frail . Introduction : Exercise is said to have a positive impact on muscle mass and strength which improves physical function and hence is beneficial for the treatment of frailty . Several systematic review s discuss the effects of exercise interventions on physical function parameters , such as strength , mobility , gait , balance and physical performance , and indicate that multi-component exercise , including resistance , aerobic , balance and flexibility training , appears to be the best way in which to improve physical function parameters in frail older people . However , there is still uncertainty as to which exercise characteristics ( type , frequency , intensity , duration and combinations ) are the most effective and sustainable over the long-term . Inclusion criteria : Participants were adults , 60 years or over , living in the community and identified as pre-frail or frail . Quantitative systematic review s , with or without meta- analysis that examined the effectiveness of exercise interventions of any form , duration , frequency and intensity , alone or in combination with other interventions design ed to alter physical function parameters in frail older people , were considered . The quantitative outcome measures were physical function , including muscular strength , gait , balance , mobility and physical performance . Methods : An iterative search strategy for ten bibliometric data bases and gray literature was developed . Critical appraisal of seven systematic review s was conducted independently by two review ers using a st and ard Joanna Briggs Institute tool . Data was extracted independently by two review ers using a st and ard Joanna Briggs Institute data extraction tool and summarized using a narrative synthesis approach . Results : Seven systematic review s were included in this umbrella review , with a total of 58 relevant r and omized controlled trials and 6927 participants . Five systematic review s examined the effects of exercise only , while two systematic review s reported on exercise in combination with a nutritional approach , including protein supplementations , as well as fruit and dairy products . The average  exercise frequency was 2–3 times per week ( mean 3.0 ± 1.5 times per week ; range 1–7 weekly ) for 10–90 minutes per session ( mean of 52.0 ± 16.5 mins ) and a total duration of 5–72 weeks with the majority lasting a minimum of 2.5 months ( mean 22.7 ± 17.7 weeks ) . Multi-component exercise interventions can currently be recommended for pre-frail and frail older adults to improve muscular strength , gait speed , balance and physical performance , including resistance , aerobic , balance and flexibility tasks . Resistance training alone also appeared to be beneficial , in particular for improving muscular strength , gait speed and physical performance . Other types of exercise were not sufficiently studied and their effectiveness is yet to be established . Conclusions : Interventions for pre-frail and frail older adults should include multi-component exercises , including in particular resistance training , as well as aerobic , balance and flexibility tasks . Future research should adopt a consistent definition of frailty and investigate the effects of other types of exercise alone or in combination with nutritional interventions so that more specific recommendations can be made 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 Study design A thematic review . Objectives To evaluate if physical activity enhances muscle strength , improves balance , and reduces the fall frequency and the fracture incidence .  Background One of the major medical problems of today is the increasing incidence of fragility fractures .  Muscle strength and fall is one of the major determinants of a fracture . If physical activity could increase muscle strength , improve balance and reduce the fall frequency , then training could be recommended as prevention for fractures . Methods The review used Medline ( Pub Med ) and the search words exercise , physical activity , muscle strength , balance , falls , fractures . R and omized controlled trials ( RCT ) were predominantly included , although this not is a systematic review . Results The evidence that physical activity modifies the risk factors for fall is compelling , although RCT with fractures as end point are lacking . Physical activity is associated with improved muscle strength , co-ordination and balance .  Physical training increases muscle strength also in octogenarians by up to 200 % , i.e. a much more pronounced effect than the corresponding increase in muscle volume or bone mass . There is also evidence that physical activity decreases the actual number of falls . Observational cohort and case-control studies imply that physical activity is associated with reduced hip fracture risk . If exercise reduces the number of vertebral fractures and other fragility fractures are less evaluated . Conclusions Physical activity in older ages can be recommended to improve muscle strength and balance , to reduce the risk to fall and fractures , although the highest level of evidence – RCT with fracture as endpoint – is lacking INTRODUCTION Ovarian cancer is the leading cause of death among gynecological malignancies . Its usual clinical manifestation is at advanced stages , with nutritional impairment , weight loss , and a consequent decline in skeletal muscle mass and strength ( defined as sarcopenia ) . The relationship between sarcopenia and decreased survival was demonstrated not only in ovarian cancer but also in other cancer types , such as hepatocellular , pancreatic , lung , colon , cervical , metastatic breast , and renal cancer . The aim of this study is to review the current evidence regarding the relationship between sarcopenia and the surgical and oncological outcomes in ovarian cancer patients . METHODS The systematic search was performed according to the Preferred Reporting Items for Systematic Review s and Meta-Analyses ( PRSIMA ) statement . The terms " SARCOPENIA " AND " OVARIAN CANCER " were systematic ally used to search PubMed and Scopus data bases . Original reports in English language were identified , with the purpose to include all relevant papers regarding the role of sarcopenia and indicators of skeletal muscle quality assessment in gynecological ovarian cancer . RESULTS A total of 9 studies were considered eligible for the present review . The strength of recommendation was moderate and the level of evidence was low in all selected articles . No prospect i ve studies were conducted and most of the papers were case-control series comparing ovarian cancer sarcopenic population vs. non sarcopenic population . CONCLUSIONS Sarcopenia appears to have an important role in oncological outcomes of ovarian cancer patients . However , sarcopenia occurrence during disease history and mechanisms underlying the possible impairment in prognosis should be better investigated . Prospect i ve trials are awaited in order to obtain a better insight in this topic Purpose : The purpose of the present review was to assess the quality of evidence in the literature regarding the specific benefits of inspiratory muscle training ( IMT ) with an emphasis on training intensity and the relationships between changes in inspiratory muscle function and other clinical outcome measures . Methods : Articles were found by search ing CINAHL , PubMed , Medline via First Search , and ProQuest data bases . Articles used in the review were r and omized trials of IMT vs. sham IMT or no intervention  , published in English in a peer‐ review ed journal , included patients with chronic obstructive pulmonary disease ( COPD ) , and specified the intensity of training . The quality of the studies was evaluated by 2 independent review ers using the method ological rigor scale described by Medlicott and Harris as well as Sackett 's levels of evidence . Fifteen articles met the inclusion criteria and were used in this review . Results : Consistent improvements in maximal inspiratory pressures ( ranging from ‐11 to ‐30 cm H2O ) and inspiratory muscle endurance were found . Improvements in dyspnea and health‐related quality of life were also observed . Inspiratory muscle training may result in improved exercise tolerance as measured using walking tests . High‐intensity IMT result ed in improved training efficiency with respect to inspiratory muscle strength , but evidence of the effect of high‐intensity IMT on other clinical outcomes is lacking . Conclusion : Despite research spanning decades , there are numerous limitations in the literature regarding IMT . IMT appears to improve dyspnea , waking test distance , and health‐related quality of life in individuals with COPD , but it is not clear whether this improvement is mediated through improved inspiratory muscle strength and endurance . This review discussed several considerations critical to the design of future trials INTRODUCTION Pelvic floor muscle exercise ( PFME ) is recommended as a first-line treatment for  urinary incontinence . However , a review of the literature suggests the effect of PFME on sexual function ( SF ) , particularly during pregnancy and the postpartum period , is understudied . AIM To assess the effect of PFME on SF during pregnancy and the postpartum period . METHODS The following data bases were search ed : CINAHL ( EBSCOhost ) , Health Collection ( Informit ) , PubMed ( National Center for Biotechnology Information ) , Embase ( Ovid ) , MEDLINE , Cochrane , Health Source , Scopus , Wiley , Health & Medical Complete ( ProQuest ) , Joanna Briggs Institute , and Google Scholar . Results from published r and omized controlled trials ( RCTs ) and non- RCTs from 2004 to January 2018 on pregnant and postnatal women were included . PEDro and Critical Appraisal Skills Programme scores were used to assess the quality of studies . Data were analysed using a qualitative approach . MAIN OUTCOME MEASURE The primary outcome was the impact of antenatal or postnatal PFME on at least 1 SF variable , including desire , arousal , orgasm , pain , lubrication , and satisfaction . The secondary outcome was the impact of PFME on PFM strength . RESULTS We identified 10 studies with a total of 3607 participants . These included 4 RCTs , 1 quasi-experimental study , 3 interventional cohort studies , and 2 long-term follow up cohort studies . No studies examined the effect of PFME on SF during pregnancy . 7 studies reported that PFME alone improved sexual desire , arousal , orgasm , and satisfaction in the postpartum period . CONCLUSION The current data needs to be interpreted in the context of the studies ' risk of bias , small sample sizes , and varying outcome assessment tools . The majority of the included studies reported that postnatal PFME was effective in improving SF . However , there is a lack of studies describing the effect of PFME on SF during pregnancy , and only minimal data are available on the postpartum period . More RCTs are needed in this area . Sobhgol SS , Priddis H , Smith CA , et al. The Effect of Pelvic Floor Muscle Exercise on Female Sexual Function During Pregnancy and Postpartum : A Systematic Review . Sex Med Rev 2019;7:13 - 28 BACKGROUND Hamstring strains are the most common soft-tissue injury observed in recreational and athletic activities , yet no consensus exists regarding appropriate primary and secondary strategies to prevent these strains . Eccentric exercise has been reported to reduce the incidence of ham-string strains but its role has not been clearly defined . OBJECTIVE The objective of this systematic review was to determine the effectiveness of eccentric exercise in preventing hamstring strains . DATA SOURCES Online data bases , including MED-LINE , PubMed , CINAHL , PEDro , SPORTD iscus , EMBASE , Cochrane Data base of Systematic Review s , Cochrane Central Register of Controlled Trials , and Web of Science were search ed for relevant articles . Each data base was search ed from the earliest date to July 2007 . STUDY SELECTION Selection criteria included diagnosis of hamstring strain , otherwise healthy individuals , and at least one group receiving an eccentric exercise intervention . Seven articles { three r and omized controlled trials ( RCTs ) and four cohort studies } met the inclusion criteria . DATA EXTRACTION Data were extracted using a customized form . Method ological rigor of included studies was assessed using the PEDro scale and Oxford Centre for Evidence -based Medicine Levels of Evidence . DATA SYNTHESIS STUDIES WERE GROUPED BY ECCENTRIC EXERCISE INTERVENTION PROTOCOL : hamstring lowers , isokinetic strengthening , and other strengthening . A best- evidence synthesis of pooled data was qualitatively summarized . CONCLUSIONS Findings suggest that eccentric training is effective in primary and secondary prevention of hamstring strains . Study heterogeneity and poor method ological rigor limit the ability to provide clinical recommendations . Further RCTs are needed to support the use of eccentric training protocol s in the prevention of hamstring strains The link diet-cognitive function/dementia has been largely investigated in observational studies ; however , there was a lack of evidence from r and omized clinical trials ( RCTs ) on the prevention of late-life cognitive disorders though dietary intervention in cognitively healthy older adults . In the present article , we systematic ally review ed RCTs published in the last four years ( 2014 - 2017 ) exploring nutritional intervention efficacy in preventing the onset of late-life cognitive disorders and dementia in cognitively healthy subjects aged 60 years and older using different levels of investigation ( i.e. , dietary pattern changes/medical food/nutraceutical supplementation/multidomain approach and dietary macro- and micronutrient approaches ) as well as possible underlying mechanisms of nutritional prevention . From the 35 included RCTs , there was moderate evidence that intervention through dietary pattern changes , medical food/nutraceutical supplementation , and multidomain approach improved specific cognitive domains or cognitive-related blood biomarkers . There was high evidence that protein supplementation improved specific cognitive domains or functional status in prefrail older adults without effect on cognitive function . For fatty acid supplementation , mainly long-chain polyunsaturated fatty acids , there was emerging evidence suggesting an impact of this approach in improving specific cognitive domains , magnetic resonance imaging ( MRI ) findings , and /or cognitive-related biomarkers also in selected subgroups of older subjects , although some results were conflicting . There was convincing evidence of an impact of non-flavonoid polyphenol and flavonoid supplementations in improving specific cognitive domains and /or MRI findings . Finally , there was only low evidence suggesting efficacy of intervention with homocysteine-related and antioxidant vitamins in improving cognitive functions , dementia incidence , or cognitive-related biomarkers in cognitively healthy older subjects Abstract Objective : to review and up date the evidence for different forms of manual therapy ( MT ) for patients with different stages of non-specific low back pain ( LBP ) . Data sources : MEDLINE , Cochrane-Register-of-Controlled-Trials , PEDro , EMBASE . Method : A systematic review of MT with a literature search covering the period of January 2000 to April 2013 was conducted by two independent review ers according to Cochrane and PRISMA guidelines . A total of 360 studies were evaluated using qualitative criteria . Two stages of LBP were categorized ; combined acute – subacute and chronic . Further sub-classification was made according to MT intervention : MT1 ( manipulation ) ; MT2 ( mobilization and soft-tissue-techniques ) ; and MT3 ( MT1 combined with MT2 ) . In each sub-category , MT could be combined or not with exercise or usual medical care ( UMC ) . Consequently , quantitative evaluation criteria were applied to 56 eligible r and omized controlled trials ( RCTs ) , and hence 23 low-risk of bias RCTs were identified for review . Only studies providing new up date d information ( 11/23 RCTs ) are presented here . Results : Acute – subacute LBP : STRONG- evidence in favour of MT1 when compared to sham for pain , function and health improvements in the short-term ( 1–3 months ) . MODERATE- evidence to support MT1 and MT3 combined with UMC in comparison to UMC alone for pain , function and health improvements in the short-term . Chronic LBP : MODERATE to STRONG- evidence in favour of MT1 in comparison to sham for pain , function and overall-health in the short-term . MODERATE- evidence in favour of MT3 combined with exercise or UMC in comparison to  exercise  and back-school was established for pain , function and quality -of-life in the short and long-term . LIMITED- evidence in favour of MT2 combined with exercise and UMC in comparison to UMC alone for pain and function from short to long-term . LIMITED- evidence of no effect for MT1 with extension-exercise compared to extension-exercise alone for pain in the short to long-term . Conclusion : This systematic review up date s the evidence for MT with exercise or UMC for different stages of LBP and provides recommendations for future studies The purpose of this review is to summarize literature that describes the impact of exercise on health and physical function among children during and after treatment for cancer . Relevant studies were identified by entering the following search terms into Pubmed : aerobic training ; resistance training ; stretching ; pediatric ; children ; AND cancer . Reference lists in retrieved manuscripts were also review ed to identify additional trials . We include fifteen intervention trials published between 1993 and 2011 that included children younger than age 21 years with cancer diagnoses . Nine included children with an acute lymphoblastic leukemia ( ALL ) diagnosis , and six children with mixed cancer diagnoses . Generally , interventions tested were either in-hospital supervised exercise training or home based programs design ed to promote physical activity . Early evidence from small studies indicates that the effects of exercise include increased cardiopulmonary fitness , improved muscle strength and flexibility , reduced fatigue and improved physical function . Generalizations to the entire childhood cancer and childhood cancer survivor population s are difficult as most of the work has been done in children during treatment for and among survivors of ALL . Additional r and omized studies are needed to confirm these benefits in larger population s of children with ALL , and in population s with cancer diagnoses other than ALL For decades , exercise has been considered a cornerstone of diabetes management , along with diet and medication . However , high- quality evidence on the importance of exercise and fitness in diabetes was lacking until recent years . The present document summarizes the most clinical ly relevant recent advances related to people with type 2 diabetes and the recommendations that follow from these . Our recently published technical review on physical activity/exercise and type 2 diabetes ( 1 ) includes greater detail on individual studies , on prevention of diabetes , and on the physiology of exercise . The present statement focuses on type 2 diabetes . Issues primarily germane to type 1 diabetes will be covered in a subsequent technical review and ADA Statement . The levels of evidence used are defined by the ADA in ref . 2 . Two r and omized trials each found that lifestyle interventions including ∼150 min/week of physical activity and  diet-induced weight loss of 5–7 % reduced the risk of progression from impaired glucose tolerance ( IGT ) to type 2 diabetes by 58 % ( 3,4 ) . A cluster-r and omized trial found that diet alone , exercise alone , and combined diet and exercise were equally effective in reducting the progression from IGT to diabetes ( 5 ) . Therefore , there is firm and consistent evidence that programs of increased physical activity  and modest weight loss reduce the incidence of type 2 diabetes in individuals with IGT . Boule et al. ( 6 ) undertook a systematic review and meta- analysis on the effects of structured exercise interventions in clinical trials of ≥8 weeks duration on HbA1c ( A1C ) and body mass in people with type 2 diabetes . Postintervention A1C was significantly lower in exercise than control groups ( 7.65 vs. 8.31 % , weighted mean difference −0.66 % ; P < 0.001 ) . In contrast , postintervention body weight did not differ between the exercise and control groups . Meta-regression confirmed that the beneficial effect of exercise on A1C This systematic overview summarizes the relevant evidence from multiple systematic review s of the benefits of nonpharmacological interventions for preventing  type 2 diabetes mellitus ( T2MD ) in women diagnosed with gestational diabetes mellitus ( GDM ) . A comprehensive search using the Cochrane Library , CINAHL , EMBASE and MEDLINE via Ovid SP , and PubMed data bases was completed on 18 November 2015 . Any systematic review s that evaluated r and omized controlled trials ( RCTs ) with defined nonpharmacological interventions for preventing T2DM in women diagnosed with GDM were eligible for inclusion . The authors independently performed critical appraisal s and quality assessment s of the included review s using the AMSTAR tool , and extracted data were converted to coherent values for tabular summarization . Six eligible review s of diet and /or exercise , breastfeeding , and reminder interventions were identified ; however , the method ologies of the review s varied greatly , and the majority of the evidence suggested unclear bias . We found inconsistent reporting on the rates at which diet and exercise interventions reduced the risk of T2DM progression , but these interventions were found to be effective at reducing glycemic load . Combined diet , exercise , and breastfeeding interventions proved to be effective at returning women to their postpartum weight . Neither diet alone nor exercise alone proved to be effective at lowering the risk of T2DM . Overall , there was no robust evidence to support the hypothesis that nonpharmacological interventions are effective at lowering the risk of T2DM in women diagnosed with GDM , and there was no consistent evidence showing that these interventions improved the predictor outcomes of T2DM , such as glycemic load or anthropometric changes The Bulletin ’s editorial team has decided to encourage systematic review s. This is an important decision and is to be welcomed . However it is possible that it will not be received positively by all . Some may feel that systematic review s are not suitable for answering wider public health questions , and that the new section will simply result in the publication of systematic review s addressing narrowly focused , clinical questions with a focus on r and omized controlled trials alone.1 There is no reason why this should be so , and there are far too many examples of systematic review s of non- clinical interventions ( including government policies ) , which include non-r and omized studies , to list.2 Systematic review s of qualitative research are also becoming more common.3 Nonetheless misconceptions about the scope and flexibility of systematic review s still surface occasionally and it never fails to surprise me when I stumble across one of these hoary old chestnuts . If it really were true that systematic review s were only for simple , individual-level interventions , systematic review ers working in public health would be very concerned . After all , public health problems require us to draw on complex sets of qualitative as well as quantitative evidence ; and some policy interventions have never been subjected to r and omized controlled trials ( RCTs ) but have been evaluated using other approaches ; everything from controlled and uncontrolled before- and -after studies , to time series analyses , to qualitative methods . In such cases , systematic review s that focused on RCTs alone would have little to say and we would end up producing many “ empty review s ” , which contain no studies at all . These would be undoubtedly quicker to do and quicker to read than the typical systematic review , but would be of limited use for making policy . However this is not the case . In public health we already have a wealth of review s that prioritize RCTs where they are available , but which draw upon a range of other evidence where they are appropriate to answering the review question .2 Take , as an example , transport policies , an important social determinant of health.4 Public health decision-makers have been interested in the effects on health of building new roads for decades , but there has never been a r and omized controlled trial , for obvious reasons . Yet it would make no sense to cl aim that there is no evidence to be review ed ; rather , there have been many controlled and uncontrolled studies that have examined the effects of new roads on respiratory symptoms , injuries , community severance , disturbance and a variety of other outcomes of public health importance . These studies have in fact been systematic ally review ed.5 Many other examples of review s of complex interventions that impact on public health could be given , which appear on the Cochrane Data base and elsewhere,6,7 and such review s are the main focus of the recently-established Cochrane Public Health Review Group . It is also worth noting that both the Cochrane and Campbell Collaboration include increasing numbers of review s that are relevant to low- and middle- income countries,8 though there is a particular need for more systematic review s that consider the effects on equity of the interventions that they include.9 Currently systematic review s have a “ utilitarian bias ” – they tend to be concerned more with the effects on population s and average effects than with distributional effects and impacts in disadvantaged subgroups . It is to be hoped that systematic review s su bmi tted to the Bulletin will routinely consider the effects of interventions on health inequities . The Cochrane Health Equity Field ( http://equity.cochrane.org/en/index.html ) was set up explicitly to further this agenda , to encourage systematic review authors to explicitly assess the effects of interventions not only on the whole population , but on the disadvantaged . So where does this leave non- systematic review s ? Should every review be a systematic review ? This is a difficult question to answer in a short editorial . My own view is that not all review s need to be systematic review s ; there is still a place for review papers that provide a broad overview , and that discuss a range of evidence and make a contribution to wider debates about what might work in particular setting s. However , while such discussion s help place evidence in context and suggest how it may be used , they should not be confused with the evidence -based conclusions of a transparent , scientific review , which systematic ally attempts to find all the relevant evidence , appraises its strengths and limitations in a transparent fashion , and draws that evidence together in such a way that the more robust studies are given greater weight . Finally , the challenges are many . Evidence on interventions to improve public health is in short supply , particularly evidence on social determinants . Systematic review ers therefore face a real challenge in making best use of the sometimes poor , often sparse and usually heterogeneous evidence available to them . It is easy to set narrow inclusion criteria for a review and then sift through the evidence before concluding that there is n’t enough – and what there is , is n’t very good anyway . Such “ evidential nihilism ” is probably not helpful to decision-makers , and public health systematic review ers need to continue to develop new methods and better frameworks within which different types of research evidence can be integrated to inform decision-making . Publishing systematic review s in the Bulletin should give an added impetus to this ongoing work . Fighting against inactivity and inadequate nutritional intake are of utmost importance in the elderly . To our knowledge , the few studies which have been performed were conducted for only a short period and the results do not permit formal conclusions to be drawn . We therefore tried to fill this gap in our knowledge by determining whether an intervention combining an acceptable progressive exercise programme and nutritional supplements would be feasible for a long-term period in the very frail elderly , and would bring about concomitant benefits in body composition and muscle power . Accordingly , this exercise and nutritional combination was assessed in the frail elderly in a 9-month r and omised trial with a factorial design . Fifty-seven elderly volunteers over 72 years , from sixteen retirement homes in Lyon , France participated in the study .  Dietary supplements were compared with placebo , and physical exercise was compared with memory training . Main outcome measures were fat-free mass ( FFM ) and muscle power . FFM was determined by labelled water , and muscle power was measured by a leg-extensor machine . At 9 months , the compliance was 63 % for exercise sessions , and 54 % for nutritional supplements . In patients with dietary supplements , muscle power increased by 57 % at 3 months ( P=0.03 ) , and showed only a tendency at 9 months ; although FFM increased by 2.7 % at 9 months , the difference was not significant ( P=0.10 ) . Exercise did not improve muscle power at 9 months , but improved functional tests ( five-time-chair rise , P=0.01 ) . BMI increased with supplements ( + 3.65 % ) , but decreased with placebo ( -0.5 % ) at 9 months ( P=0.007 ) . A long-term combined intervention is feasible in frail elderly individuals with a good rate of compliance . Nutritional supplements and exercise may improve muscle function . Despite no significant results on FFM , due to the limited number of volunteers , combined intervention should be suggested to counteract muscle weakness in the frail elderly Background Stress urinary incontinence ( SUI ) is a prevalent and costly condition which may be treated surgically or by physical therapy . The aim of this review was to systematic ally assess the literature and present the best available evidence for the efficacy and effectiveness of pelvic floor muscle training ( PFMT ) performed alone and together with adjunctive therapies ( eg biofeedback , electrical stimulation , vaginal cones ) for the treatment of female SUI . Methods All major electronic sources of relevant information were systematic ally search ed to identify peer- review ed English language abstract s or papers published between 1995 and 2005 . R and omised controlled trials ( RCTs ) and other study design s eg non-r and omised trials , cohort studies , case series , were considered for this review in order to source all the available evidence relevant to clinical practice . Studies of adult women with a urodynamic or clinical diagnosis of SUI were eligible for inclusion . Excluded were studies of women who were pregnant , immediately post-partum or with a diagnosis of mixed or urge incontinence . Studies with a PFMT protocol alone and in combination with adjunctive physical therapies were considered . Two independent review ers assessed the eligibility of each study , its level of evidence and the method ological quality . Due to the heterogeneity of study design s , the results are presented in narrative format . Results Twenty four studies , including 17 RCTs and seven non- RCTs , met the inclusion criteria . The method ological quality of the studies varied but lower quality scores did not necessarily indicate studies from lower levels of evidence . This review found consistent evidence from a number of high quality RCTs that PFMT alone and in combination with adjunctive therapies is effective treatment for  women  with  SUI  with rates of ' cure ' and ' cure/improvement ' up to 73 % and 97 % respectively . The contribution of adjunctive therapies is unclear and there is limited evidence about treatment outcomes in primary care setting s. Conclusion There is strong evidence for the efficacy of physical therapy for the treatment for SUI in women but further high quality studies are needed to evaluate the optimal treatment programs and training protocol s in subgroups of women and their effectiveness in clinical practice Background Nutrition intake in the context of a resistance training ( RT ) bout may affect body composition and muscle strength . However , the individual and combined effects of whey protein and carbohydrates on long-term resistance training adaptations are poorly understood . Methods A four-week preparatory RT period was conducted in previously untrained males to st and ardize the training background of the subjects . Thereafter , the subjects were r and omized into three groups : 30 g of whey proteins ( n = 22 ) , isocaloric carbohydrates ( maltodextrin , n = 21 ) , or protein + carbohydrates ( n = 25 ) . Within these groups , the subjects were further r and omized into two whole-body 12-week RT regimens aim ing either for muscle hypertrophy and maximal strength or muscle strength , hypertrophy and power . The post-exercise drink was always ingested immediately after the exercise bout , 2–3 times per week depending on the training period . Body composition ( by DXA ) , quadriceps femoris muscle cross-sectional area ( by panoramic ultrasound ) , maximal strength ( by dynamic and isometric leg press ) and serum lipids as basic markers of cardiovascular health , were analysed before and after the intervention . Results Twelve-week RT led to increased fat-free mass , muscle size and strength independent of post-exercise nutrient intake ( P < 0.05 ) . However , the whey protein group reduced more total and abdominal area fat when compared to the carbohydrate group independent of the type of RT ( P < 0.05 ) . Thus , a larger relative increase ( per kg bodyweight ) in fat-free mass was observed in the protein vs. carbohydrate group ( P < 0.05 ) without significant differences to the combined group . No systematic effects of the interventions were found for serum lipids . The RT type did not have an effect on the adaptations in response to different supplementation paradigms . Conclusions Post-exercise supplementation with whey proteins when compared to carbohydrates or combination of proteins and carbohydrates did not have a major effect on muscle size or strength when ingested two to three times a week . However , whey proteins may increase abdominal fat loss and relative fat-free mass adaptations in response to resistance training when compared to fast-acting carbohydrates Aims : With the increase in the number of systematic review s available , a logical next step to provide decision makers in healthcare with the evidence they require has been the conduct of review s of existing systematic review s. Syntheses of existing systematic review s are referred to by many different names , one of which is an umbrella review . An umbrella review allows the findings of review s relevant to a review question to be compared and contrasted . An umbrella review 's most characteristic feature is that this type of evidence synthesis only considers for inclusion the highest level of evidence , namely other systematic review s and meta-analyses . A methodology working group was formed by the Joanna Briggs Institute to develop method ological guidance for the conduct of an umbrella review , including diverse types of evidence , both quantitative and qualitative . The aim of this study is to describe the development and guidance for the conduct of an umbrella review . Methods : Discussion and testing of the elements of methods for the conduct of an umbrella review were held over a 6-month period by members of a methodology working group . The working group comprised six participants who corresponded via teleconference , e-mail and face-to-face meeting during this development period . In October 2013 , the methodology was presented in a workshop at the Joanna Briggs Institute Convention . Workshop participants , review authors and method ologists provided further testing , critique and feedback on the proposed methodology . Results : This study describes the methodology and methods developed for the conduct of an umbrella review that includes published systematic review s and meta-analyses as the analytical unit of the review . Details are provided regarding the essential elements of an umbrella review , including presentation of the review question in a Population , Intervention , Comparator , Outcome format , nuances of the inclusion criteria and search strategy . A critical appraisal tool with 10 questions to help assess risk of bias in systematic review s and meta-analyses was also developed and tested . Relevant details to extract from included review s and how to best present the findings of both quantitative and qualitative systematic review s in a reader friendly format are provided . Conclusions : Umbrella review s provide a ready means for decision makers in healthcare to gain a clear underst and ing of a broad topic area . The umbrella review methodology described here is the first to consider review s that report other than quantitative evidence derived from r and omized controlled trials . The methodology includes an easy to use and informative summary of evidence table to readily provide decision makers with the available , highest level of evidence relevant to the question posed 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 Executive summary Background Older adults with dementia may have feeding difficulties for several reasons : they may experience deterioration in motor and cognitive skills making eating difficult , they may forget to eat , fail to recognise food or they may suffer from dysphagia . Food intake is often poor and malnutrition is common , leading to adverse health outcomes . This review specifically focussed on how best to promote and achieve ‘ normal ’ eating and feeding in older adults with dementia , in order that undernutrition and its consequences could be avoided . Review Objectives The aim was to identify and assess the effectiveness of interventions that encouraged eating and minimised risk of undernutrition in older adults with dementia . Types of Participants Adults over the age of sixty with dementia in any care setting ( who were not living independently ) . People receiving enteral tube feeding were excluded . Types of Interventions Any intervention that promoted dietary intake e.g. changes in practice of health care workers , family or volunteers , educational interventions , changes in food service . Types of Outcomes The primary outcomes were improvement in dietary intake and /or nutritional status . Measurements included : dietary intake , anthropometry , clinical outcomes , functional indicators . Types of Studies R and omised controlled trials , controlled trials and quasi‐experimental studies with a ‘ before and after ’ design . Search Strategy The search strategy aim ed to find both published and unpublished studies using a three‐step approach . Papers were limited to the English language and a date restriction of 1999 to 2009 was set . Critical appraisal Papers selected for retrieval were assessed by two independent review ers for method ological validity prior to inclusion in the review . Disagreements that arose between the review ers were resolved through discussion . Data Extraction For quantitative studies , data was extracted using a data extraction form developed to include specific details about the interventions , population s , study methods and outcomes of significance to the review question and specific objectives . This was based on the JBI data extraction tool from MAStARI and 2 review ers extracted data independently . Data synthesis Heterogeneity in study design s , interventions and outcomes meant meta‐ analysis was not possible . Findings were discussed in a narrative summary . Results The review included 11 studies . This included one RCT , 1 r and omised crossover study , 3 controlled non‐r and omised trials , 6 quasi‐experimental studies . None of the studies provided robust evidence , however there was moderate evidence ( Level 3 ) to support a Grade B recommendation for improvements in dietary intake and /or nutritional status with the following interventions : education of healthcare staff , simple environmental manipulations such as the use of high contrast tableware or small dining rooms , the introduction of something of interest such as an aquarium or background music , or the provision of feeding assistance , provision of enhanced menus , use of a de central ised food service , enhanced nutritional screening combined with increased dietetic time .  Conclusion There is moderate ( Level 3 ) evidence to support each of the interventions appraised in this review . Implication s for Practice There is moderate support that warrants consideration of the interventions listed above . Careful monitoring of weight of individual residents would help to determine the effectiveness of any such change in delivery of care . Implication s for Research Future research into interventions to improve eating and minimise undernutrition in older people with dementia should feature the following : inclusion of reliable outcome measures , full details of interventions , r and omisation of participants , inclusion of control groups , adequate sample sizes , longitudinal follow up , consideration of baseline demographics of intervention groups , and experimental design that allows the determination of the effectiveness of individual definable changes in delivery of care OBJECTIVES To investigate the effects of exercise and /or nutritional supplementation on body composition , blood components , and physical function in community-dwelling elderly Japanese women with sarcopenic obesity . DESIGN R and omized controlled trial . SETTING Urban community in Tokyo , Japan . PARTICIPANTS Among 1213 community-dwelling elderly women over 70 years of age , 307 were defined with sarcopenic obesity , and 139 women participated in the study . INTERVENTION Participants were r and omly assigned to one of four intervention groups . The exercise and nutrition ( Ex + N ) and exercise only ( Ex ) groups attended 60-minute exercise classes twice a week for 3 months . The Ex + N and nutrition only ( N ) groups were provided with essential amino acid supplementation and tea fortified with catechins to be taken daily for 3 months . Health education classes were provided to the control ( HE ) group every 2 weeks . MEASUREMENTS Bioelectric impedance analysis was used to measure body composition . Skeletal muscle mass index was calculated using measures of muscle mass and height . Physical function measures included grip strength , knee extension strength , usual walking speed , and walking parameters ( stride , step length , width , walking angles ) . Blood sample s were obtained to analyze levels of albumin , triglycerides , cholesterol , hemoglobin A1c , leptin , cystatin C , vitamin D , interleukin-6 , and high-sensitivity C-reactive protein . RESULTS Significant between-group × time interactions were observed in usual walking speed ( P = .012 ) , stride ( P = .004 ) , right step length ( P = .003 ) , average number of steps ( P = .029 ) , and vitamin D ( P < .001 ) . Compared to the HE group , the Ex + N intervention significantly decreased total body fat mass ( P = .036 ) and increased stride ( P = .038 ) and vitamin D ( P < .001 ) . Significant reductions in trunk fat were observed in the Ex group compared with HE ( P = .014 ) . The Ex + N and Ex interventions were over four times as likely ( odds ratio [ 95 % confidence interval ] ) to reduce body fat mass than the HE group ( 4.42 [ 1.21 - 16.19 ] ; 4.50 [ 1.13 - 17.9 ] , respectively ) . Significant odds ratios of the Ex + N intervention improving walking speed ( 3.05 [ 1.01 - 9.19 ] ) , vitamin D ( 14.22 [ 1.64 - 123.02 ] ) , and leptin ( 3.86 [ 1.19 - 12.47 ] ) were also observed . CONCLUSION Although exercise and nutrition have beneficial effects on individual variables of body composition , blood components , and physical function , improvements in muscle mass and variable combinations such as percent fat + skeletal muscle mass index or percent fat + physical functions were not observed in this population . Further large-scale and long-term investigation is necessary Background There are numerous published controlled trials assessing the safety and the benefits of physical activity ( PA ) for child and adult cancer survivors . However , trials exclusively comprised of adolescent cancer survivors aged 13 - 19 years , who may experience different health and quality of life ( QOL ) effects as a function of their developmental status , are lacking . Rather , some trials have included both adolescent and child cancer survivors together . Objective The aim of this systematic review was to synthesize the findings from r and omized controlled trails ( RCTs ) and controlled clinical trials ( CCTs ) investigating the effects of PA on health and QOL outcomes in sample s comprised of > 50 % adolescent cancer survivors to summarize the current state of evidence , identify knowledge gaps , and highlight areas in need of additional research within this population . Methods Using a search strategy developed for this review , 10 electronic data bases were search ed for RCTs and CCTs that reported on the effects of PA on at least 1 health and /or QOL outcome in sample s comprised of > 50 % adolescent cancer survivors . Results From the 2249 articles identified , 2 CCTs met the predetermined eligibility criteria and were included in this review . Combined , 28 adolescents ( of 41 participants ) who were receiving active treatment participated in the 2 studies review ed . A total of 4 health and QOL outcomes ( ie , bone mass , fatigue , grip strength , QOL ) were assessed pre- and post-PA intervention . Conclusions On the basis of the 2 studies review ed , PA appears to be safe and feasible .  PA also shows promise to mitigate reductions in bone mass and might be a viable strategy to improve fatigue , grip strength , and QOL . High- quality controlled trials with larger sample s exclusively comprised of adolescent cancer survivors that assess a wide range of outcomes are needed to determine the effects of PA on health and QOL outcomes in this population Objectives Leucine-rich milk and whey proteins have been suggested for prevention of age related loss of muscle mass and strength i.e. sarcopenia . The effects of milk protein supplementation and low intensity home based physical exercise on body composition and muscle functions were investigated . Design A r and omized double blind crossover trial . Setting Community dwelling members of Helsinki rheumatoid association . Participants Older people ( N = 47 , mean age 69.5 years ) suffering from polymyalgia rheumatica . Intervention Patients performed as many st and ups as possible twice a day after which they ingested a regular ( Control ) or a whey protein enriched dairy product with high leucine content ( Test ) . The 8-week intervention periods were separated by a 4-week wash-out . Measurements Body composition was measured by dual x-ray absorptiometry and muscle functions by h and grip strength , force platform countermovement jump performance , chair st and test , and walking speed . Results The 16-week home-based post-exercise supplementation result ed in a 1.8 % increase ( p = 0.052 ) in lower limb muscle mass . Walking speed ( + 5.3 % , p = 0.007 ) and chair st and test performance ( −12.2 % , p < 0.001 ) were also improved . Furthermore , a tendency for increased jump power ( + 3.0 % , p = 0.084 ) was observed . However , significant and consistent differences were not found in the changes of muscle mass indices or muscle functions between supplements , but the test supplement tended to prevent accumulation of body fat . Conclusion A low intensity home based exercise program combined with post-exercise milk protein supplementation is feasible despite some gastrointestinal complaints and seems effective in improving the muscle mass and functions of older persons with a inflammatory disease . Further studies are needed to establish , whether and to what extent the use of leucine-enriched whey products prevent or treat age-associated sarcopenia and whether they are superior to the present commercial milk products Background Loss of muscle mass is common among old people living in institutions but trials that evaluate interventions aim ed at increasing the muscle mass arc lacking . Objective , participants and interventionThis r and omized controlled trial was performed to evaluate the effect of a high intensity functional exercise program and a timed protein-enriched drink on muscle mass in 177 people aged 65 to 99 with severe physical or cognitive impairments , and living in residential care facilities . Design Three-month high-intensity exercise was compared with a control activity and a protein-enriched drink was compared with a placebo drink A bioeicctrical impedance spectrometer ( BIS ) was used in the evaluation The amount of muscle mass and body weight ( BW ) were followed-up at three and six months and analyzed in a 2 × 2 factorial ANCOVA , using the intention to treat principle , and controlling for baseline values . Results At 3-month follow-up there were no differences in muscle mass and BW between the exercise and the control group or between the protein and the placebo group . No interaction effects were seen between the exercise and nutritional intervention . Long term negative effects on muscle mass and BW was seen in the exercise group at the 6-month follow-up . Conclusion A three month high-intensity functional exercise program did not increase the amount of muscle mass and an intake of a protein-enriched drink immediately after the exercise did not induce any additional effect on muscle mass . There were negative long term effects on muscle mass and BW , indicating that it is probably necessary to compensate for an increased energy dem and when offering a high-intensity exercise program INTRODUCTION Although h and grip strength is considered a strong predictor of negative health outcomes , it is unclear whether h and grip strength represents a useful measure to evaluate changes in muscle strength following resistance-type exercise training in older people . We assessed whether measuring h and grip strength provides proper insight in the efficacy of resistance-type exercise training to increase muscle mass , strength , and physical performance in frail older people . METHODS Prefrail and frail older people ( ≥ 65 y ) were either conducting a 24-week resistance-type exercise training or no exercise training . Before , during , and after the intervention , h and grip strength ( JAMAR ) , lean body mass ( DXA ) , leg strength ( 1-RM ) , and physical performance ( SPPB ) were assessed . RESULTS H and grip strength correlated with appendicular lean mass ( r = 0.68 ; p < .001 ) and leg strength ( r = 0.67 ; p < .001 ) . After 24 weeks of whole body resistance-type exercise training , leg extension strength improved significantly better when compared with the control group ( 57 ± 2 - 78 ± 3 kg vs 57 ± 3 - 65 ± 3 kg : p < .001 ) . Moreover , physical performance improved significantly more in the exercise group ( 8.0 ± 0.4 - 9.3 ± 0.4 points ) when compared with the control group ( 8.3 ± 0.4 - 8.9 ± 0.4 points : p < .05 ) . These positive changes were not accompanied with any significant changes in h and grip strength ( 26.3 ± 1.2 - 27.6 ± 1.2 kg in the exercise group vs 26.6 ± 1.2 - 26.3 ± 1.3 kg in the control group : p = .71 ) . CONCLUSION Although h and grip strength strongly correlates with muscle mass and leg strength in frail older people , h and grip strength does not provide a valid means to evaluate the efficacy of exercise intervention programs to increase muscle mass or strength in an older population Background Identifying all existing evidence is a crucial aspect in conducting systematic review s. Since the retrieval of electronic data base search es alone is limited , guidelines recommend the use of additional search strategies . The aim of this investigation was to assess the efficiency and contribution of additional search strategies for identifying r and omized controlled trials in conducting a systematic review on interventions after performing a sensitive electronic data base search . Design and Methods Seven electronic data bases , 3 journals and 11 systematic review s were search ed . All first authors of the included studies were contacted ; citation tracking and a search in clinical trial registers were performed . A priori defined evaluation criteria were calculated for each search strategy . Results A total of 358 full-text articles were identified ; 50 studies were included in the systematic review , wherefrom 84.0 % ( 42 ) were acquired by the sensitive electronic data base search and 16.0 % ( 8) through additional search strategies . Screening reference lists of related systematic review s was the most beneficial additional search strategy , with an efficiency of 31.3 % ( 5 ) and a contribution of 10.0 % ( 5/50 ) , whereas h and - search ing and author contacts contributed two and one additional studies , respectively . Citation tracking and search ing clinical trial registers did not lead to any further inclusion of primary studies . Conclusions Based on our findings , h and - search ing contents of relevant journals and screening reference lists of related systematic review s may be helpful additional strategies to identify an extensive body of evidence . In case of limited re sources , a sensitive electronic data base search may constitute an appropriate alternative for identifying relevant trials . Significance for public health Systematic review s provide the strongest form of evidence synthesis for therapeutic interventions and are of high relevance for decision makers in public health . Preparing high quality systematic review s can be very time-consuming since all existing evidence should be identified , but the retrieval of electronic data base search es is limited and therefore additional search strategies are recommended . However , the time needed for conducting full systematic review s does often not address the need for urgent evidence . Thus , priorities of summarizing all available evidence and providing fast evidence -based recommendations may conflict . So far , no consensus exists regarding which additional search strategies are beneficial and sparsely time-consuming for conducting systematic review s. We examined the efficiency and contribution of additional search strategies performed after a sensitive electronic data base search . Our results provide highly relevant information for research ers conducting systematic review s in various fields of public health research and for establishing guidelines for conducting rapid review Description The American College of Physicians ( ACP ) developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain . Methods Using the ACP grading system , the committee based these recommendations on a systematic review of r and omized , controlled trials and systematic review s published through April 2015 on noninvasive pharmacologic and nonpharmacologic treatments for low back pain . Up date d search es were performed through November 2016 . Clinical outcomes evaluated included reduction or elimination of low back pain , improvement in back-specific and overall function , improvement in health-related quality of life , reduction in work disability and return to work , global improvement , number of back pain episodes or time between episodes , patient satisfaction , and adverse effects . Target Audience and Patient Population The target audience for this guideline includes all clinicians , and the target patient population includes adults with acute , subacute , or chronic low back pain . Recommendation 1 Given that most patients with acute or subacute low back pain improve over time regardless of treatment , clinicians and patients should select nonpharmacologic treatment with superficial heat ( moderate- quality evidence ) , massage , acupuncture , or spinal manipulation ( low- quality evidence ) . If pharmacologic treatment is desired , clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants ( moderate- quality evidence ) . ( Grade : strong recommendation ) . Recommendation 2 For patients with chronic low back pain , clinicians and patients should initially select nonpharmacologic treatment with exercise , multidisciplinary rehabilitation , acupuncture , mindfulness-based stress reduction ( moderate- quality evidence ) , tai chi , yoga , motor control exercise , progressive relaxation , electromyography biofeedback , low-level laser therapy , operant therapy , cognitive behavioral therapy , or spinal manipulation ( low- quality evidence ) . ( Grade : strong recommendation ) . Recommendation 3 In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy  , clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy , or tramadol or duloxetine as second-line therapy . Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients . ( Grade : weak recommendation , moderate- quality evidence ) The m and ate of Human Reproduction Up date involves several roles : ( i ) to provide a synthesis of evidence that can aid scientists and clinicians in their daily work ; ( ii ) to help reproductive specialists underst and concepts from related disciplines ; and ( iii ) to summarize current knowledge generated by basic science as the foundation of future scientific and clinical advancement . Given that review and synthesis are central to good scientific and clinical practice , and that a grasp of the current state of knowledge is a prerequisite to design ing new studies , it is pertinent to ask which review s are most likely to fulfil the needs of readers . A related question concerns whether systematic review s meet the needs of all review topics and all readers . Summarizing evidence or knowledge is a difficult problem in reproductive medicine , as in other branches of science and medical care ( Eddy et al. , 1992 ) . For each question there may be multiple studies that use different design s and inclusion criteria . For clinical questions , the interventions , outcomes and measures of effect may vary : the effect measures in treatment studies include odds ratios , relative risks and absolute differences . For scientific questions , the experimental species , models and design s may differ . Moreover , it is always uncertain whether all of the relevant evidence has been evaluated . Even when the search has been exhaustive , there are no simple guides on how to interpret conflicting results and whether to accept apparently outlying studies . The choices that the review er makes to address the variable conditions and uncertainties may be conservative , strict and exclusive , or liberal , open and inclusive . The decisions made by the review er may not be consistent throughout and these choices may or may not satisfy the reader who seeks out the review to address a clinical or research question . Faced with uncertainty and doubt , readers nonetheless must form an impression of the evidence and synthesize the state of knowledge in order to address the clinical or research question that stimulated their interest in the review . We argue that the reader is better served when the choices made in the review , regardless of whether they are strict or open , should be explicit , transparent , clearly stated and reproducible by interested readers . This list of objectives for review s is more easily satisfied by systematic review s , which use explicit methods to method ically search , critically appraise and synthesize the available literature on a specific issue . The question or issue need not be clinical : indeed , the concept evolved primarily in psychology studies ( Light and Pillemer , 1984 ) . The systematic review attempts to reduce review er bias through the use of objective , reproducible criteria to select relevant individual publications and assess their validity . A systematic review may include a meta- analysis or statistical summary of the individual study results : the aggregate of effects from several studies yields an average treatment effect that is more precise than the individual study results ( Schlesselman and Collins , 2003 ) . Thus , the systematic review involves explicit , transparent methods which are clearly stated , and reproducible by others . Whether a systematic review of r and omized controlled trials adheres to the guidelines can easily be evaluated by means of a widely used checklist ( the QUORUM statement ) ( Moher et al. , 1999 ) . The strengths of the systematic review include the narrow focus of the question , the comprehensive search for evidence , the criterion-based selection of relevant evidence , the rigorous appraisal of validity , the objective or quantitative summary , and the evidence -based inferences ( Cook et al. , 1997 ) . For some review topics , however , the strengths of the systematic review may turn into weaknesses . The primary problem is that the narrow focus and prescribed methods of the systematic review do not allow for comprehensive coverage . For example , the historical review is an irreplaceable means of tracing the development of a scientific principle or clinical concept , but the narrative thread could be lost in the strict rules of systematic review . As other examples , it would be burdensome to apply systematic methods to a survey on  aneuploidy and fertility in the aging female or to an assessment of mouse knockout models and polycystic ovarian phenotype . Such topics would require the wider scope of a traditional narrative review , in Human Reproduction Up date , Vol.11 , No.2 pp . 103–104 , 2005 doi:10.1093/humupd/dmh058 Advance Access publication December 23 , OBJECTIVES Protein supplementation has been proposed as an effective dietary strategy to augment the skeletal muscle adaptive response to prolonged resistance-type exercise training in elderly people . Our objective was to assess the impact of protein supplementation on muscle mass , strength , and physical performance during prolonged resistance-type exercise training in frail elderly men and women . DESIGN / SETTING / PARTICIPANTS A r and omized , double-blind , placebo-controlled trial with 2 arms in parallel among 62 frail elderly subjects ( 78 ± 1 year ) . These elderly subjects participated in a progressive resistance-type exercise training program ( 2 sessions per week for 24 weeks ) during which they were supplemented twice daily with either protein ( 2 * 15 g ) or a placebo .  MEASUREMENTS Lean body mass ( DXA ) , strength ( 1-RM ) , and physical performance ( SPPB ) were assessed at baseline , and after 12 and 24 weeks of intervention . RESULTS Lean body mass increased from 47.2 kg ( 95 % CI , 43.5 - 50.9 ) to 48.5 kg ( 95 % CI , 44.8 - 52.1 ) in the protein group and did not change in the placebo group ( from 45.7 kg , 95 % CI , 42.1 - 49.2 to 45.4 kg , 95 % CI , 41.8 - 48.9 ) following the intervention ( P value for treatment × time interaction = .006 ) . Strength and physical performance improved significantly in both groups ( P = .000 ) with no interaction effect of dietary protein supplementation . CONCLUSIONS Prolonged resistance-type exercise training represents an effective strategy to improve strength and physical performance in frail elderly people  . Dietary protein supplementation is required to allow muscle mass gain during exercise training in frail elderly people . TRIAL REGISTRATION clinical trials.gov identifier : NCT01110369 BACKGROUND Interventions to attenuate the adverse effects of age-related loss of skeletal muscle and function include increased physical activity and nutritional supplementation . OBJECTIVE This study tested the hypothesis that nutritional supplementation with whey protein ( 22 g ) , essential amino acids ( 10.9 g , including 4 g leucine ) , and vitamin D [ 2.5 μg ( 100 IU ) ] concurrent with regular , controlled physical activity would increase fat-free mass , strength , physical function , and quality of life , and reduce the risk of malnutrition in sarcopenic elderly persons . DESIGN A total of 130 sarcopenic elderly people ( 53 men and 77 women ; mean age : 80.3 y ) participated in a 12-wk r and omized , double-blind , placebo-controlled  supplementation trial . All participants concurrently took part in a controlled physical activity program . We examined body composition with dual-energy X-ray absorptiometry , muscle strength with a h and grip dynamometer , and blood biochemical indexes of nutritional and health status , and evaluated global nutritional status , physical function , and quality of life before and after the 12 wk of intervention . RESULTS Compared with physical activity and placebo , supplementation plus physical activity  increased fat-free mass ( 1.7-kg gain , P < 0.001 ) , relative skeletal muscle mass ( P = 0.009 ) , and roid distribution of fat ( P = 0.021 ) , h and grip strength ( P = 0.001 ) , st and ardized summary scores for physical components ( P = 0.030 ) , activities of daily living ( P = 0.001 ) , mini nutritional assessment ( P = 0.003 ) , and insulin-like growth factor I ( P = 0.002 ) , and lowered C-reactive protein ( P = 0.038 ) . CONCLUSION Supplementation with whey protein , essential amino acids , and vitamin D , in conjunction with age-appropriate exercise , not only boosts fat-free mass and strength but also enhances other aspects that contribute to well-being in sarcopenic elderly . This trial was registered at clinical trials.gov as NCT02402608 RATIONALE AND AIM Over the past 12 years , thous and s of authors working with the Cochrane Collaboration around the world have produced systematic review s to reduce uncertainty in health care decision making . We evaluated the conclusions from Cochrane systematic review s of r and omized controlled trials in terms of their recommendations for clinical practice and research . METHODS In our cross-sectional study of systematic review s published in the Cochrane Library , we r and omly selected and analysed completed systematic review s published across all 50 Cochrane Collaborative Review Groups . RESULTS We analysed 1016 completed systematic review s. Of these , 44 % concluded that the interventions studied were likely to be beneficial , of which 1 % recommended no further research and 43 % recommended additional research . Also , 7 % of the review s concluded that the interventions were likely to be harmful , of which 2 % did not recommend further studies and 5 % recommended additional studies . In total , 49 % of the review s reported that the evidence did not support either benefit or harm , of which 1 % did not recommend further studies and 48 % recommended additional studies . Overall , 96 % of the review s recommended further research . CONCLUSIONS Cochrane systematic review s were about evenly split between those in which the authors concluded that at least one of the interventions was beneficial and those in which the evidence neither supported nor refuted the intervention tested . The Cochrane Collaboration needs to include clinical trial protocol summaries with a study design optimized to answer the relevant research questions This systematic review examines the effectiveness of current exercise interventions for the management of frailty . Eight electronic data bases were search ed for r and omized controlled trials that identified their participants as “ frail ” either in the title , abstract , and /or text and included exercise as an independent component of the intervention . Three of the 47 included studies utilized a vali date d definition of frailty to categorize participants . Emerging evidence suggests that exercise  has a positive impact on some physical determinants and on all functional ability outcomes reported in this systematic review . Exercise programs that optimize the health of frail older adults seem to be different from those recommended for healthy older adults . There was a paucity of evidence to characterize the most beneficial exercise program for this population . However , multicomponent training interventions , of long duration ( ≥5 months ) , performed three times per week , for 30–45 minutes per session , generally had superior outcomes than other exercise programs . In conclusion , structured exercise training seems to have a positive impact on frail older adults and may be used for the management of frailty AIM To produce dietetic guidelines summarizing the systematic review evidence on dietary advice for secondary prevention of cardiovascular disease . METHODS The Cochrane Library , MEDLINE and EMBASE were comprehensively search ed for systematic review s on aspects of diet and heart health . Review s were included if they search ed systematic ally for r and omised controlled trials relating to diet and secondary prevention of cardiovascular disease . Two members of the UK Heart Health and Thoracic Dietitians Group critically appraised each review . The quality and results of each review were discussed and summarized in a whole group meeting . The guidelines were trialled in seven dietetic departments and modified where necessary . RESULTS Providing evidence -based dietary information ( including increasing omega-3 fat plus fruit and vegetable intake ) to all people after myocardial infa rct ion will save more lives than concentrating dietary advice on those in need of weight loss or lipid lowering . The practice of prioritizing dietetic time to those with raised lipids is out of date since the advent of statin therapy . CONCLUSION There is good systematic review evidence that dietary advice to those with cardiovascular disease can reduce mortality and morbidity as well as modify risk factors .  Dietary advice that does this most effectively should be prioritized Protein-energy wasting ( PEW ) , defined as a loss of body protein mass and fuel reserves , is a powerful predictor of adverse outcomes in haemodialysis ( HD ) patients . Robust arguments suggest that intra-dialytic exercise , combined with oral/parenteral nutrition , enhances the effect of nutritional interventions in HD patients . This pilot r and omized controlled trial investigated the feasibility and the effects of a 6 month intra-dialytic cycling program combined to a nutritional support on PEW , physical functioning ( gait , balance , muscle strength ) and quality of life ( QoL ) in older HD patients ( mean age 69.7 ± 14.2 years).Twenty-one patients fulfilling diagnostic criteria of PEW were r and omly assigned to Nutrition-Exercise group ( GN-Ex , n = 10 ) or Nutrition group ( GN , n = 11 ) . Both groups received nutritional supplements in order to reach recommended protein and energy intake goals . In addition GN-Ex completed a cycling program . No significant difference between groups was found in the number of patients having reached remission of PEW . Likewise , no change was observed in serum-albumin , -prealbumin , C-reactive protein , body mass index , lean- and fat-tissue index , or quadriceps force . Interestingly , we found positive effects of exercise on physical function and QoL for the GN-Ex , as evidence d by a significant improvement in the 6-min walk test ( + 22 % ) , the absence of decline in balance ( unlike the GN ) , and a noteworthy increase in QoL ( + 53 % ) . Combining intra-dialytic exercise and nutrition in HD patients is feasible , and well accepted , improves physical function and QoL but it appears not to have the potential to reverse PEW BACKGROUND Mild frailty or pre-frailty is common and yet is potentially reversible . Preventing progression to worsening frailty may benefit individuals and lower health/social care costs . However , we know little about effective approaches to preventing frailty progression . OBJECTIVES ( 1 ) To develop an evidence - and theory-based home-based health promotion intervention for older people with mild frailty . ( 2 ) To assess feasibility , costs and acceptability of ( i ) the intervention and ( ii ) a full-scale clinical effectiveness and cost-effectiveness r and omised controlled trial ( RCT ) . DESIGN Evidence review s , qualitative studies , intervention development and a feasibility RCT with process evaluation . INTERVENTION DEVELOPMENT Two systematic review s ( including systematic search es of 14 data bases and registries , 1990 - 2016 and 1980 - 2014 ) , a state-of-the-art review ( from inception to 2015 ) and policy review identified effective components for our intervention . We collected data on health priorities and potential intervention components from semistructured interviews and focus groups with older people ( aged 65 - 94 years ) ( n = 44 ) , carers ( n = 12 ) and health/social care professionals ( n = 27 ) . These data , and our evidence review s , fed into development of the ' HomeHealth ' intervention in collaboration with older people and multidisciplinary stakeholders . ' HomeHealth ' comprised 3 - 6 sessions with a support worker trained in behaviour change techniques , communication skills , exercise , nutrition and mood . Participants addressed self-directed independence and well-being goals , supported through education , skills training , enabling individuals to overcome barriers , providing feedback , maximising motivation and promoting habit formation . FEASIBILITY RCT Single-blind RCT , individually r and omised to ' HomeHealth ' or treatment as usual ( TAU ) . SETTING Community setting s in London and Hertfordshire , UK . PARTICIPANTS A total of 51 community-dwelling adults aged ≥ 65 years with mild frailty . MAIN OUTCOME MEASURES Feasibility - recruitment , retention , acceptability and intervention costs . Clinical and health economic outcome data at 6 months included functioning , frailty status , well-being , psychological distress , quality of life , capability and NHS and societal service utilisation/costs . RESULTS We successfully recruited to target , with good 6-month retention ( 94 % ) . Trial procedures were acceptable with minimal missing data . Individual r and omisation was feasible . The intervention was acceptable , with good fidelity and modest delivery costs ( £ 307 per patient ) . A total of 96 % of participants identified at least one goal , which were mostly exercise related ( 73 % ) . We found significantly better functioning ( Barthel Index + 1.68 ; p = 0.004 ) , better grip strength ( + 6.48 kg ; p = 0.02 ) , reduced psychological distress ( 12-item General Health Question naire -3.92 ; p = 0.01 ) and increased capability-adjusted life-years [ + 0.017 ; 95 % confidence interval ( CI ) 0.001 to 0.031 ] at 6 months in the intervention arm than the TAU arm , with no differences in other outcomes . NHS and carer support costs were variable but , overall , were lower in the intervention arm than the TAU arm . The main limitation was difficulty maintaining outcome assessor blinding . CONCLUSIONS Evidence is lacking to inform frailty prevention service design , with no large-scale trials of multidomain interventions . From stakeholder/public perspectives , new frailty prevention services should be personalised and encompass multiple domains , particularly socialising and mobility , and can be delivered by trained non-specialists . Our multicomponent health promotion intervention was acceptable and delivered at modest cost . Our small study shows promise for improving clinical outcomes , including functioning and independence . A full-scale individually RCT is feasible . FUTURE WORK A large , definitive RCT of the HomeHealth service is warranted . STUDY REGISTRATION This study is registered as PROSPERO CRD42014010370 and Current Controlled Trials IS RCT N11986672 . FUNDING This project was funded by the National Institute for Health Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 21 , No. 73 . See the NIHR Journals Library website for further project information Background Meeting the needs of the growing number of older people is a challenge for health and social care services . Home-based interventions aim ing to modify health-related behaviours of frail older people have the potential to improve functioning and well-being . Previous review s have focused on whether such interventions are effective , rather than what might make them effective . Recent advances in behavioural science make possible the identification of potential ‘ active ingredients ’ of effective interventions , such as component behaviour change techniques ( BCTs ) , and intended intervention functions ( IFs ; e.g. to educate , to impart skills ) . This paper reports a protocol for a systematic review that seeks to ( a ) identify health behaviour change interventions for older frail people , ( b ) describe the content of these interventions , and ( c ) explore links between intervention content and effectiveness . The protocol is reported in accordance with Preferred Reporting Items for Systematic Review s and Meta-Analyses Protocol s ( PRISMA -P ) 2015 guidelines . Methods / design Studies will be identified through a systematic search of 15 electronic data bases , supplemented by citation tracking . Studies will be retained for review where they report r and omised controlled trials focusing on home-based health promotion delivered by a health professional for frail older people in community setting s , written in English , and either published from 1980 onwards , or , for registered trials only , unpublished but completed with results obtainable from authors . Interventions will be coded for their content ( BCTs , IFs ) and for evidence of effectiveness ( outcome data relating to behavioural and health outcomes ) . Analyses will describe characteristics of all interventions . Interventions for which effectiveness data are available will be categorised into those showing evidence of effectiveness versus those showing no such evidence . The potential for each intervention characteristic to contribute to change in behaviour or health outcomes will be estimated by calculating the percentage of all interventions featuring those characteristics that have shown effectiveness . Discussion Results will reveal the strategies that have been drawn on within home-based interventions to modify the health behaviours of frail older people , and highlight those more associated with positive changes in behaviour and health . Findings from this review will provide a useful basis for underst and ing , developing , and implementing behaviour change interventions in this field . Systematic review registration PROSPERO Introduction Type 2 diabetes ( T2D ) is a major health concern among population s of South Asian ethnicity . Although dietary and physical activity interventions may reduce the risk of T2D , the effectiveness has been moderate among South Asians . This might ( in part ) be because this subgroup follows strategies that were originally developed for interventions among other population s. Therefore , this review aims to assess the evidence for the current dietary and physical activity strategies recommended in T2D prevention intervention studies and guidelines for South Asians . Methods and analysis Included will be all studies and guidelines on dietary and /or physical activity strategies to prevent T2D in adult South Asians . Two review ers will search online data bases from their start until the present date for published and unpublished experimental/quasiexperimental studies , with at least an abstract in English . References of identified articles and key review s will be screened for additional studies . Guidelines will be identified by search es in online data bases and websites of public organisations . Finally , expert consultations will be held to supplement any missing information . Trial quality will be assessed with the Quality Assessment Tool for Quantitative Studies Data , and guidelines with the Appraisal of Guidelines for Research & Evaluation II . Data on the strategies recommended , targeting and evidence on effectiveness will be extracted by two review ers and presented in tabular and narrative forms . Recommendations will be compared with the National Institute for Health and Care Excellence guidelines [ PH35 ] . Overall findings on  dietary and physical activity recommendations , as well as findings for specific subgroups ( eg , by sex ) , will be discussed . Ethics and dissemination Ethics assessment is not required . Start date : 1 January 2016 , finishing and reporting date 31 July 2016 . Results will be published in a peer- review ed scientific journal , the project report of EuroDHYAN ( www.eurodhyan.eu ) and in a PhD dissertation . Trial registration number The protocol is registered with the International Prospect i ve Register of Systematic Review s ( PROSPERO ) registration number CRD42015027067
Results indicate that physical exercise has a positive impact on muscle mass and muscle function in subjects aged 65 years and older .
Conclusion Physical exercise has a positive impact on muscle mass and muscle function in healthy subjects aged 60 years and older .
The biggest effect of exercise intervention , of any type , has been seen on physical performance ( gait speed , chair rising test , balance , SPPB test , etc . )
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We observed huge variations in regard to the dietary supplementation protocol s. Based on the included studies , mainly performed on well-nourished subjects , the interactive effect of dietary supplementation on muscle function appears limited
Summary This systematic review summarizes the effect of combined exercise and nutrition intervention on muscle mass and muscle function .
However , any interactive effect of dietary supplementation appears to be limited .
Introduction In 2013 , Denison et al. conducted a systematic review including 17 r and omized controlled trials ( RCTs ) to explore the effect of combined exercise and nutrition intervention to improve muscle mass , muscle strength , or physical performance in older people .
They concluded that further studies were needed to provide evidence upon which public health and clinical recommendations could be based .
The purpose of the present work was to up date the prior systematic review and include studies published up to October 2015 .