Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report Review article: Methodology for the ‘rapid review’ series on musculoskeletal injuries in the emergency department Evidence-based medicine and the challenge of low back pain: where are we now? Acute and Chronic Effects of Endurance Running on Inflammatory Markers: A Systematic Review Wasted research when systematic reviews fail to provide a complete and up-to-date evidence synthesis: the example of lung cancer Application of Platelet-Rich Plasma to Disorders of the Knee Joint Lower extremity stiffness: implications for performance and injury. Effectiveness of trigger point dry needling for multiple body regions: a systematic review Training errors and running related injuries: a systematic review. The use of systematic reviews in the planning, design and conduct of randomised trials: a retrospective cohort of NIHR HTA funded trials Job task and psychosocial risk factors for work-related musculoskeletal disorders among newspaper employees. Protocol for a systematic review of psychological interventions for cancer-related fatigue in post-treatment cancer survivors Systematic reviews showed insufficient evidence for clinical practice in 2004: what about in 2011? The next appeal for the evidence-based medicine age. Relationship between training load and injury in professional rugby league players. Balancing the strengths of systematic and narrative reviews. Issues related to the conduct of systematic reviews: a focus on the nutrition field. A Systematic Review of the Effect of Expectancy on Treatment Responses to Acupuncture Effectiveness of education in evidence-based healthcare: the current state of outcome assessments and a framework for future evaluations. A systematic review of the effectiveness of eccentric strength training in the prevention of hamstring muscle strains in otherwise healthy individuals. Neuromuscular training with injury prevention counselling to decrease the risk of acute musculoskeletal injury in young men during military service: a population-based, randomised study Does Cryotherapy Hasten Return to Participation? A Systematic Review. Should journals publish systematic reviews that find no evidence to guide practice? Examples from injury research Electromyography as a measure of peak and cumulative workload in intermediate care and its relationship to musculoskeletal injury: an exploratory ergonomic study. Effects of Traditional Sit-up Training Versus Core Stabilization Exercises on Short-Term Musculoskeletal Injuries in US Army Soldiers: A Cluster Randomized Trial Anterior cruciate ligament repair with LARS (ligament advanced reinforcement system): a systematic review Continued Significant Effect of Physical Training as Treatment for Overuse Injury Safety and efficacy of supervised strength training adopted in pregnancy. Evidence regarding the utility of multiple mini-interview (MMI) for selection to undergraduate health programs: A BEME systematic review: BEME Guide No. 37 How Quickly Do Systematic Reviews Go Out of Date? A Survival Analysis
Background This systematic review up date d and extended the " UK evidence report " by Bronfort et al. ( Chiropr Osteopath 18:3 , 2010 ) with respect to conditions/ interventions that received an ' inconclusive ’ or ' negative ’ evidence rating or were not covered in the report . Methods A literature search of more than 10 general medical and specialised data bases was conducted in August 2011 and up date d in March 2013 . Systematic review s , primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included . Study quality was assessed using st and ardised instruments , studies were summarised , and the results were compared against the evidence ratings of Bronfort . These were either confirmed , up date d , or new categories not assessed by Bronfort were added . Results 25,539 records were found ; 178 new and additional studies were identified , of which 72 were systematic review s , 96 were r and omised controlled trials , and 10 were non-r and omised primary studies . Most ' inconclusive ’ or ' moderate ’ evidence ratings of the UK evidence report were confirmed . Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases ( manipulation/mobilisation [ with exercise ] for rotator cuff disorder ; spinal mobilisation for cervicogenic headache ; and mobilisation for miscellaneous headache ) . In addition , evidence was identified on a large number of non-musculoskeletal conditions not previously considered ; most of this evidence was rated as inconclusive . Conclusions Overall , there was limited high quality evidence for the effectiveness of manual therapy . Most review ed evidence was of low to moderate quality and inconsistent due to substantial method ological and clinical diversity . Areas requiring further research are highlighted Musculoskeletal injuries are a common presentation to the ED , with significant costs involved in the management of these injuries , variances in care within the ED and associated morbidity . A series of rapid review papers were completed to guide best practice for the assessment and management of common musculoskeletal injuries presenting to the ED . This paper presents the methodology used across the rapid review s. PubMed , CINAHL , EMBASE , TRIP and the grey literature , including relevant organisational websites , were search ed in 2015 . The search was repeated consistently for each topic area ( injuries of the foot and ankle , knee , h and and wrist , elbow , shoulder , lumbar spine and cervical spine ) . English- language primary studies , systematic review s and guidelines that were published in the last 10 years and addressed acute musculoskeletal injury management were considered for inclusion . Data extraction of each included article was conducted , followed by a quality appraisal . The extracted data from each article was synthesis ed to group similar evidence together . For each rapid review , the evidence has been organised in a way that a clinician can direct their attention to a specific component of the clinical cycle of care in the ED , such as the assessment , diagnostic tests , management and follow-up considerations from ED . The series of rapid review s are design ed to foster evidence -based practice within the ED , targeting the injuries most commonly presenting . The review s provide clinicians in EDs with rapid access to the best current evidence , which has been synthesis ed and organised to assist decision-making Low  back pain  has long been described as a challenge for both primary care physicians and specialists . Management of  low back pain  has also been criticized as frequently arbitrary , inappropriate , or ineffective . Contributing factors have been an inadequate evidence base and a need for more rigorous appraisal s of the available literature . Evidence -based medicine , an approach to clinical problem solving , is predicated on the premise that high- quality health care will result from practice s consistent with the best evidence . In contrast to the traditional medical paradigm that placed a heavy reliance on expert opinion , authority , and un systematic clinical observations , evidence -based medicine emphasizes the need for rigorous critical appraisal s of the scientific literature to inform medical decision making . Evidence -based medicine places strong weight on the requirement for valid studies , particularly r and omized controlled trials , to appropriately evaluate the effectiveness of health care interventions . Because of the rapidly increasing volume of medical literature , however , most clinicians are unable to keep up-to- date with all the new data . Two types of preprocessed evidence that can aid busy clinicians in medical decision making are systematic review s and evidence -based clinical practice guidelines . Like primary studies , systematic review s and clinical practice guidelines must adhere to high method ologic st and ards to reduce error and bias . As in other areas of medicine , the approach to the management of low back pain has been positively affected by the availability of more clinical trials and better use of critical appraisal techniques to evaluate and apply research findings . In addition to more rigorous primary studies , an increasing number of high- quality systematic review s and evidence -based clinical practice guidelines for low back pain are also available . Although some research gaps and method ologic shortcomings persist , the richer evidence base has greatly improved our underst and ing of what does and does not work for low back pain . Despite these advances , the best available evidence often does not inform everyday clinical decisions for low back pain . Nonetheless , there is widespread agreement that adherence to evidence -based practice will help improve low back pain patient outcomes and reduce arbitrary variations in care . This article review s basic principles of evidence -based medicine , discusses evidence -based medicine in the context of low back pain management , and summarizes some useful evidence -based medicine re sources In order to underst and the effect of endurance running on inflammation , it is necessary to quantify the extent to which acute and chronic running affects inflammatory mediators . The aim of this study was to summarize the literature on the effects of endurance running on inflammation mediators . Electronic search es were conducted on PubMED and Science Direct with no limits of date and language of publication . R and omized controlled trials ( RCTs ) and non-r and omized controlled trials ( N RCTs ) investigating the acute and chronic effects of running on inflammation markers in runners were review ed by two research ers for eligibility . The modified Downs and Black checklist for the assesssments of the method ological quality of studies was subsequently used . Fifty-one studies were finally included . There were no studies with elite athletes . Only two studies were chronic interventions . Results revealed that acute and chronic endurance running may affect anti- and pro-inflammatory markers but method ological differences between studies do not allow comparisons or generalization of the results . The information provided in this systematic review would help practitioners for better design ing further studies while providing reference values for a better underst and ing of inflammatory responses after different running events . Further longitudinal studies are needed to identify the influence of training load parameters on inflammatory markers in runners of different levels and training background Background Multiple treatments are frequently available for a given condition , and clinicians and patients need a comprehensive , up-to- date synthesis of evidence for all competing treatments . We aim ed to quantify the waste of research related to the failure of systematic review s to provide a complete and up-to- date evidence synthesis over time . Methods We performed a series of systematic overviews and networks of r and omized trials assessing the gap between evidence covered by systematic review s and available trials of second-line treatments for advanced non-small cell lung cancer . We search ed the Cochrane Data base of Systematic Review s , Data base of Abstract s of Review s of Effects , MEDLINE , EMBASE , and other re sources sequentially by year from 2009 to March 2 , 2015 . We sequentially compared the amount of evidence missing from systematic review s to the r and omized evidence available for inclusion each year . We constructed cumulative networks of r and omized evidence over time and evaluated the proportion of trials , patients , treatments , and treatment comparisons not covered by systematic review s on December 31 each year from 2009 to 2015 . Results We identified 77 trials ( 28,636 patients ) assessing 47 treatments with 54 comparisons and 29 systematic review s ( 13 published after 2013 ) . From 2009 to 2015 , the evidence covered by existing systematic review s was consistently incomplete : 45 % to 70 % of trials ; 30 % to 58 % of patients ; 40 % to 66 % of treatments ; and 38 % to 71 % of comparisons were missing . In the cumulative networks of r and omized evidence , 10 % to 17 % of treatment comparisons were partially covered by systematic review s and 55 % to 85 % were partially or not covered . Conclusions We illustrate how systematic review s of a given condition provide a fragmented , out-of- date panorama of the evidence for all treatments . This waste of research might be reduced by the development of live cumulative network meta-analyses Importance : The promising therapeutic potential and regenerative properties of platelet-rich plasma ( PRP ) have rapidly led to its widespread clinical use in musculoskeletal injury and disease . Although the basic scientific rationale surrounding PRP products is compelling , the clinical application has outpaced the research . Objective : The purpose of this article is to examine the current concepts around the basic science of PRP application , different preparation systems , and clinical application of PRP in disorders in the knee . Evidence Acquisition : A systematic search of PubMed for studies that evaluated the basic science , preparation and clinical application of platelet concentrates was performed . The search used terms , including platelet-rich plasma or PRP preparation , activation , use in the knee , cartilage , ligament , and meniscus . Studies found in the initial search and related studies were review ed . Results : A comprehensive review of the literature supports the potential use of PRP  both nonoperatively and intraoperatively , but highlights the absence of large clinical studies and the lack of st and ardization between method , product , and clinical efficacy . Conclusions and Relevance . In addition to the call for more r and omized , controlled clinical studies to assess the clinical effect of PRP , at this point , it is necessary to investigate PRP product composition and eventually have the ability to tailor the therapeutic product for specific indications BACKGROUND Lower extremity stiffness is thought to be an important factor in musculoskeletal performance . However , too little or too much stiffness is believed to increase the risk of musculoskeletal injury . PURPOSE To provide a current up date of the lower extremity stiffness literature as it pertains to both performance and injury . SUMMARY It appears that increased stiffness is beneficial to performance . As well it appears that there may be an optimal amount of stiffness that allows for injury-free performance . There is some evidence that increased stiffness may be related to bony injuries and decreased stiffness may be associated with soft tissue injuries . Further investigations should evaluate the relationship between stiffness and injury prospect ively . Initial reports suggest that stiffness can be modified in response to the external environment or verbal cues . RELEVANCE A greater underst and ing of the role of stiffness in both performance and injury will provide a stronger foundation for the development of optimal training intervention programs Background : Trigger point dry needling ( TDN ) is commonly used to treat musculoskeletal pain related to myofascial trigger points ( MTrPs ) . To date , no systematic review of high- quality r and omised controlled trials ( RCTs ) investigating TDN to multiple body regions exists . Purpose : The aim of this review is to determine the effectiveness of TDN based on high- quality RCTs for all body regions . Methods : To ensure thorough reporting , Preferred Reporting Items for Systematic Review s and Meta-Analyses ( PRISMA ) guidelines were followed as the method ological basis for this systematic review . PubMed , Physiotherapy Evidence Data base ( PEDro ) , Cinahl , Cochrane and reference lists were search ed for the years 2000–2014 and the terms ‘ TDN ’ , ‘ dry needling NOT trigger point ’ , ‘ functional dry needling ’ and ‘ intramuscular manual therapy ’ . Inclusion criteria : RCTs with PEDro scores 6–10 investigating TDN . Exclusion criteria : duplicates , non-human participants , non-English language , exclusive focus on acupuncture or medicinal injections . Three investigators search ed data bases , applied criteria , read and assigned PEDro scores to every RCT . Nineteen studies met the criteria . As compared to either baseline or control groups , significant differences were found for pain ( 14 studies ) , range of motion ( ROM ) ( five studies ) and at least one item on function and quality of life measures ( six studies ) . Limitations : This review was limited by inclusion criteria , timeframe , language and data bases search ed . Conclusion : The majority of high- quality studies included in this review show measured benefit from TDN for MTrPs in multiple body areas , suggesting broad applicability of TDN treatment for multiple muscle groups . Further high- quality research is warranted to st and ardise TDN methods to determine clinical applicability PURPOSE The purpose of this systematic review was to examine the link between training characteristics ( volume , duration , frequency , and intensity ) and running related injuries .  METHODS A systematic search was performed in PubMed , Web of Science , Embase , and SportD iscus . Studies were included if they examined novice , recreational , or elite runners between the ages of 18 and 65 . Exposure variables were training characteristics defined as volume , distance or mileage , time or duration , frequency , intensity , speed or pace , or similar terms . The outcome of interest was Running Related Injuries ( RRI ) in general or specific RRI in the lower extremity or lower back . Method ological quality was evaluated using quality assessment tools of 11 to 16 items . RESULTS After examining 4561 titles and abstract s , 63 articles were identified as potentially relevant . Finally , nine retrospective cohort studies , 13 prospect i ve cohort studies , six case-control studies , and three r and omized controlled trials were included . The mean quality score was 44.1 % . Conflicting results were reported on the relationships between volume , duration , intensity , and frequency and RRI . CONCLUSION It was not possible to identify which training errors were related to running related injuries . Still , well supported data on which training errors relate to or cause running related injuries is highly important for determining proper prevention strategies . If method ological limitations in measuring training variables can be resolved , more work can be conducted to define training and the interactions between different training variables , create several hypotheses , test the hypotheses in a large scale prospect i ve study , and explore cause and effect relationships in r and omized controlled trials . LEVEL OF EVIDENCE 2a Background A systematic review , with or without a meta- analysis , should be undertaken to determine if the research question of interest has already been answered before a new trial begins . There has been limited research on how systematic review s are used within the design of new trials , the aims of this study were to investigate how systematic review s of earlier trials are used in the planning and design of new r and omised trials . Methods Documentation from the application process for all r and omised trials funded by the National Institute for Health Research Health Technology Assessment ( NIHR HTA ) between 2006 and 2008 were obtained . This included the : commissioning brief ( if appropriate ) , outline application , minutes of the Board meeting in which the outline application was discussed , full application , detailed project description , referee comments , investigator response to referee comments , Board minutes on the full application and the trial protocol . Data were extracted on references to systematic review s and how any such review s had been used in the planning and design of the trial . Results 50 r and omised trials were funded by NIHR HTA during this period and documentation was available for 48 of these . The cohort was predominately individually r and omised parallel trials aim ing to detect superiority between two treatments for a single primary outcome . 37 trials ( 77.1 % ) referenced a systematic review within the application and 20 of these ( i.e. 41.7 % of the total ) used information contained in the systematic review in the design or planning of the new trial . The main areas in which systematic review s were used were in the selection or definition of an outcome to be measured in the trial ( 7 of 37 , 18.9 % ) , the sample size calculation ( 7 , 18.9 % ) , the duration of follow up ( 8 , 21.6 % ) and the approach to describing adverse events ( 9 , 24.3 % ) . Boards did not comment on the presence/absence or use of systematic review s in any application . Conclusions Systematic review s were referenced in most funded applications but just over half of these used the review to inform the design . There is an expectation from funders that applicants will use a systematic review to justify the need for a new trial but no expectation regarding further use of a systematic review to aid planning and design of the trial . Guidelines for applicants and funders should be developed to promote the use of systematic review s in the design and planning of r and omised trials , to optimise delivery of new studies informed by the most up-to- date evidence base and to minimise waste in research OBJECTIVES A cross-sectional study was conducted to assess the association of upper extremity musculoskeletal disorders and work-related factors among employees using video display terminals at a large metropolitan newspaper . METHODS The study included 1050 r and omly selected workers from four departments . The workers were asked to complete question naires on symptoms , job tasks , and psychosocial and work organization conditions . Musculoskeletal disorders of the upper extremities were defined by frequency , duration , and intensity of symptoms not attributable to acute injury . Data were analyzed with the use of logistic regression . RESULTS A total of 973 workers completed the survey . The one-year period prevalence rate for any musculoskeletal disorder of the upper extremities was 41 % . Neck symptoms ( 26 % ) were the most frequently reported , followed by h and or wrist ( 22 % ) , shoulder ( 17 % ) , and elbow ( 10 % ) symptoms . Greater time working at the video display station was associated with increased h and or wrist symptoms in a dose-response relationship . In addition , variables corresponding to increased work-load dem and s ( eg , increased time working under deadline and increased job pressure ) were associated with increased neck , shoulder , and h and or wrist disorders . Women were more likely to report symptoms in several areas , but this finding may reflect the concentration of women in jobs involving more risk factors . CONCLUSIONS The results suggest a high prevalence of musculoskeletal disorders of the upper extremities among newspaper employees , and they provide additional evidence that increased work load , time pressure , and greater hours of computer use are related to the occurrence of work-related musculoskeletal disorders among these workers , particularly for disorders in the h and or wrist area Background Fatigue is a common symptom in cancer patients that can persist beyond the curative treatment phase . Some evidence has been reported for interventions for fatigue during active treatment . However , to date , there is no systematic review on psychological interventions for fatigue after the completion of curative treatment for cancer . This is a protocol for a systematic review that aims to evaluate the effectiveness of psychological interventions for cancer-related fatigue in post-treatment cancer survivors . This systematic review protocol was registered with the International Prospect i ve Register of Systematic Review s ( PROSPERO ) data base . Methods / design We will search the Cochrane Central Register of Controlled Trials ( CENTRAL ; The Cochrane Library ) , PubMed , MEDLINE , EMBASE , CINAHL , PsycINFO , and relevant sources of grey literature . R and omised controlled trials ( RCTs ) which have evaluated psychological interventions in adult cancer patients after the completion of treatment , with fatigue as an outcome measure , will be included . Two review authors will independently extract data from the selected studies and assess the method ological quality using the Cochrane Collaboration Risk of Bias Tool . Discussion Most existing evidence on cancer-related fatigue is from those in active cancer treatment . This systematic review and meta- analysis will build upon previous evaluations of psychological interventions in people during and after cancer treatment . With the growing need for stage-specific research in cancer , this review seeks to highlight a gap in current practice and to strengthen the evidence base of r and omised controlled trials in the area . Systematic review registration PROSPERO CRD42014015219 RATIONALE AND AIM The aims of the Cochrane systematic review s are to make readily available and up-to- date information for clinical practice , offering consistent evidence and straightforward recommendations . In 2004 , we evaluated the conclusions from Cochrane systematic review s of r and omized controlled trials in terms of their recommendations for clinical practice and found that 47.83 % of them had insufficient evidence for use in clinical practice . We proposed to reanalyze the review s to evaluate whether this percentage had significantly decreased . METHODS A cross-sectional study of systematic review s published in the Cochrane Library ( Issue 7 , 2011 ) was conducted . We r and omly selected review s across all 52 Cochrane Collaborative Review Groups . RESULTS We analyzed 1128 completed systematic review s. Of these , 45.30 % concluded that the interventions studied were likely to be beneficial , of which only 2.04 % recommended no further research . In total , 45.04 % of the review s reported that the evidence did not support either benefit or harm , of which 0.8 % did not recommend further studies and 44.24 % recommended additional studies ; the latter has decreased from our previous study with a difference of 3.59 % . CONCLUSION Only a small number of the Cochrane collaboration 's systematic review s support clinical interventions with no need for additional research . A larger number of high- quality r and omized clinical trials are necessary to change the ' insufficient evidence ' scenario for clinical practice illustrated by the Cochrane data base . It is recommended that we should produce higher- quality primary studies in active collaboration and consultation with global scholars and societies so that this can represent a major component of method ological advance in this context OBJECTIVES To investigate the relationship between training load and injury in professional rugby league players ; DESIGN Prospect i ve cohort study ; METHODS Seventy-nine professional rugby league players ( mean±SD age , 23.3±3.8 years ) participated in this four-year study . A periodized field , strength , and power training program was implemented , with training loads progressively increased in the general preparatory phase of the season and reduced during the competitive phase of the season . Training loads and injuries were recorded for each training session . RESULTS Training load was significantly related ( P<0.05 ) to overall injury ( r=0.82 ) , non-contact field injury ( r=0.82 ) , and contact field injury ( r=0.80 ) rates . Significant relationships were also observed between the field training load and overall field injury ( r=0.68 ) , non-contact field injury ( r=0.65 ) , and contact field injury ( r=0.63 ) rates . Strength and power training loads were significantly related to the incidence of strength and power injuries ( r=0.63 ) . There was no significant relationship between field training loads and the incidence of strength and power injuries . However , strength and power training loads were significantly ( P<0.01 ) associated with the incidence of contact ( r=0.75 ) and non-contact ( r=0.82 ) field training injuries . CONCLUSIONS These findings suggest that the harder rugby league players train , the more injuries they will sustain , and that high strength and power training loads may contribute indirectly to field injuries . Monitoring of training loads and careful scheduling of field and gymnasium sessions to avoid residual fatigue is warranted to minimize the effect of training-related injuries on professional rugby league players 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 , Systematic review s ( SRs ) are an increasingly popular evidence -based tool and are often used to answer complex research questions across many different research domains . Early SR methodology was advanced by social scientists , and the term meta- analysis was coined by a social scientist who also conducted research in psychology . SRs have recently become popular in healthcare and are likely to be beneficial in any field . The aim of this report is to highlight issues in SR conduct with a focus on the field of nutrition and to make recommendations on improving SR conduct in this area . Development of the research question is probably the most important step in conducting an SR . The 4 main components of an answerable question are 1 ) the patient , population , or problem ; 2 ) the intervention , independent variable , or exposure ; 3 ) the comparators ; and 4 ) the dependent variables or outcomes of interest . The question will be used to determine the optimal methods for conducting the SR . SRs often include study design s beyond r and omized trials and do not always include a meta- analysis of the results . Other topics explored include underst and ing and interpreting discordant review s and the importance of reporting tools [ eg , QUality Of Reporting Of Meta-analyses ( QUOROM Statement ) or CONsoli date d St and ards Of Reporting of Trials ( CONSORT Statement ) ] . Recommendations are then provided , such as developing a capacity-building program , search ing the primary literature for research gaps , and extending reporting tools such as the QUOROM Statement to the field of nutrition R and omised controlled trials ( RCTs ) of acupuncture often find equivalent responses to real and placebo acupuncture despite both appearing superior to no treatment . This raises questions regarding the mechanisms of acupuncture , especially the contribution of patient expectancies . We systematic ally review ed previous research assessing the relationship between expectancy and treatment responses following acupuncture , whether real or placebo . To be included , studies needed to assess and /or manipulate expectancies about acupuncture and relate these to at least one health-relevant outcome . Nine such independent studies were identified through systematic search es of Medline , PsycInfo , PubMed , and Cochrane Clinical Trials Register . The methodology and reporting of these studies were quite heterogeneous , meaning that meta- analysis was not possible . A descriptive review revealed that five studies found statistically significant effects of expectancy on a least one outcome , with three also finding evidence suggestive of an interaction between expectancy and type of acupuncture ( real or placebo ) . While there were some trends in significant effects in terms of study characteristics , their generality is limited by the heterogeneity of study design s. The differences in design across studies highlight some important method ological considerations for future research in this area , particularly regarding whether to assess or manipulate expectancies and how best to assess expectancies Background A discipline which critically looks at the evidence for practice should itself be critically examined . Credible evidence for the effectiveness of training in evidence -based healthcare ( EBHC ) is essential . We attempted to summarise the current knowledge on evaluating the effectiveness of training in EBHC while identifying the gaps . Methods A working group of EBHC teachers developed a conceptual framework of key areas of EBHC teaching and practice in need of evidence mapped to appropriate methods and outcomes . A literature search was conducted to review the current state of research in these key areas . Studies of training interventions that evaluated effectiveness by considering learner , patient or health system outcomes in terms of knowledge , skills , attitude , judgement , competence , decision-making , patient satisfaction , quality of life , clinical indicators or cost were included . There was no language restriction . Results Of 55 articles review ed , 15 met the inclusion criteria : six systematic review s , three r and omised controlled trials and six before-after studies . We found weak indications that undergraduate training in EBHC improves knowledge but not skills , and that clinical ly integrated postgraduate teaching improves both knowledge and skills . Two r and omised controlled trials reported no impact on attitudes or behaviour . One before-after study found a positive impact on decision-making , while another suggested change in learners ' behaviour and improved patient outcome . We found no studies assessing the impact of EBHC training on patient satisfaction , health-related quality of life , cost or population -level indicators of health . Conclusions Literature evaluating the effectiveness of training in EBHC has focused on short-term acquisition of knowledge and skills . Evaluation design s were method ologically weak , controlled trials appeared inadequately powered and systematic review s could not provide conclusive evidence owing to weakness of study design BACKGROUND 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 Background The rapidly increasing number of activity-induced musculoskeletal injuries among adolescents and young adults is currently a true public health burden . The objective of this study was to investigate whether a neuromuscular training programme with injury prevention counselling is effective in preventing acute musculoskeletal injuries in young men during military service . Methods The trial design was a population -based , r and omised study . Two successive cohorts of male conscripts in four companies of one brigade in the Finnish Defence Forces were first followed prospect ively for one 6-month term to determine the baseline incidence of injury . After this period , two new successive cohorts in the same four companies were r and omised into two groups and followed prospect ively for 6 months . Military service is compulsory for about 90 % of 19-year-old Finnish men annually , who comprised the cohort in this study . This r and omised , controlled trial included 968 conscripts comprising 501 conscripts in the intervention group and 467 conscripts in the control group .  A neuromuscular training programme was used to enhance conscripts ' motor skills and body control , and an educational injury prevention programme was used to increase knowledge and awareness of acute musculoskeletal injuries . The main outcome measures were acute injuries of the lower and upper limbs . Results In the intervention groups , the risk for acute ankle injury decreased significantly compared to control groups ( adjusted hazards ratio ( HR ) = 0.34 , 95 % confidence interval ( 95 % CI ) = 0.15 to 0.78 , P = 0.011 ) . This risk decline was observed in conscripts with low as well as moderate to high baseline fitness levels . In the latter group of conscripts , the risk of upper-extremity injuries also decreased significantly ( adjusted HR = 0.37 , 95 % CI 0.14 to 0.99 , P = 0.047 ) . In addition , the intervention groups tended to have less time loss due to injuries ( adjusted HR = 0.55 , 95 % CI 0.29 to 1.04 ) . Conclusions A neuromuscular training and injury prevention counselling programme was effective in preventing acute ankle and upper-extremity injuries in young male army conscripts . A similar programme could be useful for all young individuals by initiating a regular exercise routine . Trial registration Clinical Trials.gov identifier number NCT00595816 OBJECTIVE : To search the English- language literature for original research addressing the effect of  cryotherapy  on return to participation after injury . DATA SOURCES : We search ed MEDLINE , the Physiotherapy Evidence Data base , SPORT Discus , the Cochrane Review s data base , and CINAHL from 1976 to 2003 to identify r and omized clinical trials of  cryotherapy .  Key words used were cryotherapy , return to participation , cold treatment , ice , injury , sport , edema , and pain . DATA SYNTHESIS : Original research , including outcomes - assessment measures of return to participation of injured subjects , was review ed using the Physiotherapy Evidence Data base ( PEDro ) Scale . Four studies were identified and review ed by a panel of certified athletic trainers . The 4 articles ' scores ranged from 2 to 4 on the PEDro scale , which has a maximum of 10 points . Two of the articles suggested that cryotherapy speeds return to participation after ankle sprains . However , these authors failed to provide in-depth statistical analysis of their results . A confounding factor of compression as part of the treatment prevented interpretation of the effects of cryotherapy in 1 article . CONCLUSIONS : After critically review ing the literature for the effect of cryotherapy on return-to-participation measures , we conclude that cryotherapy may have a positive effect . Despite the extensive use of cryotherapy in the management of acute injury , few authors have actually examined the effect of cryotherapy alone on return-to-participation measures . The relatively poor quality of the studies review ed is of concern . R and omized , controlled clinical studies of the effect of cryotherapy on acute injury and return to participation are needed to better eluci date the treatment responses Many systematic review s are inconclusive and reinforce the message that there is clinical uncertainty . Phil Alderson and Ian Roberts argue that journals should make a point of publishing such review s rather than waiting for review s that show marked benefit or harm . Some experts disagree , however , but we failed to persuade them to commit their views to print . Studies with dramatic findings make interesting reading . Journal editors underst and ably want to publish articles that their readers will enjoy . This is one cause of publication bias , where research with less dramatic results tends to be published in journals with a smaller circulation , if indeed it is published at all . Systematic review s are no less vulnerable to this bias than other types of research . Should journals resist this pressure and make a point of publishing systematic review s even if all they show is continuing clinical uncertainty ? The answer will depend on the importance we attach to demonstrating uncertainty in medical practice . # # # # Summary points Denying uncertainty does not benefit patients and may increase health service costs More large scale r and omised trials need to be conducted based on the “ uncertainty principle ” Systematic review s with more dramatic results tend Injury rates in Intermediate Care ( IC ) facilities are high and the factors related to these injuries are unclear . The objectives of this exploratory sub- study , which is part of a large multi-faceted study in 8 IC facilities are to : ( 1 ) evaluate  EMG measured over a full-shift in the back and shoulders of 32 care aides ( CAs ) as an indicator of peak and cumulative workload ( n = 4 x 8 facilities ) ; investigate the relationship between EMG measures and injury indicators ; and explore the relationship between EMG measures and other workload measurements . Lumbar EMG  was converted to predicted cumulative spinal compression  and ranged in CAs from 11.7 to 22.8 MNs with a mean of 16.4 MNs . Average compression was significantly different during different periods of the day ( p < 0.001 ) with highest compression during pre-breakfast when CAs assist most with activities of daily living . Significant differences were found in average compression between low and high injury facilities for 3 of 5 periods of the day ( p < 0.010 ) . Peak compressions exceeding 3400 N occurred for very little of the workday ( e.g. 11.25s during the 75 min period pre-breakfast ) . Peak neck/shoulder muscle activity is low ( 99 % APDF ranged from 8.33 % to 28 % MVC ) . Peak and cumulative spinal compression were significantly correlated with lost-time and musculoskeletal injury rates as well as with total tasks observed in the CAs ( p < 0.01 ) . Perceived exertion was only correlated with peak compressions ( p < 0.01 ) . Facilities with low injury rates provided significantly more CAs ( p < 0.01 ) to meet resident needs , and subsequently CAs performed fewer tasks , result ing in less peak and cumulative spinal loading over the day Background The US Army has traditionally utilized bent-knee sit-ups as part of physical training and testing . It is unknown whether the short-term effects of a core stabilization exercise program without sit-up training may result in decreased musculoskeletal injury incidence and work restriction compared with traditional training . Objective The objective of this study was to explore the short-term effects of a core stabilization exercise program ( CSEP ) without sit-up training and a traditional exercise program ( TEP ) on musculoskeletal injury incidence and work restriction . Design The study was design ed as a cluster r and omized trial . Setting The setting was a 16-week training program at Fort Sam Houston ( San Antonio , Texas ) . Participants The study participants were soldiers with a mean age of 22.9 years ( SD=4,7 , range=18–35 ) for whom complete injury data were available for analysis ( n=1,141 ) . Intervention Twenty companies of soldiers were cluster r and omized to complete the CSEP ( 10 companies of 542 soldiers ) or the TEP ( 10 companies of 599 soldiers ) . The CSEP included exercises targeting the transversus abdominus and multifidus musculature . The TEP comprised exercises targeting the rectus abdominus , oblique abdominal , and hip flexor musculature . Measurements Research staff recorded all injuries result ing in the inability to complete full duty responsibilities . Differences in the percentages of musculoskeletal injuries were examined with chi-square analysis ; independent sample t tests were used to examine differences in the numbers of days of work restriction . Results Of the 1,141 soldiers for whom complete injury data were available for analysis , 511 ( 44.8 % ) experienced musculoskeletal injuries during training that result ed in work restrictions . There were no differences in the percentages of soldiers with musculoskeletal injuries . There also were no differences in the numbers of days of work restriction for musculoskeletal injuries overall or specific to the upper extremity . However , soldiers who completed the TEP and experienced a low back injury had more days of work restriction : 8.3 days ( SD=14.5 ) for the TEP group and 4.2 days ( SD=8.0 ) for the CSEP group . Limitations A limitation of this study was the inconsistent reporting of injuries during training . However , the rates of reporting were similar between the groups . Conclusions The incidence of musculoskeletal injuries was similar between the groups . There was marginal evidence that the CSEP result ed in fewer days of work restriction for low back injuries Background Injury to the anterior cruciate ligament ( ACL ) of the knee is common . Following complete rupture of the ACL , insufficient re-vascularization of the ligament prevents it from healing completely , creating a need for reconstruction . A variety of grafts are available for use in ACL reconstruction surgery , including synthetic grafts . Over the last two decades new types of synthetic ligaments have been developed . One of these synthetic ligaments , the Ligament Advanced Reinforcement System ( LARS ) , has recently gained popularity . The aim of this systematic review was to assess the current best available evidence for the effectiveness of the LARS as a surgical option for symptomatic , anterior cruciate ligament rupture in terms of graft stability , rehabilitation time and return to pre-injury function . Method This systematic review included studies using subjects with symptomatic , ACL ruptures undergoing LARS reconstruction .  A range of electronic data bases were search ed in May 2010 . The method ological quality of studies was appraised with a modified version of the Law critical appraisal tool . Data relating to study characteristics , surgical times , complication rates , outcomes related to knee stability , quality of life , function , and return to sport as well as details of rehabilitation programs and timeframes were collected . Results This review identified four studies of various design s , of a moderate method ological quality . Only one case of knee synovitis was reported . Patient satisfaction with LARS was high . Graft stability outcomes were found to be inconsistent both at post operative and at follow up periods . The time frames of rehabilitation periods were poorly reported and at times omitted . Return to pre-injury function and activity was often discussed but not reported in results . Conclusions There is an emerging body of evidence for LARS with comparable complication rates to traditional surgical techniques , and high patient satisfaction scores . However , this systematic review has highlighted several important gaps in the existing literature that require future prospect i ve investigation . The findings of this review were equivocal with regards to other measures such as graft stability and long term functional outcomes . While the importance of rehabilitation following LARS is well recognised , there is limited evidence to guide rehabilitation protocol Background : The treatment of exercise-related injuries is often a problem , and recurrent injuries are common . Two recent systematic review s found only one high- quality paper on the treatment of long-st and ing groin pain .  In this r and omized clinical trial , a training program including strength training result ed in a return of 79 % of the athletes to the previous level of sport without any groin pain . The long-term effect of this exercise program was evaluated . Hypothesis : The effect of the exercise program for adductor-related groin pain is long lasting . Study Design : R and omized controlled trial ; Level of evidence , 1 . Methods : Forty-seven ( 80 % ) of the 59 original participants of the study agreed to participate in this 8- to 12-year follow-up . They were all interviewed and examined using a st and ardized and reproducible protocol , identical to the one used in the original trial . The investigating physician ( P.N. ) was not involved in the original study and was unaware of the original treatment allocation . Results : A significant effect of the active training treatment  still existed for the whole group ( P = .047 ) and even more for the subgroup of 39 ( 83 % ) soccer players ( P = .012 ) . No significant differences were found regarding age , present sports activity , reasons for activity reduction , or time to follow-up . Conclusion : The beneficial short-term effect of the exercise program used in the primary r and omized clinical trial for treating long-st and ing adductor-related groin pain in athletes was found to be lasting , both for the whole group and even more for the large subgroup of soccer players . This is the first time an exercise treatment for overuse injuries to the musculoskeletal system has been shown to have a long-lasting effect ( 8 - 12 years ) OBJECTIVE Describe safety and efficacy of a supervised , low-to-moderate intensity strength training program adopted during pregnancy among women at increased risk for back pain . METHODS 32 women adopted strength training twice per week for 12 weeks . Data on musculoskeletal injuries , symptoms , blood pressure , and the absolute external load used for 5 of 6 exercises were obtained during each session . A submaximal lumbar extension endurance exercise test was performed at weeks 5 , 10 , and 13 . RESULTS The mean ( ± SD ) exercise session attendance rate was 80.5 % ( ± 11.3 % ) . No musculoskeletal injuries occurred . Potentially adverse symptoms ( eg , dizziness ) were infrequent ( 2.1 % of sessions ) . Repeated- measures ANOVA showed large increases in the external load across 12 weeks ( all P values < .001 ) and the percentage increases in external load from weeks 1 to 12 were 36 % for leg press , 39 % for leg curl , 39 % for lat pull down , 41 % for lumbar extension and 56 % for leg extension . Training was associated with a 14 % increase in lumbar endurance . Blood pressure was unchanged following acute exercise sessions and after 12 weeks of exercise training . CONCLUSION The adoption of a supervised , low-to-moderate intensity strength training program during pregnancy can be safe and efficacious for pregnant women Abstract Background : In the 11 years since its development at McMaster University Medical School , the multiple mini-interview ( MMI ) has become a popular selection tool . We aim ed to systematic ally explore , analyze and synthesize the evidence regarding MMIs for selection to undergraduate health programs . Methods : The review protocol was peer- review ed and prospect ively registered with the Best Evidence Medical Education ( BEME ) collaboration . Thirteen data bases were search ed through 34 terms and their Boolean combinations . Seven key journals were h and - search ed since 2004 . The reference sections of all included studies were screened . Studies meeting the inclusion criteria were coded independently by two review ers using a modified BEME coding sheet . Extracted data were synthesized through narrative synthesis . Results : A total of 4338 citations were identified and screened , result ing in 41 papers that met inclusion criteria . Thirty-two studies report data for selection to medicine , six for dentistry , three for veterinary medicine , one for pharmacy , one for nursing , one for rehabilitation , and one for health science . Five studies investigated selection to more than one profession . MMIs used for selection to undergraduate health programs appear to have reasonable feasibility , acceptability , validity , and reliability . Reliability is optimized by including 7–12 stations , each with one examiner . The evidence is stronger for face validity , with more research needed to explore content validity and predictive validity . In published studies , MMIs do not appear biased against applicants on the basis of age , gender , or socio-economic status . However , applicants of certain ethnic and social background s did less well in a very small number of published studies . Performance on MMIs does not correlate strongly with other measures of noncognitive attributes , such as personality inventories and measures of emotional intelligence . Discussion : MMI does not automatically mean a more reliable selection process but it can do , if carefully design ed . Effective MMIs require careful identification of the noncognitive attributes sought by the program and institution . Attention needs to be given to the number of stations , the blueprint and examiner training . Conclusion : More work is required on MMIs as they may disadvantage groups of certain ethnic or social background s. There is a compelling argument for multi-institutional studies to investigate areas such as the relationship of MMI content to curriculum domains , graduate outcomes , and social missions ; relationships of applicants ’ performance on different MMIs ; bias in selecting applicants of minority groups ; and the long-term outcomes appropriate for studies of predictive validity Context Clinicians rely on systematic review s for current , evidence -based information . Contribution This survival analysis of 100 meta-analyses indexed in ACP Journal Club from 1995 to 2005 found that new evidence that substantively changed conclusions about the effectiveness or harms of therapies arose frequently and within relatively short time periods . The median survival time without substantive new evidence for the meta-analyses was 5.5 years . Significant new evidence was already available for 7 % of the review s at the time of publication and became available for 23 % within 2 years . Implication Clinical ly important evidence that alters conclusions about the effectiveness and harms of treatments can accumulate rapidly . The Editors Systematic review s have become increasingly common in recent years ( 1 ) and are recommended by many as the best sources of evidence to guide both clinical decisions ( 2 ) and health care policy ( 3 ) . For systematic review s to fulfill these roles , their findings must remain relatively stable for at least several years or effective mechanisms must exist for alerting end users to important changes in evidence . Yet , surprisingly little research has assessed the extent to which systematic review s become out of date or the rate at which this occurs ( 47 ) . Some organizations , such as the Cochrane Collaboration , recommend updating systematic review s every 2 years , but few empirical data guide this or other recommendations about updating . We sought to determine how quickly systematic review s meet explicitly defined criteria for changes in evidence of sufficient importance to warrant updating . We also sought to identify predictors of survival time , the time to such important changes in evidence . Survival time might vary depending on many factors , including the type of question posed by the original review ( for example , therapeutic or diagnostic ) , the types of studies included ( for example , r and omized trials or observational studies ) , and whether the systematic review provided quantitative synthesis . To limit such variation , we focused on systematic review s of r and omized , controlled trials that evaluated therapeutic benefit or harm by providing quantitative synthesis ( meta- analysis ) for at least 1 outcome . Methods Study Design and Sample We used a quasi-r and om process ( alphabetical sort order by author ) to select 100 systematic review s that were indexed in ACP Journal Club with an accompanying commentary between January 1995 and December 2005 ( with a search date no later than 31 December 2004 to ensure at least 1 full year for new evidence to appear ) . We chose this sampling frame because ACP Journal Club selects systematic review s that meet explicit quality st and ards and are deemed directly relevant to clinical practice ( 8) . We regarded the sample size of 100 as sufficiently large to achieve suitably narrow confidence intervals and to permit evaluation of up to 5 potential predictors of survival . Eligibility Criteria Eligible review s evaluated the benefit or harm of a specific drug , class of drug , device , or procedure ( invasive procedure or surgery ) and included r and omized or quasi-r and omized , controlled trials . We excluded evaluations of alternative and complementary medicines because the stability of review s of such therapies might differ substantially from review s of conventional therapies . We required that review s provide a point estimate and 95 % confidence interval for at least 1 outcome in the form of a relative risk , odds ratio , or absolute risk difference for binary outcomes and weighted mean differences for continuous outcomes . We excluded meta-analyses of individual-patient data , meta-regressions , and indirect meta-analyses because of the difficulty of determining whether new data would alter previous quantitative results . Two team members independently assessed eligibility , with disagreements resolved by consensus involving a third review er . When more than 1 review on the same topic was identified , only the earliest was included . Search ing For each review , search es for new trials included identifying new systematic review s on the same topic , su bmi tting relevant content terms to the Clinical Queries function in Ovid , applying the Related Articles function in PubMed to the 3 largest and the 3 most recent trials in the original review ( up to 6 trials in total ) , and using Scopus ( www . scopus .com/ scopus /home.url ) to identify new r and omized trials that cited the original review . When these search strategies yielded no eligible new trials , we conducted more comprehensive electronic search es and review ed relevant chapters in such sources as Clinical Evidence and UpTo Date to ensure that we had not missed new trials . Team members who had background s in both medicine and clinical research screened citations retrieved by the preceding methods to identify trials that would have met the inclusion criteria in the original review . Retrieved articles were screened in chronological order to ascertain quantitative or qualitative signals for the need for updating . The review protocol stopped when any criteria for updating were met . Each systematic review was discussed in detail , with the final statussignal for updating was or was not detectedadjudicated by consensus ( Figure 1 ) . Figure 1 . Overall process for determining updating status . ACP Journal Club Signals for the Need to Up date Systematic Review s In design ing criteria for comparing new findings with those in a previous review , we adapted methods used by other investigators to address similar problems with comparing 2 sets of results relating to the same question ( 913 ) , such as r and omized and nonr and omized studies of the same intervention . These investigators identified conflicting findings among different publications using a combination of quantitative thresholds for differences in effect magnitude and qualitative judgments about the language used to describe the results . We have similarly conceptualized quantitative and qualitative signals of potential changes in evidence that are sufficiently important to warrant updating previous systematic review s. Quantitative Signals Quantitative signals consisted of a change in statistical significance or relative change in effect magnitude of at least 50 % . We restricted these changes to those involving 1 of the primary outcomes of the original review or any mortality outcome . We also ignored trivial changes in statistical significance when the original and up date d meta-analytic results both had P values between 0.04 and 0.06so that quantitative signals of changes in evidence would represent robust indicators of the need to up date previous review s. Quantitative signals were detected by combining data from eligible new trials with the previous results using a fixed-effects approach . Use of fixed-effect models allowed pooling of the new trials with the previous meta-analytic result , as opposed to having to obtain original data from all of the included trials in each of 100 systematic review s. Although r and om-effects models are usually preferred to avoid spurious precision in the face of heterogeneity , our goal was to detect potential changes in evidence that would warrant a formal up date , not produce exact estimates of the up date d results . Qualitative Signals Qualitative signals included new information about harm sufficient to affect clinical decision making , important caveats to the original results , emergence of a superior alternate therapy , and important changes in certainty or direction of effect . Qualitative signals were detected by using explicit criteria for comparing the language in the original review with descriptions of findings in new systematic review s that addressed the same topic , pivotal trials , clinical practice guidelines , or recent editions of major textbooks ( for example , UpTo Date ) . Pivotal trials were defined as trials that had a sample size at least 3 times larger than that of the previous largest trial or were published in 1 of the 5 highest-impact general medical journals ( The New Engl and Journal of Medicine , Lancet , Journal of the American Medical Association , Annals of Internal Medicine , and the British Medical Journal ) . We defined 2 levels of importance for qualitative signals : potentially invalidating changes in evidence , which would make one no longer want clinicians or policymakers to base decisions on the original findings ( such as a pivotal trial that characterized treatment effectiveness in terms opposite of those in the original systematic review ) , and major changes in evidence , which would affect clinical decision making in important ways without invalidating the previous results ( such as the identification of patient population s for whom treatment is more or less beneficial ) . Major changes also included differing characterizations of effectiveness that were less extreme than those for potentially invalidating signals but that would still affect clinical decision making ( for example , a change from possibly beneficial to definitely beneficial ) . Of importance , such characterizations as possibly effective , probably effective , and promising , were all categorized as possibly effective . Thus , qualitative signals for changes in evidence captured substantive differences in the characterization of treatment effects , not merely semantic differences . Full definitions for each of the specific signals can be found at www.ohri.ca/UpdatingSystRevs . Data Collection For each review , we characterized the clinical content area , eligibility criteria for included trials , definitions of reported outcomes , number of included trials and participants , meta-analytic result for each outcome , identification of statistical heterogeneity , and excerpted quotations of the authors ' characterizations of the main results . We also abstract ed whether a given outcome was explicitly identified as 1 of the primary or main outcomes . We discounted identification of more than 3 such outcomes as inconsistent with the
Conclusions Our results demonstrate that the existence of a relationship between training load and injury continues to be well supported in the literature and is strongest for subjective internal training load .
The directionality of this relationship appears to depend on the type and timeframe of load measured
Background The relationship between training load and musculoskeletal injury is a rapidly advancing area of research in need of an up date d systematic review .