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Conclusiveness of Cochrane Reviews In.1
Conclusiveness of Cochrane Reviews In.1
Conclusiveness of Cochrane Reviews In.1
Numerous Cochrane Reviews (CRs) in the field studies. Most CRs in physiotherapy are inconclusive, and
of physiotherapy have been published, but their most emphasize the need for further research. The ability
conclusiveness has not been investigated. The purpose of a Cochrane Review to reach a conclusion is affected
of this study was to provide an overview and describe by the cumulative patient sample size and number of
the conclusiveness of evidence from CRs regarding trials included in the analysis. International Journal of
physiotherapy. We conducted a systematic search using Rehabilitation Research 42:97–105 Copyright © 2019
the Cochrane Database of Systematic Reviews in the Wolters Kluwer Health, Inc. All rights reserved.
Cochrane Library from 2008 through 2017 in the field International Journal of Rehabilitation Research 2019, 42:97–105
of physiotherapy, the Physical Rehabilitation Evidence
Keywords: Cochrane review, conclusiveness, meta-analysis, physiotherapy,
Database, and the CRs list on the Cochrane Rehabilitation systematic review
website. Reviewers extracted the following data: year of
a
publication, editorial group, number of articles meeting Department of Rehabilitation Medicine, Teikyo University School of Medicine
University Hospital, Mizonokuchi, bDepartment of Rehabilitation Medicine, The
the criteria, number of patients enrolled, conclusiveness, Jikei University School of Medicine, cDepartment of Clinical Epidemiology and
and need for additional studies. Linear regression was Health Economics, School of Public Health, Graduate School of Medicine,
The University of Tokyo, Tokyo, dDepartment of Physical Therapy, Faculty of
used to determine whether the percentage of conclusive Health Sciences, Kyoto Tachibana University, Kyoto, eDepartment of Oral
reviews was affected by the year of publication. Reviewers and Maxillofacial Surgery, Hirosaki University Graduate School of Medicine,
Hirosaki, fDepartment of Physical Therapy, School of Health Sciences, Japan
found 283 CRs in the field of physiotherapy, and only 16 University of Health Sciences, Satte and gDepartment of Anesthesiology, Nara
(5.7%) of which were conclusive. The number of trials Medical University, Kashihara, Japan
and participants enrolled in conclusive reviews were Correspondence to Ryo Momosaki, MD, PhD, MPH, Department of
significantly higher than those in inconclusive reviews Rehabilitation Medicine, Teikyo University School of Medicine University
Hospital, Mizonokuchi, 5-1-1 Futako, Takatsu-ku, Kawasaki, Kanagawa
(P < 0.001). The percentage of conclusive reviews was 213-8507, Japan
significantly correlated with year of publication (P = 0.03). Tel: +81 448 443 333; fax: +81 448 443 201; e-mail: momosakiryo@gmail.com
Almost all reviews recognized the need for additional Received 18 November 2018 Accepted 4 January 2019
0342-5282 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/MRR.0000000000000338
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
98 International Journal of Rehabilitation Research 2019, Vol 42 No 2
on the number of studies included in the review and the Cochrane Rehabilitation website (http://rehabilitation.
cumulative number of patients enrolled; and (d) conclu- cochrane.org/evidence). We excluded outdated versions of
siveness may be influenced by year of publication. reviews, withdrawn reviews, and protocol reviews.
by the Cochrane Library (http://www.cochranelibrary.com/) our searches and excluded obviously irrelevant reports.
from 2008 through 2017 in the field of physiotherapy We retrieved full-text articles for the remaining refer-
0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 10/05/2023
(The search strategy is available to interested researchers ences, and two review authors (R.M. and M.Y.) inde-
upon request to the corresponding author.). We included pendently screened these to identify studies for inclusion.
reviews that assessed the effect of physiotherapy, defined We identified and recorded reasons for exclusion of ineli-
as any type and intensity of rehabilitation possibly admin- gible studies. We resolved disagreements through discus-
istered by physical therapists (physical exercise, physio- sion, or if necessary, consulted a third person (Y.Y.). We
therapy, orthotic therapy, education, etc.) to improve or recorded the selection process and completed a PRISMA
prevent impairment, disability, and handicap. To identify flow diagram.
additional publications that were potentially relevant
for inclusion in the study, we also searched the Physical Data extraction
Rehabilitation Evidence Database (PEDro; http://www. Reviewers (R.M., M.T., Y.Y., K.F., T.K., and K.U.) inde-
pedro.fhs.usyd.edu.au/) and screened the CRs list on the pendently extracted characteristics of the included
Fig. 1
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Conclusiveness of CRs in physiotherapy Momosaki et al. 99
Musculoskeletal 32
Back and Neck 28
Bone, Joint, and Muscle Trauma 28
Stroke 28
Neuromuscular 20
Airways 18
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Heart 12
Pain, Palliative, and Supportive Care 12
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100 International Journal of Rehabilitation Research 2019, Vol 42 No 2
Acute Respiratory Infections Chest physiotherapy for acute bronchiolitis in pediatric patients between 0 and 24 months old
Chest physiotherapy for pneumonia in adults
Chest physiotherapy for pneumonia in children
Exercise versus no exercise for the occurrence, severity, and duration of acute respiratory infections
Airways Airway clearance techniques for bronchiectasis
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Airway clearance techniques for chronic obstructive pulmonary disease Breathing exercises for children with asthma
Breathing exercises for chronic obstructive pulmonary disease
Breathing exercises for dysfunctional breathing/hyperventilation syndrome in children
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Conclusiveness of CRs in physiotherapy Momosaki et al. 101
Table 3 (continued)
Editorial groups Title
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102 International Journal of Rehabilitation Research 2019, Vol 42 No 2
Table 3 (continued)
Editorial groups Title
Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women
Pelvic floor muscle training added to another active treatment versus the same active treatment alone for urinary inconti-
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nence in women
Pelvic floor muscle training for prevention and treatment of urinary and fecal incontinence in antenatal and postnatal
women
Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women
Treatment of urinary incontinence after stroke in adults
Injuries Fitness training for cardiorespiratory conditioning after traumatic brain injury
Locomotor training for walking after spinal cord injury
Modification of the home environment for the reduction of injuries
Multidisciplinary rehabilitation for acquired brain injury in adults of working age
Nonpharmacological interventions for chronic pain in people with spinal cord injury
Nonpharmacological interventions for depression in adults and children with traumatic brain injury
Passive movements for the treatment and prevention of contractures
Respiratory muscle training for cervical spinal cord injury
Kidney and Transplant Exercise training for adults with chronic kidney disease
Interventions for chronic kidney disease-associated restless legs syndrome
Lung Cancer Exercise training undertaken by people within 12 months of lung resection for non-small-cell lung cancer
Noninvasive interventions for improving well-being and quality of life in patients with lung cancer
Preoperative exercise training for patients with non-small-cell lung cancer
Metabolic and Endocrine Disorders Diet, physical activity, and behavioral interventions for the treatment of overweight or obese adolescents aged 12–17
years
Diet, physical activity, and behavioral interventions for the treatment of overweight or obese children from the age of 6–11
years
Diet, physical activity, and behavioral interventions for the treatment of overweight or obesity in preschool children up to
the age of 6 years
Exercise or exercise and diet for preventing type 2 diabetes mellitus
Transtheoretical model stages of change for dietary and physical exercise modification in weight loss management for
overweight and obese adults
Movement Disorders Interventions for fatigue in Parkinson’s disease
Physiotherapy for Parkinson’s disease: a comparison of techniques
Physiotherapy versus placebo or no intervention in Parkinson’s disease
Therapeutic interventions for symptomatic treatment in Huntington’s disease
Treadmill training for patients with Parkinson’s disease
Virtual reality for rehabilitation in Parkinson’s disease
Whole-body vibration training for patients with neurodegenerative disease
Multiple Sclerosis and Rare Diseases of the Exercise therapy for fatigue in multiple sclerosis Neuropsychological rehabilitation for multiple sclerosis
CNS Nonpharmacological interventions for spasticity in multiple sclerosis
Telerehabilitation for persons with multiple sclerosis
Musculoskeletal Aerobic exercise training for adults with fibromyalgia
Aquatic exercise for the treatment of knee and hip osteoarthritis
Assistive devices, hip precautions, environmental modifications, and training to prevent dislocation and improve function
after hip arthroplasty
Balance training (proprioceptive training) for patients with rheumatoid arthritis
Braces and orthoses for treating osteoarthritis of the knee
Continuous passive motion following total knee arthroplasty in people with arthritis
Cryotherapy following total knee replacement
Deep transverse friction massage for treating lateral elbow or lateral knee tendinitis
Dynamic exercise programs (aerobic capacity and/or muscle strength training) in patients with rheumatoid arthritis
Electromagnetic fields for treating osteoarthritis
Electrotherapy modalities for adhesive capsulitis (frozen shoulder) Exercise for improving outcomes after osteoporotic
vertebral fracture
Exercise for osteoarthritis of the knee
Exercise for preventing and treating osteoporosis in postmenopausal women
Exercise therapy in juvenile idiopathic arthritis
High-intensity versus low-intensity physical activity or exercise in people with hip or knee osteoarthritis
Interventions for treating osteoarthritis of the big toe joint
Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults
Joint lavage for osteoarthritis of the knee
Manual therapy and exercise for adhesive capsulitis (frozen shoulder) Manual therapy and exercise for rotator cuff disease
Mind and body therapy for fibromyalgia
Multidisciplinary rehabilitation programs following joint replacement at the hip and knee in chronic arthropathy
Nonsurgical interventions for pediatric pes planus
Physiotherapy interventions for ankylosing spondylitis
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Conclusiveness of CRs in physiotherapy Momosaki et al. 103
Table 3 (continued)
Editorial groups Title
Physical activity programs for promoting bone mineralization and growth in preterm infants
Neuromuscular Interventions for congenital talipes equinovarus (clubfoot) Interventions for fatigue in peripheral neuropathy
Interventions for increasing ankle range of motion in patients with neuromuscular disease
Interventions for preventing critical illness polyneuropathy and critical illness myopathy
Multidisciplinary care for adults with amyotrophic lateral sclerosis or motor neuron disease
Multidisciplinary care for Guillain-Barré syndrome
Nondrug therapies for lower limb muscle cramps
Physical rehabilitation for critical illness myopathy and neuropathy
Physical therapy for Bell’s palsy (idiopathic facial paralysis)
Physical training for McArdle disease
Rehabilitation following carpal tunnel release
Strength training and aerobic exercise training for muscle disease
Symptomatic treatments for amyotrophic lateral sclerosis/motor neuron disease
Therapeutic exercise for people with amyotrophic lateral sclerosis or motor neuron disease
Treatment for Charcot-Marie-Tooth disease
Treatment for cramps in amyotrophic lateral sclerosis/motor neuron disease
Treatment for mitochondrial disorders
Treatment for periodic paralysis
Treatment for postpolio syndrome
Treatment for spasticity in amyotrophic lateral sclerosis/motor neuron disease
Oral Health Interventions for the management of temporomandibular joint osteoarthritis
Pain, Palliative care, and Supportive Care Exercise for cancer cachexia in adults
Exercise for the management of cancer-related fatigue in adults
Interventions for treating pain and disability in adults with complex regional pain syndrome: an overview of systematic
reviews
Multidisciplinary rehabilitation after primary brain tumor treatment
Neuromuscular electrical stimulation for muscle weakness in adults with advanced disease
Physiotherapy for pain and disability in adults with complex regional pain syndrome types I and II
Positioning and spinal bracing for pain relief in metastatic spinal cord compression in adults
Transcutaneous electric nerve stimulation for cancer pain in adults
Transcutaneous electrical nerve stimulation for fibromyalgia in adults
Transcutaneous electrical nerve stimulation for neuropathic pain in adults
Transcutaneous electrical nerve stimulation for phantom pain and stump pain following amputation in adults
Transcutaneous electrical nerve stimulation for acute pain
Pregnancy and Childbirth Diet and exercise interventions for preventing gestational diabetes mellitus
Diet or exercise, or both, for preventing excessive weight gain in pregnancy
Diet or exercise, or both, for weight reduction in women after childbirth
Exercise for pregnant women for preventing gestational diabetes mellitus
Interventions for preventing and treating low-back and pelvic pain during pregnancy
Massage, reflexology, and other manual methods for pain management in labor
Transcutaneous electrical nerve stimulation for pain management in labor
Schizophrenia Exercise therapy for schizophrenia
General physical health advice for people with serious mental illness
Stroke Circuit class therapy for improving mobility after stroke
Early versus delayed mobilization for aneurysmal subarachnoid hemorrhage
Electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle
strength after stroke
Electromechanical-assisted training for walking after stroke
Home-based therapy programs for upper-limb functional recovery following stroke
Inspiratory muscle training for the recovery of function after stroke
Interventions for improving sit-to-stand ability following stroke
Interventions for motor apraxia following stroke
Interventions for preventing falls in people after stroke
Mirror therapy for improving motor function after stroke
Multidisciplinary rehabilitation following botulinum toxin and other focal intramuscular treatment for poststroke spasticity
Nonpharmacological interventions for perceptual disorders following stroke and other adult-acquired, nonprogressive
brain injury
Overground physical therapy gait training for patients with chronic stroke with mobility deficits
Physical fitness training for patients with stroke
Physical methods for preventing deep vein thrombosis in stroke
Physical rehabilitation approaches for the recovery of function and mobility following stroke
Physical rehabilitation for older people in long-term care
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104 International Journal of Rehabilitation Research 2019, Vol 42 No 2
Table 3 (continued)
Editorial groups Title
Repetitive peripheral magnetic stimulation for activities of daily living and functional ability in people after stroke
Repetitive task training for improving functional ability after stroke
Repetitive transcranial magnetic stimulation for improving function after stroke
Simultaneous bilateral training for improving arm function after stroke
Telerehabilitation services for stroke
Therapy-based rehabilitation services for patients living at home more than one year after stroke
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Transcranial direct current stimulation for improving activities of daily living, and physical and cognitive functioning, in
people after stroke
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Treadmill training and body weight support for walking after stroke
Very early versus delayed mobilization after stroke
Virtual reality for stroke rehabilitation
Water-based exercises for improving activities of daily living after stroke
Tobacco Addiction Exercise interventions for smoking cessation
Vascular Continuous passive motion for preventing venous thromboembolism after total knee arthroplasty
Exercise for intermittent claudication
Modes of exercise training for intermittent claudication
Physical exercise for the treatment of nonulcerated chronic venous insufficiency
Prosthetic rehabilitation for older dysvascular people following a unilateral transfemoral amputation
Supervised exercise therapy versus nonsupervised exercise therapy for intermittent claudication
Work Conservative interventions for treating work-related complaints of the arm, neck, or shoulder in adults
Exercise training to improve exercise capacity and quality of life in people with nonmalignant dust-related respiratory
diseases
Interventions to enhance return to work for patients with cancer
All inconclusive reviews recognized the need for further total number of patients enrolled in the analyzed stud-
studies, whereas the need for further studies was stated ies. Meta-analyses with small sample sizes sometime fail
in only 68.8% of conclusive reviews (P < 0.001). Linear to detect statistical differences. Evaluation of studies
regression analysis showed a significant correlation requires careful consideration of the extent to which each
between the percentage of conclusive reviews and the trial contributes to the estimate of magnitude of effect.
year of publication (R2 = 17%, P = 0.03; Fig. 2). Each trial’s contribution will usually reflect its sam-
ple size; larger trials with many patients will contribute
We compiled a list of 283 CRs in physiotherapy as shown
more to magnitude of effect, and thus to conclusiveness
in Table 3.
(Guyatt et al., 2011).
Almost all CRs in our systemic analysis recognized the
Discussion
need for further studies. Potential reasons for the need
Consistent with our hypothesis, a large proportion of
for further research include low methodological quality,
CRs in physiotherapy were inconclusive. In fact, 94.3%
small sample size, not enough studies, not enough data
of reviews fulfilled our criteria for being inconclusive. In
in subgroups, not enough data on adverse effects, and
the current state, a researcher or clinician would not nec-
others (Brown et al., 2006). These findings indicate that
essarily be able to turn to CRs for a definite answer on a
many current RCTs for physiotherapy have not been well
specific issue associated with physiotherapy. Our result
designed.
was much higher than those found in previous analyses of
CRs from other fields. The low proportion of conclusive The percentage of conclusive reviews correlated weakly
studies may be attributable to the poor quality of evidence and positively with the year of publication. Consistent
in the field of physiotherapy, suggesting a need for more with our hypothesis, newer reviews had a higher proba-
high-quality clinical evidence in this field. High-quality bility of being conclusive than older reviews. It is possi-
controlled trials are difficult to conduct in physiotherapy ble that an increasing number of physiotherapy clinical
for several reasons. Blind RCTs in physiotherapy pose trials were conducted cumulatively over the years; thus,
particular difficulties compared with those conducted in new or updated CRs had access to more clinical trial data
other fields of medicine, as successful blinding is often and could more easily generate conclusive answers (Lau
hard to achieve (Boutron et al., 2004; Wood et al., 2008). et al., 1995).
In addition, it appears difficult in practice to conduct a
Inconclusiveness and quality of review are two com-
RCT to examine the effect of physiotherapy because of
pletely different factors. High-quality inconclusive
the widespread use of this therapeutic approach (Fregni
reviews as with conclusive ones are of great value for
et al., 2010).
clinicians and researchers in terms of identifying gaps
As hypothesized, conclusiveness was associated with in their understanding and setting priorities for future
the number of studies included in the review and the research. The aim of CRs is not decision making as to
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Conclusiveness of CRs in physiotherapy Momosaki et al. 105
whether an intervention is better or not but to develop Ryo Momosaki is currently receiving a grant (#15K01395)
the best available evidence from a systematic review. from the Japan Society for the Promotion of Science.
Although inconclusiveness of CRs may disappoint those
seeking evidence, such CRs are valuable in prioritizing Conflicts of interest
important research questions and highlighting areas of There are no conflicts of interest.
practice where research investment is needed.
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