OBJECTIVES: Globally, healthcare policy promotes supported self-management as a strategy for people with long-term conditions. This meta-review aimed to explore how people with hypertension make sense of their condition, to assess the effectiveness of supported self-management in hypertension, and to identify effective components of support.
METHODS: From a search of eight databases (January 1993-October 2012; update June 2017) we included systematic syntheses of qualitative studies of patients' experiences, and systematic reviews of randomized controlled trials evaluating the impact of supported self-management on blood pressure and medication adherence. We used meta-ethnography, meta-Forest plots and narrative analysis to synthesise the data.
RESULTS: Six qualitative and 29 quantitative reviews provided data from 98 and 446 unique studies, respectively. Self-management support consistently reduced SBP (by between 2 and 6 mmHg), and DBP (by between 1 and 5 mmHg). Information about hypertension and treatment, home BP monitoring (HBPM) and feedback (including telehealth) were widely used in effective interventions. Patients' perceptions of a disease with multiple symptoms contrasted with the professional view of an asymptomatic condition. HBPM, in the context of a supportive patient-professional relationship, changed perceptions of the significance of symptoms and fostered confidence in ability to self-manage hypertension.
CONCLUSION: Our systematic qualitative and quantitative meta-reviews tell complementary stories. Supported self-management can improve blood pressure control. Interventions are complex and encompass a broad range of support strategies. HBPM (with or without telehealth) within the context of a supportive patient-professional partnership can bridge the gap between medical and lay perspectives of hypertension and enable effective self-management.
INTRODUCTION: Cannabinoids have been proposed as a therapeutic alternative for fibromyalgia. However, their clinical effectiveness is a matter of debate. METHODS: To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified fifteen systematic reviews including two randomized trials overall. We concluded it is not clear whether cannabinoids have any benefit in fibromyalgia because the certainty of the evidence is very low. On the other hand, they are associated to frequent adverse effects.
BACKGROUND & AIMS: Musculoskeletal pain, the most common cause of disability globally, is most frequently managed in primary care. People with musculoskeletal pain in different body regions share similar characteristics, prognosis, and may respond to similar treatments. This overview aims to summarise current best evidence on currently available treatment options for the five most common musculoskeletal pain presentations (back, neck, shoulder, knee and multi-site pain) in primary care.
METHODS: A systematic search was conducted. Initial searches identified clinical guidelines, clinical pathways and systematic reviews. Additional searches found recently published trials and those addressing gaps in the evidence base. Data on study populations, interventions, and outcomes of intervention on pain and function were extracted. Quality of systematic reviews was assessed using AMSTAR, and strength of evidence rated using a modified GRADE approach.
RESULTS: Moderate to strong evidence suggests that exercise therapy and psychosocial interventions are effective for relieving pain and improving function for musculoskeletal pain. NSAIDs and opioids reduce pain in the short-term, but the effect size is modest and the potential for adverse effects need careful consideration. Corticosteroid injections were found to be beneficial for short-term pain relief among patients with knee and shoulder pain. However, current evidence remains equivocal on optimal dose, intensity and frequency, or mode of application for most treatment options.
CONCLUSION: This review presents a comprehensive summary and critical assessment of current evidence for the treatment of pain presentations in primary care. The evidence synthesis of interventions for common musculoskeletal pain presentations shows moderate-strong evidence for exercise therapy and psychosocial interventions, with short-term benefits only from pharmacological treatments. Future research into optimal dose and application of the most promising treatments is needed.
BACKGROUND: Fibromyalgia (FM) is a chronic, debilitating pain disorder. Dissatisfaction with conventional medicine can lead people with FM to turn to complementary and alternative medicine (CAM). Two previous overviews of systematic reviews of CAM for FM have been published, but they did not assessed for risk of bias in the review process.
METHODS: Five databases Medline, Embase, AMED (via OVID), Web of Science and Central were searched from their inception to December 2015. Reference lists were hand-searched. We had two aims: the first was to provide an up-to-date and rigorously conducted synthesis of systematic reviews of CAM literature on FM; the second was to evaluate the quality of the available systematic review evidence using two different tools: AMSTAR (Shea et al. BMC Med Res Methodol 15; 7:10, 2007) and a more recently developed tool ROBIS (Whiting et al. J Clin Epidemiol 69:225-34, 2016) specifically designed to assess risk of bias in systematic reviews. Any review that assessed one of eight CAM therapies for participants diagnosed with FM was considered. The individual studies had to be randomised controlled trials where the intervention was compared to placebo, treatment as usual or waitlist controls to be included. The primary outcome measure was pain, and the secondary outcome measure was adverse events.
RESULTS: We identified 15 reviews that met inclusion criteria. There was low-quality evidence that acupuncture improves pain compared to no treatment or standard treatment, but good evidence that it is no better than sham acupuncture. The evidence for homoeopathy, spinal manipulation and herbal medicine was limited.
CONCLUSIONS: Overall, five reviews scored 6 or above using the AMSTAR scale and the inter-rater agreement was good (83.6%), whereas seven reviews achieved a low risk of bias rating using ROBIS and the inter-rater agreement was fair (60.0%). No firm conclusions were drawn for efficacy of either spinal manipulation or homoeopathy for FM. There is limited evidence for topical Capsicum, but further research is required. There is some evidence to support the effectiveness of acupuncture for FM, but further high-quality trials are needed to investigate its benefits, harms and mechanisms of action, compared with no or standard treatment.
SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016035846 .
Objectives. This systematic overview of reviews aimed to summarize evidence and methodological quality from systematic reviews of complementary and alternative medicine (CAM) for the fibromyalgia syndrome (FMS). Methods. The PubMed/MEDLINE, Cochrane Library, and Scopus databases were screened from their inception to Sept 2013 to identify systematic reviews and meta-analyses of CAM interventions for FMS. Methodological quality of reviews was rated using the AMSTAR instrument. Results. Altogether 25 systematic reviews were found; they investigated the evidence of CAM in general, exercised-based CAM therapies, manipulative therapies, Mind/Body therapies, acupuncture, hydrotherapy, phytotherapy, and homeopathy. Methodological quality of reviews ranged from lowest to highest possible quality. Consistently positive results were found for tai chi, yoga, meditation and mindfulness-based interventions, hypnosis or guided imagery, electromyogram (EMG) biofeedback, and balneotherapy/hydrotherapy. Inconsistent results concerned qigong, acupuncture, chiropractic interventions, electroencephalogram (EEG) biofeedback, and nutritional supplements. Inconclusive results were found for homeopathy and phytotherapy. Major methodological flaws included missing details on data extraction process, included or excluded studies, study details, and adaption of conclusions based on quality assessment. Conclusions. Despite a growing body of scientific evidence of CAM therapies for the management of FMS systematic reviews still show methodological flaws limiting definite conclusions about their efficacy and safety.
It has been proposed that fibromyalgia could be managed by pharmacological and non-pharmacological interventions. Regular physical exercise is commonly used as a non-pharmacological intervention. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified 14 systematic reviews including 25 randomized trials. We combined the evidence using meta-analysis and generated a summary of findings table following the GRADE approach. We conclude that regular physical exercise probably reduces pain in patients with fibromyalgia. ; Se postula que la fibromialgia se podría manejar tanto de manera farmacológica como no farmacológica. El ejercicio físico regular corresponde a una de las intervenciones no farmacológicas más comúnmente planteadas. Utilizando la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en 30 bases de datos, identificamos 14 revisiones sistemáticas que en conjunto incluyen 25 estudios aleatorizados. Realizamos un metanálisis y tablas de resumen de los resultados utilizando el método GRADE. Concluimos que el ejercicio probablemente disminuye el dolor en pacientes con fibromialgia.
Post-operative pain affects millions of patients worldwide and the post-operative period has high rates of morbidity and mortality. Some of this morbidity may be related to analgesics. The aim of this review was to provide an update of current knowledge of adverse events (AE) associated with the most common perioperative non-opioid analgesics: paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids (GCCs), gabapentinoids and their combinations. The review is based on data from systematic reviews with meta-analyses of analgesic efficacy and/or adverse effects of perioperative non-opioid analgesics, and randomised trials and cohort/retrospective studies. Generally, data on AE are sparse and related to the immediate post-operative period. For paracetamol, the incidence of AEs appears trivial. Data are inconclusive regarding an association of NSAIDs with mortality, cardiovascular events, surgical bleeding and renal impairment. Anastomotic leakage may be associated with NSAID usage. No firm evidence exists for an association of NSAIDs with impaired bone healing. Single-dose GCCs were not significantly related to increased infection rates or delayed wound healing. Gabapentinoid treatment was associated with increased sedation, dizziness and visual disturbances, but the clinical relevance needs clarification. Importantly, data on AEs of combinations of the above analgesics are sparse and inconclusive. Despite the potential adverse events associated with the most commonly applied non-opioid analgesics, including their combinations, reporting of such events is sparse and confined to the immediate perioperative period. Knowledge of benefit and harm related to multimodal pain treatment is deficient and needs clarification in large trials with prolonged observation.
This evidence map provides an overview of “mindfulness” intervention research and describes its volume and focus. It summarizes patient outcomes as reported in systematic reviews of randomized controlled trial evidence. We searched 10 electronic databases to February 2014, screened reviews of reviews, and consulted topic experts. We used a bubble plot as a visual overview of the distribution of evidence and synthesized results narratively in an executive summary. In total, 81 systematic reviews met inclusion criteria and the largest review included 109 mindfulness RCTs. Most research is available for general overviews on health benefits or psychological wellbeing. Reviews on chronic illness, depression, substance use, somatization, distress, and mental illness included 10 or more RCTs. Reviews suggest differential effects of mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), and other mindfulness-based interventions, and definitions of “mindfulness-based” varied. The most consistent effect was reported for depression but published meta-analyses also indicated effects compared to passive control of MBSR on overall health, chronic illness, and psychological variables; MBCT for mental illness; and mindfulness interventions for somatization disorders. Limited evidence is also available for mindfulness interventions for pain, anxiety, and psychosis compared to passive control groups. More detail is provided for priority areas post-traumatic stress disorder, stress, depression, and wellness. The evidence map provides a broad overview (not detailed or definitive effectiveness evidence) over the existing research to help interpret the state of the evidence to inform policy and clinical decision making.
ABSTRACT: Overall the evidence base was large; we identified 43 systematic reviews covering hundreds of studies and thousands of participants. Evidence clustered around particular outcomes, interventions and populations. Outcomes The vast majority of evidence is on quality of life and prevention outcomes Evidence on satisfaction with services and safeguarding is severely limited Interventions Physical activity interventions are those most widely evaluated in systematic reviews, followed by occupational therapy interventions No evidence is available on some key social care interventions, e.g. direct payments Populations The majority of evidence concerns people with long-term conditions (e.g. dementia, cancer, stroke) There is much less evidence on older people or people with mental health problems Evidence on learning or physical disabilities is extremely limited. Interventions with evidence of positive effect Evidence of positive impact was found for seven of the 14 social care interventions examined in the included reviews: physical activity, occupational therapy, supported employment, lay/peer support, hip protectors, assistive devices and personal assistance. Evidence on the scale of positive impacts was available for five of these interventions. Larger positive impacts resulted from integrated employment and mental health support and from hip protectors. Both larger and smaller impacts were found across eight physical activity reviews and two occupational therapy reviews. Smaller impacts resulted from a lay-led self-management intervention. Interventions with evidence of harm Two reviews contained evidence that interventions shown to be effective for some populations could potentially cause harm to vulnerable social care recipients. Tai chi, though effective for older people in general, was found to increase the rate of falls among frail older people. Exercise was found to have positive impacts on people exercising for rehabilitation after a period of ill health, but a negative impact on the psychological QoL of people exercising to manage their condition. Interventions not shown to be effective There were seven interventions for which no conclusive positive evidence was found. All available evidence on the following interventions was inconclusive: structured communication, safeguarding training, home hazard assessment. All available evidence on case management and social support interventions showed no evidence of difference between intervention and control groups. Of two reviews on alternative therapies, one found no evidence of difference between groups and another found inconclusive evidence. Inconclusive evidence was also found for some interventions shown to be positive in other reviews: physical activity, occupational therapy, personal assistance, assistive devices, lay/peer support, supported employment. No evidence of difference was found in some reviews for interventions which were found in other reviews to have positive effects: physical activity, assistive devices, lay/peer support, supported employment. On balance, the overall evidence suggests that physical activity interventions and occupational therapy are effective. What are the implications? Implications for policy and practice The greatest portion of evidence included in this review of reviews is about physical activity – evidence suggests that these types of interventions can be effective for people with long-term conditions and non-frail older people and may address both quality of life and delay or reduce the need for social care support. Moreover, although physical activity interventions may typically be regarded as not within the remit of social care, they may be relatively cheap and easy to implement, and therefore worth considering. More complex and perhaps more recognisably social care interventions such as occupational therapy are also supported by the review-level literature. The large and medium effects resulting from integrated mental health and employment services also underscore the value of complex social care interventions. Moreover, the integrated nature of this particular intervention suggests that the current drive in the UK to integrate health and social services (Department of Health 2011) may prove to be successful. Wider evaluation of integrated services is certainly warranted. A last key message for policymakers and practitioners is the need to recognise the influence of contextual factors on the success of social care interventions, in particular the need for safety measures when implementing social care interventions with particularly vulnerable groups. Implications for research The great breadth and extent of evidence contained within this review of reviews is clear. However, assessing the available review-level evidence across the whole of social care also makes clear that there are significant gaps in the evidence examining impact on ASCOF outcomes. There is severely limited evidence on satisfaction with services and safeguarding outcomes in existing systematic reviews There is little use of quality of life measures designed to evaluate the impact of social care interventions included in reviews There is limited review-level evidence on many social care interventions, and none for some key intervention types There is scant evidence on key populations groups – people with physical and learning disabilities There is no review-level evidence on cost-effectiveness. How did we get these results? The research involved identifying and analysing evidence from systematic reviews to answer the following research questions: Which social care interventions can effectively improve outcomes for services users in the four outcome domains set out in the ASCOF: quality of life, prevention, satisfaction and safeguarding? How much impact do effective social care interventions have on ASCOF outcomes?
Globally, healthcare policy promotes supported self-management as a strategy for people with long-term conditions. This meta-review aimed to explore how people with hypertension make sense of their condition, to assess the effectiveness of supported self-management in hypertension, and to identify effective components of support.
METHODS:
From a search of eight databases (January 1993-October 2012; update June 2017) we included systematic syntheses of qualitative studies of patients' experiences, and systematic reviews of randomized controlled trials evaluating the impact of supported self-management on blood pressure and medication adherence. We used meta-ethnography, meta-Forest plots and narrative analysis to synthesise the data.
RESULTS:
Six qualitative and 29 quantitative reviews provided data from 98 and 446 unique studies, respectively. Self-management support consistently reduced SBP (by between 2 and 6 mmHg), and DBP (by between 1 and 5 mmHg). Information about hypertension and treatment, home BP monitoring (HBPM) and feedback (including telehealth) were widely used in effective interventions. Patients' perceptions of a disease with multiple symptoms contrasted with the professional view of an asymptomatic condition. HBPM, in the context of a supportive patient-professional relationship, changed perceptions of the significance of symptoms and fostered confidence in ability to self-manage hypertension.
CONCLUSION:
Our systematic qualitative and quantitative meta-reviews tell complementary stories. Supported self-management can improve blood pressure control. Interventions are complex and encompass a broad range of support strategies. HBPM (with or without telehealth) within the context of a supportive patient-professional partnership can bridge the gap between medical and lay perspectives of hypertension and enable effective self-management.
