It is exciting to be involved with the new Evidence-Based Practice section of the Internet Journal of Allied Health Sciences and Practice. Finding and establishing the current evidence-base to assist with making clinical decisions is a challenge for many researchers and clinicians, and thus this new section of the IJAHSP should start to provide readers with a library of evidence-based recommendations to which they can refer. Congratulations go to the inaugural authors, and many thanks go to the reviewers for assisting in producing the first two systematic reviews for this new IJAHSP initiative. This new section aims to present secondary evidence (structured reviews of primary research) which will synthesise the current evidence base and make evidence recommendations, by balancing primary study findings by study design, study quality, significance of findings, and clinical utility.
The first two systematic reviews presented in this section were written by Masters students at the University of South Australia. Barbara Pumberger and Carla van Usen posed clinical questions that concern many physiotherapists working in orthopaedics and sports medicine.
How effective is eccentric training compared with other types of interventions for the management of chronic Achilles tendinosis? How effective are closed kinetic chain exercises versus open kinetic chain exercises for anterior cruciate ligament rehabilitation?
Neither author found clear evidence with which to answer the question. Readers will note that even setting the search strategies with which to find the evidence required the authors to establish clear definitions of terms, to undertake an extensive review of available databases, and hand-search literature in order to unearth all possible relevant primary studies. The authors acted as independent reviewers for each other, at each step of the way through the review, to ensure rigor of process and transparency of decision-making. The studies included in the review differed in design type and methodology (even when the criteria for inclusion was "experimental"). This highlights the difficulty that many systematic reviewers have in obtaining homogenous primary studies for inclusion in the review. Lack of homogeneity in studies included in the review means that reviews need to be descriptive rather than meta-analyses of homogenous datasets. Moreover in these reviews, readers will note that the interventions were not always clearly defined or described, and outcome measures differed between studies. This constrained opportunities to make clear statements of what treatment was most effective when answering the clinical review questions were challenging.
Many systematic reviews conclude with unclear statements on the current evidence-base, or report "more research needs to be undertaken" or "clearer definitions of interventions or outcomes are required in future research." A challenge that we pose to authors in this new systematic review section is to make common sense of their findings and provide readers with a definitive answer to the clinical question, even when the evidence-based from which they are working is unclear. Thus our inaugural authors are congratulated on producing their conclusions, which provide clinicians and researchers with some clarity regarding the current clinical evidence base:
"Eccentric exercises are simple to perform and provide a cost effective way to treat Achilles tendinopathy. They should be considered for all patients before continuing to more invasive interventions such as surgery and drug therapy" (Van Usen and Pumberger 2007).
"There is moderate evidence to recommend closed kinetic chain exercises or a combination of closed kinetic chain and open kinetic chain exercises, rather than open kinetic chain exercises alone, for anterior cruciate ligament rehabilitation" (Pumberger and Van Usen 2007).
We anticipate that the availability of this new section in the journal will provide the impetus for other students and more senior researchers to present their evidence-reviews. The more reviews the better, because this provides more information for journal readers to use when considering the best treatment options for their patients. Criteria required for completing a systematic review for this new section in the journal include:
- evidence of independent reviewing at each step of the review process,
- a clear review question with achievable aims, defined search terms and a wide search of available library databases,
- hand-searching journal reference lists where indicated,
- clear inclusion and exclusion criteria (including years of literature, languages allowed, types of study designs), and then clear reporting related to the numbers of articles included (and excluded),
- the type of study design of each article,
- its critical appraisal scores, its key findings and their significance, and then,
- a commonsense discussion on the findings.
We look forward to an increasing number of systematic review papers submitted to the journal for consideration in this section, and a heightened awareness of the value of such review amongst IJAHSP readers. Good reading!!
Grimmer-Somers K. Systematic Reviews. The Internet Journal of Allied Health Sciences and Practice. 2007 Apr 01;5(2), Article 3.