Review article 97
Conclusiveness of Cochrane Reviews in physiotherapy:
a systematic search and analytical review
Ryo Momosakia,b, Marika Tsuboib, Yuichi Yasufukud, Ken Furudatee,
Tomohiko Kamof, Kazuaki Udac, Yuu Tanakag and Masahiro Abob
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Numerous Cochrane Reviews (CRs) in the field
of physiotherapy have been published, but their
conclusiveness has not been investigated. The purpose
of this study was to provide an overview and describe
the conclusiveness of evidence from CRs regarding
physiotherapy. We conducted a systematic search using
the Cochrane Database of Systematic Reviews in the
Cochrane Library from 2008 through 2017 in the field
of physiotherapy, the Physical Rehabilitation Evidence
Database, and the CRs list on the Cochrane Rehabilitation
website. Reviewers extracted the following data: year of
publication, editorial group, number of articles meeting
the criteria, number of patients enrolled, conclusiveness,
and need for additional studies. Linear regression was
used to determine whether the percentage of conclusive
reviews was affected by the year of publication. Reviewers
found 283 CRs in the field of physiotherapy, and only 16
(5.7%) of which were conclusive. The number of trials
and participants enrolled in conclusive reviews were
significantly higher than those in inconclusive reviews
(P < 0.001). The percentage of conclusive reviews was
significantly correlated with year of publication (P = 0.03).
Almost all reviews recognized the need for additional
Introduction
The Cochrane Collaboration is an international, inde-
pendent, not-for-profit organization with more than 37 000
contributors from more than 130 countries (http://www.
cochrane.org). The Cochrane Library gathers and summa-
rizes the best evidence from research to help inform treat-
ment choices. Cochrane Reviews (CRs) are considered an
international gold standard for high-quality, popular, and
up-to-date systematic reviews. Cochrane Rehabilitation
was established in October 2016, to act as a bridge
between Cochrane and Rehabilitation stakeholders by
systematically identifying and disseminating evidence
from Cochrane to rehabilitation providers, policy makers,
and patients, and improving the quality, quantity, and rel-
evance of Cochrane’s work from a rehabilitation perspec-
tive, including physiotherapy (Negrini et al., 2018).
A typical CR aims to systematically analyze evidence
obtained from relevant randomized clinical trials (RCTs)
to provide, whenever possible, updated recommenda-
tions on the efficacy of a particular medical intervention.
However, all CRs are not conclusive. Conclusiveness has
0342-5282 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
studies. Most CRs in physiotherapy are inconclusive, and
most emphasize the need for further research. The ability
of a Cochrane Review to reach a conclusion is affected
by the cumulative patient sample size and number of
trials included in the analysis. International Journal of
Rehabilitation Research 42:97–105 Copyright © 2019
Wolters Kluwer Health, Inc. All rights reserved.
International Journal of Rehabilitation Research 2019, 42:97–105
Keywords: Cochrane review, conclusiveness, meta-analysis, physiotherapy,
systematic review
a
Department of Rehabilitation Medicine, Teikyo University School of Medicine
University Hospital, Mizonokuchi, bDepartment of Rehabilitation Medicine, The
Jikei University School of Medicine, cDepartment of Clinical Epidemiology and
Health Economics, School of Public Health, Graduate School of Medicine,
The University of Tokyo, Tokyo, dDepartment of Physical Therapy, Faculty of
Health Sciences, Kyoto Tachibana University, Kyoto, eDepartment of Oral
and Maxillofacial Surgery, Hirosaki University Graduate School of Medicine,
Hirosaki, fDepartment of Physical Therapy, School of Health Sciences, Japan
University of Health Sciences, Satte and gDepartment of Anesthesiology, Nara
Medical University, Kashihara, Japan
Correspondence to Ryo Momosaki, MD, PhD, MPH, Department of
Rehabilitation Medicine, Teikyo University School of Medicine University
Hospital, Mizonokuchi, 5-1-1 Futako, Takatsu-ku, Kawasaki, Kanagawa
213-8507, Japan
Tel: +81 448 443 333; fax: +81 448 443 201; e-mail: momosakiryo@gmail.com
Received 18 November 2018 Accepted 4 January 2019
been defined as the ability to reach a practical definitive
conclusion stating that one treatment is significantly supe-
rior, equivalent, or inferior to another treatment or placebo
(Mandel et al., 2006). CRs often show a lack of strong evi-
dence for the efficacy of a particular treatment or strategy,
leading to the recommendation that additional medical
studies be carried out before a final conclusion is reached.
According to previous reports, 45–80% of CRs are conclu-
sive (Mandel et al., 2006; Cohen et al., 2013, 2014; Mimouni
et al., 2015; Yin et al., 2015; Zhang et al., 2017); however,
a substantial proportion of CRs emphasize the need for
additional research. We hypothesized that the same would
be true of CRs in the field of physiotherapy. Investigating
the conclusiveness of current CRs in this field would help
clarify the requirement for further studies.
The aim of the present study was to establish the clini-
cal conclusiveness of CRs in the field of physiotherapy,
which to the best of our knowledge has not been previ-
ously examined. We hypothesized that (a) most reviews
are inconclusive; (b) most reviews require further stud-
ies; (c) the conclusiveness of a given review is dependent
DOI: 10.1097/MRR.0000000000000338
 98 International Journal of Rehabilitation Research 2019, Vol 42 No 2
on the number of studies included in the review and the
cumulative number of patients enrolled; and (d) conclu-
siveness may be influenced by year of publication.
Materials and methods
Search methods
We performed a systematic search for all CRs published
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by the Cochrane Library (http://www.cochranelibrary.com/)
from 2008 through 2017 in the field of physiotherapy
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(The search strategy is available to interested researchers
upon request to the corresponding author.). We included
reviews that assessed the effect of physiotherapy, defined
as any type and intensity of rehabilitation possibly admin-
istered by physical therapists (physical exercise, physio-
therapy, orthotic therapy, education, etc.) to improve or
prevent impairment, disability, and handicap. To identify
additional publications that were potentially relevant
for inclusion in the study, we also searched the Physical
Rehabilitation Evidence Database (PEDro; http://www.
pedro.fhs.usyd.edu.au/) and screened the CRs list on the
Fig. 1
Study flow diagram.
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Cochrane Rehabilitation website (http://rehabilitation.
cochrane.org/evidence). We excluded outdated versions of
reviews, withdrawn reviews, and protocol reviews.
Selection of reviews
Two review authors (R.M. and M.T.) independently
screened titles and abstracts of references obtained from
our searches and excluded obviously irrelevant reports.
We retrieved full-text articles for the remaining refer-
ences, and two review authors (R.M. and M.Y.) inde-
pendently screened these to identify studies for inclusion.
We identified and recorded reasons for exclusion of ineli-
gible studies. We resolved disagreements through discus-
sion, or if necessary, consulted a third person (Y.Y.). We
recorded the selection process and completed a PRISMA
flow diagram.
Data extraction
Reviewers (R.M., M.T., Y.Y., K.F., T.K., and K.U.) inde-
pendently extracted characteristics of the included
 Conclusiveness of CRs in physiotherapy Momosaki et al. 99

Table 1 Number of Cochrane Reviews in each editorial group Fig. 2

Editorial groups Number of reviews

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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Cystic Fibrosis and Genetic Disorders 8

Incontinence 8
Injuries 8
Movement Disorders 7
Pregnancy and Childbirth 7
Vascular 6
Dementia and Cognitive Improvement 5
Gynecological, Neuro-oncology, and Orphan Cancer 5
Metabolic and Endocrine Disorders 5
Acute Respiratory Infections 4
Common Mental Disorders 4
Multiple Sclerosis and Rare Diseases of the CNS 4
Anesthesia, Critical care, and Emergency Care 3
Breast Cancer 3
Developmental, Psychosocial, and Learning Problems 3
Lung Cancer 3 Correlation between the percentage of conclusive Cochrane Reviews
Work 3 and the year of publication.
ENT 2
Gynecology and Fertility 2
Kidney and Transplant 2
Neonatal 2 Requirement of further study was determined according
Schizophrenia 2
Other 9
to the following criteria: need for further and higher qual-
Total 283 ity studies among a subgroup of patients in the review,
sample size too small in existing RCTs, number of RCTs
too small, need for further studies to detect potential side
effects, need for further studies to determine long-term
Table 2 Study characteristics of Cochrane Reviews in outcomes, need for further studies comparing multiple or
physiotherapy new strategies, and other reasons.
Conclusive reviews Inconclusive reviews
(n = 16) (n = 267) P value Data analysis
Studies enrolled 46.2 (36.1) 15.0 (16.8) <0.001 SPSS software (IBM SPSS Statistics 19.0, IBM Corp.,
[mean (SD)] Armonk, New York, USA) was used for statistical analyses.
Patients enrolled 3550 (1861–7367) 652 (209–1617) <0.001
[median (IQR)]
Differences between conclusive and inconclusive reviews
Further study required 11 (68.8) 267 (100) <0.001 were analyzed using the χ2-test and Mann–Whitney
[n (%)] U-test. Linear regression analysis was used to evaluate
IQR, interquartile range. the correlation between percentage of conclusive reviews
and year of publication. Results were expressed as mean
(SD), median (interquartile range) or n (%). A P value of
reviews (year of publication, Cochrane Review Group less than 0.05 was considered significant.
published review, conclusive or inconclusive review,
number of RCTs enrolled, total cumulative number of Results
patients enrolled, and the need for further studies) and After screening 2447 titles and abstracts, we identified
conducted checks of each other’s work. Disagreements 364 potentially relevant articles (Fig. 1). After reviewing
were resolved by discussion. the full text of the 364 articles, we included 283 CRs.
Conclusiveness was assessed using the following crite- Most reviews were published from the Musculoskeletal
ria: one intervention is superior to the alternative; the Group (32/283); Back and Neck Group (28/283); Bone,
interventions are equivalent; no decision can be reached Joint, and Muscle Trauma Group (28/283); and Stroke
because the quality of the studies is inadequate; no deci- Group (28/283) (Table 1). We found that 16 (5.7%) reviews
sion can be reached because there are not enough data; were conclusive and 276 (94.3%) inconclusive (Table 2).
and no decision can be reached because existing RCTs The number of studies enrolled was significantly higher
are outdated. The first two categories were classified as in conclusive CRs than in inconclusive CRs (mean:
‘conclusive’ and the last three as ‘inconclusive’. For this 46.2 vs. 15.0, P < 0.001). The number of patients enrolled
analysis, only the main outcome of each review was con- was significantly higher in conclusive reviews than in
sidered and not the secondary outcomes. inconclusive reviews (median: 3550 vs. 652, P < 0.001).

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 100 International Journal of Rehabilitation Research 2019, Vol 42 No 2

Table 3 List of Cochrane Reviews associated with physiotherapy

Editorial groups Title

Acute Respiratory Infections
Airways
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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
Airway clearance techniques for bronchiectasis

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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Exercise-based rehabilitation programs for pulmonary hypertension

Inspiratory muscle training for asthma
Noninvasive ventilation during exercise training for people with chronic obstructive pulmonary disease
Nonpharmaceutical management of respiratory morbidity in children with severe global developmental delay
Optimal intensity and type of leg exercise training for people with chronic obstructive pulmonary disease
Physical training for asthma
Positive expiratory pressure therapy versus other airway clearance techniques for bronchiectasis
Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease
Pulmonary rehabilitation for chronic obstructive pulmonary disease
Pulmonary rehabilitation for interstitial lung disease
Upper-limb exercise training for COPD
Water-based exercise for adults with asthma Water-based exercise training for chronic obstructive pulmonary disease
Anesthesia, Critical care, and Emergency Exercise rehabilitation following intensive care unit discharge for recovery from critical illness
Care Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery
Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and
major abdominal surgery
Back and Neck Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica
Behavioral treatment for chronic low-back pain
Electrotherapy for neck pain
Exercises for adolescent idiopathic scoliosis
Exercises for mechanical neck disorders
Exercises for prevention of recurrences of low-back pain
Individual patient education for low-back pain
Pilates for low-back pain
Rehabilitation after lumbar disc surgery
Rehabilitation following surgery for lumbar spinal stenosis
Spinal manipulative therapy for acute low-back pain
Spinal manipulative therapy for chronic low-back pain
Surgical versus nonsurgical interventions in people with adolescent idiopathic scoliosis
Therapeutic ultrasound for chronic low-back pain
Traction for low-back pain with or without sciatica
Transcutaneous electrical nerve stimulation versus placebo for chronic low-back pain
Low-level laser therapy for nonspecific low-back pain
Lumbar supports for prevention and treatment of low-back pain
Manipulation and mobilization for neck pain contrasted against an inactive control or another active treatment
Massage for low-back pain
Mechanical traction for neck pain with or without radiculopathy
Motor control exercise for acute nonspecific low-back pain
Multidisciplinary biopsychosocial rehabilitation for chronic low-back pain
Multidisciplinary biopsychosocial rehabilitation for subacute low-back pain
Muscle energy technique for nonspecific low-back pain
Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication
Patient education for neck pain
Physical conditioning as part of a return-to-work strategy to reduce sickness absence for workers with back pain
Pilates for low-back pain
Rehabilitation after lumbar disc surgery
Rehabilitation following surgery for lumbar spinal stenosis
Spinal manipulative therapy for acute low-back pain
Spinal manipulative therapy for chronic low-back pain
Surgical versus nonsurgical interventions in people with adolescent idiopathic scoliosis
Therapeutic ultrasound for chronic low-back pain
Traction for low-back pain with or without sciatica
Transcutaneous electrical nerve stimulation versus placebo for chronic low-back pain
Bone, Joint and Muscle Trauma Cold-water immersion (cryotherapy) for preventing and treating muscle soreness after exercise
Conservative interventions for treating exercise-related musculotendinous, ligamentous, and osseous groin pain
Conservative versus operative treatment for hip fractures in adults
Exercise for improving balance in older people
Exercise for reducing fear of falling in older people living in the community
Exercise for treating patellofemoral pain syndrome
Foot orthoses for patellofemoral pain in adults
Hip protectors for preventing hip fractures in older people
Interventions for improving mobility after hip fracture surgery in adults
Interventions for preventing falls in older people in care facilities and hospitals

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Table 3 (continued)
Editorial groups
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Breast Cancer
Childhood Cancer
Common Mental Disorders
Consumers and Communication
Cystic Fibrosis and Genetic Disorders
Dementia and Cognitive Improvement
Developmental, Psychosocial, and Learning
Problems
Effective Practice and Organization of Care
ENT
Eyes and Vision
Gynecological, Neuro-oncology, and
Orphan Cancer
Gynecology and Fertility
Hematological Malignancies
Heart
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Conclusiveness of CRs in physiotherapy Momosaki et al. 101
Title
Interventions for preventing falls in older people living in the community
Interventions for preventing hamstring injuries
Interventions for preventing lower limb soft-tissue running injuries
Interventions for treating chronic ankle instability
Interventions for treating proximal humeral fractures in adults
Knee orthoses for treating patellofemoral pain syndrome
Multidisciplinary rehabilitation for older people with hip fractures
Progressive resistance strength training for improving physical function in older adults
Rehabilitation for ankle fractures in adults
Rehabilitation for distal radial fractures in adults
Rehabilitation for hamstring injuries
Rehabilitation interventions for improving physical and psychosocial functioning after hip fracture in older people
Stretching to prevent or reduce muscle soreness after exercise
Surgical versus conservative interventions for displaced intra-articular calcaneal fractures
Surgical versus conservative interventions for treating ankle fractures in adults
Surgical versus conservative interventions for treating fractures of the middle third of the clavicle
Surgical versus nonsurgical interventions for treating patellar dislocation
Surgical versus nonsurgical treatment for thoracolumbar burst fractures without neurological deficit
Exercise for women receiving adjuvant therapy for breast cancer
Exercise interventions for upper-limb dysfunction owing to breast cancer treatment
Multidisciplinary rehabilitation for follow-up of women treated for breast cancer
Physical exercise training interventions for children and young adults during and after treatment for childhood cancer
Exercise for depression
Exercise therapy for chronic fatigue syndrome
Nonpharmacological interventions for somatoform disorders and medically unexplained physical symptoms in adults
Sports and games for post-traumatic stress disorder
Time-limited home-care reablement services for maintaining and improving the functional independence of older adults
Autogenic drainage for airway clearance in cystic fibrosis
Chest physiotherapy compared with no chest physiotherapy for cystic fibrosis
Exercise for hemophilia
Inspiratory muscle training for cystic fibrosis
Interventions for promoting physical activity in people with cystic fibrosis
Physical exercise training for cystic fibrosis
Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis
Treatment for avascular necrosis of bone in people with sickle cell disease
Aerobic exercise to improve cognitive function in older people without known cognitive impairment
Dance movement therapy for dementia
Enhanced rehabilitation and care models for adults with dementia following hip fracture surgery
Exercise programs for people with dementia
Interventions for preventing and reducing the use of physical restraints in long-term geriatric care
Aerobic exercise training programs for improving physical and psychosocial health in adults with
Down’s syndrome
Exercise interventions for cerebral palsy
Treadmill interventions in children under 6 years of age at risk of neuromotor delay
Care home versus hospital and own home environments for rehabilitation of older people
Exercise interventions for shoulder dysfunction in patients treated for head and neck cancer
Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Environmental and behavioral interventions for reducing physical activity limitation in community-dwelling visually impaired
older people
Dance/movement therapy for improving psychological and physical outcomes in patients with cancer
Exercise interventions on health-related quality of life for cancer survivors
Interventions for promoting habitual exercise in people living with and beyond cancer
Multidimensional rehabilitation programs for adult cancer survivors
Nonpharmacological interventions for cognitive impairment owing to systemic cancer treatment
Exercise for vasomotor menopausal symptoms
Nonsurgical interventions for the management of chronic pelvic pain
Aerobic physical exercise for adult patients with hematological malignancies
Exercise for people with high cardiovascular risk
Exercise-based cardiac rehabilitation for adults after heart valve surgery
Exercise-based cardiac rehabilitation for adults with atrial fibrillation
Exercise-based cardiac rehabilitation for coronary heart disease
Exercise-based cardiac rehabilitation in heart transplant recipients
Exercise-based rehabilitation for heart failure
Face-to-face interventions for promoting physical activity
Home-based versus center-based cardiac rehabilitation
Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft
Patient education in the management of coronary heart disease
Preoperative physical therapy for elective cardiac surgery patients
Promoting patient uptake and adherence in cardiac rehabilitation
 102 International Journal of Rehabilitation Research 2019, Vol 42 No 2

Table 3 (continued)
Editorial groups Title

Hepato-Biliary Weight reduction for nonalcoholic fatty liver disease

HIV/AIDS Aerobic exercise interventions for adults living with HIV/AIDS
Incontinence Biofeedback and/or sphincter exercises for the treatment of fecal incontinence in adults
Comparisons of approaches to pelvic floor muscle training for urinary incontinence in women
Conservative management for postprostatectomy urinary incontinence
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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

Preoperative education for hip or knee replacement

Resistance exercise training for fibromyalgia
Self-management education programs for osteoarthritis
Stretch for the treatment and prevention of contractures
Surface neuromuscular electrical stimulation for quadriceps strengthening pre and post total knee replacement
Therapeutic ultrasound for osteoarthritis of the knee or hip
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Transcutaneous electrostimulation for osteoarthritis of the knee

Neonatal Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support
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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
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Interventions to enhance return to work for patients with cancer

COPD, chronic obstructive pulmonary disease.

All inconclusive reviews recognized the need for further
studies, whereas the need for further studies was stated
in only 68.8% of conclusive reviews (P < 0.001). Linear
regression analysis showed a significant correlation
between the percentage of conclusive reviews and the
year of publication (R2 = 17%, P = 0.03; Fig. 2).
We compiled a list of 283 CRs in physiotherapy as shown
in Table 3.
Discussion
Consistent with our hypothesis, a large proportion of
CRs in physiotherapy were inconclusive. In fact, 94.3%
of reviews fulfilled our criteria for being inconclusive. In
the current state, a researcher or clinician would not nec-
essarily be able to turn to CRs for a definite answer on a
specific issue associated with physiotherapy. Our result
was much higher than those found in previous analyses of
CRs from other fields. The low proportion of conclusive
studies may be attributable to the poor quality of evidence
in the field of physiotherapy, suggesting a need for more
high-quality clinical evidence in this field. High-quality
controlled trials are difficult to conduct in physiotherapy
for several reasons. Blind RCTs in physiotherapy pose
particular difficulties compared with those conducted in
other fields of medicine, as successful blinding is often
hard to achieve (Boutron et al., 2004; Wood et al., 2008).
In addition, it appears difficult in practice to conduct a
RCT to examine the effect of physiotherapy because of
the widespread use of this therapeutic approach (Fregni
et al., 2010).
As hypothesized, conclusiveness was associated with
the number of studies included in the review and the
total number of patients enrolled in the analyzed stud-
ies. Meta-analyses with small sample sizes sometime fail
to detect statistical differences. Evaluation of studies
requires careful consideration of the extent to which each
trial contributes to the estimate of magnitude of effect.
Each trial’s contribution will usually reflect its sam-
ple size; larger trials with many patients will contribute
more to magnitude of effect, and thus to conclusiveness
(Guyatt et al., 2011).
Almost all CRs in our systemic analysis recognized the
need for further studies. Potential reasons for the need
for further research include low methodological quality,
small sample size, not enough studies, not enough data
in subgroups, not enough data on adverse effects, and
others (Brown et al., 2006). These findings indicate that
many current RCTs for physiotherapy have not been well
designed.
The percentage of conclusive reviews correlated weakly
and positively with the year of publication. Consistent
with our hypothesis, newer reviews had a higher proba-
bility of being conclusive than older reviews. It is possi-
ble that an increasing number of physiotherapy clinical
trials were conducted cumulatively over the years; thus,
new or updated CRs had access to more clinical trial data
and could more easily generate conclusive answers (Lau
et al., 1995).
Inconclusiveness and quality of review are two com-
pletely different factors. High-quality inconclusive
reviews as with conclusive ones are of great value for
clinicians and researchers in terms of identifying gaps
in their understanding and setting priorities for future
research. The aim of CRs is not decision making as to

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whether an intervention is better or not but to develop
the best available evidence from a systematic review.
Although inconclusiveness of CRs may disappoint those
seeking evidence, such CRs are valuable in prioritizing
important research questions and highlighting areas of
practice where research investment is needed.
The present study had several limitations. First, we did
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not include systematic reviews other than CRs published
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in other journals or databases because other reviews often
had different levels of methodological quality. Second,
we did not perform any subcategorical analyses because
the numbers of CRs in each physiotherapy topic subcat-
egory were too small. These potential biases were iden-
tified during the process of analysis and might affect the
final conclusion of the study.
Conclusion
We concluded that in the field of physiotherapy, a large
number of clinical trials were not well designed, and
only 4.7% of the CRs produced definitive clinical rec-
ommendations as determined by the number of RCTs
performed, the number of patients enrolled, and the year
of publication; furthermore, nearly all CRs emphasized
the need for further studies. The percentage of conclu-
sive CRs is lower in physiotherapy than in other fields
of medicine studied in a similar fashion. Trials in physi-
otherapy are worth conducting, as the field is positioned
as a new frontier and is receiving much attention. Future
research in physiotherapy and further development of
the Cochrane Rehabilitation are eagerly awaited.‍
Acknowledgements
The authors thank Takaaki Suzuki (Nara Medical
University Library) for helping to develop the search
strategy and for conducting the searches.
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Conclusiveness of CRs in physiotherapy Momosaki et al. 105
Ryo Momosaki is currently receiving a grant (#15K01395)
from the Japan Society for the Promotion of Science.
Conflicts of interest
There are no conflicts of interest.
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