Israel Richter 2011 A Guide To Understanding Meta Analysis

[ clinical commentary ]
HEIDI ISRAEL, FNP, PhD1 • RANDY R. RICHTER, PT, PhD2
A Guide to Understanding
Meta-Analysis
M
eta-analysis is a popular and frequently used statistical able one to combine data and summarize
technique used to combine data from several studies and the findings of several clinical trials that
Downloaded from www.jospt.org at on March 26, 2024. For personal use only. No other uses without permission.
evaluate the effectiveness or efficacy of a

reexamine the effectiveness of treatment interventions. As
similar treatment approach on similar
the number of articles using meta-analysis increases, under- group of patients. This technique can
standing of the benefits and drawbacks of the technique is essential. prove especially useful when there are
several similar clinical trials with or with-
Copyright © 2011 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Well-conducted systematic reviews of high level of evidence, and enhanced clin- out consistent outcomes, or when there
randomized controlled trials are regarded ical interpretation of treatment effects, are smaller to medium-sized trials with
as representing a high level of evidence.28 interpreting a meta-analysis is an impor- inconclusive results.
Practicing in an evidence-based manner tant skill for physical therapists. The pur- By combining the results from 2 or
is a recognized goal for the profession.3 pose of this commentary is to expand on more studies, a meta-analysis can in-
Systematic reviews are used to answer existing articles describing meta-analysis crease statistical power18 and provide
questions7,10,40 about the evidence sup- interpretation,6,13,14,42,61 discuss differences a single numerical value of the overall
porting or refuting the effectiveness or in the results of a meta-analysis based on treatment effect. The meta-analysis result
efficacy of an intervention. When certain the treatment questions, explore special may show either a benefit or lack of ben-
Journal of Orthopaedic & Sports Physical Therapy®
conditions are met, a systematic review cases in the use of meta-analysis, and efit of a treatment approach that will be
may be extended to include a meta- provide physical therapists guidance in indicated by the effect size, which is the
analysis, a statistical procedure used to interpreting a meta-analysis. term used to describe the treatment ef-
numerically summarize the included fect of an intervention. Treatment effect is
studies’ treatment effect.56 A meta-anal- WHY META-ANALYSIS the gain (or loss) seen in the experimental
ysis provides a single, overall measure of group relative to the control group. The
A
the treatment effect, enhancing the clini- number of reasons exist for overall positive or negative change may
cal interpretation of findings across sev- considering the use of meta-anal- be hard to discern from individual stud-
eral studies. Because of its increasing use, ysis techniques. Meta-analyses en- ies. For example, Clare et al15 used a meta-
analysis to examine the treatment effect
TTSYNOPSIS: With the focus on evidence- meta-analysis, and strengths and weaknesses of
of McKenzie therapy for spinal pain.
based practice in healthcare, a well-conducted meta-analysis. Common components like forest Three studies supported the use of McK-
systematic review that includes a meta-analysis plot interpretation, software that may be used, enzie therapy for short-term pain. Two of
where indicated represents a high level of evidence special cases for meta-analysis, such as subgroup the 3 studies reported a small but similar
for treatment effectiveness. The purpose of this analysis, individual patient data, and meta-regres- reduction in pain, which was statistically
commentary is to assist clinicians in understand- sion, and a discussion of criticisms, are included. significant for only 1 of the 2 studies. The
ing meta-analysis as a statistical tool using both third study reported a reduction of pain
J Orthop Sports Phys Ther 2011;41(7):496-504.
published articles and explanations of components
doi:10.2519/jospt.2011.3333 that was twice the magnitude of the other
of the technique. We describe what meta-analysis
TTKEY WORDS: forest plot, literature review,
studies. The results of the meta-analysis
is, what heterogeneity is, and how it affects meta-
analysis, effect size, the modeling techniques of statistical analysis, systematic review indicated an overall treatment effect that
was statistically significant and closer
Assistant Professor, Saint Louis University, Department of Orthopaedic Surgery, St Louis, MO. 2Associate Professor, Saint Louis University, Program in Physical Therapy, St Louis,
1
MO. Address correspondence to Dr Heidi Israel, Saint Louis University, Department of Orthopaedic Surgery, 3635 Vista FDT7N, St Louis, MO 63104. E-mail: Israelha@slu.edu
496 | july 2011 | volume 41 | number 7 | journal of orthopaedic & sports physical therapy
41-07 Israel.indd 496 6/15/2011 3:14:46 PM

in magnitude to the 2 studies reporting
a small reduction in pain. This example TABLE 1 Selected Concepts in Meta-Analysis
illustrates the potential value of meta-
analysis when direction of the treatment
Concept Definition
effect is the same across all studies but the
Meta-analysis Statistical analysis that integrates results from 2 or more studies,27 providing a single numerical
magnitude and statistical significance of
value of the overall treatment effect for that group of studies.
the treatment effect varies. A meta-anal-
Effect size A dimensionless estimate (ie, a measure with no units) that indicates both direction and magni-
ysis can also be used to show changes in
tude of the treatment effect.16,36
the treatment effect that occur over time.
Odds ratio The odds the ratio of the probability of an event occurring compared to the event not occurring
For example, Zhang et al,60 in an update
in a particular group. The odds ratio is the ratio of the odds between 2 groups.9
of the management of hip and knee os-
Relative risk Relative risk is equal to the risk among exposed subjects divided by the risk among unexposed
teoarthritis (2006 to 2009), determined
subjects.49
that the treatment effect sizes for exercise
Fixed-effects A model that assumes that each study included in the meta-analysis is estimating the same
and acupuncture did not change at mul-
model population treatment effect, which, in theory, represents the true population treatment effect.21
tiple time points, while the treatment ef-
Random-effects A model that assumes that the treatment effects of the included studies are part of a distribution
fect sizes for weight reduction eventually
model of treatment effects that fall along a range of values.21
reached statistical significance at later
Forest plot A graph that visually shows the results from the individual studies (treatment effect and confidence
time points, and the treatment effect size
interval), as well as the estimate of overall treatment effect and associated confidence interval.34
for electromagnetic therapy was no lon-
Confidence Confidence intervals (CIs) provide upper and lower limits that capture the range of values around
ger significant at later time points. These
interval the true but unknown population value. The 95% CI is most commonly used and corresponds
type of results obtained from meta-anal-
with the typical 5% significance level used in hypothesis tests. CIs of continuous measures that
ysis can be used to make better informed
include 0 represent nonsignificant results. CIs of odds ratios and relative risk that include 1.0
treatment decisions.
represent nonsignificant results.23
To interpret a meta-analysis, the read-
er needs to understand several concepts,
including effect size, heterogeneity, the inal units, the interpretation is clearer. size estimates.36 Finally, variables such as
model used to conduct the meta-analy- When the effect sizes are in standardized gender, age differences, or differences in
sis, and the forest plot, a graphical rep- units, the interpretation is more difficult the intervention provided, such as dose,
resentation of the meta-analysis. These and published guidelines for interpret- can influence the magnitude and direc-
concepts are discussed below and sum- ing effect sizes may be used.17 Whether tion of the effect size.
marized in TABLE 1. standardized or not, the overall effect size Use of the confidence interval can lend
derived from the meta-analysis is calcu- insight into the precision of the treatment
EFFECT SIZE lated by combining the effect sizes of the estimates of the included studies. A wider
included studies. There are several types confidence interval may be a function of a
S
tudies included in a meta-anal- of effect sizes. For dichotomous data, small sample size, as well as imprecision
ysis must have common outcome such as improved or not improved, odds in the measurement. Larger sample sizes
statistics that allow their results to ratios or relative risks are used for effect provide more precise estimates of the ef-
be combined.31 Effect sizes, which re- sizes. Other types of effect sizes are often fect size,36 whereas smaller studies are
flect the magnitude and direction of the reported in meta-analysis, and these are less precise, unless these smaller studies
treatment effect for each study, serve this described in TABLE 2. have little variance. Confidence intervals,
purpose. When all the studies to be in- Because several factors, such as sam- which are reported as a probability (eg,
cluded in a meta-analysis have the same ple size, variance, and reliability of the 95% confidence interval), provide a range
outcome measure, an effect size in the outcome measures, can influence the (upper and lower bounds) that indicate
original units may be calculated. For ex- magnitude and direction of the effect the precision of the estimate of the effect
ample, if all studies in the meta-analysis size, the estimates of the effect sizes will size.23,48 If the confidence interval of the
measure a continuous outcome, such as vary among studies. In addition, the ef- effect size falls within an area considered
range of motion, the mean difference fect size of the individual studies may be as clinically meaningful, then applica-
can be used as the effect size. Standard- somewhat imprecise and, therefore, lead tions of the results in clinical care may be
ization of the effect size is needed when to an unstable finding when multiple justified.39,51 Conversely, wide confidence
treatments are not measured in the same small studies are utilized. Weighting of intervals indicate less precise estimates
units. Standardization makes data unit- the standard error based on sample size and, coupled with a small sample size,
less. When the effect sizes are in the orig- allows for the best precision of the effect can lead to questions about the stability
journal of orthopaedic & sports physical therapy | volume 41 | number 7 | july 2011 | 497
41-07 Israel.indd 497 6/15/2011 3:14:47 PM

Typical Effect Size Calculations With Various
TABLE 2
Data Types Used in Meta-Analysis
Type of Data Type of Effect Size Reported Examples of Outcome Measures

Continuous data Standardized mean difference (eg, Cohen d) Various measures of strength16
Unstandardized mean difference 100-mm visual analog pain scale8,41
Pretest-posttest difference Depression preintervention/postintervention19
Binary (dichotomous) data Odds ratio Risk factors for persistent problems following whiplash58
Relative risk Rates of rerupture in Achilles tendon repair32
of the effect size estimates. By combining overall confidence interval.34 Even when an effect size can be used to interpret the
the results of small studies, a meta-anal- a systematic review does not include a results of a meta-analysis in a clinically
ysis may provide a more precise estimate meta-analysis, a forest plot can be used meaningful manner.39,51 For example, if a
of the treatment effect. to compare the effect size of the included 10° change in range of motion is consid-
For example, Khan et al32 examined studies.44 ered clinically meaningful and the lower
randomized trials of operative versus In addition to illustrating the effect bound of the 95% confidence interval
nonoperative treatment of Achilles ten- sizes and related confidence intervals of is 12° and the upper bound is 18°, the
don rupture and calculated effect sizes individual studies, a forest plot can illus- statistically significant difference is also
for rerupture, infection rates, and other trate the extent to which the results from clinically meaningful, as the confidence
complications. One aspect of this meta- individual studies vary. Variability in re- interval exceeds the clinically meaningful
analysis examined complications other sults among studies on the same topic value of 10°. This type of finding based
than rerupture for postoperative man- is called heterogeneity. When the mag- on randomized controlled trials should
agement that included splinting with nitude and direction of the effect sizes prompt the adoption of the intervention
casting alone versus casting followed by among the studies are similar, heteroge- that lead to those gains. However, if the
functional bracing. The confidence in- neity is less likely and meta-analysis may MCID falls within the lower and upper
tervals of estimates of the relative risks be appropriate. Conversely, when study bounds of the confidence interval, the
in the individual studies were quite wide, results vary, heterogeneity is possible and clinician will have to determine if adop-
especially in trials with a smaller sample a meta-analysis may not be appropriate. tion of the intervention is warranted or if
size; but the meta-analysis effect size fa- A forest plot of a meta-analysis typi- additional evidence is needed.51
vored functional bracing with a smaller cally includes the numerical value of the
confidence interval than that of the in- treatment effect and variability for each HETEROGENEITY
dividual studies. Mollon et al38 make the individual study, the modeling technique
H
point that even when many studies are assumed (random or fixed), the “line of eterogeneity is a term used to
excluded from a meta-analysis, based on no effect,” a test and corresponding value describe variability among stud-
the stringent inclusion criteria of the sys- for heterogeneity, and the numerical es- ies,21 and both statistical and clini-
tematic review protocol, the confidence timate of overall treatment effect (FIGURES cal heterogeneity need to be considered.54
intervals surrounding the overall esti- 1-2). The forest plot, therefore, provides a Statistical heterogeneity occurs when the
mated effect size is larger when the small quick visual assessment of the individual treatment effect estimates of a set of stud-
studies are included. studies included in the meta-analysis, a ies vary among one another.21 Because
visual assessment of heterogeneity, and some variation in treatment effect among
FOREST PLOTS the overall treatment effect of the indi- studies would be expected by chance,
vidual studies included. statistical heterogeneity refers to the
O
ne of the most useful tools The clinical context or clinical sig- amount of variation in treatment effect
used in meta-analysis is the forest nificance of the findings must be con- present beyond chance.21 By convention,
plot, which provides a visual sum- sidered when interpreting effect sizes. statistical heterogeneity is referred to as
mary of the analysis and findings. A for- Some researchers use the term “minimal just heterogeneity.21 Studies with meth-
est plot graphically represents estimates clinically important difference” (MCID) odological flaws and small studies may
of the effect size and corresponding confi- to indicate clinical versus statistical sig- overestimate treatment effects45,59 and
dence intervals for each study, along with nificance. Because statistical significance can contribute to statistical heterogene-
an estimate of overall effect size of all does not always translate into clinical ity. Statistical heterogeneity can be exam-
included studies and the corresponding significance, the confidence intervals of ined and quantified using statistical tests.
41-07 Israel.indd 498 6/15/2011 3:14:49 PM

Review: Laser knee osteoarthritis
Comparison: 05 Pain outcome RCTs, knee osteoarthritis
Outcome: 06 Pain relief on 100-mm VAS, end of therapy with optimal dose
Study/Subcategory n Treatment (Mean  SD) n Control (Mean  SD) WMD (Fixed) 95% CI* Weight, %† WMD (Fixed) 95% CI
01 Electroacupuncture
‡
Yurtkuran 25 25.00  12.00 25 5.00  8.90 22.83 20.00 (14.14, 25.86)
Sangdee 48 48.00  24.30 47 23.00  24.20 8.23 25.00 (15.25, 34.75)
Vas 48 53.50  21.40 49 28.50  35.20 5.85 25.00 (13.43, 36.57)
Subtotal (95% CI) 121 121 36.92 21.91 (17.30, 26.51)
Test for heterogeneity: χ2 = 1.07, df = 2 (P = .59), I2 = 0%§ Line of no effect
Test for overall effect: z = 9.32 (P<.00001)
FIGURE 1. Forest plot suggesting little heterogeneity. Abbreviations: CI, confidence interval; RCT, randomized controlled trial; VAS, visual analog scale; WMD, weighted mean
difference. *A fixed-effects model, which assumes a common, fixed treatment effect. Between-study differences are assumed due to chance and not incorporated into the
model. †Larger studies have a greater influence (weight) than smaller studies. ‡A qualitative visual analysis of the studies’ results suggests little between-study variability. The
individual study point estimates of the treatment effect (blue squares) are on the same side of the line of no effect and closely line up on a vertical axis, indicating a similar
treatment effect magnitude. The confidence intervals for each study’s treatment effect (horizontal line) overlap one another, and none cross the line of no effect, indicating a
similar estimation of the population treatment effect between studies. These qualitative results suggest that there is little heterogeneity. §The chi-square test for heterogeneity
was nonsignificant. The I2 value was zero. These quantitative results suggest that there was little between-study variability (ie, heterogeneity). Adapted from Bjordal JM,
Johnson MI, Lopes-Martins RA, Bogen B, Chow R, Ljunggren AE. Short-term efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta-analysis
of randomised placebo-controlled trials. BMC Musculoskelet Disord. 2007;8:51. © 2007 Bjordal et al; licensee BioMed Central Ltd.
However, despite having statistical tests heterogeneity is too great2; in others, they findings may lead one to conclude that
for statistical heterogeneity, there are no may decide to do so, using a subgroup the choice of a fixed- or random-effects
accepted guidelines for when a meta- analysis to explore the origin of the clini- model is not critical, which is an incorrect
analysis should not be completed due to cal heterogeneity8 (for example, to insure conclusion. Understanding the assump-
statistical heterogeneity, and it is left to that certain included populations are not tions of each model sheds light on when
the author’s discretion to determine if a affected adversely by a generally overall one model will be more appropriate than
meta-analysis is appropriate. favorable intervention for the general the other.
Clinical heterogeneity refers to dif- population in the meta-analysis). Other The fixed- and random-effects models
ferences in study methods that affect the authors may attempt to minimize clini- differ in assumptions related to the ob-
ability to compare and/or combine data cal heterogeneity within a meta-analysis served differences among study results.
from different studies. Examples of dif- by limiting study eligibility. Carey et al12 The 2 models are actually answering
ferences in study methods that may lead decided which studies should be included slightly different questions. In the fixed-
to clinical heterogeneity include differ- in an allograft meta-analysis before start- effects model, the question is “What is
ences in participant demographics, such ing the study, based on acceptable clinical the best estimate of the population effect
as risk or severity of disease, the settings heterogeneity and the quality of assess- size?”18 An assumption of the fixed-effects
in which the research was conducted, the ment for inclusion. This approach, while model is that among a fixed set of stud-
frequency and intensity of the interven- reducing heterogeneity, typically results ies there is a common treatment effect18,26
tion, and how outcomes were measured in the total number of articles included and between-study differences in results
across studies.54 While there are statisti- on a topic to be reduced. occur by chance.22,53 In other words, the
cal tests to estimate the extent of statis- true treatment effect is assumed to be
tical heterogeneity, there are no tests to MODELING DATA: FIXED- AND fixed22 and variability of between-study
determine the extent of clinical hetero- RANDOM-EFFECTS MODELS results is not incorporated into the mod-
geneity. Researchers and clinicians must el. Because of this assumption of fixed
T
decide if the studies contributing to a me- he 2 most frequently used mod- treatment effect, larger studies are given
ta-analysis are similar enough clinically els to conduct a meta-analysis are greater weight than the smaller stud-
to make meta-analysis sensible. the fixed- and random-effects mod- ies.11 Different calculation methods are
Whether the amount of clinical het- els,53 each of which handles statistical available under the fixed-effects model.22
erogeneity is too great to warrant meta- heterogeneity differently. Although the Three common fixed-effect methods are
analysis is a matter of judgment. In some assumptions of each model differ, they the inverse variance method, the Mantel-
instances, authors may decide not to con- frequently lead to similar results when Haenszel method, and the Peto method.22
duct a meta-analysis because the clinical heterogeneity is not extreme. These The random-effects model, which
41-07 Israel.indd 499 6/15/2011 3:14:50 PM

Review: Laser knee osteoarthritis
Comparison: 05 Pain outcome RCTs, knee osteoarthritis
Outcome: 06 Pain relief on 100-mm VAS, end of therapy with optimal dose
Study/Subcategory n Treatment (Mean  SD) n Control (Mean  SD) WMD (Fixed) 95% CI Weight, % WMD (Fixed) 95% CI
02 Transcutaneous electrical
stimulation
Fargas Babjak 19 56.00  37.50 18 10.70  64.00 * 0.68 45.30 (11.26, 79.34)
Yurtkuran 25 25.00  12.00 25 5.00  8.90 22.83 20.00 (14.14, 25.86)
Cheing 16 58.00  27.00 16 4.96  42.40 1.29 53.04 (28.41, 77.67)
Adeboyin 15 68.70  24.00 15 43.00  24.00 2.65 25.70 (8.52, 42.88)
Cheing 30 35.20  41.50 10 30.00  24.10 1.75 5.20 (–15.94, 26.34)
Defrin 33 28.40  11.10 21 5.70  13.40 16.59 22.70 (15.83, 29.57
Law 25 46.70  24.40 9 17.00  39.70 1.02 29.70 (2.06, 57.34)
Subtotal (95% CI) 163 114 46.82 22.21 (18.12, 26.30)

Line of no effect
Test for heterogeneity: χ2 = 11.28, df = 6 ( P = .08), I2 = 46.8%†
Test for overall effect: z = 10.65 (P<.00001)
FIGURE 2. Forest plot suggesting heterogeneity. Abbreviations: CI, confidence interval; RCT, randomized controlled trial; VAS, visual analog scale; WMD, weighted mean
difference. *Qualitative analysis of heterogeneity. A qualitative visual analysis of the studies’ results suggests between-study variability. The individual study point estimates of
the treatment effect (blue squares) are on the same side of the line of no effect but do not line up on a vertical axis, indicating a difference in treatment effect magnitude among
studies. The confidence intervals for each study’s treatment effect (horizontal lines) overlap one another, but the upper and lower limits of the CI do not consistently line up on
a vertical axis, indicating differences in estimation of the population treatment effect among studies. These qualitative results suggest that there is heterogeneity. †Quantitative
tests of heterogeneity. The chi-square test for heterogeneity was significant at a level of less than .10. The I2 value was 47%. These quantitative results suggest there was
study variability (ie, heterogeneity). Adapted from Bjordal JM, Johnson MI, Lopes-Martins RA, Bogen B, Chow R, Ljunggren AE. Short-term efficacy of physical interventions in
osteoarthritic knee pain. A systematic review and meta-analysis of randomised placebo-controlled trials. BMC Musculoskelet Disord. 2007;8:51. © 2007 Bjordal et al; licensee
BioMed Central Ltd.
assumes a distribution of treatment ef- study is accounted for in the calcula- graph, the interpretation is not absolute.
fects, answers the question “What is the tion.22,26 A calculation method under the Two statistical methods to analyze sta-
average treatment effect?” The random- random-effects model is the DerSimo- tistical heterogeneity that are frequently
effects model assumes a distribution of nian and Laird method.22 reported are the Cochran Q test (also
the treatment effect for some popula- When heterogeneity is present, the known as chi-square test for heterogene-
tions, meaning that the treatment effect random-effects model will weight the ity or the chi-square test for homogene-
falls along a range of values, not a single studies comprising the meta-analysis ity) and the I2 (also known as Higgins I2).
value, as in the fixed-effects model. Be- more equally, resulting in smaller studies The Cochran Q tests whether the in-
cause of this distribution, the effect size having greater relative influence on the dividual studies’ treatment effects are
may be positive for some populations but combined overall effect than in the fixed- farther away from the common effect,
may be negative or harmful for others.18,29 effects model.50 To the extent that smaller beyond what is expected by chance.22,30
Studies included in the meta-analysis studies overestimate treatment effects, a When the chi-square test is significant,
using a random-effects model are as- random-effects model may overestimate statistical heterogeneity is present. This
sumed to represent a random sample of treatment effects when heterogeneity is test has low power when few studies
a population of studies. The results of present. In this case, one recommenda- make up the meta-analysis,30 and, as a re-
each study included in the meta-analysis tion is to compare the fixed- and random- sult, a nonsignificant test may lead to the
represent a study-specific effect size that effects models.50 wrong conclusion regarding heterogene-
varies around a mean population ef- ity. A compensation for the low power of
fect size.18,26 In other words, the results EXAMING STUDIES FOR the Cochran Q is to test for heterogeneity
of each study in the meta-analysis are HETEROGENEITY at an alpha level of .10, rather than at .05,
assumed to represent a unique effect. thereby increasing the chance of finding
H
Because of this assumption, larger stud- igh heterogeneity may indicate heterogeneity.
ies are given proportionally less weight, that it is inappropriate to combine The test can have excessive power
while smaller studies are given propor- studies in a meta-analysis. Hetero- when there are many large studies,30
tionally more weight.11 In the random- geneity can be visualized using forest which is similar to the problems encoun-
effects model, the unique effect of each plots (FIGURES 1 and 2); however, like any tered in other statistics with large sample
41-07 Israel.indd 500 6/15/2011 3:14:51 PM

sizes. Finally, the Cochran Q reduces the prevented Achilles tendon rupture32 was determine if the meta-analysis findings
question of heterogeneity to a dichotomy acknowledged by the authors to be a pos- change when different decisions related
based on the P value, so there is no quan- sible result of both low event occurrence to the systematic review/meta-analysis
tification of the amount of heterogeneity, and numerous small randomized clini- process are made.21 For example, a sensi-
just whether or not there is statistically cal trials included in the meta-analysis. tivity analysis could be conducted to de-
significant heterogeneity. When the event in question happens termine if a fixed- versus random-effects
A different question to ask is “How rarely or infrequently, or is captured in analysis reach different conclusions.21
much heterogeneity is present?” The I2 small numbers within small trials, cau-
statistic was developed to answer this tion should be exercised in interpreting Meta-Regression
question.30 The range of I2 is from 0% the meta-analysis. While a random-ef- Often, the studies included in a meta-
to 100%. This percentage represents fects model is advocated by many au- analysis vary in their study charac-
the percentage of total variation across thors, a fixed-effects model should be teristics (eg, variations in participant
studies due to heterogeneity. The test is considered, because the random effects characteristics). Rather than not ac-
not influenced by the number of studies model is influenced more by smaller counting for these differences, a meta-
in the meta-analysis, and, rather than studies. regression tries to relate the size of the
a dichotomy, the results indicate how effect to characteristics of the studies in-
much heterogeneity is present. Another Subgroup Analysis volved.55 Conceptually, meta-regression
advantage of I2 is that this test can be in- The meta-analysis produces an average is similar to regression. The predictor
terpreted similarly, regardless of the type effect for all the trials included in the variables are the characteristics of the
of outcome data and choice of effect mea- analysis. A question that may be asked is, studies (ie, sample size, randomization)
sure. An important disadvantage of I2 is does this average treatment effect hold that influence the effect size, which is the
that there are no empirically developed true for all types of groups included in outcome variable.21 The associations de-
cut-points to determine when there is too the meta-analysis? A subgroup analysis rived from meta-regressions are observa-
much heterogeneity to do a meta-analy- can be used to compare the overall ef- tional and have a weaker interpretation
sis. Higgins et al30 have suggested rule- fect of the meta-analysis to a particular than the causal relationships derived
of-thumb interpretations, such as 25% subgroup of patients within the meta- from randomized studies. This applies
equals low heterogeneity, 50% equals analysis. A subgroup effect can occur by particularly when averages of patient
medium heterogeneity, and 75% equals chance.20 Because of the possibility of characteristics in each trial are used as
high heterogeneity. Other authors may a chance finding, care should be taken covariates in the regression. Data dredg-
choose a cut-off for heterogeneity when when interpreting the results of a sub- ing is the main pitfall in reaching reli-
choosing whether a fixed or random group analysis. Some authors suggest able conclusions from meta-regression.
model is appropriate. determining prior to the analysis which It can only be avoided by prespecification
The decision to move forward with factors to include in a subgroup analy- of variables that are believed to be po-
the meta-analysis or stop at the system- sis.21 Risk stratification encourages the tential sources of heterogeneity.55 While
atic review should be made based on the same phenomenon, in which those at some sources of heterogeneity may be
results of the test of heterogeneity and higher risk are more likely to benefit from expected due to differences in study de-
clinical judgment. High heterogeneity a treatment. In fact, detrimental effects sign (use and nonuse of randomization),
implies dissimilarity in the studies, and a of a treatment may outweigh the ben- others sources of heterogeneity related
meta-analysis should be conducted with efits in the low-risk group. If the results to patient characteristics require expert
caution. The question that the informed in the subgroups are very different, then knowledge of the clinical area.
clinician should evaluate is whether using meta-analysis to produce an aver-
this amount of heterogeneity is so large age effect may not be appropriate. Lastly, Meta-Analysis Using Individual Patient
that the results of the meta-analysis are including randomized trials in the meta- Data (IPD)
problematic. analysis does not mean that comparisons Some critics of meta-analysis have stated
between the trials are random,20 mak- that group-level analysis can lead to over-
OTHER CONSIDERATIONS ing interpretation of subgroup analysis estimation of low-occurrence events and
difficult. nondetection of important subset effects.
Event Rarity In theory, using IPD allows for a larger
E
vent rarity usually leads to Sensitivity Analysis sample size and potentially better stan-
overestimate of effect size. 36 For While a subgroup analysis attempts to es- dardization of the data, because the data
example, the result that functional timate a treatment effect for a particular are reanalyzed by the researchers doing
bracing instead of operative intervention subgroup, a sensitivity analysis is used to the meta-analysis, rather than relying
41-07 Israel.indd 501 6/15/2011 3:14:52 PM

on the estimates provided in group-level CRITICISMS OF plored with meta-analysis.2
data. For these reasons, some research- META-ANALYSIS Other critics25,33 have claimed that
ers recommend use of IPD, rather than meta-analysis techniques represent the
M
group-level data alone, when possible.5 eta-analysis is not without its destruction of the scientific methods
However, IPD analysis has a number of critics. Rosenthal43 cautions that, formed to provide statistical accuracy
drawbacks. For example, IPD analysis while there are many positive as- and reproducibility in research. The ag-
techniques are not standardized, IPD pects to meta-analysis, researchers must gregation of the data is a concern and, as
data require sharing of the data among be cognizant that studies may vary con- discussed earlier in this paper, without a
investigators, the use of IDP requires all siderably in their operational definitions good systematic review and a protocol for
data to be available,52 and the research of the independent and dependent vari- inclusion of studies into the meta-analy-
questions, recruitment criteria, and mea- ables, methods of measuring variables, sis, these concerns may be valid.
sures of treatment effect need to be simi- data-analytic approaches, and results. Most of these criticisms can be ad-
lar. Differences in how data are collected Eysenck24 has published numerous dressed by conducting a quality system-
can lead to limitations in the use of IDP. criticisms of the assumptions and the atic review and then deciding whether
When any of these elements differ, uncer- techniques of meta-analysis. Eysenck24 meta-analysis is appropriate. Having a
tainty or error is introduced into the over- believes that meta-analysis encourages a study team with expertise in the area of
all analysis. However, IPD is certainly an narrow focus on the effect size, without the research topic, in searching databas-
alternative that can be appealing when consideration of other aspects of the in- es, and in the technique of meta-analysis
answering questions related to group or cluded studies, such as methods or indi- can help guard against some of these po-
subset differences. vidual study outcomes that are in opposite tential problems.
directions. This may lead to an erroneous
When Meta-Analysis Results are conclusion. As with many other statistical CONCLUSION
Counterintuitive techniques, a focus on singular aspects of
M
When results of the meta-analysis are the data (eg, the overall effect) can lead to eta-analysis is a valuable tool
counterintuitive, clinical judgment will conflicting interpretations, thus the en- for researchers, because this tech-
be needed to decipher the unexpected tire body of evidence should be part of the nique allows a reexamination of
results. This judgment, based on expe- interpretation of any statistical analysis. treatment effect of several studies using
rience, education, and current practic- Appraising a systematic review using the a larger sample than is possible for most
es, will help the clinician to determine PRISMA (Preferred Reporting Items for researchers to recruit on their own. In
whether to accept the findings or ques- Systematic Reviews and Meta-Analyses) many ways, meta-analysis allows, with-
tion the statistical technique. One op- statement35,37 or a standardized appraisal out additional clinical resources, explo-
tion is to go back to the original articles, tool, such as the AMSTAR (a measure- ration of potential treatment benefits or
reassess the inclusion of the articles ment tool to assess the methodological drawbacks and utilizes information made
into the analysis, and judge whether quality of systematic reviews) tool46,47 available in smaller clinical trials.
the inclusion made clinical sense. In will help clinicians focus on all aspects Clinicians reading the results of a
meta-analysis there can be a loss of the of the systematic review. A meta-analysis meta-analysis should have a clear under-
original individual study assumptions. should, at a minimum, include forest standing of the strengths and limitations
Similar to assumptions regarding the re- plots with effect size estimates and confi- of the technique. In clinical medicine,
search question and data collection in a dence intervals for each included study, a many small studies are performed due
given study, assumptions of the original measure of heterogeneity, and the meta- to lack of access to patients, resources for
research question can be lost when the analysis overall treatment effect and re- conducting studies, or other forces that
studies are combined together.25 lated confidence interval. drive clinical practice. Meta-analysis
Eysenck24 also argues that only meta- provides a way to reevaluate the results
Software Packages analysis of a simple question is valid and, of a particular clinical question. Meta-
There are a variety of free and propri- when several studies are positive but analysis can be misleading if the studies
etary software packages for meta-anal- not significant because of insufficient included are dissimilar in their research
ysis.4 One well-known software package statistical power, using meta-analysis to question or collect different types of out-
offered by the Cochrane Collaboration examine effect size can lead to spurious come data. Meta-analysis, like any other
is RevMan (http://www.cc-ims.net/rev- conclusions. Clinicians should examine statistical method, is unable to identify
man). Another free meta-analysis soft- the results of the systematic review and whether the data being utilized are ap-
ware package was recently described by the protocol for article inclusion to judge propriate. It is the responsibility of clini-
Wallace et al.57 whether a research question can be ex- cians and researchers in the field to be
41-07 Israel.indd 502 6/15/2011 3:14:53 PM

well informed about the evaluation and Spindler KP. A systematic review of anterior 2001;6:203-217.
cruciate ligament reconstruction with autograft 30. H iggins JP, Thompson SG, Deeks JJ, Altman
interpretation of the research informa-
compared with allograft. J Bone Joint Surg Am. DG. Measuring inconsistency in meta-anal-
tion before them, so as to make good 2009;91:2242-2250. http://dx.doi.org/10.2106/ yses. BMJ. 2003;327:557-560. http://dx.doi.
clinical decisions for their patients. t JBJS.I.00610 org/10.1136/bmj.327.7414.557
13. Chan KS, Morton SC, Shekelle PG. Systematic 31. Kane RL, Saleh KJ, Wilt TJ, Bershadsky B. The
reviews for evidence-based management: how functional outcomes of total knee arthroplasty. J
to find them and what to do with them. Am J Bone Joint Surg Am. 2005;87:1719-1724. http://
REFERENCES
Manag Care. 2004;10:806-812. dx.doi.org/10.2106/JBJS.D.02714
14. Chung KC, Burns PB, Kim HM. A practical 32. Khan RJ, Fick D, Keogh A, Crawford J, Bram-
1. A da L, Dorsch S, Canning CG. Strengthening guide to meta-analysis. J Hand Surg Am. mar T, Parker M. Treatment of acute achilles
interventions increase strength and improve 2006;31:1671-1678. http://dx.doi.org/10.1016/j. tendon ruptures. A meta-analysis of random-
activity after stroke: a systematic review. Aust J jhsa.2006.09.002 ized, controlled trials. J Bone Joint Surg Am.
Physiother. 2006;52:241-248. 15. Clare HA, Adams R, Maher CG. A systematic 2005;87:2202-2210. http://dx.doi.org/10.2106/
2. Alexander LD, Gilman DR, Brown DR, Brown review of efficacy of McKenzie therapy for spinal JBJS.D.03049
JL, Houghton PE. Exposure to low amounts of pain. Aust J Physiother. 2004;50:209-216. 33. Lau J, Ioannidis JP, Schmid CH. Summing up ev-
ultrasound energy does not improve soft tissue 16. Cochrane Collaboration. Glossary of Terms in idence: one answer is not always enough. Lan-
shoulder pathology: a systematic review. Phys
The Cochrane Collaboration Version 4.2.5. Avail- cet. 1998;351:123-127. http://dx.doi.org/10.1016/

Ther. 2010;90:14-25. http://dx.doi.org/10.2522/ able at: http://www.cochrane.org/sites/default/ S0140-6736(97)08468-7
ptj.20080272 files/uploads/glossary.pdf. Accessed March 22, 34. Lewis S, Clarke M. Forest plots: trying to see the
3. American Physical Therapy Association. 2005. wood and the trees. BMJ. 2001;322:1479-1480.
APTA Vision Statement for Physical Therapy 17. Cohen J. Statistical Power Analysis for the 35. Liberati A, Altman DG, Tetzlaff J, et al. The
2020. Available at: http://www.apta.org/ Behavioural Sciences. 2nd ed. Hillsdale, NJ: PRISMA statement for reporting systematic
AM/Template.cfm?Section=Vision_20201&T Lawrence Erlbaum Associates, Inc; 1988. reviews and meta-analyses of studies that evalu-
emplate=/TaggedPage/TaggedPageDisplay. 18. Cohn LD, Becker BJ. How meta-analysis ate health care interventions: explanation and
cfm&TPLID=285&ContentID=32061. Accessed increases statistical power. Psychol elaboration. Ann Intern Med. 2009;151:W65-94.
July 22, 2000. Methods. 2003;8:243-253. http://dx.doi. 36. Lipsey M, Wilson D. Practical Meta-Analysis.
4. Bax L, Yu LM, Ikeda N, Moons KG. A system- org/10.1037/1082-989X.8.3.243 Thousand Oaks, CA: Sage Publications; 2000.
atic comparison of software dedicated to 19. Cuijpers P, van Straten A, Warmerdam L. Prob- 37. Moher D, Liberati A, Tetzlaff J, Altman DG.
meta-analysis of causal studies. BMC Med lem solving therapies for depression: a meta- Preferred reporting items for systematic reviews
Res Methodol. 2007;7:40. http://dx.doi. analysis. Eur Psychiatry. 2007;22:9-15. http:// and meta-analyses: the PRISMA statement. Ann
org/10.1186/1471-2288-7-40 dx.doi.org/10.1016/j.eurpsy.2006.11.001 Intern Med. 2009;151:264-269, W264.
5. Berlin JA, Santanna J, Schmid CH, Szczech LA, 20. Davey Smith G, Egger M, Phillips A. Meta- 38. Mollon B, da Silva V, Busse JW, Einhorn TA,
Feldman HI. Individual patient- versus group- analysis. Beyond the grand mean? BMJ. Bhandari M. Electrical stimulation for long-bone
level data meta-regressions for the investigation 1997;315:1610-1614. fracture-healing: a meta-analysis of random-
of treatment effect modifiers: ecological bias 21. Deeks J, Higgins JP, Altman D. Analysing data ized controlled trials. J Bone Joint Surg Am.
rears its ugly head. Stat Med. 2002;21:371-387. and undertaking meta-analyses. In: Higgins JP, 2008;90:2322-2330. http://dx.doi.org/10.2106/
6. Bhandari M, Devereaux PJ, Montori V, Cina Green S, eds. Cochrane Handbook for System- JBJS.H.00111
C, Tandan V, Guyatt GH. Users’ guide to the atic Reviews of Interventions. Chichester, West 39. Montori VM, Kleinbart J, Newman TB, et al.
surgical literature: how to use a systematic Sussex, UK: John Wiley & Sons; 2008:243-296. Tips for learners of evidence-based medicine:
literature review and meta-analysis. Can J Surg. 22. Deeks JJ, Altman D, Bradburn M. Statistical 2. Measures of precision (confidence inter-
2004;47:60-67. methods for examining heterogeneity and vals). CMAJ. 2004;171:611-615. http://dx.doi.
7. Bhandari M, Montori VM, Devereaux PJ, Wilc- combining results from several studies in meta- org/10.1503/cmaj.1031667
zynski NL, Morgan D, Haynes RB. Doubling the analysis. In: Egger M, Smith GD, Altman D, 40. Patsopoulos NA, Analatos AA, Ioannidis JP.
impact: publication of systematic review articles eds. Systematic Reviews in Health Care: Meta- Relative citation impact of various study designs
in orthopaedic journals. J Bone Joint Surg Am. Analysis in Context. London, UK: BMJ Books; in the health sciences. JAMA. 2005;293:2362-
2004;86-A:1012-1016. 2001:285-312. 2366. http://dx.doi.org/10.1001/
8. Bjordal JM, Johnson MI, Lopes-Martins RA, 23. Doll H, Carney S. Statistical approaches to jama.293.19.2362
Bogen B, Chow R, Ljunggren AE. Short-term ef- uncertainty: P values and confidence intervals 41. Pittler MH, Brown EM, Ernst E. Static magnets
ficacy of physical interventions in osteoarthritic unpacked. Equine Vet J. 2007;39:275-276. for reducing pain: systematic review and
knee pain. A systematic review and meta-anal- 24. Eysenck HJ. Meta-analysis of best-evidence meta-analysis of randomized trials. CMAJ.
ysis of randomised placebo-controlled trials. synthesis? J Eval Clin Pract. 1995;1:29-36. 2007;177:736-742. http://dx.doi.org/10.1503/
BMC Musculoskelet Disord. 2007;8:51. http:// 25. Feinstein AR. Meta-analysis: statistical al- cmaj.061344
dx.doi.org/10.1186/1471-2474-8-51 chemy for the 21st century. J Clin Epidemiol. 42. Ried K. Interpreting and understanding meta-
9. Bloch J. Interpreting odds ratios and logistic 1995;48:71-79. analysis graphs--a practical guide. Aust Fam
regression: a neccessity for evidence-based 26. Fleiss JL. The statistical basis of meta-analysis. Physician. 2006;35:635-638.
practice. Am J Nurse Pract. 2008;12:39-43. Stat Methods Med Res. 1993;2:121-145. 43. Rosenthal R, DiMatteo MR. Meta-analysis: recent
10. Bolland MJ, Grey A, Reid IR. The randomised 27. Glass GV. Primary, secondary, and meta-analysis developments in quantitative methods for litera-
controlled trial to meta-analysis ratio: original of research. Educ Res. 1976;5:3-8. ture reviews. Annu Rev Psychol. 2001;52:59-82.
data versus systematic reviews in the medical 28. Guyatt G, Rennie D. Users’ Guides to the Medi- http://dx.doi.org/10.1146/annurev.psych.52.1.59
literature. N Z Med J. 2007;120:U2804. cal Literature: A Manual for Evidence-Based 44. Santamaria LJ, Webster KE. The effect of fatigue
11. Borenstein M, Hedges L, Higgins J, Rothstein H. Clinical Practice. Chicago, IL: American Medical on lower-limb biomechanics during single-limb
Introduction to Meta-Analysis. Chichester, West Association; 2002. landings: a systematic review. J Orthop Sports
Sussex, UK: John Wiley & Sons; 2009. 29. Hedges LV, Pigott TD. The power of statisti- Phys Ther. 2010;40:464-473. http://dx.doi.
12. Carey JL, Dunn WR, Dahm DL, Zeger SL, cal tests in meta-analysis. Psychol Methods. org/10.2519/jospt.2010.3295
41-07 Israel.indd 503 6/15/2011 3:14:54 PM

45. S chulz KF, Chalmers I, Hayes RJ, Altman DG. dx.doi.org/10.2522/ptj.2010.90.3.333 2009;39:334-350. http://dx.doi.org/10.2519/
Empirical evidence of bias. Dimensions of meth- 52. S ud S, Douketis J. The devil is in the details...or jospt.2009.2765
odological quality associated with estimates not? A primer on individual patient data meta- 59. Wood L, Egger M, Gluud LL, et al. Empirical
of treatment effects in controlled trials. JAMA. analysis. Evid Based Med. 2009;14:100-101. evidence of bias in treatment effect estimates in
1995;273:408-412. 53. Sutton AJ, Higgins JP. Recent developments
controlled trials with different interventions and
46. Shea BJ, Grimshaw JM, Wells GA, et al. Devel- in meta-analysis. Stat Med. 2008;27:625-650.
outcomes: meta-epidemiological study. BMJ.
opment of AMSTAR: a measurement tool to http://dx.doi.org/10.1002/sim.2934
assess the methodological quality of systematic 54. Thompson SG. Why and how sources of hetero- 2008;336:601-605. http://dx.doi.org/10.1136/
reviews. BMC Med Res Methodol. 2007;7:10. geneity should be investigated. In: Egger M, Dav- bmj.39465.451748.AD
http://dx.doi.org/10.1186/1471-2288-7-10 ey Smith G, Altman D, eds. Systematic Reviews 60. Zhang W, Nuki G, Moskowitz RW, et al. OARSI
47. Shea BJ, Hamel C, Wells GA, et al. AMSTAR is in Health Care: Meta-Analysis in Context. Lon- recommendations for the management of
a reliable and valid measurement tool to as- don, UK: BMJ Publishing Group; 2001:157-175. hip and knee osteoarthritis: part III: Changes
sess the methodological quality of systematic 55. Thompson SG, Higgins JP. How should meta- in evidence following systematic cumulative
reviews. J Clin Epidemiol. 2009;62:1013-1020. regression analyses be undertaken and inter- update of research published through January
48. Sim J, Reid N. Statistical inference by confi- preted? Stat Med. 2002;21:1559-1573. http:// 2009. Osteoarthritis Cartilage. 2010;18:476-499.
dence intervals: issues of interpretation and dx.doi.org/10.1002/sim.1187
http://dx.doi.org/10.1016/j.joca.2010.01.013
utilization. Phys Ther. 1999;79:186-195. 56. Thompson SG, Pocock SJ. Can meta-analyses
61. Zlowodzki M, Poolman RW, Kerkhoffs GM,
49. Sistrom CL, Garvan CW. Proportions, odds, and be trusted? Lancet. 1991;338:1127-1130.
risk. Radiology. 2004;230:12-19. http://dx.doi. 57. Wallace BC, Schmid CH, Lau J, Trikalinos TA. Tornetta P, 3rd, Bhandari M. How to interpret a
org/10.1148/radiol.2301031028 Meta-Analyst: software for meta-analysis of meta-analysis and judge its value as a guide for
50. Sterne JA, Egger M, Moher D. Addressing binary, continuous and diagnostic data. BMC clinical practice. Acta Orthop. 2007;78:598-609.
reporting biases. In: Higgins JP, Green S, eds. Med Res Methodol. 2009;9:80. http://dx.doi. http://dx.doi.org/10.1080/17453670710014284
Cochrane Handbook for Systematic Reviews org/10.1186/1471-2288-9-80
of Interventions. Chichester, West Sussex, UK: 58. Walton DM, Pretty J, MacDermid JC, Teasell RW.
@ MORE INFORMATION
John Wiley & Sons; 2008:297-333. Risk factors for persistent problems following
51. Stratford PW. The added value of confidence whiplash injury: results of a systematic review
intervals. Phys Ther. 2010;90:333-335. http:// and meta-analysis. J Orthop Sports Phys Ther. WWW.JOSPT.ORG
CHECK Your References With the JOSPT Reference Library

JOSPT has created an EndNote reference library for authors to use in
conjunction with PubMed/Medline when assembling their manuscript
references. This addition to “INFORMATION FOR AUTHORS” on the JOSPT
website under “Complete Author Instructions” offers a compilation of all
article reference sections published in the Journal from 2006 to date as
well as complete references for all articles published by JOSPT since
1979—a total of nearly 10,000 unique references. Each reference has been
checked for accuracy.
This resource is updated monthly with each new issue of the Journal. The
JOSPT Reference Library can be found at http://www.jospt.org/aboutus/
for_authors.asp.
41-07 Israel.indd 504 6/15/2011 3:14:55 PM

This article has been cited by:
1. Hunduma Dina Hambisa, Berhane Teklay Asfaha, Biniam Ambisa, Abebech Gudeta Beyisho. 2024. Common predictors of
cervical cancer related mortality in Ethiopia. A systematic review and meta-analysis. BMC Public Health 24:1. . [Crossref]
2. Nina F. Kelly, Cody J. Mansfield, Eric Schneider, Josh C. Moeller, Jerald S. Bleacher, Ruchika S. Prakash, Matthew S.
Briggs. 2024. Functional connectivity patterns are altered by low back pain and cause different responses to sham and real
dry needling therapies: a systematic review of fMRI studies. Physiotherapy Theory and Practice 40:4, 671-688. [Crossref]
3. Ronak J. Mahatme, Maxwell Modrak, Christopher Wilhelm, Michael S. Lee, Jade S. Owens, Stephen M. Gillinov, Scott
Fong, Nicholas Pettinelli, Wasif Islam, Andrew E. Jimenez. 2024. Glenohumeral Superior Translation and Subacromial
Contract Pressure Are Both Improved With Superior Capsular Reconstruction: A Systematic Review and Meta-analysis
of Biomechanical Investigations. Arthroscopy: The Journal of Arthroscopic & Related Surgery 40:4, 1279-1287. [Crossref]
4. Jaruwan Kownaklai, Titaree Phanwichatkul, Atchara Chaichan, Amanda Lee. 2024. Effectiveness of Spontaneous Pushing
versus Valsalva Pushing in the Second Stage of Labor on Maternal and Neonatal Outcomes: A Systematic Review and
Meta-analysis. Pacific Rim International Journal of Nursing Research 28:2, 407-420. [Crossref]
5. Rebecca Hymas, Johanna C. Badcock, Elizabeth Milne. 2024. Loneliness in Autism and Its Association with Anxiety
and Depression: A Systematic Review with Meta-Analyses. Review Journal of Autism and Developmental Disorders 11:1,
121-156. [Crossref]
6. Pan Chen, Mei Ieng Lam, Tong Leong Si, Ling Zhang, Lloyd Balbuena, Zhaohui Su, Teris Cheung, Gabor S. Ungvari,
Sha Sha, Yu-Tao Xiang. 2024. The prevalence of poor sleep quality in the general population in China: a meta-analysis
of epidemiological studies. European Archives of Psychiatry and Clinical Neuroscience 166. . [Crossref]
7. Tin Zar Win, Su Myat Han, Tansy Edwards, Hsu Thinzar Maung, David M Brett-Major, Chris Smith, Nathaniel Lee.
2024. Antibiotics for treatment of leptospirosis. Cochrane Database of Systematic Reviews 2024:3. . [Crossref]
8. Tin Zar Win, Tanaraj Perinpanathan, Patrick Mukadi, Chris Smith, Tansy Edwards, Su Myat Han, Hsu Thinzar Maung,
David M Brett-Major, Nathaniel Lee. 2024. Antibiotic prophylaxis for leptospirosis. Cochrane Database of Systematic
Reviews 2024:3. . [Crossref]
9. Temesgen Gebeyehu Wondmeneh, Jemal Abdu Mohammed. 2024. COVID-19 mortality rate and its determinants in
Ethiopia: a systematic review and meta-analysis. Frontiers in Medicine 11. . [Crossref]
10. Ryan Berkey, Afsar Sunesara, Lindsay Allen, Ryan Pontiff, Alison DeVries, Steve R. Fisher. 2024. Ankle Injury Prevention
Programs for Youth Sports: A Systematic Review and Meta-analysis. Sports Health: A Multidisciplinary Approach 13. .
[Crossref]
11. Seetha Anitha, Takuji W. Tsusaka, D. Ian Givens, Joanna Kane-Potaka, Rosemary Botha, Nur Liana Binti Sulaiman,
Shweta Upadhyay, Mani Vetriventhan, Ananthan Rajendran, Devraj J. Parasannanavar, Thingnganing Longvah, Kowsalya
Subramaniam, Raj Kumar Bhandari. 2024. Does millet consumption contribute to raising blood hemoglobin levels
compared to regular refined staples?: a systematic review and meta-analysis. Frontiers in Nutrition 11. . [Crossref]
12. Antonella LoMauro, Fabrizio Gervasoni. 2024. 20 years of neuromuscular electrical stimulation in COPD. European
Respiratory Review 33:171, 220247. [Crossref]
13. Seetha Anitha, Takuji W. Tsusaka, Rosemary Botha, D. Ian Givens, Ananthan Rajendran, Devraj J. Parasannanavar,
Kowsalya Subramaniam, Raj Kumar Bhandari, Joanna Kane-Potaka. 2024. Impact of regular consumption of millets on
fasting and post-prandial blood glucose level: a systematic review and meta-analysis. Frontiers in Sustainable Food Systems
7. . [Crossref]
14. Christine W. Lary, Samuel Ghatan, Meghan Gerety, Alexandra Hinton, Archana Nagarajan, Clifford Rosen, Ryan D. Ross,
David A. Bennett, Anita L. DeStefano, Mohammad A. Ikram, Fernando Rivadeneira, Douglas P. Kiel, Sudha Seshadri,
Alexa Beiser. 2024. Bone mineral density and the risk of incident dementia: A meta‐analysis. Journal of the American
Geriatrics Society 72:1, 194-200. [Crossref]
15. Meryem KONU KADİRHANOĞULLARI. 2023. The Effect of Teaching with Concept Maps on Academic Success
in Biology Teaching: A Meta-Analysis Study. Dokuz Eylül Üniversitesi Buca Eğitim Fakültesi Dergisi :58, 2781-2796.
[Crossref]
16. Eleftherios Paraskevopoulos, Stefanos Karanasios, Georgios Gioftsos, Petros Tatsios, Georgios Koumantakis, Maria
Papandreou. 2023. The effectiveness of neuromobilization exercises in carpal tunnel syndrome: Systematic review and
meta-analysis. Physiotherapy Theory and Practice 39:10, 2037-2076. [Crossref]
17. Alexandre Wojciechowski, Célia Seassau, Lucas Soerensen, Lionel Alletto, Jay Ram Lamichhane. 2023. Effects of cover
crops on maize establishment, root mycorrhizal colonization, plant growth and grain yield depend on their botanical family:
A global meta-analysis. Agriculture, Ecosystems & Environment 356, 108648. [Crossref]
18. Rebecca B. Carlson, Jennifer R. Martin, Robert D. Beckett. 2023. Ten simple rules for interpreting and evaluating a
meta-analysis. PLOS Computational Biology 19:9, e1011461. [Crossref]
19. Katherine K Rethman, Cody J Mansfield, Josh Moeller, Danilo De Oliveira Silva, Julie A Stephens, Stephanie Di Stasi,
Matthew S Briggs. 2023. Kinesiophobia Is Associated With Poor Function and Modifiable Through Interventions in
People With Patellofemoral Pain: A Systematic Review With Individual Participant Data Correlation Meta-Analysis.
Physical Therapy 103:9. . [Crossref]
20. Emily Colton, Kira-Elise Wilson, Trevor T.-J. Chong, Antonio Verdejo-Garcia. 2023. Dysfunctional decision-making in
binge-eating disorder: A meta-analysis and systematic review. Neuroscience & Biobehavioral Reviews 152, 105250. [Crossref]
21. Lichi Ashwin Solanki, S.P. Saravana Dinesh, Ravindra Kumar Jain, Arthi Balasubramaniam. 2023. Effects of titanium oxide
coating on the antimicrobial properties, surface characteristics, and cytotoxicity of orthodontic brackets - A systematic
review and meta analysis of in-vitro studies. Journal of Oral Biology and Craniofacial Research 13:5, 553-562. [Crossref]
22. Nur Liyana Hasnaa Mohd Daud, Noraishah Mohamed Nor, Nurul Hazirah Jaafar, Wan Azdie Mohd Abu Bakar,
Nor Azwani Mohd Shukri. 2023. The Feasibility and Effectiveness of Telenutrition for Remote Dietary Consultation:
A Systematic Review and Meta-analysis Protocol. Malaysian Journal of Medicine and Health Sciences 19:s9, 337-342.
[Crossref]
23. Mohammad Mirza-Aghazadeh-Attari, Seyedeh Panid Madani, Haneyeh Shahbazian, Golnoosh Ansari, Alireza Mohseni,
Ali Borhani, Shadi Afyouni, Ihab R. Kamel. 2023. Predictive role of radiomics features extracted from preoperative cross-
sectional imaging of pancreatic ductal adenocarcinoma in detecting lymph node metastasis: a systemic review and meta-
analysis. Abdominal Radiology 48:8, 2570-2584. [Crossref]
24. Hunduma Dina Hambisa, Samuel Gedamu, Zelalem Birku, Desalegn Jabana Emana. 2023. The top determinants and
magnitude of preterm neonatal mortality in Ethiopia. Systematic review and meta-analysis. Journal of Neonatal Nursing
29:4, 612-619. [Crossref]
25. Hafte Kahsay Kebede, Hailay Gesesew, Paul Ward. 2023. Impact of armed conflicts on HIV treatment outcomes in sub-
Saharan Africa: protocol for a systematic review and meta-analysis. BMJ Open 13:8, e069308. [Crossref]
26. Taylor Galonski, Cody Mansfield, Josh Moeller, Ricky Miller, Katherine Rethman, Matthew S. Briggs. 2023. Does
graded motor imagery benefit individuals with knee pain: A systematic review and meta-analysis. Journal of Bodywork and
Movement Therapies 35, 130-139. [Crossref]

27. Huiqi Song, Jing-Jing Wang, Borui Zhang, Lei Shi, Patrick W.C. Lau. 2023. Do acute and chronic physical activity
interventions affect the cognitive function of preschool children? A meta-analysis. Psychology of Sport and Exercise 67,
102419. [Crossref]
28. Will D. Swansson, Bennett M. Anderson, Sern Wei Yeoh, Diana J. Lewis. 2023. Management of minimal and overt
hepatic encephalopathy with branched-chain amino acids: a review of the evidence. European Journal of Gastroenterology
& Hepatology 17. . [Crossref]
29. Ana Inês Silva, Manuel Direito, Filipa Pinto-Ribeiro, Paula Ludovico, Belém Sampaio-Marques. 2023. Effects of
Intermittent Fasting on Regulation of Metabolic Homeostasis: A Systematic Review and Meta-Analysis in Health and
Metabolic-Related Disorders. Journal of Clinical Medicine 12:11, 3699. [Crossref]
30. Christine Azar, Paul Raffoul, Rana Rizk, Celina Boutros, Nadine Saleh, Patrick Maison. 2023. Prevalence of medication
administration errors in hospitalized adults: A systematic review and meta‐analysis up to 2017 to explore sources of
heterogeneity. Fundamental & Clinical Pharmacology 37:3, 531-548. [Crossref]
31. Indita Dorina, Barbara Mullan, Mark Boyes, Caitlin Liddelow. 2023. Utility of temporal self‐regulation theory in health
and social behaviours: A meta‐analysis. British Journal of Health Psychology 28:2, 397-438. [Crossref]
32. Vittoria Ardito, Lilit Sarucanian, Carla Rognoni, Marina Pieri, Anna Mara Scandroglio, Rosanna Tarricone. 2023. Impella
Versus VA-ECMO for Patients with Cardiogenic Shock: Comprehensive Systematic Literature Review and Meta-Analyses.
Journal of Cardiovascular Development and Disease 10:4, 158. [Crossref]
33. Ali Hendi Alghamdi, Aimun A.E. Ahmed, Mahadi Bashir, Haidar Abdalgadir, Asaad Khalid, Sheraz Gul. 2023. The use of
medicinal plants in common ophthalmic disorders: A systematic review with meta-analysis. Heliyon 9:4, e15340. [Crossref]
34. Mohamed Marzok, Mahmoud Kandeel, Hussein Babiker, Khalid M. Alkhodair, Alshimaa Farag, Hussam Ibrahim, Maged
El-Ashker, Yousef Alghuwainem, Sabry El-khodery. 2023. M-Mode Echocardiographic Measurements of Interventricular
Septum, Left Ventricular Internal Diameter, and Left Ventricular Free-Wall Thickness in Normal Horses—A Meta-
Analytical Study. Animals 13:5, 809. [Crossref]
35. Jeffrey Kay, Kyle N. Kunze, Ayoosh Pareek, Jari Dahmen, Darren de SA, Jon Karlsson. 2023. A guide to appropriately
planning and conducting meta-analyses—Part 1: indications, assumptions and understanding risk of bias. Knee Surgery,
Sports Traumatology, Arthroscopy 31:3, 725-732. [Crossref]
36. Rashid Maqbool, Mohammed Rayan Saiba, Saleha Ashfaq. 2023. Emerging industry 4.0 and Internet of Things
(IoT) technologies in the Ghanaian construction industry: sustainability, implementation challenges, and benefits.
Environmental Science and Pollution Research 30:13, 37076-37091. [Crossref]
37. Kelly Westlake, Ruth Akinlosotu, Jean Udo, Andrea Goldstein Shipper, Sandy McCombe Waller, Jill Whitall. 2023.
Some home-based self-managed rehabilitation interventions can improve arm activity after stroke: A systematic review
and narrative synthesis. Frontiers in Neurology 14. . [Crossref]
38. Yuchuan Fan, Jie Zhuang, Michael Essington, Sindhu Jagadamma, John Schwartz, Jaehoon Lee. 2023. Global Significance
of Substrates for Nitrate Removal in Denitrifying Bioreactors Revealed by Meta-Analysis. Engineering 21, 214-226.
[Crossref]
39. Diane D. Allen, Sang S. Pak. Improving Clinical Practice with Person-Centered Outcome Measurement 53-105. [Crossref]
40. Sujitra Raj Genga Raj, Kalaivani Nadarajah. 2023. QTL and Candidate Genes: Techniques and Advancement in Abiotic
Stress Resistance Breeding of Major Cereals. International Journal of Molecular Sciences 24:1, 6. [Crossref]
41. Mark Overton, Sarah Ward, Nicola Swain, Carrie Falling, David Gwynne-Jones, Roger Fillingim, Ramakrishnan Mani.
2023. Are Ecological Momentary Assessments of Pain Valid and Reliable? A Systematic Review and Meta-analysis. The
Clinical Journal of Pain 39:1, 29-40. [Crossref]
42. M. M. Sulphey. 2022. A Meta-analytic Literature Study on the Relationship Between Workplace Spirituality and
Sustainability. Journal of Religion and Health 61:6, 4674-4695. [Crossref]
43. Guilherme S. Nunes, Diênifer Zilmer Rodrigues, Luiza Hörbe, Izabela Prates, Bruna M. Tessarin, Fábio V. Serrão, Marcos
de Noronha. 2022. Is Postural Control Affected in People with Patellofemoral Pain and Should it be Part of Rehabilitation?
A Systematic Review with Meta-analysis. Sports Medicine - Open 8:1. . [Crossref]
44. Santhi Priya Sobha, Kumar Ebenezar Kesavarao. 2022. Contribution of Glutathione-S-Transferases Polymorphism and
Risk of Coronary Artery Diseases: A Meta-Analysis. Current Aging Science 15:3, 282-292. [Crossref]
45. CLOVIS MARIANO FAGGION. 2022. COMBINATION OF Nd:YAG AND Er:YAG LASERS MIGHT IMPROVE
PERIODONTAL PROBING DEPTHS AND CLINICAL ATTACHMENT LEVELS, BUT THE LEVEL OF
EVIDENCE IS VERY WEAK. Journal of Evidence-Based Dental Practice 22:3, 101753. [Crossref]
46. Leanne Fleming, Sommer Agnew, Nicola Peddie, Megan Crawford, Diane Dixon, Iain MacPherson. 2022. The impact
of medication side effects on adherence and persistence to hormone therapy in breast cancer survivors: A quantitative
systematic review. The Breast 64, 63-84. [Crossref]
47. Tin Zar Win, Kozue Tabei, Patrick Mukadi, Tansy Edwards, Chris Smith, Nathaniel Lee. 2022. Corticosteroids for
treatment of leptospirosis. Cochrane Database of Systematic Reviews 2022:7. . [Crossref]
48. Yunxing Ma, Julia Brettschneider, Joanna F. Collingwood. 2022. A Systematic Review and Meta-Analysis of Cerebrospinal
Fluid Amyloid and Tau Levels Identifies Mild Cognitive Impairment Patients Progressing to Alzheimer’s Disease.
Biomedicines 10:7, 1713. [Crossref]
49. M. Rais RİDWAN, Samsul HADİ. 2022. A meta-analysis study on the effectiveness of a cooperative learning model
on vocational high school students’ mathematics learning outcomes. Participatory Educational Research 9:4, 396-421.
[Crossref]
50. Amanda J. Vinson, Xun Zhang, Mourad Dahhou, Caner Süsal, Bernd Döhler, Ruth Sapir-Pichhadze, Heloise Cardinal,
Anette Melk, Germaine Wong, Anna Francis, Helen Pilmore, Bethany J. Foster. 2022. Age-dependent Sex Differences in
Graft Loss After Kidney Transplantation. Transplantation 106:7, 1473-1484. [Crossref]
51. Seetha Anitha, Takuji Tsusaka, Rosemary Botha, Joanna Kane-Potaka, David Givens, Ananthan Rajendran, Raj Bhandari.
2022. Are Millets More Effective in Managing Hyperlipidaemia and Obesity than Major Cereal Staples? A Systematic
Review and Meta-Analysis. Sustainability 14:11, 6659. [Crossref]
52. Claire Spech, Matthew Paponetti, Cody Mansfield, Laura Schmitt, Matthew Briggs. 2022. Biomechanical variations in
children who are overweight and obese during high‐impact activities: A systematic review and meta‐analysis. Obesity
Reviews 23:6. . [Crossref]
53. Patrick Mukadi, Kozue Tabei, Tansy Edwards, David M Brett-Major, Chris Smith, Emi Kitashoji, Tin Zar Win. 2022.
Antibiotics for treatment of leptospirosis. Cochrane Database of Systematic Reviews 2022:5. . [Crossref]
54. Hikmet Özgün İŞCAN, Abdurrahman AKSOY. 2022. VETERİNER FARMAKOLOJİ VE TOKSİKOLOJİ’DE META-
ANALİZ, SİSTEMATİK DERLEME VE HIZLI DERLEME. Veteriner Farmakoloji ve Toksikoloji Derneği Bülteni .
[Crossref]
55. Rochelle Furtado, Pavlos Bobos, Christina Ziebart, Joshua Vincent, Joy MacDermid. 2022. Patient-reported outcome
measures used for shoulder disorders: An overview of systematic reviews. Journal of Hand Therapy 35:2, 174-185. [Crossref]
56. Muhammad Sholihin, Hardivizon Hardivizon, Deri Wanto, Hasep Saputra. 2022. The effect of religiosity on life
satisfaction: A meta-analysis. HTS Teologiese Studies / Theological Studies 78:4. . [Crossref]
57. Cara Donohue, Giselle Carnaby, Kendrea L. (Focht) Garand. 2022. How to Interpret and Evaluate a Meta-Analysis in
the Field of Speech-Language Pathology: A Tutorial for Clinicians. American Journal of Speech-Language Pathology 31:2,
664-677. [Crossref]
58. Kozue Tabei, Tin Zar Win, Emi Kitashoji, David M Brett-Major, Tansy Edwards, Chris Smith, Patrick Mukadi. 2022.
Antibiotic prophylaxis for leptospirosis. Cochrane Database of Systematic Reviews 2022:2. . [Crossref]
59. Xu Han, Ying Chen, Qinna Feng, Heng Luo. 2022. Augmented Reality in Professional Training: A Review of the
Literature from 2001 to 2020. Applied Sciences 12:3, 1024. [Crossref]
60. Argyrios Stampas, Michelle Hook, Radha Korupolu, Lavina Jethani, Mahmut T. Kaner, Erinn Pemberton, Sheng Li,
Gerard E. Francisco. 2022. Evidence of treating spasticity before it develops: a systematic review of spasticity outcomes
in acute spinal cord injury interventional trials. Therapeutic Advances in Neurological Disorders 15, 175628642110706.
[Crossref]
61. Seetha Anitha, David Ian Givens, Kowsalya Subramaniam, Shweta Upadhyay, Joanna Kane-Potaka, Yakima D.
Vogtschmidt, Rosemary Botha, Takuji W. Tsusaka, Swamikannu Nedumaran, Hemalatha Rajkumar, Ananthan
Rajendran, Devraj J. Parasannanavar, Mani Vetriventhan, Raj Kumar Bhandari. 2022. Can Feeding a Millet-Based Diet
Improve the Growth of Children?—A Systematic Review and Meta-Analysis. Nutrients 14:1, 225. [Crossref]
62. Yaser Hamad, Marwa Younis, Hussam Ibrahim, Maged El-Ashker, Mohamed Youssef, Sabry El-khodery. 2022. Effect of
chelated zinc on milk production in dairy cows: Meta-analysis. CABI Reviews 2022. . [Crossref]
63. Olawale Festus Olaniyan, Ibrahim Kaya, Arss Secka. 2021. Trypanosomosis prevalence in natural field-based infection:
insights into systematic review and meta-analysis of studies from 1980 to 2018 on The Gambian ruminants with special
emphasis on cattle. Tropical Animal Health and Production 53:1. . [Crossref]
64. Daniel Holanda Barroso, Jurema Guerrieri Brandão, Elaine Silva Nascimento Andrade, Ana Clara Banhatto Correia,
Danielle Costa Aquino, Ana Carolina Rios Chen, Sebastian Vernal, Wildo Navegantes de Araújo, Lícia Maria Henrique
da Mota, Raimunda Nonata Ribeiro Sampaio, Patrícia Shu Kurizky, Ciro Martins Gomes. 2021. Leprosy detection rate in
patients under immunosuppression for the treatment of dermatological, rheumatological, and gastroenterological diseases:
a systematic review of the literature and meta-analysis. BMC Infectious Diseases 21:1. . [Crossref]
65. Dawit Gebreegziabiher Hagos, Henk D. F. H. Schallig, Yazezew K. Kiros, Mahmud Abdulkadir, Dawit Wolday. 2021.
Performance of rapid rk39 tests for the diagnosis of visceral leishmaniasis in Ethiopia: a systematic review and meta-
analysis. BMC Infectious Diseases 21:1. . [Crossref]
66. Vinodh Bhoopathi. 2021. INCONCLUSIVE EVIDENCE INDICATES COMMUNITY BASED COMPREHENSIVE
ORAL HEALTH INTERVENTION IMPROVES ORAL HEALTH STATUS COMPARED TO ONLY ORAL
HEALTH EDUCATION. Journal of Evidence Based Dental Practice 21:4, 101655. [Crossref]
67. Cody J. Mansfield, Charlie Domnisch, Laura Iglar, Laura Boucher, James Onate, Matt Briggs. 2021. Response to letter
to the editor. Journal of Manual & Manipulative Therapy 29:6, 339-340. [Crossref]
68. Lucas Ogura Dantas, Mikala C. Osani, Raveendhara R. Bannuru. 2021. Therapeutic ultrasound for knee osteoarthritis:
A systematic review and meta-analysis with grade quality assessment. Brazilian Journal of Physical Therapy 25:6, 688-697.
[Crossref]
69. Michael-Alexander Malahias, Rafael Loucas, Marios Loucas, Matteo Denti, Peter K. Sculco, Alexander Greenberg. 2021.
Preoperative Opioid Use Is Associated With Higher Revision Rates in Total Joint Arthroplasty: A Systematic Review.
The Journal of Arthroplasty 36:11, 3814-3821. [Crossref]
70. Seetha Anitha, Joanna Kane-Potaka, Rosemary Botha, D. Ian Givens, Nur Liana Binti Sulaiman, Shweta Upadhyay, Mani
Vetriventhan, Takuji W. Tsusaka, Devraj J. Parasannanavar, Thingnganing Longvah, Ananthan Rajendran, Kowsalya
Subramaniam, Raj Kumar Bhandari. 2021. Millets Can Have a Major Impact on Improving Iron Status, Hemoglobin
Level, and in Reducing Iron Deficiency Anemia–A Systematic Review and Meta-Analysis. Frontiers in Nutrition 8. .
[Crossref]
71. Rajesh K. Ahir, Basab Chakraborty. 2021. A meta-analytic approach for determining the success factors for energy
conservation. Energy 230, 120821. [Crossref]
72. Seetha Anitha, Rosemary Botha, Joanna Kane-Potaka, D. Ian Givens, Ananthan Rajendran, Takuji W. Tsusaka, Raj
Kumar Bhandari. 2021. Can Millet Consumption Help Manage Hyperlipidemia and Obesity?: A Systematic Review and
Meta-Analysis. Frontiers in Nutrition 8. . [Crossref]
73. Seetha Anitha, David Ian Givens, Rosemary Botha, Joanna Kane-Potaka, Nur Liana Binti Sulaiman, Takuji W. Tsusaka,
Kowsalya Subramaniam, Ananthan Rajendran, Devraj J. Parasannanavar, Raj Kumar Bhandari. 2021. Calcium from Finger
Millet—A Systematic Review and Meta-Analysis on Calcium Retention, Bone Resorption, and In Vitro Bioavailability.
Sustainability 13:16, 8677. [Crossref]

74. Seetha Anitha, Joanna Kane-Potaka, Takuji W. Tsusaka, Rosemary Botha, Ananthan Rajendran, D. Ian Givens, Devraj
J. Parasannanavar, Kowsalya Subramaniam, Kanaka Durga Veera Prasad, Mani Vetriventhan, Raj Kumar Bhandari. 2021.
A Systematic Review and Meta-Analysis of the Potential of Millets for Managing and Reducing the Risk of Developing
Diabetes Mellitus. Frontiers in Nutrition 8. . [Crossref]
75. Lory Zephyr, Chantal Cyr, Sébastien Monette, Maude Archambault, Stine Lehmann, Helen Minnis. 2021. Meta-
Analyses of the Associations Between Disinhibited Social Engagement Behaviors and Child Attachment Insecurity or
Disorganization. Research on Child and Adolescent Psychopathology 49:7, 949-962. [Crossref]
76. Mariana Rocha, Daniel Wang, Victor Avila-Quintero, Michael H. Bloch, Arie Kaffman. 2021. Deficits in hippocampal-
dependent memory across different rodent models of early life stress: systematic review and meta-analysis. Translational
Psychiatry 11:1. . [Crossref]
77. Vinodh Bhoopathi, Marisol Tellez. 2021. Limited quality evidence suggests children and adolescents with down syndrome
have lower prevalence of dental caries compared to non-syndromic children. Journal of Evidence Based Dental Practice 21:2,
101571. [Crossref]
78. Hafte Kahsay Kebede, Hailay Abrha Gesesew, Lillian Mwanri, Paul Ward. 2021. The Impact of Peer Educators or
Community Health Workers on the Progress of the UNAIDS 90-90-90 Targets in Africa: A Systematic Review and
Meta-Analysis Protocol. International Journal of Environmental Research and Public Health 18:8, 3917. [Crossref]
79. Pankaj Taneja, Håkan Olausson, Mats Trulsson, Peter Svensson, Lene Baad-Hansen. 2021. Defining pleasant touch
stimuli: a systematic review and meta-analysis. Psychological Research 85:1, 20-35. [Crossref]
80. Clifford Waller, Bahram Sangelaji, Peter Lamb, Suzanne Kuys, Stephanie J. Woodley. 2021. Biomechanical differences
at the hemiparetic knee in people with stroke: a systematic review and meta-analysis protocol. Physical Therapy Reviews
26:1, 25-33. [Crossref]
81. Shakti Shrestha, Arjun Poudel, Magnolia Cardona, Kathryn J. Steadman, Lisa M. Nissen. 2021. Impact of deprescribing
dual-purpose medications on patient-related outcomes for older adults near end-of-life: a systematic review and meta-
analysis. Therapeutic Advances in Drug Safety 12, 204209862110523. [Crossref]
82. Louise Lynch, Mary McCarron, Philip McCallion, Eilish Burke. 2021. Sedentary behaviour levels in adults with an
intellectual disability: a systematic review and meta-analysis. HRB Open Research 4, 69. [Crossref]
83. Louise Lynch, Mary McCarron, Philip McCallion, Eilish Burke. 2021. Sedentary behaviour levels in adults with an
intellectual disability: a systematic review and meta-analysis. HRB Open Research 4, 69. [Crossref]
84. Daniel Wang, Jessica L. S. Levine, Victor Avila-Quintero, Michael Bloch, Arie Kaffman. 2020. Systematic review and
meta-analysis: effects of maternal separation on anxiety-like behavior in rodents. Translational Psychiatry 10:1. . [Crossref]
85. Lanyan Fang, Xuyang Song, Ping Ji, Yaning Wang, Janet Maynard, Sarah Yim, Chandrahas Sahajwalla, Mingjiang Xu,
Myong‐Jin Kim, Liang Zhao. 2020. Impact of Sex on Clinical Response in Rheumatoid Arthritis Patients Treated With
Biologics at Approved Dosing Regimens. The Journal of Clinical Pharmacology 60:S2. . [Crossref]
86. Eva-Marie Meemken. 2020. Do smallholder farmers benefit from sustainability standards? A systematic review and meta-
analysis. Global Food Security 26, 100373. [Crossref]
87. Ama G. Ampofo, Ehsan Khan, Mary B. Ibitoye. 2020. Understanding the role of educational interventions on medication
adherence in hypertension: A systematic review and meta-analysis. Heart & Lung 49:5, 537-547. [Crossref]
88. Andrew T. Schilling, Jeff Ehresman, Sakibul Huq, A. Karim Ahmed, Daniel Lubelski, Ethan Cottrill, Zach Pennington,
John H. Shin, Daniel M. Sciubba. 2020. Risk Factors for Wound-Related Complications After Surgery for Primary and
Metastatic Spine Tumors: A Systematic Review and Meta-Analysis. World Neurosurgery 141, 467-478.e3. [Crossref]
89. Linda Farmus, Robert A. Cribbie, Michael A. Rotondi. 2020. The Flipped Classroom in Introductory Statistics: Early
Evidence From a Systematic Review and Meta-Analysis. Journal of Statistics Education 28:3, 316-325. [Crossref]
90. Natalie Lander, Jo Salmon, Philip J. Morgan, Naomi Symington, Lisa M. Barnett. 2020. Three-year maintenance of a
teacher-led programme targeting motor competence in early adolescent girls. Journal of Sports Sciences 38:16, 1886-1896.
[Crossref]
91. Rosa Andias, Anabela G. Silva. 2020. Psychosocial Variables and Sleep Associated With Neck Pain in Adolescents: A
Systematic Review. Physical & Occupational Therapy In Pediatrics 40:2, 168-191. [Crossref]
92. John Nyland, Philip Collis, Austin Huffstutler, Shikha Sachdeva, James R. Spears, Joseph Greene, David N. M. Caborn.
2020. Quadriceps tendon autograft ACL reconstruction has less pivot shift laxity and lower failure rates than hamstring
tendon autografts. Knee Surgery, Sports Traumatology, Arthroscopy 28:2, 509-518. [Crossref]
93. Janett A. Hildebrand, John Billimek, Jung-Ah Lee, Dara H. Sorkin, Ellen F. Olshansky, Stephen L. Clancy, Lorraine S.
Evangelista. 2020. Effect of diabetes self-management education on glycemic control in Latino adults with type 2 diabetes:
A systematic review and meta-analysis. Patient Education and Counseling 103:2, 266-275. [Crossref]
94. Peter B. Imrey. 2020. Limitations of Meta-analyses of Studies With High Heterogeneity. JAMA Network Open 3:1,
e1919325. [Crossref]
95. Ric G. Steele, Austen McGuire, Christopher C. Cushing. Methodological Issues in the Evaluation of Therapies 15-23.
[Crossref]
96. A.N.H. Bulabula, A. Dramowski, S. Mehtar. 2020. Transmission of multidrug-resistant Gram-negative bacteria from
colonized mothers to their infants: a systematic review and meta-analysis. Journal of Hospital Infection 104:1, 57-67.
[Crossref]
97. Cristoforo Incorvaia, Eleni Makri, Erminia Ridolo, Irene Pellicelli, Lorenzo Panella. 2019. Advances in allergen
immunotherapy as a treatment of asthma. Expert Review of Respiratory Medicine 13:12, 1161-1167. [Crossref]
98. Shalom Grace C. Sugano, Edna B. Nabua, Manuel B. Barquilla, Amelia T. Buan, Ellen N. Inutan. 2019. Meta-analytic
review of studies on the effectiveness of chemistry teaching methods on student transformation. Journal of Physics:
Conference Series 1340:1, 012082. [Crossref]
99. Maranda Herner. 2019. Perfect Top of the Evidence Hierarchy Pyramid, Maybe Not So Perfect: lessons learned by a novice
researcher engaging in a meta-analysis project. BMJ Evidence-Based Medicine 24:4, 130-132. [Crossref]
100. Nikolaos Stathopoulos, Zacharias Dimitriadis, George A. Koumantakis. 2019. Effectiveness of Mulligan’s Mobilization
With Movement Techniques on Range of Motion in Peripheral Joint Pathologies: A Systematic Review With Meta-
analysis Between 2008 and 2018. Journal of Manipulative and Physiological Therapeutics 42:6, 439-449. [Crossref]
101. Todd E. Davenport, Mary Lehnen, Staci R. Stevens, J. Mark VanNess, Jared Stevens, Christopher R. Snell.
2019. Chronotropic Intolerance: An Overlooked Determinant of Symptoms and Activity Limitation in Myalgic
Encephalomyelitis/Chronic Fatigue Syndrome?. Frontiers in Pediatrics 7. . [Crossref]
102. Nikolaos Stathopoulos, Zacharias Dimitriadis, George A. Koumantakis. 2019. Effectiveness of Mulligan’s mobilization
with movement techniques on pain and disability of peripheral joints: a systematic review with meta-analysis between
2008–2017. Physiotherapy 105:1, 1-9. [Crossref]
103. Andrzej Zybert, Krystian Tarczyński, Halina Sieczkowska. 2019. A meta‐analysis of the effect of high pressure processing
on four quality traits of fresh pork. Journal of Food Processing and Preservation 43:3, e13895. [Crossref]
104. Rosa Andias, Anabela G. Silva. 2019. A systematic review with meta‐analysis on functional changes associated with neck
pain in adolescents. Musculoskeletal Care 17:1, 23-36. [Crossref]
105. Audrey Siew Foong Kow, Azirah Chik, Kuan-Meng Soo, Leng Wei Khoo, Faridah Abas, Chau Ling Tham. 2019.
Identification of Soluble Mediators in IgG-Mediated Anaphylaxis via Fcγ Receptor: A Meta-Analysis. Frontiers in
Immunology 10. . [Crossref]
106. Alberto Grassi, Riccardo Compagnoni, Kristian Samuelsson, Pietro Randelli, Corrado Bait, Stefano Zaffagnini. A Practical
Guide to Writing (and Understanding) a Scientific Paper: Meta-Analyses 471-497. [Crossref]
107. Pasyodun Koralage Buddhika Mahesh, Moraendage Wasantha Gunathunga, Suriyakumara Mahendra Arnold, Chintha
Jayasinghe, Sisira Pathirana, Mohamed Fahmy Makarim, Pradeep Malaka Manawadu, Sameera Jayan Senanayake. 2018.
Effectiveness of targeting fathers for breastfeeding promotion: systematic review and meta-analysis. BMC Public Health
18:1. . [Crossref]
108. Monique K. Vallabhan, Elizabeth Y. Jimenez, Jacob L. Nash, Diana Gonzales-Pacheco, Kathryn E. Coakley, Shelly R.
Noe, Conni J. DeBlieck, Linda C. Summers, Sarah W. Feldstein-Ewing, Alberta S. Kong. 2018. Motivational Interviewing
to Treat Adolescents With Obesity: A Meta-analysis. Pediatrics 142:5. . [Crossref]
109. I. J. H. Chu, A. Y. T. Lim, C. L. W. Ng. 2018. Effects of meaningful weight loss beyond symptomatic relief in adults
with knee osteoarthritis and obesity: a systematic review and meta-analysis. Obesity Reviews 19:11, 1597-1607. [Crossref]
110. Alejandra Maldonado, Oliver Laugisch, Walter Bürgin, Anton Sculean, Sigrun Eick. 2018. Clinical periodontal variables in
patients with and without dementia—a systematic review and meta-analysis. Clinical Oral Investigations 22:7, 2463-2474.
[Crossref]
111. Mark Overton, Heleen Du Plessis, Gisela Sole. 2018. Electromyography of neck and shoulder muscles in instrumental
musicians with musculoskeletal pain compared to asymptomatic controls: A systematic review and meta-analysis.
Musculoskeletal Science and Practice 36, 32-42. [Crossref]
112. Alexandra B. Gil, Sara R. Piva, James J. Irrgang. 2018. Considerations for Assessment and Applicability of Studies of
Intervention. Clinics in Sports Medicine 37:3, 427-440. [Crossref]
113. A. Chernet, J. Utzinger, V. Sydow, N. Probst-Hensch, D. H. Paris, N. D. Labhardt, A. Neumayr. 2018. Prevalence rates
of six selected infectious diseases among African migrants and refugees: a systematic review and meta-analysis. European
Journal of Clinical Microbiology & Infectious Diseases 37:4, 605-619. [Crossref]
114. Tomasz Cudejko, Martin van der Esch, Marike van der Leeden, Leo D. Roorda, Jari Pallari, Kim L. Bennell, Hans Lund,
Joost Dekker. 2018. Effect of Soft Braces on Pain and Physical Function in Patients With Knee Osteoarthritis: Systematic
Review With Meta-Analyses. Archives of Physical Medicine and Rehabilitation 99:1, 153-163. [Crossref]
115. Ke-Jian Zhang, Jia-Zhen Zhu, Xiao-Yi Bao, Qun Zheng, Guo-qing Zheng, Yan Wang. 2017. Shexiang Baoxin Pills for
Coronary Heart Disease in Animal Models: Preclinical Evidence and Promoting Angiogenesis Mechanism. Frontiers in
Pharmacology 8. . [Crossref]
116. Peter Spall, Daniel Cury Ribeiro, Gisela Sole. 2016. Electromyographic Activity of Shoulder Girdle Muscles in Patients
With Symptomatic and Asymptomatic Rotator Cuff Tears: A Systematic Review and Meta‐Analysis. PM&R 8:9, 894-906.
[Crossref]
117. Mark A. Feger, C. Collin Herb, John J. Fraser, Neal Glaviano, Jay Hertel. 2015. Supervised Rehabilitation Versus Home
Exercise in the Treatment of Acute Ankle Sprains. Clinics in Sports Medicine 34:2, 329-346. [Crossref]
118. Charlotte Fyhr, Linnéa Gustavsson, Craig Wassinger, Gisela Sole. 2015. The effects of shoulder injury on kinaesthesia:
A systematic review and meta-analysis. Manual Therapy 20:1, 28-37. [Crossref]
119. Arianne P Verhagen, Manuela L Ferreira. 2014. Forest plots. Journal of Physiotherapy 60:3, 170-173. [Crossref]
120. Raewyn Bassett, Elizabeth McGibbon. 2013. A critical participatory and collaborative method for scoping the literature.
Quality & Quantity 47:6, 3249-3259. [Crossref]
121. Nienke E. Lankhorst, Sita M.A. Bierma-Zeinstra, Marienke van Middelkoop. 2012. Risk Factors for Patellofemoral Pain
Syndrome: A Systematic Review. Journal of Orthopaedic & Sports Physical Therapy 42:2, 81-94. [Abstract] [Full Text]
[PDF] [PDF Plus]

Israel Richter 2011 A Guide To Understanding Meta Analysis

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Israel Richter 2011 A Guide To Understanding Meta Analysis

Uploaded by

Copyright:

Available Formats

[ clinical commentary ]

HEIDI ISRAEL, FNP, PhD1 • RANDY R. RICHTER, PT, PhD2

evaluate the effectiveness or efficacy of a

41-07 Israel.indd 496 6/15/2011 3:14:46 PM

41-07 Israel.indd 497 6/15/2011 3:14:47 PM

Type of Data Type of Effect Size Reported Examples of Outcome Measures

41-07 Israel.indd 498 6/15/2011 3:14:49 PM

Test for overall effect: z = 9.32 (P<.00001)

41-07 Israel.indd 499 6/15/2011 3:14:50 PM

Subtotal (95% CI) 163 114 46.82 22.21 (18.12, 26.30)

41-07 Israel.indd 500 6/15/2011 3:14:51 PM

41-07 Israel.indd 501 6/15/2011 3:14:52 PM

41-07 Israel.indd 502 6/15/2011 3:14:53 PM

The Cochrane Collaboration Version 4.2.5. Avail- cet. 1998;351:123-127. http://dx.doi.org/10.1016/

41-07 Israel.indd 503 6/15/2011 3:14:54 PM

CHECK Your References With the JOSPT Reference Library

41-07 Israel.indd 504 6/15/2011 3:14:55 PM

Movement Therapies 35, 130-139. [Crossref]

Sustainability 13:16, 8677. [Crossref]

You might also like