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DödingR, etal. BMJ Open Sp Ex Med 2024;10:e002032. doi:10.1136/bmjsem-2024-002032 1
Open access Protocol
Evidence gaps in conservative non-
pharmacological interventions and
guideline implementation for high-
burden non- communicable diseases:
protocol for an overview of reviews
Rebekka Döding ,1 Tobias Braun,1,2 Katja Ehrenbrusthoff ,1 Bernhard Elsner,3
Christian Kopkow,4 Toni Lange,5 Kerstin Lüdtke,3 Andres Jung,6 Clint Miller,7
Patrick J Owen ,8,9 Tobias Saueressig,10 Axel Schäfer,11 Robin Schäfer,1
Tim Schleimer,1 Rilind Shala,12,13 Tibor Szikszay,3 Jochen Zebisch,10
Daniel L Belavý 1
To cite: DödingR, BraunT,
EhrenbrusthoffK, etal.
Evidence gaps in conservative
non- pharmacological
interventions and guideline
implementation for high-
burden non- communicable
diseases: protocol for an
overview of reviews. BMJ Open
Sport & Exercise Medicine
2024;10:e002032. doi:10.1136/
bmjsem-2024-002032
►Additional supplemental
material is published online
only. To view, please visit the
journal online (https:// doi.
org/ 10. 1136/ bmjsem- 2024-
002032).
Accepted 3 September 2024
For numbered afliations see
end of article.
Correspondence to
Professor Daniel L Belavý;
belavy@ gmail. com
© Author(s) (or their
employer(s)) 2024. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ.
ABSTRACT
Non- communicable diseases (NCDs) represent a
high burden for the society and affected individuals.
Conservative non- pharmacological interventions play a
rst- line role in the treatment and management of most
NCDs. Systematic reviews (SRs) provide the highest
level of evidence and signicantly inuence clinical
decision- making. The primary aim of this study is to
provide an overview of the evidence on the effectiveness
of recommended conservative non- pharmacological
interventions for highly burdensome NCDs. The
secondary aim is to provide an overview of the evidence
for guideline implementation. A literature search was
performed in Medline (PubMed), EMBASE and Cochrane
CENTRAL. Six reviewers will, in duplicate, independently
screen and select studies following eligibility criteria.
The population will include individuals with NCDs from
disease categories chosen based on WHO burden
of disease data and the importance of conservative
rehabilitation for their management. Eligible interventions
will encompass conservative non- pharmacological
approaches recommended by clinical practice guidelines
(ie, physical, psychological and education/advice). Eligible
comparator will include no or minimal intervention and
other competitive interventions. Outcomes will comprise
proposed core outcomes for the respective diseases,
including patient- reported (eg, pain) and performance-
based (eg, physical functioning) outcomes. SRs published
in the last 5 years as peer- reviewed journal article in the
English language will be eligible. The overview will be
reported in accordance with the Preferred Reporting Items
for Overviews of reviews.
INTRODUCTION
With the increasing prevalence of non-
communicable diseases and an ageing
population, the number of people suffering
from high- burden (ie, highly prevalent, highly
disabling) diseases is expected to increase.1–3
Global Burden of Disease estimates show
that in 2019, 2.41 billion people worldwide
suffered from non- communicable diseases,
which contributed to 310 million years of
disability, an increase of 63% between 1990
and 2019.3 In addition, global demand for
health services and associated costs are likely
WHAT IS ALREADY KNOWN ON THIS TOPIC
⇒Worldwide, there is a high burden of non-
communicable diseases (NCDs), and the prevalence
is expected to increase further.
⇒Conservative non- pharmacological interventions
delivered by various rehabilitation professionals are
considered a cornerstone in the management of
most NCDs.
⇒Numerous systematic reviews with varying degrees
of scope, rigour and up- to- dateness are available,
limiting current understanding of treatment effec-
tiveness, evidence gaps and needed implementation
efforts.
WHAT THIS STUDY ADDS
⇒This overview of reviews will provide a comprehen-
sive summary of the available systematic review
literature on the effectiveness and barriers/facilita-
tors for implementing the top- ranked conservative
non- pharmacological interventions for the highest
burdensome NCDs.
HOW THIS STUDY MIGHT AFFECT RESEARCH,
PRACTICE OR POLICY
⇒The ndings of this overview will guide and improve
future research decision- making by informing about
evidence gaps in multiple disease categories.
⇒The overview will provide a comprehensive and
accessible document for clinicians, enabling better
evidence- based clinical decisions.
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Open access
to climb. Similar trends have been observed in the USA
(from US$1.4 trillion in 2000 to US$4.3 trillion in 2021),4
Australia (US$50.6 billion in 20125 to US$94.4 billion
in 20216) and Germany (€218.4 billion in 20007 to
€440.6 billion in 20208).
Conservative non- pharmacological treatments (eg,
exercise, respiratory training and education) are typi-
cally offered by allied health professions, such as
physiotherapy, exercise physiology and psychology, to
manage non- communicable chronic diseases. Many
international guidelines now recommend conservative
non- pharmacological interventions as the first- line treat-
ment or therapy for non- communicable diseases.9–13 The
delivery of conservative non- pharmacological treatments
can improve symptoms and enable patients to manage
them independently, reducing costs overall.14–17 System-
atic reviews and meta- analyses provide higher- quality
clinical practice guidelines, representing the highest
level of evidence for clinical practice.18 19
As new primary research is published, existing system-
atic reviews and associated meta- analyses lose currency
over time. One analysis20 published in 2007 proved
that approximately 25% of systematic reviews that met
predefined minimum quality standards were no longer
up to date after 2 years, and approximately 50% were
outdated after 5 years. Similarly, an analysis21 of Spanish
clinical practice guidelines noted that one in five recom-
mendations were outdated after 3 years. A consensus
publication in the BMJ22 guided decision- making when
a given systematic review may no longer be current.
For example, the authors suggest that a new systematic
review may no longer be current if there are new rele-
vant (systematic review) methods, new primary research
or updated information on existing included studies (eg,
retractions).22 In informing clinical practice and guide-
lines, it is relevant to assess the presence and recency
of systematic reviews for key diseases as well as their
treatments. Furthermore, recent findings suggest that
96% of published reviews in psychology report positive
statistically significant results23 as opposed to only 5%
in Cochrane Reviews, including high- quality evidence.24
These findings highlight the need to systematically iden-
tify high- quality reviews to make trustworthy clinical
recommendations. We aim to conduct an overview of
systematic reviews for high- burden non- communicable
diseases that are amenable to management via non-
pharmacological conservative interventions.
In doing so, the prioritisation of diseases to assess
may be driven by assessing the burden of disease data.25
In prioritising which treatments should be included
in this assessment, existing evidence- based clinical
practice guidelines inform which interventions are
currently recommended for routine care. In addition,
understanding the barriers and facilitators to guideline
implementation is critical to providing high- quality care
to those who need it most. However, to our knowledge,
work has yet to be done to identify existing research gaps
and update research priorities.
The objectives of this overview of reviews are to provide
an overview (presence and currency of systematic
reviews) in two areas: (1) intervention effectiveness in
high burden and relevant to conservative rehabilitative
professions diseases and (2) barriers and facilitators to
guideline implementation in clinical practice.
METHODS
This overview of reviews is conducted and reported
following the PRIOR reporting guideline for overviews
of reviews26 (online supplemental data 1). The review
was prospectively registered (Open Science Framework:
https://osf.io/s94qf).
Patient and public involvement
Patients and/or the public were not involved in the
design and conduct of this research.
Search strategy
The full search strategy can be found in the appendix
(online supplemental data 2,3). The following databases
(limits) were searched from the last 5 years to the current
date: MEDLINE via PubMed (last 5 years), EMBASE via
Ovid (Exclude MEDLINE; last 5 years) and CENTRAL
(no time limit). Searches were performed in March
2023. We chose to target only these three databases as
the major medical databases, as higher- quality systematic
reviews are more likely to be published in journals listed
in these databases. As we were not searching for primary
randomised controlled trials, where broad search terms
are required to ensure all relevant literature is captured,
search terms were chosen that focused specifically on the
disease and intervention of interest. Citation tracking was
not performed as systematic reviews are readily identifi-
able in databases, and citation tracking has been shown27
to have minimal additional benefits in identifying system-
atic reviews.
If no relevant studies were identified from the last 5
years, an additional hand search was performed, and
the most recent review was included. Two independent
assessors (RD, TSaueressig, TB, JZ, AJ and RSchäfer)
screened the studies using Covidence. Disagreements
were resolved through collaborative discussion within
the review team and involved a three- stage process: first,
reviewers and extractors engaged in discussions; second,
in cases of uncertainty, there was consultation with an
adjudicator (RD or TSchleimer); and finally, if no resolu-
tion could be achieved at the previous stages, the matter
was referred to a designated team member.
Before each phase (title/abstract and full- text
screening), a pilot was conducted. Each reviewer inde-
pendently screened the same randomly chosen 100 titles/
abstracts (RD, TSaueressig, TB, JZ, AJ and RSchäfer) and
20 full texts (RD, TSzikszay, TB, JZ, AJ and RShala). Article
data (eg, author, publication year, title and abstract) and
inclusion/exclusion criteria were copied into a Microsoft
Excel (V.16.0) spreadsheet template. After collating the
results, all reviewers discussed themes of disagreement
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and refinement of the screening process. This procedure
was repeated if no consensus was reached.
Eligibility criteria
Inclusion criteria followed the Participants, Interventions,
Comparators, Outcomes and Study design framework.28
Systematic reviews of treatment efcacy (primary research
question)
Participants: In line with data from the Global Burden
of Disease Study 2019,1 3 the following high- burden
diseases were chosen to be included: back pain, osteoar-
thritis, rheumatoid arthritis, cerebral palsy, Alzheimer/
dementia, stroke, chronic obstructive pulmonary disease
(COPD), ischaemic heart disease (IHD) and lung cancer
(see online supplemental data 4) for detail on the process
of population selection). The target population(s) were
included if separate analysis was performed per disease
category. Reviews that encompassed studies/reports with
participants who had undergone surgery before or after
rehabilitation were excluded.
Interventions: The approach from Rauch et al29 was
adopted to identify relevant interventions; clinical prac-
tice guidelines from the UK, USA and Germany reporting
on non- pharmacological interventions were evaluated
(see online supplemental data 5) for a list of guide-
lines used) and if relevant guidelines were not available,
expert team members were asked to provide suggestions
on current conservative non- pharmacological inter-
ventions (see online supplemental data 6) for details
on the interventions considered). In total, 12 experts,
comprising team members and international experts,
ranked the suggested interventions based on the impor-
tance of evidence mapping with the question: ‘Select
(tick) the interventions according to your view of the
importance/urgency to do evidence mapping and iden-
tify knowledge gaps’. The top three interventions for
each disease category were selected. If more than three
interventions received equal votes in the survey, a panel
of three experts (DLB, TSzikszay and RD) met to discuss
and select the top interventions. Table 1 lists the resulting
interventions, of which one had to be included in the
review.
Comparators: Reviews were included if the intervention
was compared with minimal or no intervention (eg, ‘usual
care’, placebo/sham, true (no intervention) control) or
with other interventions. The rationale for including
other interventions as comparators was that most inter-
ventions show efficacy compared with, for example, no
intervention, and it is, therefore, more informative for
clinical practice if data on the comparative effects of
different interventions are also presented. Reviews were
excluded if a combination of non- pharmacological
conservative interventions with pharmacological or non-
conservative interventions (eg, exercise plus surgery) was
examined. Similarly, the comparison of different aspects
within the same intervention domain, such as exercise
against another form of exercise, was also excluded.
Outcomes: The inclusion criteria for reviews were based
on the assessment of specific core outcomes for various
disease categories, including the consideration of conser-
vative non- pharmacological interventions. This approach
was adopted to ensure a comprehensive evaluation of the
effectiveness and relevance of different treatment modal-
ities in managing specific disease categories.
For back pain, osteoarthritis or rheumatoid arthritis,
reviews were included if they evaluated pain, disability
and/or quality of life.30–32 For cerebral palsy, Alzheimer’s
disease or dementia, the assessments of physical func-
tioning and/or quality of life were considered.33 34 For
stroke, COPD, IHD or lung cancer, reviews that evaluated
exercise capacity and/or quality of life were included.35–38
Study design: Systematic reviews of randomised
controlled trials (RCTs) in English were included. We
defined a systematic review as a study that addresses
a specific research question by identifying primary
research evidence that meets defined eligibility criteria
identified by a search of academic research databases.
Further, peer- reviewed full- text journal publications
from the last 5 years (ie, with reference to publication
date) were eligible. The rationale for this was that reviews
should be recent, as per findings20 on the loss of currency
of reviews. The most recent Cochrane review on the topic
will be included, irrespective of the time frame. Suppose
there are more than five reviews of the last 5 years. In that
case, the reviews available will be prioritised according
to (a) how specific the included population was to the
target population, (b) the relevance of the intervention
evaluated to the target intervention, (c) in what setting
the intervention was performed (d), number of databases
searched, (e) number of RCTs included and (f) whether
the study was published in a journal from a potentially
predatory publisher (see online supplemental data 7).
The levels of priority (=Prio) were assigned an ordinal
value of 1 for ‘high’, 0 for ‘moderate’ and −1 for ‘low’
and were summed for each review based on the afore-
mentioned criteria. The five highest priority reviews will
be included.
Our operationalisation of the inclusion criteria as part
of the screening process is presented in online supple-
mental data 8.
Systematic reviews of implementation (secondary research
question)
For systematic reviews of implementation (focusing on
barriers/facilitators and trials of guideline implemen-
tation), the same criteria were used for participants as
for the primary research question on systematic reviews
of treatment efficacy. There were no restrictions on the
criteria for interventions, comparators or outcomes. The
systematic review had to be focused on either barriers/
facilitators to implementing evidence in clinical practice
or trials for implementing evidence in clinical practice.
Systematic reviews, which included RCT or cluster trials
and non- randomised study designs such as interrupted
time series and controlled before/after studies and/or
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Table 1 Diseases, interventions and outcomes considered
Disease Outcome
Quality
of life
Pain
intensity
Physical
functioning
Exercise
capacity
Back pain
(acute)
Back pain
(subacute/
chronic)
Osteoarthritis
Rheumatoid
arthritis
Cerebral palsy
Alzheimer/
dementia
Stroke
Chronic
obstructive
pulmonary
disease
Ischaemic
heart disease
Lung cancer
Intervention Education Cognitive
behavioural
therapy
Exercise Cognitive
behavioural
therapy+exercise
Physical
activity/
promotion
Behavioural
change
technique
Postural
training
Occupational
therapy
Telehealth Early
mobilisation
Intensive
mobilisation
Breathing
technique
Physical functioning refers to the ability to perform physical tasks and/or activities related to daily living.44 This includes aspects such as strength, exibility, balance and coordination, as well as walking, climbing stairs and others. In this review, we dened it as being measured by a questionnaire.
Exercise capacity is a specic component of overall physical functioning that focuses on the maximum amount of physical exertion one can sustain.45 This review dened it as performance- based tests rather than patient- reported outcomes.
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qualitative or mixed- methods studies, were included as
long as these addressed the research question.
Data extraction
Two independent reviewers will extract the data of
included reviews, including publication demographics
(eg, authors, publication year), population (name of
diagnosis/condition), stage of the condition (acute,
subacute, chronic), intervention, comparators in a meta-
analysis, outcomes included in our review (number of
reports included, number of patients, effect size estimate,
Grading of Recommendations Assessment, Development
and Evaluation assessment if performed). The data will
be compiled and organised in a spreadsheet using Micro-
soft Excel (V.16.0). If conflicts arise, the two reviewers
will discuss them, and the adjudicator will be consulted
if a conflict cannot be resolved. When only figures are
presented (rather than numerical data within the text),
data will be extracted using the web app WebPlotDigi-
tizer (https://automeris.io/WebPlotDigitizer/). If not
possible, data will be manually extracted using ImageJ
(https://imagej.nih.gov/ij/) to measure the length (in
pixels) of the axes to calibrate and then the length in
pixels of the data points of interest.39 Where information
was unavailable within a paper, authors will be contacted
at least three times over 4 weeks to request the data.
Data extraction will be piloted on five reports chosen
at random before extraction. All reviewers will conduct
the pilot extraction independently. The results will be
discussed with all coauthors to refine the extraction
template. This step will be repeated unless a consensus
is reached.
Identication of study overlap
To quantitatively assess the degree of overlap between
included systematic reviews, the corrected covered area
(CCA) will be calculated.40 The CCA considers the
degree of similarity between different systematic reviews
and provides a measure of the extent to which they have
studied, populations, interventions, comparators and/or
outcomes in common. In addition, a qualitative assess-
ment will be conducted to describe the percentage of
overlap in the findings.
Quality of included systematic reviews
Two reviewers will independently assess the methodolog-
ical quality of the included systematic reviews using (A
MeaSurement Tool to Assess systematic Reviews; https://
amstar.ca/Amstar-2.php) according to an internal
protocol (see online supplemental data 9). In case of
conflicts, the two reviewers will discuss and contact an
adjudicator if conflicts persist.
Quality of primary studies included in the systematic review
The method (eg, Cochrane Risk of Bias version 1 or 2,41
PEDRO scale)42 used in the systematic review to assess
the risk of bias in the primary studies will be recorded.
Furthermore, the summary estimates of the risk of bias of
the included studies (ie, percentage rated as low risk of
bias) will be recorded.
Synthesis methods
The data synthesis will be performed narratively and via
summary information (eg, the number of reviews on a
particular research question). A reanalysis of underlying
primary studies will not be performed.
Reporting bias
Whether authors attempted to assess reporting bias will
be recorded. If it is present, we will record whether this
was via statistical (eg, Egger’s test) or visual (eg, assess-
ment of funnel plot asymmetry) means only or whether
authors attempted to identify potentially unpublished
studies (eg, via assessment of clinical trial registries).
Certainty assessment
Whether a certainty assessment is present in a systematic
review will be assessed. If it is present, the certainty assess-
ment made by the authors will be recorded.
DISCUSSION
Our study protocol outlines the need for up- to- date
evidence in the management of high- burden diseases.
The emphasis on non- pharmacological conservative
treatments aligns with current healthcare trends and
international guidelines, which focus on patient- centred,
cost- effective approaches. We aim to produce evidence
maps on the existence and recency of systematic reviews
of non- pharmacological conservative treatments for
high- burden diseases, which, together with identifying
facilitators and barriers to treatment uptake, will inform
the design of future health strategies and research
initiatives. Pending a more conclusive understanding of
the evidence, our work supports urging public health
authorities (eg, WHO, Centers for Disease Control
and Prevention, National Institute for Health and Care
Excellence and Robert Koch Institute) to adopt refined
programmes based on the latest high- quality evidence.
Strengths
Recognising the diminishing relevance of systematic
reviews over time, our study addresses this challenge
by providing a contemporary overview of the evidence
landscape. We aim for a focused examination of relevant
evidence, emphasising high- quality sources, particularly
systematic reviews, including those published by the
Cochrane Collaboration. We enhance the reliability and
generalisability of the findings by mapping the current
state of systematic reviews of RCTs. This emphasis on
RCTs highlights their methodological rigour and unique
strengths in minimising bias and providing reliable
evidence for informed decision- making.43 Furthermore,
the integration of evidence- based clinical practice guide-
lines into our disease selection process will provide a
robust basis for recommendations. In addition, our
careful disease selection process, informed by the latest
burden of disease data and guided by specialists in the
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field, ensures the relevance of our findings. The use of
expert panels is a distinct advantage, facilitating nuanced
selections.
Limitations
While expert panels are adept at identifying nuances
in the available evidence, they introduce a potential for
subjectivity in the delineation of disease and treatment
categories. Similarly, we recognise the impact of national
perspectives on our findings, which may underscore the
different disease and treatment landscapes in global
contexts. This, together with our prioritisation strategy
based on review quality, may result in a limited number
of reviews being considered. Furthermore, the hetero-
geneity of disease definitions, diagnoses, interventions
and comparison groups presents a major challenge to
evidence synthesis. Hence, the methods we have outlined
for the qualitative presentation and synthesis of evidence
should provide the reader with a comprehensive frame-
work for interpreting the results.
In perspective, recognising the inherent limitations
of heterogeneity of evidence, our work will provide a
contemporary and focused overview of reviews, empha-
sising high- quality sources and expert input.
Author afliations
1Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für
Gesundheit Bochum, Bochum, Germany
2Department of Health, University of Applied Sciences Döpfer, Koln, Germany
3Institute of Health Sciences, Department of Physiotherapy, Universität zu Lübeck,
Lubeck, Germany
4Department of Therapy Sciences, Brandenburg University of Technology Cottbus-
Senftenberg, Cottbus, Germany
5Faculty of Medicine and University Hospital Carl Gustav, Center for Evidence- based
Healthcare, TU Dresden, Dresden, Germany
6Department of Sport Science and Sport, Friedrich- Alexander- Universität Erlangen-
Nürnberg, Erlangen, Germany
7Institute for Physical Activity and Nutrition (IPAN), Deakin University, Burwood,
Victoria, Australia
8Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
9Eastern Health Emergency Medicine Program, Melbourne, Victoria, Australia
10Physio Meets Science GmbH, Heidelberg, Germany
11Faculty of Social Work and Health, HAWK, Hildesheim, Germany
12Faculty of Medicine, Department of Physiotherapy, University of Prishtina,
Prishtina, Albania
13IMPACT in Health, Allied Health and Human Performance, University of South
Australia, Adelaide, South Australia, Australia
X Patrick J Owen @PatrickOwenPhD, Rilind Shala @RilindShalaPT and Daniel L
Belavý @belavyprof
Contributors Conceptualisation: DLB, TB, KE, PE, CK and TL. KL, AJ, CM, PJO, AS,
RSchäfer, TSaueressig, RShala. TSzikszay and JZ. Methodology: DLB, TB, KE, PE,
CK, TL. KL, AJ, CM, PJO, TSaueressig, AS, RSchäfer, TSchleimer, RShala. TSzikszay,
JZ, RD and TSaueressig. Software: DLB and PJO. Search strategy development
and implementation: DLB, TSchleimer and RD. TIAB pilot: RD, TSaueressig, TB,
AJ, RShala and TSchleimer. TIAB screening: RD, TSaueressig, TB, AJ, RSchäfer
and TSchleimer. TIAB adjudication: RD. Full text pilot: RD, TSaueressig, TB, AJ,
RSchäfer, TSchleimer. Resources: DLB and PJO. Writing–original draft: RD. Writing–
review and editing: DLB, TB, KE, PE, CK and TL. KL, AJ, CM, PJO, TSaueressig, AS,
RSchäfer, TSchleimer, RShala. TSzikszay, JZ, RD; TSchleimer. Visualisation: RD.
Supervision: DLB. Project administration: DLB, RSchäfer, RD. Funding acquisition:
DLB. DLB is the guarantor.
Funding This project is supported in part by an internal institutional grant (to DLB
from the Hochschule für Gesundheit).
Competing interests The authors declare no conicts.
Patient consent for publication Not applicable.
Provenance and peer review Not commissioned; internally peer reviewed.
Data availability statement Data sharing not applicable as no datasets generated
and/or analysed for this study. No data are available.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the
use is non- commercial. See:http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iDs
RebekkaDöding http://orcid.org/0009-0003-5114-6149
KatjaEhrenbrusthoff http://orcid.org/0000-0003-1667-8943
Patrick JOwen http://orcid.org/0000-0003-3924-9375
Daniel LBelavý http://orcid.org/0000-0002-9307-832X
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