narrative literature review methods

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Literature Review and Evidence Synthesis

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What is a Narrative Literature Review

Narrative review process.

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A narrative literature review is an integrated analysis of the existing literature used to summarize a body of literature, draw conclusions about a topic, and identify research gaps. By understanding the current state of the literature, you can show how new research fits into the larger research landscape.

A narrative literature review is NOT:

Just a summary of sources
A review of everything written on a particular topic
A research paper arguing for a specific viewpoint - a lit review should avoid bias and highlight areas of disagreements
A systematic review

Purposes of a narrative literature review:

Explain the background of research on a topic
Demonstrate the importance of a topic
Suggest new areas of research
Identify major themes, concepts, and researchers in a topic
Identify critical gaps, points of disagreement, or flawed approaches for a research topic

1. Choose a topic & create a research question

Use a narrow research question for more focused search results
Use a question framework such as PICO to develop your research question
Breakdown your research question into searchable concepts and keywords
Research skills tutorials : How to choose a topic
Ask a librarian for assistance

2. Select the sources for searching & develop a search strategy

Identify databases to search for articles relevant to your topic
Ask a librarian for recommended databases
Develop a comprehensive search strategy using keywords, controlled vocabularies and Boolean operators
Research skills tutorials: How to develop a search strategy

3. Conduct the search

Use a consistent search strategy between databases
Document the strategies employed to keep track of which are more successful
Use a citation manager to organize your search results
Ask a librarian for help or refer to the Research skills tutorials

4. Review the references

Review the search results for relevant articles that answer your research question
Review the bibliography of all relevant articles for additional sources
Consider developing subfolders in the citation manager to organize sources by topic
Use interlibrary loan for any articles without full text access

5. Summarize findings

Synthesize the findings from the articles into a final paper
The final paper should cover the themes identified in the research, explain any conflicts or disagreements, identify research gaps and potential future research areas, explain how this narrative review fits within the existing research and answer the research question .

For additional information :

Hempel. (2020). Conducting your literature review. American Psychological Association .

Buchholz, & Dickins, K. A. (2023). Literature review and synthesis : a guide for nurses and other healthcare professionals . Springer Publishing Company, LLC.
Coughlan, Michael, and Patricia Cronin. Doing a Literature Review in Nursing, Health and Social Care . 2nd edition., SAGE, 2017.
Nundy, S., Kakar, A., Bhutta, Z.A. (2022). How to Do a Review of the Literature? . In: How to Practice Academic Medicine and Publish from Developing Countries?. Springer, Singapore. https://doi.org/10.1007/978-981-16-5248-6_18
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The Literature Review

Narrative Review
Systematic Review
Scoping Review

Writing your Literature Review

Once you have developed a body of literature to draw from, you can begin writing your literature review. There is no set format for a narrative literature review, and it can vary across fields. However, you will typically see the following elements:

Sections you might see in a typical research paper including Introduction, background, (possibly) methods, Main/Body, and Conclusion
Some logical structure of sections (i.e. by time period, by areas of the field, by approach of article etc.)
Analysis of the relative value of contributions across different sources
section on areas for further development or further research suggestions

Need writing help? Head to the Graduate Writing Center for help with your literature review!

What is a narrative literature review.

Narrative Literature Reviews are works in which the author reviews a body of literature on a topic and synthesizes the information into a clear narrative that demonstrates the general context of the field . They can also be called a Traditional Literature Review. Compared to Systematic and Scoping reviews, Narrative literature reviews do not use an established method or protocol, but rather take a broad, unspecified approach to what sources are selected to represent the field. Typically narrative literature reviews use peer-reviewed journal articles as their source of scholarship to review, but this might vary based on the individual assignment or review you are conducting. Below are some key elements of a Narrative Lit Review:

Places the topic within an existing context
Describes relationships between and around sources cited
Typically includes critical analysis
Organizes ideas by theme and/or relevance
Demonstrates author's knowledge

Staying Organized

Use a reference management software.

Reference Managers are tools that can help you keep track of the scholarly articles you are collecting and reading for your literature review. They can also help you generate citations and bibliographies within your writing. Use the Reference Management Software Guide linked below to learn more about how to get started with one.

Reference Management Research Guide

Keep your search terms in a document or spreadsheet.

Although in Narrative Lit Reviews you are not required to keep detailed reports on your search strategy, it is still important to keep track of the terms you are searching and include information about them to be sure you are casting the widest net possible. Organize your search terms in a way that makes sense to you. As an example, you could keep tabs on:

Broader terms
Narrower terms
Filters that work / filters that don't
Search strings you can copy and paste directly into search engines and databases

The Research Process

Start with an exploratory/preliminary search.

Use a couple key terms about your topic to try searching without keeping track to see whats out there. This is also a good time to search for already existing reviews on your topic and see if something similar has already been completed. After doing a preliminary search in your general topic, you can begin thinking about your specific research question.

Drafting a Research Question

To start drafting your research question, it may be helpful to consider how your topic fits within a couple of different broad overlapping fields of research. For example, the research question illustrated below asks about identity perspectives from Asian American students in high schools. Each individual topic in this question is its own circle, and the intersection of these circles is the main focus of the literature review. There could be more circles added for each new dimension I would like to add to my research question whether it be a location (i.e. New York City), a clarifying detail (i.e. generational identity), or other form of context.

As you are searching, use the different dimensions of your research question to find individual areas of research, For example, I may want to look at the literature around just the identity of Asian American students, or maybe just look at identity formation in High School. Then, in my literature review, I can synthesize these various fields to explain the different backgrounds and how they all converge around my central topic, the middle of the diagram.

Image from Tips and Strategies for Writing a Dissertation Proposal on Ashe Grads blog.

Conducting your Search

Once you have your research question and key terms from that research question, you can start your formal searching process. In narrative literature reviews it is less important to be comprehensive in checking every possibly relevant result, but more focused on making sure the results you are getting are representative of the fields you are analyzing.

Books in the Libraries to Help with you Narrative Lit Review

Literature Review and Research Design: A Guide to Effective Research Practice

They Say / I Say: The Moves That Matter in Academic Writing, with Readings

The Literature Review: Six Steps to Success

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Research Guides

Planning For Your Expert Literature Review

Narrative literature reviews.

Types of Expert Literature Reviews

Your Narrative Literature Review Should Have...

A clearly defined topic
A search for relevant literature
A logical organization structure
An interpretation and discussion of the selected relevant literature

A common structure for narrative literature reviews is IMRaD, or:

Introduction
What is your topic?
What are you interested in finding out?
Why did you select this topic?
How did you look for the literature?
Where did you look?
What search terms did you use?
What kind of literature did you find?
Did the literature you found change your opinion on the topic?
Did you find out something new?
What were the key concepts?
and Discussion
Evaluate and summarize the major concepts
Connect the major concepts to future research potential

While the structure above may be sufficient for your topic, you may also consider using the similar but more robust structure IAMRDC, or:

Ferrari, R. (2015). Writing narrative style literature reviews. Medical Writing, 24 (4), 230-235. https://doi.org/10.1179/2047480615Z.000000000329
Sollaci, L. B., & Pereira, M. G. (2004). The introduction, methods, results, and discussion (IMRAD) structure: a fifty-year survey. Journal of the Medical Library Association 92 (3), 364–367. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC442179/

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Literature Review: Traditional or narrative literature reviews

Traditional or narrative literature reviews.

Scoping Reviews
Systematic literature reviews
Annotated bibliography
Keeping up to date with literature
Finding a thesis
Evaluating sources and critical appraisal of literature
Managing and analysing your literature
Further reading and resources

A narrative or traditional literature review is a comprehensive, critical and objective analysis of the current knowledge on a topic. They are an essential part of the research process and help to establish a theoretical framework and focus or context for your research. A literature review will help you to identify patterns and trends in the literature so that you can identify gaps or inconsistencies in a body of knowledge. This should lead you to a sufficiently focused research question that justifies your research.

Onwuegbuzie and Frels (pp 24-25, 2016) define four common types of narrative reviews:

General literature review that provides a review of the most important and critical aspects of the current knowledge of the topic. This general literature review forms the introduction to a thesis or dissertation and must be defined by the research objective, underlying hypothesis or problem or the reviewer's argumentative thesis.
Theoretical literature review which examines how theory shapes or frames research
Methodological literature review where the research methods and design are described. These methodological reviews outline the strengths and weaknesses of the methods used and provide future direction
Historical literature review which focus on examining research throughout a period of time, often starting with the first time an issue, concept, theory, phenomena emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and to identify the likely directions for future research.

References and additional resources

Baker, J. D. (2016) The purpose, process and methods of writing a literature review: Editorial . Association of Operating Room Nurses. AORN Journal, 103 (3), 265-269. doi:10.1016/j.aorn.2016.01.016

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Charles Sturt University is an Australian University, TEQSA Provider Identification: PRV12018. CRICOS Provider: 00005F.

How to Conduct a Literature Review: A Guide for Graduate Students

Let's Get Started!

Traditional or Narrative Reviews

Systematic Reviews
Typology of Reviews
Literature Review Resources
Developing a Search Strategy
What Literature to Search
Where to Search: Indexes and Databases
Finding articles: Libkey Nomad
Finding Dissertations and Theses
Extending Your Searching with Citation Chains
Forward Citation Chains - Cited Reference Searching
Keeping up with the Literature
Managing Your References
Need More Information?

Onwuegbuzie and Frels (pp 24-25, 2016) define four common types of narrative reviews:

General literature review that provides a review of the most important and critical aspects of the current knowledge of the topic. This general literature review forms the introduction to a thesis or dissertation and must be defined by the research objective, underlying hypothesis or problem or the reviewer's argumentative thesis.
Historical literature review which focus on examining research throughout a period of time, often starting with the first time an issue, concept, theory, phenomena emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and to identify the likely directions for future research.
Methodological literature review where the research methods and design are described. These methodological reviews outline the strengths and weaknesses of the methods used and provide future direction
Theoretical literature review which examines how theory shapes or frames research

References and additional resources

Machi, Lawrence A. & Brenda T. McEvoy (2016), The Literature Review: Six steps to success . 3rd edition.; Thousand Oaks, CA: Corwin. Onwuegbuzie, A. J. & Frels, R. (2016) 7 steps to a comprehensive literature review: A multimodal & cultural approach . London: Sage Publications.

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http://orcid.org/0009-0008-8045-1704 Rebekah Aubry 1 ,
http://orcid.org/0000-0002-7777-0981 Thomas Hastings 2 , 3 ,
http://orcid.org/0009-0001-5954-4702 Micheal Morgan 4 ,
Jacqueline Hastings 5 ,
Marie Bolton 6 ,
Maura Grummell 7 ,
Sinead Killeen 1 ,
Cathal Coyne 8 ,
Risa Shorr 9 ,
http://orcid.org/0000-0003-4877-7233 Marco Solmi 10
1 Department of Psychiatry , Lucena Clinic Services , Dublin , Ireland
2 Department of Psychiatry , McMaster University , Hamilton , Ontario , Canada
3 Department of Psychiatry , University of Toronto , Toronto , Ontario , Canada
4 Department of Psychiatry , South Louth CAMHS , Drogheda , Ireland
5 School of Medicine , UCD , Dublin , Ireland
6 Department of Child and Adolescent Psychiatry , St Vincent's Hospital Fairview , Dublin , Ireland
7 Department of Psychiatry , Mater Misericordiae University Hospital , Dublin , Ireland
8 Department of Child and Adolescent Psychiatry , West Kildare CAMHS Linn Dara , Abbeylands Clane , Ireland
9 Learning Services , Ottawa Hospital , Ottawa , Ontario , Canada
10 Ottawa Hospital Research Institute , Ottawa , Ontario , Canada
Correspondence to Dr Rebekah Aubry; rebekah.aubry{at}sjog.ie

Introduction Given the increasing rates of antipsychotic use in multiple psychiatric conditions, greater attention to the assessment, monitoring and documentation of their side effects is warranted. While a significant degree of attention has been provided to metabolic side effect monitoring, comparatively little is known about how clinicians screen for, document and monitor the motor side effects of antipsychotics (ie, parkinsonism, akathisia, dystonia and dyskinesias, collectively ‘extrapyramidal side effects’, EPS). This review aims to systematically assess the literature for insights into current trends in EPS monitoring practices within various mental health settings globally.

Methods and analysis An electronic search will be performed using the OVID Medline, PubMed, Embase, CINAHL and APA PsycINFO databases for studies published in the last quarter century (1998 to present day). Two independent reviewers will conduct the initial title and abstract screenings, using predetermined criteria for inclusion and exclusion. A third reviewer will resolve disagreements if consensus cannot be reached. If selected for inclusion, full-text data extraction will then be conducted using a pilot-tested data extraction form. Quality assessment will be conducted for all included studies using a modified version of the Quality Improvement Minimum Quality Criteria Set. A narrative synthesis and summary of the data will be provided. All stages of the review process will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Ethics and dissemination Ethical approval is not required. Findings will be peer reviewed, published and shared verbally, electronically and in print with interested clinicians and will also be presented as posters or talks at relevant medical conferences and meetings.

PROSPERO registration number CRD42023482372.

Systematic Review
Schizophrenia & psychotic disorders
Protocols & guidelines

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/ .

https://doi.org/10.1136/bmjopen-2024-087632

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STRENGTHS AND LIMITATIONS OF THIS STUDY

The search strategy was developed a priori in collaboration with an experienced health sciences librarian and involves a comprehensive search across five large databases and platforms.

The protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines enhancing replicability and transparency.

Included studies will be rated based on their methodological quality using a modified version of the Quality Improvement Minimum Quality Criteria Set quality assessment tool developed by Hempel et al , which is suitable for the quality assessment of various types of service evaluation studies.

Due to resource constraints, the literature search will be restricted to English-only, peer-reviewed publications, possibly increasing the risk of selection bias and limiting the generalisability of review findings.

Introduction

Second generation antipsychotics (SGAs) are broadly used in clinical practice, not only for the treatment of psychotic and bipolar disorders but also for a variety of other conditions. 1–3 While SGAs are associated with a lower risk of motor side effects (ie, parkinsonism, akathisia, dystonia and dyskinesias, collectively ‘extrapyramidal side effects’, EPSs) than first-generation antipsychotics the rates of EPS remain significant. 4–8 Furthermore, EPSs are associated with impaired quality of life, medication non-adherence, increased morbidity, mortality, caregiver burden, utilisation of healthcare resources and higher medical costs. 8–16 This has resulted in some advocating for ‘better monitoring … to assess their true effect on patients’ quality of life and functioning and to prevent underascertainment’, 17 something especially important in higher risk populations, for instance, children, adolescents and the elderly. 18–20 The most recent American Psychiatric Association’s guidelines (2020) for the treatment of patients with schizophrenia calls for clinical assessment of EPS at baseline or initial assessment, at each subsequent visit as well as an assessment using a ‘structured instrument’ every 6 months in patients at increased risk of tardive dyskinesia and every 12 months for all other patients. 21 In the UK, the National Institute for Health and Care Excellence guidelines recommend assessment of any movement disorders before starting antipsychotic medication as part of baseline investigations and to monitor and record side effects of treatment and their impact on functioning, and the emergence of movement disorders, regularly and systematically throughout treatment and especially during titration. 22 Unfortunately, evidence demonstrates that actual monitoring rates fall far below these standards. 23–25

Rationale for the review

While a significant degree of attention has been provided to metabolic side effect monitoring, with several systematic reviews conducted on the subject, 26 27 comparatively little is known about EPS monitoring practices.

When it comes to EPS, its incidence and prevalence in research and naturalistic settings have been thoroughly investigated in numerous studies and reviews. 4–6 28 However, there seems to be a paucity of data about current practices relating to how clinicians screen for, monitor and document EPS in patients prescribed antipsychotics. Gaining a better understanding of current practice may allow for the introduction of effective interventions that help address the existing discrepancy between current practice and best practice.

Aim and objectives

The aim of this review is to systematically assess the literature, seeking insights into current EPS monitoring practices within various mental health settings globally.

Our three main objectives are as follows: (1) to identify the extent to which patients prescribed antipsychotic medication receive guideline concordant monitoring, (2) to gather data on interventions that have been proposed to improve this aspect of care and (3) to identify any existing barriers.

Research questions

In accordance with the aim and objectives outlined above, this review will seek to answer the following questions as regards EPS monitoring for patients who are prescribed antipsychotic medication:

Which guidelines if any are being used to guide current practice and arerecommended standards being met? What screening tools are being used?

What is the frequency of monitoring? Has it improved or worsened over the years?

What interventions have been proposed to improve monitoring standards?

What are some of the possible barriers to adequate monitoring?

Methods and design

All stages of the review process including literature searching, screening, applying inclusion and exclusion criteria and data extraction will be reported and documented in accordance with the Preferred Reporting Items for Systematic Review and Met-Analysis Protocol (PRISMA-P) statement. 29 The PRISMA-P was used to guide the development of the review protocol (see online supplemental file 1 for PRISMA-P checklist). 30 In accordance with the guidelines, this systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) under the reference number CRD42023482372. Any amendments to the protocol will be reported when publishing the results.

Supplemental material

Inclusion and exclusion criteria (eligibility of studies).

These are grouped under the following seven subsections:

Study design

Study designs aimed at gathering data on current practices relating to EPS documentation and monitoring as well as studies describing interventions developed to improve clinical performance in the area of documentation and monitoring of EPS will be included in the review. Examples of study designs that will be included are as follows:

Clinical audits without intervention.

Clinical audits with completed audit cycles after intervention.

Service evaluations without a quality improvement intervention.

Service evaluations following a quality improvement intervention.

However, the following study design types will be excluded:

Case reports.

Any trial design, including randomized controlled trials(RCTs).

Literature reviews.

Discussion and viewpoint studies.

Grey literature.

Abstract-only publications.

Epidemiological studies of incidence/prevalence of EPS.

Survey designs.

Types of intervention

All types of interventions concerned with the assessment, screening and monitoring of EPS will be included. This will involve gathering data on the types of processes currently used to carry out EPS monitoring and documentation as well as on any proposed interventions aimed at improving EPS documentation and monitoring such as educational interventions, adoption of novel screening instruments, etc.

Study language

This systematic review will be restricted to English language studies only.

Publication dates

Studies published from 1998 to the present will be included, spanning the last 25 years of clinical practice. We consider this sufficiently representative of contemporary trends in practice.

Study population/demographics

The first population of interest includes patients of all ages and genders receiving treatment for one or more mental health conditions and prescribed one or more antipsychotic medications. While it is true that EPS can manifest spontaneously in patients who were never exposed to antipsychotic agents 31 32 or can be caused by substances other than antipsychotics, 33–35 a substantial proportion of reported EPS is attributed to antipsychotic medication. 6 36 37 Moreover, even within cohorts of previously neuroleptic naïve patients, research suggests that dopamine D2 receptor antagonist antipsychotics interact with the disease process in such a way that ‘precipitates’ and ‘accentuates’ movement disorders intrinsic to schizophrenia’. 38 This review will, therefore, focus on patients prescribed antipsychotic medication, as they may be at higher risk of developing severe EPS. In addition, most available guidelines on EPS monitoring specifically refer to patients prescribed antipsychotic medications.

The second population of interest includes the healthcare professionals involved in the care of the patients (eg, nurses, residents, clinicians and pharmacists) and tasked with carrying out EPS monitoring.

Study settings

Studies reporting on EPS monitoring practices in any naturalistic, real-world clinical setting, including inpatient hospitals, day hospitals, outpatient clinics, community settings, etc will be included.

Other phenomena of interest

Where available, data on the views, experiences and behaviours of healthcare professionals and patients involved in the assessment, screening and monitoring of EPS will also be collected.

Patient and public involvement

Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this protocol.

Information sources

Electronic sources.

The literature search was conducted using the following five databases and search platforms: OVID Medline, PubMed, EMBASE, PsycINFO and CINAHL. The initial search covers 25 years and includes studies published between April 1998 and April 2023. These searches will be re-run immediately prior to the final analysis (projected to take place in September 2024) and potential further studies will be retrieved for inclusion, ensuring that the most up-to-date information is presented in the review. The reference lists of all eligible articles will be manually searched to identify any additional relevant citations to ensure a comprehensive search.

Search strategy

Review authors RA and RS (librarian and information specialist with expertise in electronic searching) developed and ran a comprehensive search strategy. A scoping search was undertaken against each database to inform how the search terms were being translated and hence to identify the corresponding text words in each database. Following this, the complete search strategy was tested for its sensitivity to locate the key papers that the researchers are already aware of, along with relevant articles which are consistent with the inclusion criteria just before running the search through all the selected search engines.

The search strategy used variations in text words found in the title, abstract or keyword fields, and relevant focused subject headings to retrieve articles combining the following three search concepts, linked by the Boolean operator ‘AND’:

(1) One or more medication terms: antipsychotic* OR psychotropic* OR haloperidol OR olanzapine OR quetiapine OR risperidone OR cariprazine OR amisulpride OR aripiprazole OR lurasidone etc… (to include full list of antipsychotic medication listed as per the WHO Collaboration Centre for Drug Statistics Methodology ATC classification).

(2) One or more EPS terms: “Extrapyramidal symptom*” OR “Extrapyramidal side effect*” OR “drug-induced movement disorder*” OR ‘Drug-Related Side Effects and Adverse Reactions’ OR ‘movement side effects’ OR Dystonia OR ‘acute dystonia’ OR parkinsonism OR ‘drug-induced parkinsonism’ OR akathisia OR “tardive dyskinesia” OR tremor

(3) One or more terms relating to monitoring, screening, documenting or auditing clinical practice (including screening instruments): ‘Monitoring’ OR ‘Screening’ OR ‘Documenting’ OR ‘Documentation’ OR ‘Assessing’ OR ‘Assessment’ OR ‘Abnormal Involuntary Movement Scale’ OR ‘Extrapyramidal Symptom Rating Scale’ OR ‘Simpson-Angus Scale’ OR ‘Barnes Akathisia Scale’.

The search included all relevant synonyms, truncations and Mesh terms. Full details of search terms used for the OVID Medline search are shown in online supplemental file 2 . A similar search was conducted using the other databases and search platforms. The full search strategy is available on request from the corresponding author.

Study records

Data management.

The search results will be uploaded into web-based, systematic review management software (Covidence). Duplicates will be removed automatically by Covidence software. Authors RA and MM will scan through the results to remove any remaining duplicate records manually. Using Covidence, the initial title and abstract screening, and the full-text review will be logged. All standardised forms will be piloted and revised as needed by the reviewers before starting the review.

Screening and selection process

After identification of articles from searching the electronic databases, titles and abstracts will be screened independently by two review authors according to the predefined eligibility criteria. Disagreements will be resolved by consensus and the opinion of a third reviewer will be sought if necessary. The full-text copies of each potentially relevant study will then be retrieved and screened independently by at least two reviewers including the first author (RA). Consensus will be reached through discussion, and in the event that no consensus can be reached for a study, a third reviewer will arbitrate. All studies not meeting the eligibility criteria will be excluded. The results will be reported using the PRISMA flow diagram.

Data extraction and reporting of results

A standardised data extraction form will be developed to extract all relevant data from included studies. Information to be extracted will be as follows:

Study characteristics: authors, date, settings, country of origin, study design and sample size.

Patient characteristics: demographic data (age, gender, diagnosis, type of antipsychotic prescribed, etc.).

Monitoring characteristics: frequency, use of a structured tool, healthcare professionals involved in monitoring, guidelines followed, etc.

Intervention characteristics: (if study incorporated a preintervention/postintervention design): educational intervention, adoption of a new instrument, etc.

The data extraction form will be piloted on a small random sample (n=3) of the illegible studies to assess its reliability in extracting the targeted study data. Review authors TH, MB and SK will each independently conduct data extraction on the three studies. Review authors RA and MM will then review this extracted data, checking against the full text of the three studies for any discrepancies (eg, errors, omissions or failure to have consensus in any area) and will decide on how to resolve any that may arise. If the above pilot data extraction process is deemed reliable then the review authors TH, MB and SK will each independently conduct data extraction on the remaining studies in the systematic review. Review authors RA and MM will then cross-check the extracted data against the full-text articles in a similar process to that highlighted above.

Additionally, study authors will be contacted if necessary to gain information for clarification purposes and access to raw material when needed.

Critical appraisal of study quality

Authors RA and MM will use the Quality Improvement Minimum Quality Criteria Set (QI-MQCS) developed by Hempel et al to conduct the quality assessment of included studies. 39 Disagreements will be resolved by consensus; the opinion of a third reviewer (MG) will be sought if necessary. The QI-MQCS is a 16-domain, validated, reliable critical appraisal tool that assesses expert-endorsed QI domains for studies that include a QI intervention component. The QI-MQCS will be modified to be suitable for the body of studies included in our review, and in particular, to be able to assess studies with no intervention component, that is, clinical audits and service evaluations with no intervention. This will involve accepting a broader definition of several domains of the appraisal instrument to include studies evaluating existing services or standards in addition to QI intervention. This approach was chosen in the absence of a suitable tool for critical appraisal of service evaluation studies with no intervention component.

The QI-MQCS tool is designed to provide a score for each domain as well as a total score, which is expressed as a percentage of the maximum possible score.

Data synthesis

In this review, the search is expected to reveal heterogeneous studies and meta-analysis of study findings is therefore not a study objective. Therefore, data synthesis will take the form of a structured narrative synthesis of the included studies. The defining characteristic of a narrative synthesis is that it adopts a textual approach to the process of synthesis in order to provide answers to the identified research questions in a structured manner. Study findings pertaining to the following three themes will be examined and synthesised: (1) Data concerning the extent and quality of EPS monitoring being carried out in various mental health settings will be summarised. (2) Following this, details about any potential interventions employed to improve monitoring practices will be synthesised. And finally, (3) Information about any identifiable barriers or facilitators to guideline concordant EPS monitoring will be synthesised and discussed.

Study status

The study is ongoing and is expected to be completed by September 2024.

Proposed value of the systematic review and use of the findings

This systematic review seeks to shed light on the existing patterns of EPS monitoring occurring within various mental health settings. The findings of this systematic review may be of interest to mental health organisations and services as they are expected to provide insights into the potential barriers or facilitators (including possible quality improvement interventions) influencing whether EPS monitoring is carried out in a guideline concordant manner. This may in turn encourage organisations and services to assess their existing EPS monitoring practice and/or lead them to consider the adoption or development of interventions to improve monitoring standards.

Ethics statements

Patient consent for publication.

Not applicable.

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Contributors RA is the author acting as guarantor. The study was conceived by RA, MS, MM and TH. RA and MM developed the eligibility criteria, search strategy, quality assessment strategy and data extraction plan with guidance from MS and RS. RA, TH and MM wrote the manuscript. MS, MB, MM, MG, JH, SK and CC read all drafts of the manuscript, provided feedback and approved the final manuscript. All contributors meet the ICMJE criteria for authorship.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests MS has received honoraria/has been a consultant for AbbVie, Angelini, Lundbeck, Otsuka.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Published: 12 September 2024

Harm reduction in severe and long-standing Anorexia Nervosa: part of the journey but not the destination—a narrative review with lived experience

Edwin Birch 1 ,
James Downs 2 &
Agnes Ayton 1

Journal of Eating Disorders volume 12 , Article number: 140 ( 2024 ) Cite this article

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Questions remain about the best approaches to treatment for the subset of patients with severe and long-standing Anorexia Nervosa, commonly described in the literature as “Severe and Enduring Anorexia Nervosa.” When discussing the optimal strategies and goals for treating this group, there is uncertainty over whether to focus on refining current treatment methods or exploring alternative approaches. One such alternative is “harm reduction,” which has generated a wave of positive interest from patients and clinicians alike because of its emphasis on individual autonomy, personal goals and quality of life. While harm reduction can provide an attractive alternative to seemingly endless cycles of ineffective treatment, this narrative review builds on previous work to highlight the inadequate terminology and possible dangers of considering harm reduction as the endpoint of treatment. In conjunction with perspectives from a lived experience author, we consider wider contextual and ethical issues in the field of eating disorders, which should inform the role of harm-reduction approaches in this patient group.

Plain English Summary

One model of treatment for patients with severe and long-standing Anorexia Nervosa is termed “harm reduction”, which moves away from traditional treatment aimed at full recovery and weight gain. This approach instead prioritises quality of life, giving patients greater control over their care. Harm reduction remains ethically controversial due to concerns about unaddressed malnutrition and issues of consent for this subset of patients. This review examines the inadequacies in how severe and long-standing Anorexia is defined, alongside exploring the ethical concerns of harm reduction with lived experience from one author.

Introduction

There is a need for alternative treatment modalities to alleviate the suffering from repeated cycles of failed conventional treatment in severe and long-standing Anorexia Nervosa, with “Harm reduction” being one such approach which has gained considerable attention in recent research [ 1 , 2 ].

At its core, it has been well summarised by Tumba et al. as a strategy that: “ should help the patient maintain a weight that balances quality of life but is below ideal weight range and still associated with medical risks ” [ 3 ] p 17.

They, among others, posit that harm reduction is a more ethical pathway which avoids progression to involuntary treatment methods, which may be necessary for the non-consenting patient who is severely ill [ 4 ]. By embracing a shared personal treatment goal that sits outside of conventional recovery (i.e. abandoning full weight restoration and medical stability), clinicians may promote a greater degree of patient autonomy and focus on quality of life. Furthermore, even though a personalised treatment goal can be at odds with full recovery, a recent commentary from Bianchi et al. did not find ethical concerns a barrier to the use of harm reduction in eating disorders (ED) as a whole [ 5 ].

In addition to pursuing acceptable therapeutic objectives for patients, it is essential to examine the concept of harm reduction, as data suggest that this severe and long-standing condition may impact approximately 20–30% of those diagnosed with anorexia nervosa (AN) [ 2 , 6 ].

This narrative review examines the current literature on harm reduction as a treatment strategy and, with reference to three core ethical concerns, benefits and harms.

A literature search was conducted to identify relevant papers for the present review. PubMed, Google Scholar, and Ovid MEDLINE databases were all searched between 1995 and 2024 with additional references drawn from relevant articles. Search criteria for PubMed and Ovid: (Anorexia OR Eating disorders OR Severe and enduring) AND Harm Reduction. Search criteria for Google Scholar: Anorexia AND “Harm reduction” NOT addiction NOT opioid NOT opiate NOT alcohol NOT bulimia. A total of 341 abstracts were initially retrieved and reviewed, of which 23 were identified as relevant to the subject material. We also include lived experience perspectives on this controversial issue.

What is “severe and enduring” Anorexia?

The complexity of harm reduction interventions is exacerbated by a lack of agreement regarding the patient population for which it is deemed appropriate. Nevertheless, many NHS services have developed local severe and enduring eating disorder (SEED) pathways which refer to harm reduction as a guiding principle of care, even though this category of patients is not defined by diagnostic systems. The latest editions of the ICD 11 and DSM-5 do not include diagnostic categories based on the length of illness. Both define the severity of Anorexia based on body mass index (BMI) as an indicator of the risks associated with malnutrition [ 7 , 8 ].

For chronic presentations, a diverse array of labels is in use, the most common being " Severe and enduring Anorexia Nervosa ” (SE-AN), with other entities such as “ chronic-intractable ”, “ enduring and serious ”, and “ end-stage ” appearing less frequently [ 9 , 10 ].

The SE-AN construct remains the most widespread to date, however patients prefer the term “severe and long-standing” in its place [ 11 ] as at the time of writing there remains no accepted definition for the term among research groups [ 12 , 13 ]. Hay et al. proposed a set of clinical criteria for defining SE-AN in 2018, including a triad of low body mass index (BMI) (with cardinal AN psychopathology), an illness duration of at least 3 years, and a failure of 2 evidence-based treatments [ 14 ]. However, on closer examination, there still exists a wide variation about the duration of illness required to warrant a”severe and enduring” classification, alongside variable definitions of “failed cycles of treatment”- both of which are the most common features assumed to delineate this subgroup [ 10 ].

The heterogeneity in definitions of the “enduringness” and “severity” components of SE-AN speaks to the rather arbitrary adoption of these criteria between research groups (Table 1 ).

Furthermore, although studies have identified neurochemical changes in the brain during severe disease [ 15 ], biological markers for objectively identifying SE-AN are lacking [ 16 ].

Table 1 summarises the definitions of SE-AN in the literature between 2008 and 2024. These studies used a variety of methodologies, including observational, longitudinal, qualitative, and randomised controlled trials (RCTs), with participant numbers ranging from 5 to 782 and illness durations ranging from 3 to > 40 years. Furthermore, there are inconsistencies in the use and reporting of evidence-based treatments. Whilst studies by Daansen and Haffmans [ 48 ], Touyz et al. [ 20 ], and Zhu et al. [ 23 ] explicitly mention the use of evidence-based treatments, others, such as Arkell and Robinson [ 47 ] and Robinson et al. [ 46 ], do not. Moreover, the severity of EDs is largely undefined across studies, which further complicates the interpretation of treatment outcomes. These disparities highlight the need for more standardised reporting and methodological rigour in ED research to better assess the efficacy of treatments and interventions [ 1 ].

The case for harm reduction

Hay and Touyz conducted the first systematic review of treatments specific to SE-AN in 2012 and identified only 12 studies between 1997 and 2011, with non-specific overall findings. These indicated that specialist psychotherapy modalities such as Cognitive Behavioural Therapy for Anorexia Nervosa (CBT-AN) and Enhanced Cognitive Behavioural Therapy (CBT-E) may be preferable to “treatment as usual”, which comprised of a range of modalities. The comparisons made were hampered by high study heterogeneity, but it is noteworthy that even at that time, the authors called for a move towards examining efficacy of harm minimisation beyond weight restoration as the primary end goal [ 17 ].

At the time of writing, no RCTs have examined harm reduction treatments for severe and long-standing AN, highlighting the ongoing need for explicit research in this area. Apart from the challenges of scant data, we anticipate difficulties unique to measuring the “success” of harm reduction, given discrepancy in individual patients’ own agreed treatment plan. Measures of success in this area could be further limited by disagreement on the best parameters to target; conflicts may arise over emphasis on patient led reductions in psychopathology vs. service led outcomes, such as mortality and inpatient admissions. The analysis on whether such effects are mutually exclusive remains outstanding.

Despite the lack of RCTs, we do identify research exploring interventions with a harm reduction approach, though they still have limitations and often use anecdotal data in the form of individual case series.

One prominent example is the Community Outreach Partnership Program (COPP), spearheaded by Williams et al. who found that utilising a harm reduction approach resulted in a significant decrease in ED symptoms and a modest increase in BMI (1.24 point increase across all patients included in the study). Interestingly, the primary outcome of self-reported “quality of life” showed no statistically significant difference, although only 15 patients with AN were included [ 18 ]. Additionally, Yager et al. have been vocal about the positive experiences of harm reduction, where they coin the phrase “compassionate witnessing” as a beneficial therapeutic stance to engage with patients with severe and long-standing AN [ 19 ].

We also consider the literature related to treatments which share the goals of a harm reduction approach, either as implicit or explicit component. For example, given that harm reduction prioritises an increase in quality of life and reduction in invasive interventions, it is noteworthy that an RCT of 63 patients using Specialist Supportive Clinical Management (SSCM) and CBT-AN showed significant improvements in eating disorder symptomatology and health-related quality of life, which persisted during a 1 year follow up period with a 76% completion rate [ 20 ].

Cognitive remediation therapy (CRT) was also explored by Dingemans et al. showing an improvement in eating disorder related quality of life in a mixture of chronic and acute patients [ 21 ].

Although there has been a growing demand from both clinicians and patients for the integration of harm reduction approaches in the treatment of severe and chronic AN [ 16 , 22 ], there is currently a scarcity of concrete evidence regarding their efficacy and there is no clear consensus on what constitutes effective implementation and positive outcomes in this context. It is telling that the recent 2023 Cochrane review into psychological therapies for SE-AN, full weight restoration is still maintained as the primary outcome, with features of quality of life and eating disorder symptomatology remaining secondary [ 23 ].

Is harm reduction ethical?

We highlight three core concerns in the scenario where harm reduction is considered the focus of treatment for severe and long-standing AN. We have incorporated narrative reflections from lived experience of this condition to centralise the ways in which these theoretical understandings may play out in clinical settings and individual lives. This, integrated with an overview of the evidence, will inform our conclusions regarding the use of harm reduction in modern practice.

Are we truly reducing harm? Dangers inherent in ignoring the physiological consequences of malnutrition

Harm reduction arose from addiction treatment in the 1980s, when it was recognised that for many patients, the destructive trail of drug-seeking behaviour, especially for opioids, could be offset to a degree by medically supervised provision of drugs [ 24 ]. A similar parallel has been drawn with severe and long-standing AN, whereby some of the social cost of repeated inpatient admissions and medical complications may be mitigated by accepting, in conversation with the patient, a lower BMI target. However, recent work has shown that the model derived from addiction may not be readily comparable, most pertinently because there is a misplaced assumption (or perhaps overlooked reality) that a low BMI target will offset the harms of malnutrition [ 9 , 16 ]. Furthermore, harm reduction strategies are supported by evidence of improved outcomes in the addiction field, whilst similar studies have not been conducted in the eating disorder field [ 25 ].

Malnutrition, regardless of its extent, has deleterious effects and can cause organ damage both in the short and long term. While most of the consequences are reversible with appropriate weight gain, it is important to recognise the potential for long-term damage [ 26 , 27 ]. All organ systems are affected, most notably the impact on the cardiovascular system can be life threatening [ 28 ]. The consequences of poor nutrition on bone density may worsen over time, with the potential to remain unaddressed (or unchecked) as part of a harm reduction strategy [ 29 ].

Structural changes in the brain due to malnutrition are well-documented and can be largely reversed by weight restoration [ 30 ]. A recent prospective analysis of 1648 patients by the ENIGMA group, including healthy controls, acutely underweight, and partially weight restored AN patients, found widespread reduction in cortical thickness, subcortical volumes and cortical surface area which was closely related to BMI [ 31 ]. Whilst there is significant improvement in all three parameters in the partially weight restored group (n = 251), they are still not at the level of healthy controls, highlighting the need for full weight restoration to restore pre-morbid neural architecture.

Whilst the relationship between structural brain differences and psychopathology remains uncertain, Walton et al.’s suggestion of a possible link between effects in the superior and inferior parietal gyrus to alterations in attention and “body-environment integration” is intriguing and complements a growing body of work on cognitive deficits in individuals with extremely low BMI [ 15 ].

When considering dangers of malnutrition states, we must also be cognizant of the rapidity of decline in certain cases, even amongst patients who have thus far managed to sustain severe and long-standing illness. Some patients can exhibit remarkable resilience in the face of severe malnutrition, leading clinicians to erroneously assume their medical stability [ 16 ]. Arrythmias and severe hypoglycaemia can send superficially “medically stable” patients into sudden and sometimes fatal decline; indeed, this risk of rapid decline has been noted in qualitative accounts of patients experiencing living with an extremely low BMI [ 32 ].

Considering the significant impacts and risks of persisting illness, harm reduction in these patients may therefore be a misnomer. Whilst involuntary admissions may be avoided in the short term by agreeing treatment goals that deprioritise weight status, the long-term physical and mental health consequences, even at marginally lower baseline BMI targets, must lead us to question whether harm is really being reduced enough .

In author JD’s lived experience of severe and long-standing AN, considerable physiological and psychosocial harm was incurred by the maintenance of a very low BMI for approaching a decade (Box 1 ).

To consent or not to consent? An over-reliance on presumed patient capacity

The issue of capacity in severe and long-standing AN illness (see [ 33 ]) is a major ethical barrier to harm reduction. In the research for this review, we found every proponent of harm reduction to highlight the importance of informed consent before pursuing this approach, with the default assumption that patients are able to retain capacity for such decisions [ 5 , 18 , 19 ].

However, as eloquently summarised by Geppert amongst others, when dealing with severe and long-standing AN, we must call into question the validity of this consent regarding treatment decisions, particularly the ability to weigh up information [ 9 , 34 ].

We should also be cautious of the capacity of patients consenting to a treatment plan suggested by a clinician (i.e. offered as “medical advice”). Individuals with lived and living experience of severe and long-standing AN have raised concerns that harm reduction approaches may be seen by patients as a way to engage in a form of treatment without the expectation of substantial behaviour change, thus “allowing” the perpetuation of illness [ 32 , 35 ]. There may also be a possible role for unconscious motivations in incentivising a less resource-intensive option for specialist services that are so under-resourced as to only be able to offer their patients a form of “managed decline”, rather than evidence-based and recovery-focused treatment [ 36 ].

Author JD (Box 2 ) reflects on some of the complexities of making decisions regarding treatment.

Is harm reduction an admission of futility?

Harm-reduction approaches are, by definition, closely aligned with the concept of futility in psychiatry, which remains a highly controversial area [ 37 ]. In one sense, by abandoning the traditional treatment aims, we implicitly acknowledge (at least in the given moment) that these aims are not obtainable; that is, to pursue them is futile.

This logic will lead to a host of ethical issues which are more traditionally associated with the even more contentious topic of palliative care in severe and long-standing AN and physician-assisted dying (PAD) for these patients [ 3 ]. Such ethical criticisms may refer to examples that exist of recovery from AN, even with severe levels of disease and protracted duration of illness [ 38 ]. The notion that treatment is no longer effective for patients with severe and long-standing AN has been well disputed in a 2018 paper by Raykos et al. which identified that traditional evidence-based interventions can have comparable effectiveness in chronic as well as acute patients [ 39 ]. Similar findings emerged from Dalle Grave and colleagues in an earlier 2017 study [ 40 ]. These observations were replicated in the UK by Ibrahim et al. [ 41 ]. With this in mind, we need to be careful of the blurry line in harm reduction between alleviating suffering and inadvertently reinforcing the patients’ psychopathology.

Furthermore, patients and caregivers may respond negatively to the concept that their condition is “treatment refractory”, and Elwyn gives an excellent account of how this label can in some cases generate rather than alleviate suffering, with concomitant effects on engagement with treatment [ 32 ].

It is clear from a range of evidence that for many patients, recovery is a continuous process, which may take years. Constructing a binary narrative that confines patients to being either recovered or refractory (and therefore deemed futile) could prove detrimental to how we approach this severe and long-standing AN. Similarly, other misleading binaries, such as those between early intervention and long-standing illness, and clinicians and patients themselves, should be avoided.

Is a rejection of harm reduction throwing the baby out with the bathwater?

The above critique on three domains of the ethics of harm reduction should not cause us to dismiss the utility of this approach in certain contexts. Rather than harm reduction being a focus in and of itself, it may have utility when considered as part of a broader treatment pathway for a non-consenting patient, which still leads ultimately towards optimal treatment goals as its end point. Whilst the question of specificity as to when and for whom harm reduction may be useful remains to be resolved, a recent piece from Russell’s group has been particularly insightful in considering harm reduction within a wider context [ 16 ].

As with many interventions—be they psychological, family based, or pharmacological -studying them in isolation can lead to falsely narrow narratives that detract from the reality that recovery from ED is multidisciplinary and often occurs in phases [ 16 , 42 ]. As Russell points out, it may be best to consider harm reduction as promoting the initial phase of recovery, which can then open the door for further recovery and ultimately weight restoration. Indeed, an excellent qualitative piece in recovered patients speaks of a recovery “tipping point”, whereby patients could escape from a repeated cycle of recovery and relapse by finding a new intrinsic motivation through gradual change and acceptance [ 42 ]. Furthermore, the emphasis harm reduction efforts place on quality of life may provide patients with a taster of a life worth recovering for, and more trusting relationships with healthcare professionals with whom alliance will be an essential ingredient of change-focussed evidenced-based therapies [ 36 ].

To this end, we would be interested in seeing further research conceptualising harm reduction as part of a step-wise model of recovery, and suggestions for what this could look like that are co-produced with patients. However, our tenet is that risks of a harm reduction approach should always be communicated to the patient, and the potential benefits harnessed as part of an overarching goal of full weight restoration and recovery, not the endpoint of treatment.

Conclusions

It is thought provoking to consider that in the 10 years between the first 2012 systematic review and the 2023 Cochrane review, there has been little progress in better defining , let alone developing, specific treatments for severe and long-standing AN. The ongoing lack of focussed treatment options has led to understandable pessimism, elsewhere described as a “therapeutic stagnation” in the field [ 6 ]. Clinicians doing their best with the limited resources available to them can be forgiven for reaching for harm reduction as a partial solution, albeit one still lacking a robust evidence base and ethical framework which may require years of further research to establish.

Demoralising as this progress may seem, recent findings of a large-scale meta-analysis have provided grounds for cautious optimism, given that even with the status quo, recovery rates amongst patients with AN were found to improve over the longer term [ 6 ]. The trend that has been demonstrated of recovery occurring later in life should provide an important motivation for clinicians and patients alike to engage with existing recovery-oriented approaches, and should stimulate ongoing research to establish better, more nuanced understandings of the role of harm reduction within this.

Indeed, our understanding of AN as a whole may be shifting towards a metabo-psychiatric diagnosis, with a recent genetic analysis from Watson’s group identifying several loci important in glycaemic control and lipid metabolism as being strongly associated with AN [ 43 ]. This “paradigm shift” could break new ground on what predisposes certain individuals to developing severe and long-standing presentations of AN, inspiring much-needed novel treatment innovations [ 44 ].

Further research will be crucial. This may include conducting longitudinal cohort studies to compare quality of life, morbidity, and mortality between patients receiving harm reduction therapies and those undergoing recovery-focused treatments. Additionally, economic evaluations are needed to assess the cost-effectiveness of harm reduction versus traditional methods, considering both direct and indirect healthcare costs over time. A mixed-methods study should also explore the emotional and practical impacts on patients and their families, shedding light on the social and familial consequences of different interventions. Such research could enhance our understanding of ethical management practices for this patient group.

Irrespective of future directions, it is essential to re-emphasise the potential risks associated with viewing harm reduction as the ultimate goal of treatment in severe and long-standing AN. Services must be willing to examine their motivations for using a harm reduction as an approach, the range of problems they are trying to balance when designing care pathways for their patients, and the ethical implications of treatment options for patients and their carers. As we hope to have demonstrated in the authoring of this article, collaboration with patients and carers enhances our understanding, and is achievable. We must be curious and honest about whose best interests' clinical decisions are made in, and whether harm reduction is more about removing intrapersonal and interpersonal conflicts that can arise within treatment, rather than removing harm itself.

Availability of data and materials

Data sharing is not applicable to this article as no new data were created or analysed in this study.

Abbreviations

Eating disorders
Anorexia Nervosa

Severe and enduring eating disorders

International classification of diseases 11th revision

Diagnostic and statisitical manual of mental disorders 5th edition

Severe and enduring Anorexia Nervosa

Body Mass Index

Randomised controlled trial

Cognitive behavioural therapy for Anorexia Nervosa

Enhanced cognitive behavioural therapy

Community outreach partnership program

Specialist supportive clinical management

Cognitive remediation therapy

Physician assisted dying

James Downs

Agnes Ayton

Edwin Birch

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Sources of Sexual Knowledge and Information, and Sexual Attitudes of Men: A Narrative Synthesis of the Literature

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Darlene Mwende Ndasi ORCID: orcid.org/0000-0003-1704-7342 1 ,
Victor Fannam Nunfam ORCID: orcid.org/0000-0002-4572-0904 1 , 2 ,
Kwadwo Adusei-Asante ORCID: orcid.org/0000-0002-1343-8234 1 ,
Madalena Grobbelaar ORCID: orcid.org/0000-0002-2749-2944 1 &
Anh Vo Van Ha ORCID: orcid.org/0000-0002-9495-9292 1 , 2 , 3

This study sought to synthesise evidence on the sources of sexual knowledge and information and relationship with sexual attitudes of cis men. From a review of existing literature, five categories were obtained from 11 studies and grouped into three syntheses: (1) sources of sexual knowledge and information, (2) sexual attitudes and (3) the relationship between sources of sexual knowledge and information and sexual attitudes. Sex research relation to sexual knowledge and attitudes of cis men is scant across the globe. Men desire reliable sexual information despite peers and online media being more readily available with consequences for sexual attitudes that impact on sexuality of men. We posit that research, sex education, sexological practice and policy intervention are necessary to avail knowledge that provides reliable sexual knowledge and information to men for safe sexual decision making.

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Introduction

The complexity of sexual socialisation and multi-dimensionality of sexual attitudes and influence on sexual behaviour in sub-Saharan Africa has been put on the spotlight since the advent of the unrelenting HIV/AIDS epidemic; citing men to propagate the disease through multiple sexual partnerships and sexual concurrencies reinforced by rigid gender norms and toxic masculinities. The HIV/AIDS plague and sexual health crisis is compounded by widespread ignorance in sexual knowledge and information among men (Amoo et al., 2019 ; Ogolla & Ondia, 2019 ), and complacent sexual attitudes where peers are mostly the sought-after knowledge source to inform sexual decision making (Hodes & Gittings, 2019 ).

Much of peer sources of sexual knowledge and information often involve sexual interaction leaving little chance for informed sexual decision making and when knowledge is accurate such as the comprehension of the importance of consistent condom use, this knowledge does not always translate into practice (Ogolla & Ondia, 2019 ). In Africa, there is also continued debate on the ideal curricula framework for comprehensive sexuality education in schools which is often cited to be established within colonialism to threaten traditional values that are centred on traditional gender roles and heteronormativity (Bhana et al., 2019 ; Gacoin, 2016 ). This is despite the rise in homosexuality, heterosexual anal sex (Baggaley et al., 2013 ), and the rapidly growing culture of gender diversity. Furthermore, sexual violence involving sexual coercion and assaults, and both implicit and explicit violation of sexual consent among men are perverse with sexual permissiveness represented in the practice of multiple sexual partnerships and sexual concurrencies (Kenyon et al., 2018 ). Therefore, understanding the sources of sexual knowledge and relationship with sexual attitudes and sexual behaviours is important for curricula and sexological practice programme development and research policy.

Despite much of the sexuality education research that exists in Africa largely focusing on the sexual socialisation of adolescents, sexual learning is lifelong and the sources of sexual knowledge are different and impact varies (Ballard & Morris, 1998 ; Graf & Patrick, 2015b ; Nunfam & Adjei, 2014 ). Indeed, the sources of sexual knowledge and information have impact on sexual attitudes and sexual behaviours of individuals (Shin et al., 2011 ). Permissive sexual attitudes and sexual double standards often predict sexual risk behaviours and have negative sexual health outcomes (Astle et al., 2022 ; Kirby et al., 2007 ; Nunfam, 2007 ).

Against the backdrop of studies on the extend of risky sexual behaviours, sexual violence among men and traditional gender roles that perpetuate these vices, the extent to which sex research involving acquisition of sexual knowledge and relationship with sexual attitudes of cis men in sub-Saharan Africa is not known. Also, there seems to be no specific systematic review or synthesis especially using mixed method approach (Nunfam et al., 2018 ) that have examined and highlighted the sources of sexual knowledge and information and sexual attitude of men, and how their sexual knowledge influences their sexual attitudes. Given the significance of systematic reviews and synthesis to evidence-centred policy making, it is imperative to conduct this review study in order to gather findings from extant published and unpublished studies.

Hence, this study sought to assess and synthesise the available evidence in literature on the sources of sexual knowledge and information and sexual attitude of men with emphasis on research design, study setting, methodology, and key findings. This mixed methods narrative review is guided by the following research questions: (1) What are the sources of sexual knowledge and information among men? (2) What are the sexual attitudes of men? (3) To what extent do the sources of sexual knowledge and information relate to sexual attitudes?

Materials and Methods

The philosophy of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRSMA) combined with the Joanna Briggs Institute (JBI) framework for systematic review, synthesis and reporting underpinned this study (JBI, 2017 ; Popay et al., 2006 ). Given that the systematic reviews and synthesis provide the foundation for descriptions of patterns, differences and similarities of results within included studies they were utilised on the basis of clearly defined selection criteria (Petticrew & Roberts, 2008 ; Popay et al., 2006 ).

Additionally, the utility of mixed methods was adopted to provide comprehensive understanding to the research questions (Morgan, 1998 ). The narrative synthesis used textual approach based on findings from several studies relating to sources of sexual knowledge, sexual attitudes and relationship between sexual knowledge and information and sexual attitudes among men. The aggregation of empirical studies therefore warrants the synthesis of both qualitative and quantitative evidence (Dixon-Woods et al., 2005 ). Additionally, mixed methods are agreeable with narrative synthesis permitting the mixing of diverse types of evidence from several studies of various characteristics (Gough et al., 2017 ).

Moreover, mixed methods narrative reviews can play a crucial role in identifying gaps and limitations in the extant literature in sex research. For example, a review examining the use of digital technologies in sexual health promotion may reveal a predominance of quantitative studies focused on measuring the impact of online interventions on knowledge or behavioural outcomes, while overlooking the qualitative exploration of users' experiences, preferences, and barriers to engagement (Schneider & Niederberger, 2020 ; Tariq & Woodman, 2013 ).

By highlighting these gaps, mixed methods narrative reviews can inform the design of future research that more effectively integrates both quantitative and qualitative approaches, leading to a more comprehensive understanding of the complex dynamics of human sexuality (Kajamaa et al., 2020 ; Small, 2011 ). Conclusively, the integration of mixed methods narrative reviews in sex research can address a critical need in the extant scholarship by providing a more holistic and nuanced understanding of the multifaceted nature of human sexuality.

Nevertheless, a scoping review was guided by the notion of the Population, Intervention, Comparison/Context Outcome (PICO) (Cooke et al., 2012 ). Therefore, the scope of the study included cis men 18–65 years old, sources of sexual knowledge and information, and sexual attitudes. For each included article, either the sources of sexual knowledge and information or sexual attitudes or both were addressed . The inclusion and exclusion criteria are presented in Table 1 below.

Search Strategy

A systematic search on Google Scholar, Taylor and Francis Online, Web of Science, Elsevier, Springer Nature, Sage, Wiley, and back studies in reference lists of peer reviewed studies published in English between 2012 and 2022 were searched using key words and search terms presented in Table 2 below.

Article screening occurred at the title and abstract stages, followed by a full review of the selected studies. Independent quality assessment of included articles guided by the JBI critical appraisal for systematic reviews was performed by three researchers who resolved differences through consensus. Our search resulted in 528,156 citation after which 527,731 were removed based on screening the title. After excluding most of the citations for various reasons, 425 citations were retained after which their abstracts were screened. Further review of abstracts retrieved 54 articles with 39 being considered for a full review of entire articles. Further, the full review of the 39 papers resulted in a final 10 studies that fully met the inclusion criteria. Another full review of 25 back references was performed with only one study qualifying for inclusion.

Studies were excluded for ambiguity, inappropriate topic and age, transgender men, studies involving reviews, reports, editorials, letters to editors and those which were published before 2012.The screening process and summary of included studies is presented in the PRISMA flow diagram (Page et al., 2021 ) (see Fig. 1 ).

PRISMA flow chart showing summary of included studies

Characteristics of Included Studies

The studies were characteristically heterogenous and from various countries across the globe including, Kenya, China, Vietnam, India and mostly the United States of America (USA). Most of the studies were found in continent of North America and Asia with the least found in South America. The global location of the 11 included studies included USA (36.4%), Asia (36.4%), Africa (18.1%) and South America (19.1%) as illustrated in Fig. 2 . The descriptive characteristics of the included studies were illustrated by author’s name, year in which publication occurred, the location, population, sample size, methods, data analysis and the study conclusions (Table 3 ).

Global location of included studies

Research objectives and methodologies also were used to organise the studies. Studies must have primarily involved only adult cismen aged 18 to 65 years old and not women, adolescents or transgender men primarily focused on sexuality education, any sources of sexual knowledge and information and sexual attitudes, beliefs and perspectives. Data from the included studies were therefore extracted using ‘Population, Intervention, Comparison and Outcome structure’ (Cooke et al., 2012 ).

The population refers to men aged 18–65 years old relating to sources of sexual knowledge and information and how such knowledge relates to or impact broadly on sexuality including sexual decision making. Interventions as presented in the chosen studies (primary) are the various sexual knowledge and information platforms such as school-based sexuality education, peers, parents, media platforms including religious organisations and other professional institutions such as sexual and reproductive health community settings or a combination of all of them to form blended sources. Comparisons involved different geographical locations, sexuality education platforms and their impact on sexual skills, and sexual attitudes. Outcomes relate to how these blended sources of sexual knowledge and information influence sexual attitudes (Hendrick et al., 2006 ), including consent. Both of these aspects have an intrinsic connection to sexual behaviours. The practice of multiple sexual partnerships and sexual concurrencies, modes of condom use, sexual responsibility, birth control, instrumentality and communion are such outcomes. Secondarily, the outcomes involve the skill in utilising sexual knowledge and information and understanding sexual and reproductive health outcomes and overall well-being of men.

The relationship of both the sources of sexual knowledge and information and sexual attitudes can also reflected social norms that may include the endorsement of sexual double standards and masculinity where men influence each other to maintain certain sexual behaviours. All these constitute sexual skills, values and attitudes.

Abstraction of Findings from Included Studies

We based data extraction on the findings of each included articles for categorisation and narrative synthesis using figures and tables where required (JBI, 2017 ; Popay et al., 2006 ). The JBI’s interpretation of degrees of evidence were used to determine the value of extracted data (see Tables 4 and 5 ) (JBI, 2017 ). Three researchers were involved in the data synthesis process and differences were resolved through consensus. Data were synthesised based on the study’s research questions. Data extracted from the 11 included studies are displayed in the following 11 tables (Tables 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ) according to their findings, illustrating the degree of evidence.

Narrative Synthesis and Categorisation of Included Studies

The abstraction of data resulted in 41 findings which were grouped into six categories: (1) type of sexual knowledge and information received, (2) sources of sexual knowledge and information, (3) access and accuracy of sexual knowledge and information, (4) sexual attitudes and (5) Relationship between sexual attitudes and sexual knowledge. The categories were further synthesised into themes as follows: (1) sources of sexual knowledge and information, (2) sexual attitudes and (3) the relationship between sources of sexual knowledge and information and sexual attitudes. Each of the studies addressed some questions and none answered all of the questions.

Synthesis One: Sources of Sexual Knowledge and Information

Synthesis one describes men’s perception on their sources of sexual knowledge and information, the various types of information sought and received, and their accuracy and reliability. This is the outcome of aggregating related categories comprising twenty-three findings that describe the sources of sexual knowledge and information as presented in Figs. 3 and 4 below. Finding from Category One indicates that men accessed sexual knowledge and information from different sources with various degrees of accuracy and reliability. Although men reported peers, online media and the internet to be the most easily accessible sources of sexual knowledge and information, the knowledge obtained as reportedly to be unreliable and not well understood (Graf & Patrick, 2015a ; Kirby et al., 2007 ). Much of the knowledge sought was focused on pregnancy and STIs/HIV/AIDS prevention as well as sexual pleasure which involved the use pornography and condom use mainly in casual relationships (Brown et al., 2017 ). The internet was viewed to be a confidential alternative source and efficiently accessed as soon as required (Ballester-Arnal et al., 2017 ). These sources were accessed as an alternative to school-based sexuality education which was reported to be inadequate, unreliable or completely absent (Bhana et al., 2019 ; Hodes & Gittings, 2019 ). Sexual knowledge from healthcare professionals as a formal source was not widely used.

Type of sexual knowledge and information sought and received

Sources of sexual knowledge and information

However, men reported that this source offered limited knowledge, mostly inadequate, confusing and lacked content to meet the knowledge required by men (Beia et al., 2021 ). The knowledge and information accessed from this source ranged from the correct application of condom use although as relationships became more permanent, men ceased from using condoms. Condoms were used to mainly control pregnancy and STIs with casual hook-ups (Endendijk et al., 2020 ; Garcia et al., 2012 ). Other sought-after knowledge related to sexual consent, in the context of how men treat women in their sexual engagement and sexual scripts (Ballester-Arnal et al., 2017 ; Garcia et al., 2012 ).

Men desired effective sexual knowledge and information, however the school curriculum through which formal education was accessed by all men was reportedly mainly biological and unlikely to be helpful. Few men accessed information from parents, which was mainly related to pregnancy and STI prevention (Bleakley et al., 2009 ; Khurana & Bleakley, 2014 ). Men also sought sexual knowledge and information to base their sexual decision making (Tannenbaum et al., 2016 ).

Synthesis Two: Sexual Attitudes

Synthesis two had only one category (Category Two) constituting eight findings relating to sexual permissiveness, influence of religion on sexual attitudes, causal sex, birth control attitudes toward condom use and safer sexual practices (Cruz, Legall etc.). Men reported to be less likely to engage in sexual hook-ups if they were in stable relationships. Sexual hook-ups were related to more condom use, pornography and safer sexual practices which involved more sexually permissive attitudes towards sex (Bankole et al., 2004 ). Participants with sexual permissiveness also reported multiple sexual partnerships and sexual concurrencies and sexual double standards (Endendijk et al., 2019 ; Vrangalova et al., 2014 ).

Synthesis Three: Relationship Between Sources of Sexual Knowledge and Sexual Attitudes

Synthesis three reflected the relationship between sources of sexual knowledge and sexual attitudes as presented in Figs. 5 , 6 and 7 below. Having sexual knowledge from reliable sources was associated with attitudes towards safe sexual practices and condom use. Information accessed from friends was related to permissive sexual attitudes related to casual hook-ups and use of pornography (Bridges et al., 2016 ; Lewczuk et al., 2022 ; Lo & Wei, 2005 ) Similarly accessing sexual knowledge and information from the internet and online media was related to permissive sexual attitudes involving casual sex and penetrative sexual hook-ups and infidelity (Brown et al., 2017 ; Rasmussen et al., 2018 ). However, sexual permissiveness was also linked to increased condom use (Berer, 2006 ; Evans et al., 2019 ; Hensel et al., 2012 ).

Access and accuracy sexual knowledge and information

Category three-sexual attitudes

Relationship between sources of sexual knowledge and sexual attitude

This is the most recent systematic and narrative synthesis using a mixed methods approach to assess sources of sexual knowledge and information, sexual attitudes and how the two concepts relate to influence on sexual decision making that impact on the sexuality and sexual and reproductive health of cis men. Our first question was to assess the sources of sexual knowledge and information. We found that men accessed various sources and that provided different forms of information used for sexual decision making.

Despite peers continuing to be the most preferred source of sexual knowledge and information among men (Dutt & Manjula, 2017 ; Rahimi-Naghani et al., 2016 ; Shin et al., 2019 ), the internet continues to rapidly provide instant information as required and both peers and online media is trending to replace formal sources of sexual knowledge and information (Daneback et al., 2012 ; Mustanski et al., 2011 ). Formal knowledge and information are obtainable from sexual and reproductive healthcare professionals but often reported as confusing and unreliable (Amoo et al., 2017 ). This trend indicates that men may miss out on reliable knowledge on which to base their sexual decision making as internet and peers are reported to provide unreliable information. This is consistent with earlier studies which suggest that peers and the internet are important sources of sexual knowledge and information (Ballard & Morris, 1998 ; Lo & Wei, 2005 ). Khurana and Bleakley ( 2014 ) and Bleakley et al. ( 2009 ) found that poor sexual knowledge and sexual literacy leads to unsafe and risky sexual behaviours including inconsistent condom use, lack of interest in sexual health screening and multiple and concurrent sexual partnerships (Hodes & Gittings, 2019 ), especially in sub-Saharan Africa where these practices are prevalent despite the HIV/AIDS epidemic (Kenyon et al., 2018 ). The second research question assessed the sexual attitudes of men. Our review found few studies that explored attitudes regarding sexual permissiveness among men. This study found that men with permissive or liberal views on sex, had more sexual hook-up (Braithwaite et al., 2015 ). Permissive sexual attitudes in men are likely to permit sexual double standards that allow men more sexual partners than women (Endendijk et al., 2020 ). However, men with more permissive sexual attitudes had consistent condom use and practiced safer sex than those who had regular or stable sexual partnerships (Emmers-Sommer et al., 2013 ; Endendijk et al., 2020 ). Knowledge and confidence in condom use provide confidence in sexual activity which could enhance liberal or permissive sexual attitudes (Cruz & Etienne, 2012 ; Hensel et al., 2012 ).

Our last question assessed the relationship between the sources of sexual knowledge and sexual attitudes. We found the sources of sexual knowledge influenced the attitudes men had towards sex. Peers were influential towards sexual permissiveness as men engaged in peer casual sexual hook-up from those they sought sexual information (Bhana et al., 2019 ; Hodes & Gittings, 2019 ; Rogers et al., 2019 ). This is consistent with earlier studies that established the role peers in their influence on sexual behaviours and sexual attitudes (Bhana et al., 2019 ; Bleakley et al., 2009 ). As such peer educators can be trained to provide efficient and accurate sexual knowledge and education to men for transformative sexual attitudes that foster safe sexual practices such as consistent condom uses and frequent sexual screening. This is critical for places where HIV/AIDS is still an epidemic such as sub-Saharan Africa and other developing countries where poor access to condoms and lack of accurate knowledge in their use still persists (Bhana et al., 2019 ). Shin et al. ( 2011 ) and Lyu et al. ( 2020 ) suggested that peer education can also effect change in sexual attitudes towards women.

This study contributes important knowledge to the wide body of sex research knowledge and highlights the need to involve cis men in research and policy development practices. Like all studies though, this review has limitations that are important to consider. We evaluated studies from different locations across the globe upon which cultural considerations must be made concerning how men acquire sexual knowledge and social-cultural implications pertaining to sexual attitudes.

In Africa for instance, it is expected men engage in multiple sexual partnerships as the ideal presentation of manhood (Amoo et al., 2019 ). Sexual attitudes towards masculinity in the continent would require transformative sex education in schools and the community from reliable sources for which funding is essential. Such knowledge must provide clear understanding of the consequences and rewards of sexual practices that impact men’s sexual health and that of their partners. This means that peer educators are critical in their ability to influence attitudes towards safe sexual practices by providing accurate and reliable sexuality education in male-friendly environments which also emphasize sexual pleasure.

Sexual pleasure and risk go hand in hand, and as such sexual pleasure is an important component in sexuality education. A multifaceted approach prioritizing both risk reduction and the enhancement of sexual pleasure, comprehensive programs can empower individuals to make informed decisions, practice safer sex, and experience more fulfilling intimate relationships (Melesse et al., 2020 ). For example, erotizing safe sex with condom use in educational programs, workshops and advertisements could be effective in advancing knowledge in sexual risk reduction and emphasizing sexual pleasure (Scott-Sheldon et al., 2006 ).

Implications

Discussions around sexual behavior, sexual health, and even sexual orientation may be perceived as taboo or even shameful, leading to reluctance among participants to engage openly and honestly in research activities. Moreover, cultures have a powerful influence on sexual attitudes. The topic of sexuality, particularly among men, is often shrouded in secrecy and stigma, particularly in many non-western societies (Muraguri et al., 2012 ; Onyango‐Ouma et al., 2009 ). Navigating these cultural sensitivities requires researchers to employ nuanced and empathetic approaches, building trust and rapport with communities and participants. It is also crucial to consider the role of power dynamics, both within the research process and in the broader social context, and how these may impact the willingness of men to share their experiences and perspectives (Khumalo et al., 2021 ).

In addition to cultural considerations, researchers must grapple with the complexities of gender norms and the ways in which they intersect with sexuality (Ndasi, et al., 2022a , 2022b ). In many sub-Saharan African societies for example, traditional gender roles and expectations place significant pressure on men to conform to rigid notions of masculinity, which may inhibit their ability to learn, discuss or seek support for sexual and reproductive health concerns (discuss or seek support for sexual and reproductive health concerns (Agha et al., 2002 ; Reid & Walker, 2005 ).

Moreover, a mixed methods narrative review examining sexuality topics among cis-gender men could integrate large-scale survey data on sexual issues within this population, while also incorporating in-depth interviews that capture the nuanced, lived experiences of individuals navigating issues of identity, stigma, and sexual and reproductive health support programs (Tariq & Woodman, 2013 ). By adopting this holistic approach, we can gain a richer and more nuanced understanding of the multifaceted factors shaping men’s sexuality, which can then serve as a foundation for developing more targeted and effective interventions.

Another implication relates to sexual research policy and practice. Sex research with adult cis men is generally scarce as discovered in this study. It is important to assess trends in sexual attitudes and the sources of knowledge accessed for sexual and reproductive health planning and practices that do not exclude cis men (Bancroft, 2000 ). Such research is also important for school-based sexuality education and curricula development. Nevertheless, other implications relate to sexuality educators, policy makers and sexological practitioners.

Study Limitations

This study focused on studies focusing on cis-gender men which renders it inherently restrictive. The review also involves studies conducted globally therefore the heterogeneity of the review should be viewed with these considerations. The reliance on secondary data from previously published studies is also a limitation for which the evolution of digital media and its impact on sexuality education and changing trends in research on human sexuality may not present current trends.

Conclusions

Conclusively, men require services that are considerate of their sexual needs, culturally relevant and research that puts these needs on the spotlight to avail effective support services that also benefit the sexual health and well-being of their sexual partners and communities. Additionally, is important to understand the connection between sexual knowledge and information with sexual behavior. The interdisciplinary field of sex research and sexual and reproductive health could explore the long-term effects of sources of sexual knowledge and information and sexual attitudes on sexual health outcomes for cis men.

Additionally, the integration of mixed methods approaches, particularly through the use of narrative reviews, can address a significant need in the field of sex research. By drawing on a diverse range of data sources and methodologies, these reviews can provide a more holistic and nuanced understanding of the multifaceted aspects of human sexuality, ultimately contributing to the development of person-centered and effective interventions in this crucial domain in sex research with cis men.

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Study conception and design: Darlene Mwende Ndasi. Data collection and interpretation: Darlene Mwende Ndasi. Original manuscript draft: Darlene Mwende Ndasi. Data analysis: Vo Van Anh Ha and Darlene Mwende Ndasi. Reviewed for critical imputs: Kwadwo Adusei-Asante, Madalena Grobbelaar, Vo Van Anh Ha and Victor Fannam Nunfam. Edited and approved for final version for submission to journal: Kwadwo Adusei-Asante, Madalena Grobbelaar, Vo Van Anh Ha and Victor Fannam Nunfam.

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Ndasi, D.M., Nunfam, V.F., Adusei-Asante, K. et al. Sources of Sexual Knowledge and Information, and Sexual Attitudes of Men: A Narrative Synthesis of the Literature. Sexuality & Culture (2024). https://doi.org/10.1007/s12119-024-10265-5

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v.8(11); 2016 Nov

How to Conduct a Systematic Review: A Narrative Literature Review

Nusrat jahan.

1 Psychiatry, Mount Sinai Chicago

Sadiq Naveed

2 Psychiatry, KVC Prairie Ridge Hospital

Muhammad Zeshan

3 Department of Psychiatry, Bronx Lebanon Hospital Icahn School of Medicine at Mount Sinai, Bronx, NY

Muhammad A Tahir

4 Psychiatry, Suny Upstate Medical University, Syracuse, NY

Systematic reviews are ranked very high in research and are considered the most valid form of medical evidence. They provide a complete summary of the current literature relevant to a research question and can be of immense use to medical professionals. Our goal with this paper is to conduct a narrative review of the literature about systematic reviews and outline the essential elements of a systematic review along with the limitations of such a review.

Introduction and background

A literature review provides an important insight into a particular scholarly topic. It compiles published research on a topic, surveys different sources of research, and critically examines these sources [ 1 ]. A literature review may be argumentative, integrative, historical, methodological, systematic, or theoretical, and these approaches may be adopted depending upon the types of analysis in a particular study [ 2 ].

Our topic of interest in this article is to understand the different steps of conducting a systematic review. Systematic reviews, according to Wright, et al., are defined as a “review of the evidence on a clearly formulated question that uses systematic and explicit methods to identify, select and critically appraise relevant primary research, and to extract and analyze data from the studies that are included in the review” [ 3 ]. A systematic review provides an unbiased assessment of these studies [ 4 ]. Such reviews emerged in the 1970s in the field of social sciences. Systematic reviews, as well as the meta-analyses of the appropriate studies, can be the best form of evidence available to clinicians [ 3 ]. The unsystematic narrative review is more likely to include only research selected by the authors, which introduces bias and, therefore, frequently lags behind and contradicts the available evidence [ 5 ].

Epidemiologist Archie Cochrane played a vital role in formulating the methodology of the systematic review [ 6 ]. Dr. Cochrane loved to study patterns of disease and how these related to the environment. In the early 1970s, he found that many decisions in health care were made without reliable, up-to-date evidence about the treatments used [ 6 ].

A systematic review may or may not include meta-analysis, depending on whether results from different studies can be combined to provide a meaningful conclusion. David Sackett defined meta-analysis as a “specific statistical strategy for assembling the results of several studies into a single estimate” [ 7 - 8 ].

While the systematic review has several advantages, it has several limitations which can affect the conclusion. Inadequate literature searches and heterogeneous studies can lead to false conclusions. Similarly, the quality of assessment is an important step in systematic reviews, and it can lead to adverse consequences if not done properly.

The purpose of this article is to understand the important steps involved in conducting a systematic review of all kinds of clinical studies. We conducted a narrative review of the literature about systematic reviews with a special focus on articles that discuss conducting reviews of randomized controlled trials. We discuss key guidelines and important terminologies and present the advantages and limitations of systematic reviews.

Narrative reviews are a discussion of important topics on a theoretical point of view, and they are considered an important educational tool in continuing medical education [ 9 ]. Narrative reviews take a less formal approach than systematic reviews in that narrative reviews do not require the presentation of the more rigorous aspects characteristic of a systematic review such as reporting methodology, search terms, databases used, and inclusion and exclusion criteria [ 9 ]. With this in mind, our narrative review will give a detailed explanation of the important steps of a systematic review.

Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) checklist

Systematic reviews are conducted based on predefined criteria and protocol. The PRISMA-P checklist, developed by Moher, et al., contains 17 items (26 including sub-items) comprising the important steps of a systematic review, including information about authors, co-authors, their mailing and email addresses, affiliations, and any new or updated version of a previous systematic review [ 9 ]. It also identifies a plan for documenting important protocol amendments, registry names, registration numbers, financial disclosures, and other support services [ 10 ]. Moher, et al. also state that methods of systematic reviews involve developing eligibility criteria and describing information sources, search strategies, study selection processes, outcomes, assessment of bias in individual studies, and data synthesis [ 10 ].

Research question

Writing a research question is the first step in conducting a systematic review and is of paramount importance as it outlines both the need and validity of systematic reviews (Nguyen, et al., unpublished data). It also increases the efficiency of the review by limiting the time and cost of identifying and obtaining relevant literature [ 11 ]. The research question should summarize the main objective of a systematic review.

An example research question might read, “How does attention-deficit/hyperactivity disorder (ADHD) affect the academic performance of middle school children in North America?” The question focuses on the type of data, analysis, and topic to be discussed (i.e., ADHD among North American middle school students). Try to avoid research questions that are too narrow or broad—they can lead to the selection of only a few studies and the ability to generalize results to any other populations may be limited. An example of a research question that is too narrow would be, “What is the prevalence of ADHD in children and adolescents in Chicago, IL?” Alternately, if the research question is too broad, it can be difficult to reach a conclusion due to poor methodology. An example of a research question that is too broad in scope would be, “What are the effects of ADHD on the functioning of children and adolescents in North America?”

Different tools that can be used to help devise a research question, depending on the type of question, are: population, intervention, comparator, and outcomes (PICO); sample, phenomenon of interest, design, evaluation, and research type (SPIDER); setting, perspective, intervention, comparison, and evaluation (SPICE); and expectation, client group, location, impact, professionals, and service (ECLIPSE).

The PICO approach is mostly used to compare different interventions with each other. It helps to formulate a research question related to prognosis, diagnosis, and therapies [ 12 ].

Scenario: A 50-year-old white woman visited her psychiatrist with a diagnosis of major depressive disorder. She was prescribed fluoxetine, which she feels has been helpful. However, she experienced some unpleasant side effects of nausea and abdominal discomfort. She has recently been told by a friend about the use of St. John’s wort in treating depression and would like to try this in treating her current depression. (Formulating research questions, unpublished data).

In the above-mentioned scenario, the sample population is a 50-year-old female with major depressive disorder; the intervention is St. John’s wort; the comparison is fluoxetine; and the outcome would be efficacy and safety. In order to see the outcome of both efficacy and safety, we will compare the efficacy and safety of both St. John’s wort and fluoxetine in a sample population for treating depression. This scenario represents an example where we can apply the PICO approach to compare two interventions.

In contrast, the SPIDER approach is focused more on study design and samples rather than populations [ 13 ]. The SPIDER approach can be used in this research question: “What is the experience of psychiatry residents attending a transgender education?” The sample is psychiatry residents; the phenomenon of interest is transgender education; the design is a survey; the evaluation looks at the experience; and the research type is qualitative.

The SPICE approach can be used to evaluate the outcome of a service, intervention, or project [ 14 ]. The SPICE approach applies to the following research question: “In psychiatry clinics, does the combined use of selective serotonin reuptake inhibitor (SSRI) and psychotherapy reduce depression in an outpatient clinic versus SSRI therapy alone?” The setting is the psychiatry clinic; the perspective/population is the outpatient; the intervention is combined psychotherapy and SSRI; the comparison is SSRI alone; and the evaluation is reduced depression.

The ECLIPSE approach is useful for evaluating the outcome of a policy or service (Nguyen, et al., unpublished data). ECLIPSE can apply in the following research question: “How can a resident get access to medical records of patients admitted to inpatient from other hospitals?” The expectation is: “What are you looking to improve/change to increase access to medical records for patients admitted to inpatient?” The client group is the residents; the location is the inpatient setting; the impact would be the residents having easy access to medical records from other hospitals; and the professionals in this scenario would be those involved in improving the service experiences such as hospital administrators and IT staff.

Inclusion and exclusion criteria

Establishing inclusion and exclusion criteria come after formulating research questions. The concept of inclusion and exclusion of data in a systematic review provides a basis on which the reviewer draws valid and reliable conclusions regarding the effect of the intervention for the disorder under consideration [ 11 ]. Inclusions and exclusion are based on preset criteria for specific systematic review. It should be done before starting the literature search in order to minimize the possibility of bias.

Eligibility criteria provide the boundaries of the systematic review [ 15 ]. Participants, interventions, and comparison of a research question provide the basis for eligibility criteria [ 15 ]. The inclusion criteria should be able to identify the studies of interest and, if the inclusion criteria are too broad or too narrow, it can lead to an ineffective screening process.

Protocol registration

Developing and registering research protocol is another important step of conducting a systematic review. The research protocol ensures that a systematic review is carefully planned and explicitly documented before the review starts, thus promoting consistency in conduct for the review team and supporting the accountability, research integrity, and transparency of the eventually completed review [ 10 ]. PROSPERO and the Cochrane Database of Systematic Reviews are utilized for registering research protocols and research questions, and they check for prior existing duplicate protocols or research questions. PROSPERO is an international database of prospectively registered systematic reviews related to health care and social sciences (PRISMA, 2016). It is funded by the National Institute for Health Research. The Cochrane Collaboration concentrates on producing systematic reviews of interventions and diagnostic test accuracy but does not currently produce reviews on questions of prognosis or etiology [ 16 ].

A detailed and extensive search strategy is important for the systematic review since it minimizes bias in the review process [ 17 ].

Selecting and searching appropriate electronic databases is determined by the topic of interest. Important databases are: MEDLARS Online (MEDLINE), which is the online counterpart to the Medical Literature Analysis and Retrieval System (MEDLARS); Excerpta Medica Database (EMBASE); and Google Scholar. There are multiple electronic databases available based on the area of interest. Other important databases include: PsycINFO for psychology and psychiatry; Allied and Complementary Medicine Database (AMED) for complementary medicine; Manual, Alternative, and Natural Therapy Index System (MANTIS) for alternative medical literature; and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for nursing and allied health [ 15 ].

Additional studies relevant for the review may be found by looking at the references of studies identified by different databases [ 15 ]. Non-indexed articles may be found by searching the content of journals, conferences proceedings, and abstracts. It will also help with letters and commentaries which may not get indexed [ 15 ]. Reviewing clinical trial registries can provide information about any ongoing trials or unpublished research [ 15 ]. A gray literature search can access unpublished papers, reports, and conference reports, and it generally covers studies that are published in an informal fashion, rather than in an indexed journal [ 15 ]. Further search can be performed by selecting important key articles and going through in-text citations [ 15 ].

Using Boolean operators, truncation, and wildcards

Boolean operators use the relationship between different search words to help with the search strategy. These are simple words (i.e., AND, OR, and NOT) which can help with more focused and productive results (poster, Jahan, et al.: How to conduct a systematic review. APPNA 39th Summer Convention. Washington, DC. 2016). The Boolean operator AND finds articles with all the search words. The use of OR broadens the focus of the search, and it will include articles with at least one search term. The researchers can also ignore certain results from the records by using NOT in the search strategy.

An example of AND would be using “depression” AND “children” in the search strategy with the goal of studying depression in children. This search strategy will include all the articles about both depression and children. The researchers may use OR if the emphasis of the study is mood disorders or affective disorders in adolescents. In that case, the search strategy will be “mood disorders” OR “affective disorders” AND “adolescents.” This search will find all the articles about mood disorders or affective disorders in adolescents. The researchers can use NOT if they only want to study depression in children and want to ignore bipolar disorder from the search. An example search in this scenario would be “depression” NOT “bipolar disorder” AND “children.” This will help ignore studies related to bipolar disorder in children.

Truncation and wildcards are other tools to make search strategy more comprehensive and focused. While the researchers search a database for certain articles, they frequently face terminologies that have the same initial root of a word but different endings. An example would be "autism," "autistic," and "autism spectrum disorder." These words have a similar initial root derived from “autis” but they end differently in each case. The truncation symbol (*) retrieves articles that contain words beginning with “autis” plus any additional characters. Wildcards are used for words with the same meanings but different spellings due to various reasons. For the words with spelling variations of a single letter, wildcard symbols can be used. When the researcher inputs “M+N” in the search bar, this returns results containing both “man” or “men” as the wildcard accounts for the spelling variations between the letters M and N.

Study selection

Study selection should be performed in a systematic manner, so reviewers deal with fewer errors and a lower risk of bias (online course, Li T, Dickersin K: Introduction to systematic review and meta-analysis. 2016. https://www.coursera.org/learn/systematic-review #). Study selection should involve two independent reviewers who select studies using inclusion and exclusion criteria. Any disagreements during this process should be resolved by discussion or by a third reviewer [ 10 ]. Specific study types can be selected depending on the research question. For example, questions on incidence and prevalence can be answered by surveys and cohort studies. Clinical trials can provide answers to questions related to therapy and screening. Queries regarding diagnostic accuracy can be answered by clinical trials and cross-sectional studies (online course, Li T, Dickersin K: Introduction to systematic review and meta-analysis. 2016. https://www.coursera.org/learn/systematic-review #). Prognosis and harm-related questions should use cohort studies and clinical trials, and etiology questions should use case-control and cohort studies (online course, Li T, Dickersin K: Introduction to systematic review and meta-analysis. 2016. https://www.coursera.org/learn/systematic-review #).

Data screening and data extractions are two of the major steps in conducting a systematic review [ 18 ]. Data screening involves searching for relevant articles in different databases using keywords. The next step of data screening is manuscript selection by reviewing each manuscript in the search results to compare that manuscript against the inclusion criteria [ 18 ]. The researchers should also review the references of the papers selected before selecting the final paper, which is the last step of data screening [ 18 ].

The next stage is extracting and appraising the data of the included articles [ 18 ]. A data extraction form should be used to help reduce the number of errors, and more than one person should record the data [ 17 ]. Data should be collected on specific points like population type, study authors, agency, study design, humanitarian crisis, target age groups, research strengths from the literature, setting, study country, type(s) of public health intervention, and health outcome(s) addressed by the public health intervention. All this information should then be put into an electronic database [ 18 ].

Assessing bias

Bias is a systematic error (or deviation from the truth) in results or inferences. Biases can change the results of any study and lead to an underestimation or overestimation of the true intervention effect [ 19 ]. Biases can impact any aspect of a review, including selecting studies, collecting and extracting data, and making a conclusion. Biases can vary in magnitude; some are small, with negligible effect, but some are substantial to a degree where an apparent finding may be entirely due to bias [ 19 ]. There are different types of bias, including, but not limited to, selection, detection, attrition, reporting, and performance.

Selection bias occurs when a sample selected is not representative of the whole general population. If randomization of the sample is done correctly, then chances of selection bias can be minimized [ 20 ].

Detection bias refers to systematic differences between groups in how outcomes are determined. This type of bias is based on knowledge of the intervention provided and its outcome [ 19 ].

Attrition bias refers to systematic differences between groups in withdrawals from a study [ 19 ]. The data will be considered incomplete if some subjects are withdrawn or have irregular visits during data collection.

Reporting bias refers to systematic differences between reported and unreported findings, and it is commonly seen during article reviews. Reporting bias is based on reviewer judgment about the outcome of selected articles [ 20 ].

Performance bias develops due to the knowledge of the allocated interventions by participants and personnel during the study [ 20 ]. Using a double-blind study design helps prevent performance bias, where neither the experimenter nor the subjects know which group contains controls and which group contains the test article [ 14 ].

Last step of systematic review: discussion

The discussion of a systematic review is where a summary of the available evidence for different outcomes is written and discussed [ 10 ]. The limitations of a systematic review are also discussed in detail. Finally, a conclusion is drawn after evaluating the results and considering limitations [ 10 ].

Discussion of the current article

Systematic reviews with or without a meta-analysis are currently ranked to be the best available evidence in the hierarchy of evidence-based practice [ 21 ]. We have discussed the methodology of a systematic review. A systematic review is classified in the category of filtered information because it appraises the quality of the study and its application in the field of medicine [ 21 ]. However, there are some limitations of the systematic review, as we mentioned earlier in our article. A large randomized controlled trial may provide a better conclusion than a systematic review of many smaller trials due to their larger sample sizes [ 22 ], which help the researchers generalize their conclusions for a bigger population. Other important factors to consider include higher dropout rates in large studies, co-interventions, and heterogeneity among studies included in the review.

As we discussed the limitations of the systematic review and its effect on quality of evidence, there are several tools to rate the evidence, such as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system [ 22 ]. GRADE provides a structured approach to evaluating the risk of bias, serious inconsistency between studies, indirectness, imprecision of the results, and publication bias [ 22 ]. Another approach used to rate the quality of evidence is a measurement tool to assess systematic reviews (AMSTAR) [ 23 ]. It is also available in several languages [ 23 ].

Conclusions

Despite its limitations, a systematic review can add to the knowledge of the scientific community especially when there are gaps in the existing knowledge. However, conducting a systematic review requires different steps that involve different tools and strategies. It can be difficult at times to access and utilize these resources. A researcher can understand and strategize a systematic review following the different steps outlined in this literature review. However, conducting a systematic review requires a thorough understanding of all the concepts and tools involved, which is an extensive endeavor to be summed up in one article.

The Cochrane Handbook for Systematic Reviews of Interventions and the Center for Reviews and Dissemination (CRD) provide excellent guidance through their insightful and detailed guidelines. We recommend consulting these resources for further guidance.

Given that our article is a narrative review of the scholarly literature, it contains the same limitations as noted for any narrative review. We hope that our review of the means and methods for conducting a systematic review will be helpful in providing basic knowledge to utilize the resources available to the scientific community.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

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Management options for traumatic posterior sternoclavicular joint dislocation: a narrative review with a single institution’s experience.

1. Introduction

2. methods, study design and surgical technique, 2.1. conservative treatment, 2.2. surgical treatment with a figure-of-eight semitendinosus tendon autograft reinforced with high-strength suture tape, 4. discussion, 4.1. anatomy and biomechanics of the scj, 4.2. open reduction and scj stabilization and reconstruction options, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest, abbreviations.

SCJ	sternoclavicular joint
ROM	range of motion
g	gram
ED	Emergency department
CT	computed tomography
MRI	magnetic resonance imaging
LARS	ligament augmentation and reconstruction system
ORIF	open reduction and internal fixation
RCTs	randomized controlled trials
mm	millimeters
ml	milliliters
ACJ	acromioclavicular joint

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Ciatti, C.; Masoni, V.; Maniscalco, P.; Asti, C.; Puma Pagliarello, C.; Caggiari, G.; Pes, M.; Rivera, F.; Quattrini, F. Management Options for Traumatic Posterior Sternoclavicular Joint Dislocation: A Narrative Review with a Single Institution’s Experience. J. Clin. Med. 2024 , 13 , 5428. https://doi.org/10.3390/jcm13185428

Ciatti C, Masoni V, Maniscalco P, Asti C, Puma Pagliarello C, Caggiari G, Pes M, Rivera F, Quattrini F. Management Options for Traumatic Posterior Sternoclavicular Joint Dislocation: A Narrative Review with a Single Institution’s Experience. Journal of Clinical Medicine . 2024; 13(18):5428. https://doi.org/10.3390/jcm13185428

Ciatti, Corrado, Virginia Masoni, Pietro Maniscalco, Chiara Asti, Calogero Puma Pagliarello, Gianfilippo Caggiari, Marco Pes, Fabrizio Rivera, and Fabrizio Quattrini. 2024. "Management Options for Traumatic Posterior Sternoclavicular Joint Dislocation: A Narrative Review with a Single Institution’s Experience" Journal of Clinical Medicine 13, no. 18: 5428. https://doi.org/10.3390/jcm13185428

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Published: 11 September 2024

Mechanisms of manipulation: a systematic review of the literature on immediate anatomical structural or positional changes in response to manually delivered high-velocity, low-amplitude spinal manipulation

Kenneth J. Young ORCID: orcid.org/0000-0001-8837-7977 1 , 20 ,
Charlotte Leboeuf-Yde 2 , 3 ,
Lindsay Gorrell 4 ,
Cecilia Bergström 5 ,
David W. Evans 6 ,
Iben Axén 7 , 8 ,
Kenneth Chance-Larsen 9 ,
Olivier Gagey 10 ,
Vasileios Georgopoulos 11 ,
Guillaume Goncalves 1 ,
Catherine Harris 12 , 13 ,
Steen Harsted 14 , 15 ,
Roger Kerry 16 ,
Edward Lee 17 ,
Christopher McCarthy 18 ,
Casper Nim 2 , 14 , 15 ,
Luana Nyirö 4 ,
Petra Schweinhardt 4 &
Steven Vogel 19

Chiropractic & Manual Therapies volume 32 , Article number: 28 ( 2024 ) Cite this article

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Spinal manipulation (SM) has been claimed to change anatomy, either in structure or position, and that these changes may be the cause of clinical improvements. The aim of this systematic review was to evaluate and synthesise the peer-reviewed literature on the current evidence of anatomical changes in response to SM.

The review was registered with PROSPERO (CRD42022304971) and reporting was guided by the standards of the PRISMA Statement. We searched Medline, Embase, CINAHL, AMED, Cochrane Library all databases, PEDro, and the Index to Chiropractic Literature from inception to 11 March 2022 and updated on 06 June 2023. Search terms included manipulation, adjustment, chiropractic, osteopathy, spine and spine-related structures. We included primary research studies that compared outcomes with and without SM regardless of study design. Manipulation was defined as high-velocity, low-amplitude thrust delivered by hand to the spine or directly related joints. Included studies objectively measured a potential change in an anatomical structure or in position. We developed a novel list of methodological quality items in addition to a short, customized list of risk of bias (RoB) items. We used quality and RoB items together to determine whether an article was credible or not credible. We sought differences in outcomes between SM and control groups for randomised controlled trials and crossover studies, and between pre- and post-SM outcomes for other study designs. We reported, in narrative form, whether there was a change or not.

The search retrieved 19,572 articles and 20 of those were included for review. Study topics included vertebral position (n = 3) facet joint space (n = 5), spinal stiffness (n = 3), resting muscle thickness (n = 6), intervertebral disc pressure (n = 1), myofascial hysteresis (n = 1), and further damage to already damaged arteries (n = 1). Eight articles were considered credible. The credible articles indicated that lumbar facet joint space increased and spinal stiffness decreased but that the resting muscle thickness did not change.

We found few studies on this topic. However, there are two promising areas for future study: facet joint space and spinal stiffness. A research strategy should be developed with funding for high quality research centres.

Spinal manipulation (SM) is an intervention that is commonly sought by people with back and neck pain. Manual therapists, chiropractors and osteopaths, in particular, commonly utilise SM as a therapeutic intervention [ 1 , 2 , 3 ]. SM is associated with improved clinical outcomes for certain musculoskeletal disorders [ 4 , 5 , 6 , 7 ]. As a result, SM is recommended in several treatment guidelines and reviews [ 8 , 9 , 10 , 11 ]. However, the underlying mechanism(s) of action need to be understood to determine appropriate indications for the application of SM as well as to maximize its therapeutic efficacy. That is, it is important to determine what is inside the “black box” of mechanism(s) of action of SM [ 12 ].

There are many theories and assertions on this topic [ 13 ], but there is no general consensus on the mechanism(s) of action of SM. It has been claimed that SM can change anatomy, such as repositioning vertebrae [ 14 ] or altering the thickness of muscles at rest [ 15 ]. It is proposed that these changes may be long-lasting [ 16 ]. Other claims include physiological changes, ranging from liberating Innate Intelligence [ 17 ], to modification of muscle strength [ 18 ] or reducing inflammation [ 19 ]. Historically, the nervous system has had a particular interest among chiropractors and osteopaths, as SM has been thought to affect spinal nerves [ 20 , 21 ], the autonomic nervous system [ 22 ], and even the brain [ 23 ].

These anatomical and/or physiological changes are then purported to explain any associated clinical improvements, such as increased function, reduced pain, relief from specific diseases, and better health in general [ 24 ]. If any of these proposed mechanisms can be supported by evidence, manual therapists will be able to offer to patients a coherent rationale for applying SM.

Any mechanism of manipulation is comprised of two aspects. First, the manipulation must have an effect in the body lasting beyond the application of SM, and this effect must lead to a change in clinical outcome. Both aspects must be investigated in turn to determine potential mechanisms of SM. Although it is possible that there is a cumulative effect from SM or that a minimum dosage is needed to create an effect, this has not been well documented. Therefore, to proceed in a stepwise fashion, it seems reasonable to first determine what the immediate effects may be of one single SM.

There is evidence on what happens within the spine, as a response to various forces applied during a high-velocity low-amplitude (HVLA) SM [ 25 , 26 , 27 , 28 ], such as the distribution of forces within tissues receiving the manipulation [ 29 ], and the amount and direction of displacement of vertebrae during SM [ 30 ], but a clear picture of what happens directly afterwards appears to be lacking.

Although there have been systematic reviews on some physiological effects of SM [ 31 , 32 , 33 ], to our knowledge, there are no systematic reviews that have attempted to synthesise evidence of the underlying anatomical mechanisms of SM. Therefore, we assessed the state of evidence of a measurable change anatomical structures that occurs following the application of SM.

The overall aim of this systematic review was to evaluate and synthesise the peer-reviewed literature on the immediate changes in or to anatomical structures in response to SM.

Our research objectives were as follows:

Identify, evaluate the quality of, and narratively synthesise the evidence that has been published in peer-reviewed research literature regarding immediate anatomical change after a spinal manipulation.

Identify gaps in understanding the anatomical effects of spinal manipulation and provide recommendations for future research.

Advisory board

A research project advisory board was convened for support and guidance, consisting of a chair (chiropractor KJY), an information specialist (CH), 2 chiropractors (CLY, IA), a physiotherapist (RK), an osteopath (SV), a medical doctor/chiropractor (PS), and an anatomist/orthopaedic surgeon (OG). Several had experience with systematic reviews.

Team and roles

In all, 14 people (6 chiropractors, 6 physiotherapists, and 2 osteopaths) were recruited to perform the screening of articles. Several team members practice clinically. One reviewer dropped out before screening was completed and was replaced by KJY. Another reviewer dropped out after the screening process and was replaced by LG. One researcher with a chiropractic background, experienced in systematic reviews (CLY), acted as referee and supervisor only. The screening of articles was divided between 7 teams of 2 people each.

Protocol registration and reporting

The review was registered with PROSPERO (CRD42022304971) and the reporting was guided by the standards of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Statement [ 34 ].

Search strategy

We performed a broad search to capture as many relevant articles as possible and developed our search strategies with an experienced information specialist (CH). The search strategy included relevant subject headings and search terms relating to manipulation and the spine and was adapted for use in each database. We had no resources for a translation service, so we limited the search to the English language. We searched the following databases: Medline (Ovid), Embase (Ovid), CINAHL (EBSCOhost), AMED (EBSCOhost), Cochrane Library all databases (via Wiley), PEDro ( https://pedro.org.au/ ), and the Index to Chiropractic Literature ( https://www.chiroindex.org/ ). All databases were searched from inception to 11 March 2022; the searches were updated on 06 June 2023. The full search strategy can be found in Additional File 1 .

In cases where full-text articles were not available through library services, we emailed the first author, if an email address was published in the article. If there was no email address listed, or if we received no response to an email query, we searched for the first author on ResearchGate and, if found, we sent a full-text article request. If there was no response or the author could not provide us with an article, it was excluded.

Terminology

We used the term “outcome variable” to represent what the researchers measured in each study, referring to the mechanism of manipulation being studied. For instance, if SM is hypothesised to improve a clinical outcome by restoring the position of a vertebra, the mechanism by which SM achieves this end outcome is by changing the position of a vertebra. The outcome variable measured in the experiment would, therefore, be the difference in vertebral position from pre- to post-manipulation. In relation to research findings, we used the term “positive” not as a value judgment, but rather as shorthand to denote when a post-SM change in measurement was reported, and the term “negative”, when no such change was reported.

Eligibility criteria

We included only peer-reviewed articles if they fulfilled certain criteria:

We included primary research studies that compared non-treated with treated anatomical structures, regardless of the study design. The articles had to define SM as an HVLA thrust delivered by hand to the spine or directly related joints (i.e., including the sacroiliac or costo-vertebral joints). The measurement of effect must have occurred after a single manipulation session, that is, not after a course of care. If articles did not state a specific time interval between SM and post-SM measurement, but their research designs, or the way the text was written gave the distinct impression that there was little delay between the manipulation and the post-SM measurement, they were included.

The SM could not have been combined with any other therapeutic interventions.

Studies must have objectively measured a potential change in anatomical structure (the physical attributes of one or more structures in the human body) or a change in position (the relationship of two or more structures to each other). Studies measuring range of motion were considered subjective and were not included, since participants or assessors could consciously or subconsciously influence the position during the measurement.

Anatomical change was considered to be distinct from change in physiological state. Therefore, we included articles that reported on resting muscle thickness, as opposed to contracted muscle thickness, because we considered muscle contraction to be a matter better considered under physiological effects of SM. It is possible that a change in resting muscle thickness may be due to a physiological process such as contraction/relaxation. However, there may also be a purely physical mechanism such as stretching. Therefore, we included it.

Animal studies were included, because objectively measured anatomical effects of SM are not subject to contextual effects as clinical outcomes may sometimes be.

If studies measured more than one outcome, only the relevant outcome(s) were considered for this review. For the full list of exclusion criteria, please see Additional File 2 .

Article selection

All articles retrieved through the literature searches were exported into EndNote X9.3.1 (Clarivate, Philadelphia, 2013). After duplicates were removed, the remaining articles were imported into the web-based Rayyan systematic review management application [ 35 ] for reference management and tracking of the screening process. The total number of articles was divided into 7 separate reviews on Rayyan, each given to a pair of reviewers to independently screen titles/abstracts. Full-text versions of the potentially included articles were obtained for screening by the same teams. Detailed written instructions were distributed to the reviewers prior to the screening processes and meetings were held with each pair prior to title/abstract screening to facilitate congruence in approach. In cases of disagreement between reviewers during phase one (title/abstract) or phase two (full text) screening, a third independent reviewer (KJY or LG) was consulted to achieve consensus. Finally, KJY and CB conducted a backward search, manually searching the reference lists from all articles included at the full-text screening stage for any missing articles.

Data extraction

The articles were grouped by topic, and reviewers self-assigned, as much as possible, to 1 or 2 topics, with 2 reviewers independently reviewing each topic. The reviewers were LN, DE, KJY (2 topics), RK, CB, CM, SH, VG, LG, EL GG, KCL, and CN. Each topic pair was overseen by a third reviewer, either KJY, LG or DE, who had knowledge of the topic and was designated as “leader” of the group. Calibration sessions were held by KJY with each team prior to data extraction to help ensure congruency of approach. Study descriptions, methodological quality, and risk of bias (RoB) data were extracted. The 7 pairs of reviewers independently extracted data, with conflicts resolved by discussion between them or with the leader. Findings for each team were reviewed by the leaders of each team. KJY, CLY, and DE reviewed all findings.

Extracted data

Article descriptions.

Descriptive information about each article was entered into a table. This included first author/year of publication, mechanism of spinal manipulation investigated, study design, study setting, study cohort, sample sizes of intervention and control groups, control group description, spinal region studied, outcome variable used, instrument used for measurement, and the time interval between SM and measurement.

Quality assessment and risk of bias

Because the articles we included had used objective measurements of anatomical/positional outcome variables, there were potential areas of technical error introduced during the experiments. For this reason, and informed by a previous publication [ 22 ], we considered the techniques used to study the various outcome variables, and developed a novel list of methodological quality items. These items related to technical aspects of the experiments and transparency in methods.

A standard RoB reporting tool was not applicable due to the heterogeneity of study designs. Further, RoB tools are suitable mainly for clinical studies, in which the influence of the study participant is important to account for. However, in the investigations included in our review, study participant influence would be absent, as they would not likely be able to influence technical readings relating to anatomical structures, either consciously or subconsciously. Therefore, study participants did not need to be blinded to treatment or control group allocation. They also did not need to be naïve to the treatment. Thus, we included RoB items only relating to the blinding of assessors and statisticians. We selected only RoB items that we considered appropriate for the relevant study designs, i.e., depending on if they had a control group or not. We also included random allocation when two interventions were compared because it was important that inherent differences between groups was eliminated. We then considered those quality and RoB items together to determine, whether an article was credible or not credible, in a process described below.

Results of each study were extracted, after the quality and RoB items were determined, to avoid reviewer bias of the quality/RoB assessment. The results of each of the studies were extracted from the articles by 3 members of the team. CM reviewed half the articles and SV reviewed the other half, each working in conjunction with KJY, who reviewed all articles. Conflicts and queries were resolved by discussion or consultation with CLY. Results were entered into separate tables for each outcome variable, including the ultimate finding on whether the anatomical structure was affected by the manipulation or not. All tables were consolidated and edited for readability, and each team reviewed and approved their consolidated tables.

Data synthesis

Assessment and weighting of quality and risk of bias.

Through consensus discussion, we defined the quality and RoB items by the consequences we assumed that they would have on the credibility of the data. For this purpose, we developed a dichotomous system of weighting. Items were determined to be either “critical” or “important”. “Critical” items were essential to the credibility of the results, whereas “important” items were those that were considered good practice but were not essential, in and of themselves, to a judgement on whether results could be considered credible.

Quality items

We considered 3 quality items to be “critical”. First was “evaluation tool(s) appropriate to measure outcome variable(s)”. The second critical item was “reported the reliability of outcome variable(s)”. The final critical quality item was “measurement tool calibrated” (if appropriate). The remaining quality items on our checklist were assessed as important, but not critical.

Risk of bias items

For non-RCT studies, we included only one RoB item, “assessor blinding to pre-post manipulation status”, and we considered it to be critical. For RCTs and crossover study designs, 2 RoB items were considered critical. First was “random allocation of participants”. The second was “assessor blinding to intervention group”. The remaining RoB item was “statistician blind to intervention/control group”, which is not commonly reported in articles. For this reason, we decided to classify it as important rather than critical.

Assessment of the certainty of evidence

We used the quality and RoB tables to establish “credibility” for each article and outcome variable. If a quality or RoB item was appropriately reported, it was left as white in the table. However, items that had not been reported or were poorly reported, were marked as yellow for important items and red for critical items.

We then made an overall assessment of credibility for each article, based on both the quality and RoB, after which each article was defined as “credible” or “not credible”. Articles were defined as credible if they had 0 red and 0–2 yellow items. Articles were defined as not credible if they had 1 or more red items or 3 or more yellow. Please see Table 1 for the key to interpreting the quality and RoB items as well as explanations of each.

Reporting of results

It was not suitable to pool the results for meta-analysis due to heterogeneity in outcome variables, study design, and participant characteristics. It was also not relevant, because our research question did not require a measurement (e.g., amount of facet joint space increase or cross-sectional area increase in muscle size) but rather just the presence or absence of change post-SM. These results were reported both in detail and summarized in tables as “positive” (i.e., there was a change post-SM) or “negative” (i.e., there was no change).

To excerpt maximum information from this research area, we reported results from all studies, but separately for the “credible” and “not credible” articles. We also included a summary of methodological issues in the Discussion to aid future researchers to improve this research area. Our rules on reporting data were as follows:

We reported differences between SM and control groups for RCTs and crossover studies and between pre- and post-SM groups for other study designs. When there were several results reported in one article, we used the “best” estimates (i.e., best case scenario of a “positive” outcome or difference pre-post SM). For example, one article reported a positive result when the participant was re-measured while remaining in side-posture position, but there was a “negative” result when the participant was returned to neutral (supine) position for post-SM measurement. In this case, we reported the positive result.

If there were no statistically significant differences or statistical significance tests were not reported, we provided, again, the “best” estimate (i.e., selecting the best-case scenario).

If no estimates (direct measurements) were reported, but rather only significance values, then we reported those.

Writing and editing the manuscript

To keep the workload achievable and to improve attention to detail in manuscript development, we used an iterative process. Each section of the paper (introduction, methods, results, and discussion) and all tables and figures were disseminated to the research team for comments at different stages. In cases of disagreement, an appropriate member or members of the advisory board were contacted, and discussions were held amongst team members until consensus was reached.

Of the original 19,572 articles (37,902 including duplicates), 20 articles that reported on 20 studies were ultimately included in this review (Fig. 1 ).

PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources. * Records were excluded by humans; no automation tools were used. ** Eleven articles were not available for full-text retrieval after having unsuccessfully attempted to contact the first author of each in two ways, as detailed in the Methods section. *** Three articles were retrieved which had their titles/abstracts in English but the manuscripts in a foreign language and thus were excluded at the full-text screening stage

Study descriptions

As shown in Table 2 , the reviewed articles included the following outcome variables: vertebral position (n = 3) [ 14 , 36 , 37 ], facet joint space (n = 5) [ 38 , 39 , 40 , 41 , 42 ], spinal stiffness (n = 3) [ 43 , 44 , 45 ], resting muscle thickness (n = 6) [ 15 , 46 , 47 , 48 , 49 , 50 ], intervertebral disc pressure (n = 1) [ 51 ], myofascial hysteresis (n = 1) [ 52 ], and further damage to damaged arteries (n = 1) [ 53 ].

Study designs included both controlled (n = 10) and uncontrolled (n = 10) studies. The number of study participants ranged from 1 to 250. The most commonly studied participants were healthy adults (n = 9). Two studies included animals.

Most studies (n = 12) took place in the United States of America, with a private chiropractic or osteopathic school as the most common setting (n = 6), while 3 studies explicitly stated that they used a lab setting. SM was most commonly performed on the lumbar spine or lumbopelvic area (n = 12).

Methodological quality

As can be seen in Tables 3 , 4 , 5 , 6 , and 7 , issues relating to the methodological quality varied. Regarding the two critical quality items, the first, “using an appropriate evaluation tool” was consistently lacking in the 3 articles on vertebral position, and the second, “reporting of the reliability of an outcome variable” was not present in 6 of the 11 articles.

Risk of bias

We did not find that critical RoB was a problem in studies using an RCT or crossover design (Tables 3 , 4 , 5 , 6 , and 7 ), as 7 of 9 such articles had no critical deficiencies in this domain. However, in other study designs, 7 of 11 articles did not report that outcome measurements had been taken by assessors who were blinded to the previous assessment.

Credibility

The RoB/quality tables (Tables 3 , 4 , 5 , 6 and 7 ) show that 8 of the 20 studies were considered credible, whereas the other 12 were considered not credible. Notably, two of the studies, reported by Konitzer [ 46 ] and Fritz [ 43 ], met all our quality and RoB criteria.

The numbers of articles reporting on credible studies were as follows: facet joint space (n = 4/5), spinal stiffness (n = 1/3), and resting muscle thickness (n = 3/6). Therefore, 1 of the 5 studies on facet joint space was not credible; 2 of the 3 studies on spinal stiffness were not credible and 3 of the 6 studies on resting muscle thickness were not credible. In addition, all the articles reporting on studies on vertebral position (n = 3), intervertebral disc (IVD) pressure (n = 1), further damage to damaged arteries (n = 1), and myofascial hysteresis (n = 1) were found to be not credible.

Results of credible studies by outcome variable

Results from the 8 credible studies are shown below, reported by outcome variable.

Facet joint space (n = 4/5)

Four of 5 studies on changes to facet joint space were considered credible. They all reported an increase in lumbar spine facet joint space post-side-posture manipulation for the “up” side facet joints, but only if the participant was re-scanned using magnetic resonance imaging (MRI) while maintaining side posture position. When returned to neutral position the increased joint space disappeared.

Spinal stiffness (n = 1/3)

Only 1 of the 3 studies on spinal stiffness was found credible and reported immediate reduced spinal stiffness post-SM.

Resting muscle thickness (n = 3/6)

Three of six studies on changes to resting muscle thickness were considered credible. These studies, using diagnostic ultrasound, reported no statistically significant differences in either the transverse or internal oblique abdominal muscles post-manipulation.

Results of not credible studies by outcome variable

Below are shown the results from the 12 not credible articles, reported by outcome variable.

Vertebral position (n = 3/3)

The results of these 3 not credible studies were conflicting; 2 articles reported post-SM changes in vertebral position, using plain radiography, whereas one reported no change post-SM using ultrasound.

Facet joint space (n = 1/5)

The 1 not credible study had only 2 participants measured for the relevant outcome variable as part of a larger study, in which all other participants also received traction before and after SM, and so were not considered controls. No change in facet joint space and no presence of pneumarthrosis (discrete bubble of intra-articular gas) was reported post-SM using computed tomography (CT).

Spinal stiffness (n = 2/3)

The 2 not credible studies found a reduction in spinal stiffness post-SM. One study used a mechanical indentometer; the other studied horses using a cable extensometer with a pressure sensor mat.

Results in the 3 not credible studies were conflicting. One reported a pre- post-SM difference in resting transverse abdominal muscle thickness. One reported a difference in the resting thickness of pelvic floor muscles in pregnant women but not in non-pregnant women. The third reported no difference in thickness for multifidus muscles. All studies made measurements using ultrasound.

Intervertebral disc pressure (n = 1/1)

There was 1 not credible study which found increased disc pressure post-SM for at least 15 s using a pressure probe inserted into the disc.

Myofascial hysteresis (n = 1/1)

The 1 not credible RCT used a durometer to measure hysteresis with mixed results that we found difficult to interpret.

Further damage to already damaged arteries (n = 1/1)

The 1 not credible study on this topic was an uncontrolled intervention. The article reported no further damage post-SM to vertebral arteries of dogs that were damaged prior to manipulation with an angioplasty cutting balloon. This study was stopped early for ethical reasons once no effect was detected.

Please see Table 8 for the results and credibility assessments of all studies.

Post-hoc analysis

Cross-referencing credibility with positive (change after SM) or negative (no change after SM) results of SM resulted in a mixed picture. Thus, there was no relationship between the credibility of studies with positive or negative results of these studies. For a visual summary of the findings by outcome variable, credibility, and whether an article reported positive or negative results, see Table 9 .

Summary of main findings

This systematic review included 8 articles that we considered to be credible and 12 that we regarded as not credible. They dealt with 7 proposed SM mechanisms of action: change in vertebral position, facet joint space, spinal stiffness, resting muscle thickness, IVD pressure, myofascial hysteresis, and further damage to damaged arteries. We include results from articles that we considered credible as well as ones we considered not credible, in order to report as fully and fairly as possible, any information published to this point on the immediate anatomical/positional changes in response to SM.

The credible articles reported that, post-SM, there were: (i) changes in facet joint space, (ii) changes in spinal stiffness, but (iii) no changes in resting muscle thickness after SM.

A comparison between the results of the credible and not credible articles revealed that the latter: (i) disagreed with the credible articles on facet joint space/pneumarthrosis (discrete bubble of intra-articular gas), (ii) agreed on spinal stiffness, but (iii) had conflicting results for resting muscle thickness.

In addition, the not credible articles reported (i) conflicting results between them on vertebral position, (ii) change in IVD pressure and (iii) change in myofascial hysteresis, but (iv) no further damage to already damaged arteries after SM.

Comparisons to the literature

To our knowledge, this is the first systematic review dealing exclusively with the immediate anatomical/positional changes in response to SM. However, a systematic review on spinal mobilisation (i.e., not HVLA manipulation) reported on articles that evaluated mainly clinical outcomes but also on some anatomical mechanisms [ 33 ]. Specifically, they included 4 articles that evaluated spinal stiffness, and 3 of the 4 reported reduced spinal stiffness after mobilisation (not HVLA SM). These findings thus aligned with the results in our 3 credible articles that reported reduced spinal stiffness post-SM.

Methodological considerations of the present systematic review

Literature search.

Important positive aspects of our literature search were that an experienced information specialist (CH) ensured that we consulted all relevant databases for this topic and that all databases were interrogated using the different input parameters necessary to retrieve the relevant articles. We also used broad search parameters with no date limit, to capture all relevant articles on the topic. The search was updated to ensure we captured any more recent articles prior to submission of our review. We limited the search to articles in English only. Although, therefore, we may have failed to include every relevant published article, we believe this to be a minor limitation, as most articles dealing with SM are typically published in the English language. Also, we did not follow the PRESS guideline recommendation [ 54 ] to perform a review of the search strategy, which might have affected the quality and comprehensiveness of our search.

Inclusion/exclusion criteria

To ensure that SM was the most likely reason for any potential change in an outcome variable, we included only articles on studies that performed pre- and post-SM measurements and reported this for a single SM session. If some effects of SM require multiple sessions to manifest, we would have missed out on such information. We also excluded articles that used SM in combination with any other therapeutic intervention. Therefore, if SM requires facilitation by another intervention for the effects to manifest, we would have missed those changes. There may have been differences among team members in interpretation of inclusion/exclusion criteria which could have led to articles being missed out, although we mitigated this possibility with calibration sessions and written instructions, so this is unlikely.

Full text screening

Eleven articles included at the title/abstract screening stage were not available for the full-text screening process. Nine of those were published in chiropractic subluxation-focused journals, thus not available through mainstream library systems, with authors either not found on ResearchGate or not responding to requests for articles. This missingness of data may have affected our conclusions, but our experience is that the “grey” chiropractic journals do not attract high quality articles, so we do not believe that our conclusions were impacted.

Quality/risk of bias

It is well known that clinical studies will more easily produce positive findings if the human factor is allowed to play an essential role by voluntarily or subconsciously introducing bias. This is the reason why systematic reviews assess the RoB before drawing conclusions on the validity of results. This phenomenon was clearly shown in a previous systematic review on the “effect” of spinal manipulative therapy (SMT) on non-musculoskeletal conditions [ 55 ]. All studies that were considered to have failed in preventing the “human factor” reported positive results, whereas none of the high-quality studies found there to be an “effect” of SMT [ 55 ].

We emphasized RoB only in relation to aspects that clearly could be influenced by the beliefs and wishes of the researchers. Experimental/basic science (e.g. laboratory) studies, are susceptible to fewer RoB items. Instead, commercial and university laboratories are often subjected to accreditation procedures [ 56 , 57 ], which are specific to the requirements of their area of activities and relate more to technicalities than to systematic human errors. Thus, the use of appropriate and calibrated tools that are operated by competent personnel would be paramount in preventing random errors in studies that rely on technical assessments, beyond that of human subjective observations and reactions.

Results in studies that deal with anatomical/positional changes after SM are, thus, unlikely to be influenced by the beliefs and wishes of study participants and clinicians, whereas the beliefs and wishes of the assessor and statistician could have an impact. Failing to use a reliable outcome variable, measuring changes with a non-calibrated machine, or allowing amateurs to conduct the study, could possibly induce bias but more likely result in random errors.

Therefore, in addition to the RoB, we accounted for several technical aspects, defined as “quality”. Quality issues are likely to cause non-systematic errors, as opposed to bias, which may cause systematic errors. Examples of quality issues that must be assured to prevent non-systematic errors are skills of assessment personnel and the calibration of measurement tools. To accurately judge the technical quality of studies, we ensured that each review team had at least one member with expertise in the area.

Nonetheless, the evaluation and weighting of methods was a subjective matter, and other investigators may have judged differently. There may also have been differences among team members in the interpretation of quality and RoB criteria, which could have led to differences in results. However, we mitigated that possibility with multiple calibration sessions and repeated consultations on iterations of the tables among the team members.

Results of studies

The results were extracted from each article only after the quality and RoB items were determined, to avoid reviewer bias of the quality/RoB assessment. To prevent biased results interpretation, extraction of the study outcomes and interpretation of findings were performed by other teams than the experts in the area, although the experts were invited to critically review the extracted findings and interpretations.

Part of the standard synthesis in systematic reviews is to identify ‘gaps in the literature’. However, these ‘gaps’ may not be areas that have not been studied, just areas that have not been studied well. By listing all the studies that have been conducted in this area and detailing all the methodological errors that we identified, we show which areas can be studied (or which may be too difficult to study with current technology) and also indicate how they may be studied better in the future.

Methodological considerations for reviewed articles and potential future studies

General comments.

In the hope of being helpful to future researchers, we provide some methodological comments regarding the techniques used to study the potential anatomical/positional effects of SM.

Only 8 of the 20 studies were assessed as credible. Consequently, this indicates that technical experimental studies have not been prioritised in environments that were created for such purposes, i.e., taking advantage of relevant equipment and skilled researchers working in dedicated research laboratories. Assessors for these procedures should be highly experienced or adequately trained. In addition, when there is a human element, it is important to establish inter-/intra-rater reliability of the assessors, before undertaking the study. Further, researchers must strive towards the use of measurement tools that are validated, and it is important to remember that some need to be calibrated. The use of frameworks like COSMIN (Consensus-based Standards for the selection of health Measurement Instruments) [ 58 ] may be helpful in this process. Also, when measuring positions or spaces, it would be of utmost importance to place study subjects in identical positions before and after the SM, to prevent ‘normal’ aberrations and measurement errors due to distortion.

Items relating to relevant RoB should be observed, in particular, blinding of before-after readings in studies without control groups. Statisticians should be blinded to control/intervention readings. Statistical methods, cut points, etc. should be determined a priori, rather than after any results have been returned.

Comments relating to each outcome variable

Vertebral position.

Two of 3 studies on vertebral position used radiographs to try to capture very small post-SM changes (< 2 degrees of rotation [ 14 ] or < 4mm of displacement). However, we note that the use of plain radiography to detect very small changes in vertebral position is debatable, at best, and in our opinion, the use of radiography for these measurements was not appropriate [ 59 ]. Instead, we suggest that future investigations could use computed tomography, which offers much greater resolution. The precision and likely error tolerance of the measurement instrument should be stated in future studies.

The third study used ultrasound to measure paraspinal tissue thickness as a proxy for vertebral rotation. However, the pressure on the ultrasound head was not measured. This is important, as increased pressure could compress tissues and distort readings. Nevertheless, this method could hold promise for developing a method of measuring vertebral rotation without the use of ionising radiation (Tables 2 and 3 ).

Facet joint space

All 4 credible articles found an increase in facet joint space post-SM. However, as they were conducted by the same team of researchers, these results should be confirmed by at least 1 independent team.

MRI is likely optimal for viewing facet joint space increase that is retained after the SM event, as bone and capsule detail can be captured.

Theories exist on the potential role of SM on intra-articular meniscoids/discoids, synovial folds, and adhesions within the facet joints [ 60 , 61 , 62 , 63 , 64 , 65 ]. We found no relevant articles that investigated any of these anatomical variations/pathologies. We suggest that if someone wanted to study them, they may be visualised using high resolution imaging such as MRI (Tables 2 and 4 ).

Spinal stiffness

The use of the mechanical indentometer in 2 of the 3 studies on spinal stiffness was useful because it removed the human element from the interpretation of the measurements. Calibration of the tool is important in this area (Tables 2 and 5 ).

Resting muscle thickness

Since 3 credible studies all showed absence of changes to resting muscle thickness, we believe that this area no longer warrants further study. We found the study design in one of the not credible articles [ 50 ] overly complex and difficult to understand; it seemed to report on 2 crossover studies, with important differences between the intervention and control groups (Tables 2 and 6 ).

Intervertebral disc pressure

The 1 study conducted on IVD pressure showed that it is difficult to study. The use of a pressure-measuring probe to physically penetrate the disc is not attractive to study participants and seems ethically challenging, as it damages the disc tissue to an unknown extent. Perhaps an indirect method of measuring IVD pressure could be developed in the future, for instance using fluid diffusion into or out of the disc, as measured by MRI, as an indicator of pressure. Alternatively, perhaps candidates for IVD replacement could be included as participants (Tables 2 and 7 ).

Further damage to already damaged arteries

In vivo studies of arterial walls are also difficult to perform. In addition, it seems unlikely that SM can cause arterial damage de novo [ 66 , 67 , 68 , 69 , 70 , 71 , 72 ]. The assumption tested in this article is interesting, if one thinks that it is mainly arteries with pre-existing damage or pathology that are susceptible to further damage by SM. Hence, the authors devised a method to “pre-damage” vertebral arteries in dogs, as a proxy for “naturally occurring” damage or pathology. The types of lesions created were not predictable, for which reason the usefulness of this method is unclear.

The assessment method in this study was complex, using a fluoroscopically guided ultrasound probe as the measurement tool. However, magnetic resonance angiography would offer better resolution, or a micro-video-camera could allow direct visualisation of arterial damage.

Since vertebral artery dissection is so rare and only temporally linked to SM [ 73 , 74 ], the justification of sacrificing animals to study this should be considered (Tables 2 and 7 ).

Myofascial hysteresis

There were several unclear elements in this article, making it difficult for us to interpret how well the outcome variables in the article related to the concept of hysteresis (Tables 2 and 7 ).

Conclusions

Clinical perspectives.

Although this review is primarily valuable to researchers, clinicians should also benefit from our findings. It is a common clinical observation that patients can experience sudden relief immediately after SM. In our experience, when this happens, they may ask: “What exactly happened when you cracked my back?” As this review describes, there is no easy answer because of the many theories and few facts. Nevertheless, we suggest the following, which clinicians can modify to suit their practice and patients. Regarding anatomical/positional changes, it would be possible to say: “There is no simple answer, because the spine is a difficult area to study. It seems likely that the manipulation/adjustment causes some physical changes, but it is not known exactly how. Presently, though, we are fairly confident that the facets, i.e., the small joints at the back of the spine, open up a little bit. There also seems to be a measurable change in the stiffness of the spine immediately after manipulation. We assume that these changes are part of what helps you feel better.”

Research perspectives

There has been little research on anatomical mechanisms of SM, and most of the articles we found were not credible according to our assessment methods. The few studies that have been published are on a wide variety of topics, performed by a small number of researchers, and were often small studies (only 7 studies recruited more than 50 participants) that were not followed-up by other similar studies. It seems that there has been no coherent research planning strategy undertaken by any of the manual therapy professions to investigate the anatomical/positional mechanisms of SM. Therefore, there is an opportunity to develop research centres with areas of expertise that can lead high-quality studies in these areas concentrating on anatomically feasible outcome variables.

Cut points for meaningful changes should be established and should incorporate information such as normal variations, repeatability, and inter-and intra-examiner reliability. The time between the application of SM and the measurement of the potential effect is also important to establish, to infer mechanism(s).

The results of our review indicate that the 2 most promising areas for further study are changes to facet joint space and spinal stiffness after SM.

However, after having established what actually happens anatomically in response to SM, it would be important to continue by investigating whether these mechanisms also have a lagged effect and/or result in physiological reactions. Then, this potential chain of events must be linked to the clinical picture, that is, reduction of pain or improvement in function.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

Thanks to Amber Beynon for assistance with article screening.

No specific funding was received for this project. Authors have been funded by their respective sites of employment (see affiliations) and none of the authors is dependent on present or future funding relating to mechanisms of spinal manipulation. CH is part-funded by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) North West Coast (NWC). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

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Kenneth J. Young & Guillaume Goncalves

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Charlotte Leboeuf-Yde & Casper Nim

University of Central Lancashire, Preston, UK

Charlotte Leboeuf-Yde

Department of Chiropractic Medicine, Integrative Spinal Research Group, Balgrist University Hospital, University of Zurich, Zurich, Switzerland

Lindsay Gorrell, Luana Nyirö & Petra Schweinhardt

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Concept and research design: KJY, CLY, CH. Coordination and quality assurance of article screening, critical appraisal and data extraction: KJY, CLY, PS, IA, LG, DE, OG, SV. Article screening, data extraction, and critical appraisal: KJY, CN, CB, CM, DE, EL, GG, KCL, LG, LN, RK, SH, VG, SV. Writing and final editing of the manuscript: KJY, CLY. All co-authors edited and approved the final manuscript. Humans wrote this manuscript with no assistance from artificial intelligence except for Microsoft Word autocorrect for help with spelling and grammar.

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Young, K.J., Leboeuf-Yde, C., Gorrell, L. et al. Mechanisms of manipulation: a systematic review of the literature on immediate anatomical structural or positional changes in response to manually delivered high-velocity, low-amplitude spinal manipulation. Chiropr Man Therap 32 , 28 (2024). https://doi.org/10.1186/s12998-024-00549-w

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DOI : https://doi.org/10.1186/s12998-024-00549-w

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Harm reduction in severe and long-standing Anorexia Nervosa: part of the journey but not the destination—a narrative review with lived experience

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Introduction

What is “severe and enduring” Anorexia?

The case for harm reduction

Is harm reduction ethical?

Are we truly reducing harm? Dangers inherent in ignoring the physiological consequences of malnutrition

To consent or not to consent? An over-reliance on presumed patient capacity

Is harm reduction an admission of futility?

Is a rejection of harm reduction throwing the baby out with the bathwater?

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