Malnutrition and poor diet are the largest risk factors responsible for the global burden of disease. Therefore, ending all forms of malnutrition by 2030 is a global priority. To achieve this goal, a key element is to design and implement nutrition policies based on the best available scientific evidence. The demand for evidence-based nutrition policies may originate directly from policymakers or through social actors. In both cases, the role of research institutions is to generate relevant evidence for public policy. The two key objects of analysis for the design of an effective policy are the nutrition conditions of the population and the policies and programs available, including the identification of delivery platforms and competencies required by personnel in charge of the provision of services . In addition, systematic literature reviews about risk factors of malnutrition, as well as the efficacy and effectiveness of policy actions, lead to evidence-based policy recommendations. Given the multifactorial nature of malnutrition, the drivers and risk factors operate in several sectors  and may be immediate, underlying or basic causes. This multilevel complexity should be considered when developing nutrition policy. In this article, we show two models for the evidence-based design of nutrition policies and programs that may be useful to academia and decision makers demonstrated by two examples of policy design, implementation and evaluation in Mexico. Like many countries in Latin America, Mexico experiences a double burden of malnutrition, including undernutrition such as micronutrient deficiencies and stunting, in addition to overweight and obesity . Both coPrograms and policies in public health should be based on the best available scientific evidence, generated by research institutes with experts in the area of public nutrition ,5,6. It Progresa implemented in 1997 and (2) the obesity prevention policies, particularly the implementation of fiscal policies in 2014. We chose these two experiences because they uniquely reflect how evidence was used for the approval, design and evaluation of the policies implemented in the country. These two experiences happened in very different political environments with interactions between diverse stakeholders. The first example was characterized by political will as a mean to achieve an objective, using evidence, open dialogue to interact with stakeholders and involve them in the design of the program, and under no resource constraint for implementation. In the second case, there was no consensus within the government (conflicting positions) so there was no easy ground for communication between those who generated the evidence and decision makers, therefore it was necessary to generate social support to achieve the goal.This article presents two models that emerged from a retrospective analysis of two experiences in Mexico: (1) the design of the nutrition component of the conditional cash transfer program originally called The design of sound policy to tackle malnutrition in all its forms requires that research institutions develop strategic research agendas to bridge knowledge gaps. The process to design evidence-based policies or programs applied to malnutrition begins with a study of the nutritional conditions and main drivers in the country/region, which is locally produced evidence .Research in public nutrition should consider two key objects of analysis. The first object is the study of the nutrition conditions where there are multiple factors beyond personal decisions that influence dietary choices such as culture, education, income, societal attitudes towards food, incentives, and motivation. Influences from the environment include the availability of food at school, local stores, supermarkets, and on the other hand, the food and beverage industry incentives, food safety, and food transportation and distribution, among others ,11. The The second object is the study of the social organized response, which encompasses the policies and programs currently available, including the identification of delivery platforms and competencies of personnel for the provision of nutritional products and services, as well as health care and economic systems, international trade agreements, and other factors that influence the food supply and food environment .The literature review will provide knowledge on the drivers or determinants of the malnutrition condition and the efficacy/effectiveness of interventions to tackle the condition. Also, recommendations from panels of experts or organizations can be used when available .Systematic literature reviews about the risk factors of malnutrition in all its forms, as well as the effectiveness of an array of promising policy actions, are required for evidence-based policy recommendations. In other words, ongoing synthesis and evaluation are required. For some topics, international evidence-based recommendations developed by expert panels with clear criteria for identifying and classifying the evidence are already available. Examples of useful documents with expert science-based recommendations are available from the World Health Organization , the PanKnowledge of locally produced evidence  is essential for the analysis of the local conditions and social response and for the adaptation of the efficacious or effective intervention to the local conditions, which can then be translated into a program, policy, or law. This exercise will produce locally adapted evidence-based recommendations, which ideally should be tested in small-scale interventions for feasibility and efficacy before implementing them at a larger scale.Given the multifactorial nature of malnutrition, the risk factors operate in multiple sectors  and may be immediate risk factors , underlying , or basic causes . This multilevel complexity should be considered when developing policy recommendations for the prevention and control of malnutrition in all its forms. Likewise, for the adequate implementation of these policies, the government must have the will to act and work in an intersectoral manner with other government sectors, departments and ministries. Moreover, the support of civil society and non-governmental organizations is needed to support and monitor the implementation and sustain policies . This coProgresa, which was later renamed Oportunidades and Prospera at different points in time during the last 20 years. In this first model, the demand for evidence-based nutrition policy originated through the direct interaction between academia and policymakers who were interested in the design and implementation of evidence-based policy actions (Model I). Who were the actors who identified the need for nutrition policy in Mexico? Through which mechanisms these actors identified this need? The demand for nutrition policy and programs in Mexico has originated through two different models. During the last decade of the 20th century, policymakers became interested in the use of evidence for the design of programs for poverty and undernutrition alleviation and sought the advice of investigators for that end. An example in Mexico was the interaction between investigators from the National Public Health Institute (INSP) with Mexican Government officials, for the design of the nutrition component of the conditional cash transfer program originally called In the second model, the demand came from the public, as a result of the interaction between academia, civil society, and the Government (Model II). In this model, civil society organizations, through mass media campaigns, were able to influence public opinion about the importance of public health and nutrition actions and generate public demand for such policies. Academic institutions and civil society organizations worked with those in charge of the program, policy, regulation, or law (legislative and executive branches of power) to design and implement policy actions. An example is the interaction between INSP and Civil Society Organizations, which eventually fostered the public demand for obesity prevention policies, particularly fiscal measures.In the early 1990s, a research group at INSP analyzed a National Nutrition Survey conducted in 1988 and described the nutrition conditions of the country at the time. The results showed that Mexico had a much higher prevalence of stunting and anemia, given the size of its economy. One of the reasons for this high prevalence was the profound inequities among different social sectors in Mexico. For example, the prevalence of stunting in children <5 y of age  was 55% In contrast, the prevalence in the upper socioeconomic tertile was 7%, 13.6% in Mexico City, and 13.7% in the Northern states . MoreoveAt the time of these analyses, there was evidence in the literature about the larger effectiveness of programs that targeted nutrition interventions to low income and indigenous populations . FurtherINSP conducted a simple comparison between the distribution of stunted children <5 years by different regional and socioeconomic categories versus the proportion of families who were beneficiaries of food-aid programs in each of the subgroups studied. This straightforward exercise concluded that the food programs in Mexico were not targeted to those most in need . For exaThe expectation under an adequate targeting scheme was that programs would be targeted to indigenous populations, rural areas, the southern region, those with low socioeconomic status, the younger age category (<24 months), and stunted children. However, the results showed that in all cases, the probability of receiving the benefits of nutrition programs was lower in the vulnerable categories, where the need for nutritional support was greatest. It was therefore concluded that despite the high investment of the Mexican Government in food and nutrition programs, these were not targeted to the right subpopulations and therefore, did not achieve intended results.tortillas, the Mexican staple which is made from lime-treated corn or cooking oil. These and other foods distributed were poor sources of key micronutrients that were essential, given the existing levels of stunting, anemia, infection and arrested cognitive development associated with poor diets among infants and young children. Without these micronutrients, particularly zinc [In addition to the inadequate targeting of the food aid programs mentioned before, other reasons for the food program’s lack of effectiveness included the nutrition content of the foods distributed to families in these programs. Foods distributed included rly zinc  and ironrly zinc , the groAlthough there was a large variety of food aid programs, their components or benefits were often duplicated and their actions uncoordinated. All these flaws were often inadvertent because the programs’ impact was not evaluated, so there was not an opportunity to gauge their benefits nor the convenience of modifying or eliminating them. As a result of all the reasons presented above, the malnutrition prevalence remained high, and the decline in the prevalence of stunting, an indicator of chronic malnutrition, was less than what was expected during the 1990s, given the high investment in food-aid programs .There was a clear need for evidence-based information to lead program and policy design and to identify causes of the low efficacy or effectiveness of nutrition programs, but this need was not clear to most policymakers.coordination of programs and actions to improve efficiency, and finally, monitoring and evaluation embedded in the program and design.Given the results of this analysis, researchers from INSP issued recommendations based on adequate targeting. This included focusing nutrition interventions to low income and indigenous households, rural areas, pregnant women, and children <2 years, as well as utilizing evidence-based interventions, such as nutrition education, complementary foods specifically designed for children <2 years, Progresa was created and a nutrition component was included. The program included conditional cash transfers used as incentives for investments in nutrition, health, and education. Women received the transfers that were conditional on compliance with health, nutrition, and school services. The program also provided fortified food supplements for children and women and included a nutrition education component targeted to low-income households, rural areas (during first phases), households with children <2 years of age, and pregnant and lactating women. A key component included from the beginning of the program was a robust evaluation [In 1997, aluation ,24One of the recommendations was to provide micronutrient-fortified foods for women and children. The food supplements were targeted to the groups of individuals that are more likely to benefit from the product: children aged 4 to 23 months, underweight children aged 2 to 4 years, and pregnant and lactating women in the low-income beneficiary households. The supplements were designed by a group of experts in nutrition, according to evidence on the nutritional status of the population for whom the supplements were intended. The main ingredients were dry whole milk, sugar, maltodextrin, and the micronutrients most deficient in their diet. The supplements were distributed at health centers. Mothers were instructed to add four spoons of boiled water to one ration, which produced a puree consistency product, referred to in Spanish as papilla called “Nutrisano” .Progresa was the reversal of inadequate targeting. As shown in Progresa, the probability of receiving the benefits of nutrition programs were higher in all categories in need of nutrition interventions. It was therefore concluded that Progresa was indeed targeted to the right subpopulations [An immediate effect of ulations .Progresa was characterized by political will that enabled a successful interaction between INSP researchers and the government. Key decision makers at the Ministries of Finance, Health and Social Development at the Federal Government were supportive of using the evidence for the design, implementation, and evaluation of Progresa because they were experts in the field and/or had prior academic training. In addition to political will, the government had enough resources and interest in implementing programs to reduce undernutrition. The initiative had international support as most of the recommendations were validated by international agencies such as the World Bank that shared similar goals of designing programs to reduce the intergenerational transmission of poverty.The implementation of The battle against obesity in Mexico has involved the participation and interaction of three players: research institutions, lobbyists and advocacy organizations, and legislative and executive branches of Government. Working together, these institutions and organizations were able to shape one of the most effective policy actions for the prevention of obesity, that is, the approval and implementation of fiscal policies as disincentives for the consumption of unhealthy beverages and foods . From 19The persistence of undernutrition and obesity in low and middle-income countries, such as Mexico, are related to both poor quality diets and positive energy expenditure . AnalysiA group of researchers from INSP provided evidence about a positive association between dietary energy density (DED) and excess body weight in school-age children. The mean DED was 175 kcal/100 g; only 2.5% of the study population consumed ≤125 kcal/100 , which iIn addition, INSP found that in Mexican adults, basic foods groups  contribute 74% of total energy intake, while the remaining 26% is accounted for by discretionary foods, which are not essential for a healthy diet, are high in sugar and/or saturated fats, and are mainly SSBs and high energy-dense nutrient-poor foods (ultra-processed foods) ,30.Due to the high-energy consumption derived from low quality food, establishing dietary goals in the Mexican population can help decision makers plan strategies for the prevention of obesity and other chronic diseases. Dietary goals for Mexican adults involved substantially increasing the consumption of fruit and vegetables, more than double the consumption of beans and other legumes, and in a smaller proportion increasing the intake of milk and dairy products. On the other hand, consumption of SSBs, high energy-dense nutrient-poor foods, and alcohol should be greatly reduced from the current 24.5% of total energy to 10% or less. In addition, consumption of processed meat should also be minimized and to a lesser extent, red meat and refined cereals .In Mexico, the mean consumption of added sugar from total energy is 12.5%, which is equivalent to 60 g/d . WHO recIn 2012, the prevalence of overweight and obesity in Mexico reached 70% among adults and 30% among children ,45 AlthoFiscal policies have been used as a strategy to reduce the consumption of goods that are associated with negative effects on health such as tobacco and alcohol ,47. ThesIn January 2014, Mexico implemented an excise tax of one peso per liter (approximately a 10% increase in price) on all non-alcoholic beverages with added sugars, excluding beverages with artificial sweeteners and 100% juices. The tax is paid by the producer but reflected in prices paid by consumers. The tax is adjusted when the cumulative inflation reaches 10% since implementation. A positive aspect of the tax is that it is higher for larger package sizes that are relatively less expensive (in pesos per liter) compared to smaller packages.Progresa). As expected, strong opposition of the tax came from the beverage industry throughout the full process: before, during, and after the tax was implemented. The strong power of the industry resulted in political pressures that fragmented the support from the government. Although the Ministry of Finance and the executive branch of the government supported the tax and took advantage of tax reform to introduce the SSB tax , other key sectors, including Health, were not involved in the process. In this political context, the success of the implementation and continuation of the tax was a combination of actions from different stakeholders.The implementation of the tax faced a very different political environment compared to Model 1  the magnitude, distributions , and the trends of overweight, and obesity in Mexico over time. INSP also estimated the own and cross-price elasticities of demand for SSBs, which showed that the demand for these products was elastic and higher among low-income households and that the substitutes were water and other healthy beverages . Price eThe approval of the tax is a public health success story, which resulted from the generation of evidence around a risk factor (SSBs) and the proposal of fiscal policy action to discourage the intake of this product and the use of that evidence by civil society and the Government.Evaluation is essential to provide feedback to policymakers. This should include assessing the design, implementation, and effectiveness. Design evaluation is inexpensive and is not time-consuming, making it a cost-effective tool to avoid the implementation of flawed policies or programs. Implementation of evaluation is essential for the success of a well-designed policy and provides timely feedback for improvement. Effectiveness evaluations assess the results of programs and policies on behaviors  and nutrition outcomes . The results of the evaluation guide decisions about keeping or modifying policies or lead to recommendations for improving their design or implementation. They may also generate new research questions that feed the research-to-policy cycle. The whole process for the generation and evaluation of policies should include provisions for avoiding conflicts of interest.An example of the evaluation of the two policy actions presented to illustrate each policy demand model are described in the next sections.Progresa did not reach the total target population; therefore, the study design to evaluate the program was planned, taking advantage of the implementation of the program in phases, with a randomized design that included only 300,000 households, a small fraction of the target (6 million households). The evaluation began in 1998 in localities that were to be randomized to a group that would receive the program benefits and would be followed during two years or a group that would not receive the benefits immediately but would receive them immediately after two years when the study for the evaluation would be concluded. This second group would act as a control group. However, in the period of 1999–2000, due to political pressure, the control group also received the benefits of the program. Therefore, the group that received benefits of the program from the beginning was deemed the intervention group, and the second group, which received the benefits starting at the second year, was referred to as the “crossover intervention group”. Regardless of this study design modification, it was possible to evaluate the effect of the program over two years.Due to logistic and economic reasons, the initial stages of Progresa program belonged to the lower socioeconomic tertile, those in the lower half of this group had a substantially higher prevalence of stunting. For these reasons, all comparisons were made after groups were stratified by age (<6 months and 6–12 months at enrollment) and socioeconomic level (lower than average or higher than average).It was expected that the greatest effects would be observed in children who were randomized to the intervention group . In contrast, the effects on infants in the crossover intervention group, who received the benefits of the program only during the second year , were expected to be lower. It was also expected that the greatest effect would be found in children from the lowest income level. Despite the fact that all households in the The results of the evaluation showed that, as expected, the greatest effect on growth was observed in infants younger than six months and from the lowest socioeconomic level. The effect on linear growth in this group was 1.1 cm higher compared to the group who received the benefits only the second year. In addition, the positive effects of the program were observed in lower rates of anemia and higher food purchases. Finally, dietary effects on children were documented to be due to the intake of the nutrition supplement “Nutrisano” . No effeResults from this evaluation allowed the identification of strengths of the program and areas for improvement. The positive effect of the program on linear growth and reduction of anemia deemed the program effective.The evaluation generated new research questions and further studies to identify opportunities for improving the impact of the program. One of the studies concluded that the education component of the program was of low quality. As a result, a communication strategy was designed using state of the art methods and was tested at a small scale. Results of small scale testing showed that the program improved several behaviors aimed at increasing the intake of the supplements . In addition, a follow-up study was carried out after finding that the reduction of anemia and iron deficiency was lower than expected. Further evaluation showed that the type of iron used had low bioavailability, so a reformulation of the supplements was necessary using forms of iron that proved to be bioavailable ,53. CurrAnother finding was that dietary effects were restricted to the intake of Nutrisano, not to improvements in overall infant feeding practices; this led to including the promotion of breastfeeding in the communication strategy and appropriate complementary feeding.In summary, the evaluation of the program not only documented the positive effects, but it also resulted in other studies that led to changes in the design and evaluation of the program and thus, greater impact in the population.Several papers have been published documenting how prices, household purchases, and employment changed after the SSB tax was implemented in Mexico.In urban areas, the tax passed along to the prices paid by consumers for all SSBs, i.e., prices increase on average by the amount of the tax (1.08 pesos per liter) . ResultsSeveral studies evaluated changes in taxed and untaxed beverages. A first study showed a 6% average reduction in taxed beverages in 2014 compared to predicted purchases based on pretax trends (2012–2013) in a panel of households living in 53 cities with more than 50,000 inhabitants . A seconA recent study showed that employment in the beverage industry and at commercial stores did not decrease after the tax was implemented .In summary, studies have shown that the SSB tax was effective at increasing prices and reducing consumption. The policy did not affect employment and potential effects on health, in the long run, have been estimated in simulation models ,61.It is important to note that taxes are only one component of a toolkit for obesity prevention. Fiscal policies should be combined with other strategies to reduce the burden of non-communicable diseases such as regulation of the availability of food and beverages in schools, implementation of consumer-friendly front of pack labeling, regulation of food marketing to children, and promotion of information on diet and physical activity for public awareness.The design of policy actions for the prevention of malnutrition in all its forms requires scientific evidence. Research institutions in the field of public nutrition are essential to generate this evidence. These organizations should develop research agendas aimed at developing evidence for action. The examples presented in this paper for Mexico show that the political context can enable or prevent a favorable interaction between academia and decision makers. When there is no consensus within the government or political pressure, other stakeholders can work in strategic partnership to convince and push public policy.The translation of scientific evidence to policy actions requires direct interaction between research institutions and policymakers (Model I) or civil society in order to generate public demand for policy action (Model II). In both cases, international and local evidence must be used to design evidence-based policy actions adapted to the local situation. Ideally, evidence-based locally relevant policy actions should be tested in small-scale interventions for feasibility and efficacy before implementing at scale.In some instances, when immediate action is required, locally adapted recommendations are implemented without small-scale testing. In all cases, policies or large-scale programs should be evaluated, so that the body of evidence about effective policy actions is produced. In any case, the evaluation of policy or programs is key to provide feedback to policymakers.The experiences described in this paper can be used as models in other countries under two scenarios: a political context enabling the interaction between decision-makers and academia in the use of evidence to design and implement a policy, or, in contrast, a context that requires the involvement of other stakeholders to generate social support.


Physical capacity tasks  are useful for assessing functioning in patients with low back pain.The purpose of this study was to systematically review the level of evidence for the reliability, validity, and responsiveness of physical capacity tasks.MEDLINE, CINAHL, PsycINFO, Scopus, the Cochrane Library, and relevant reference lists were used as data sources.Two authors independently selected articles addressing the reliability, validity, and responsiveness of physical capacity tasks, and a third author resolved discrepancies.One author performed data extraction, and a second author independently checked the data extraction for accuracy. Two authors independently assessed the methodological quality with the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) 4-point checklist, and a third author resolved discrepancies.Data synthesis was performed by all authors to determine the level of evidence per measurement property per physical capacity task. The 5-repetition sit-to-stand, 5-minute walk, 50-ft (∼15.3-m) walk, Progressive Isoinertial Lifting Evaluation, and Timed “Up & Go” tasks displayed moderate to strong evidence for positive ratings of both reliability and construct validity. The 1-minute stair-climbing, 5-repetition sit-to-stand, shuttle walking, and Timed “Up & Go” tasks showed limited evidence for positive ratings of responsiveness.The COSMIN 4-point checklist was originally developed for patient-reported outcome measures and not physical capacity tasks.The 5-repetition sit-to-stand, 50-ft walk, 5-minute walk, Progressive Isoinertial Lifting Evaluation, Timed “Up & Go,” and 1-minute stair-climbing tasks are promising tests for the measurement of functioning in patients with chronic low back pain. However, more research on the measurement error and responsiveness of these tasks is needed to be able to fully recommend them as outcome measures in research and clinical practice. The body functions and structures domain refers to psychological and physiological processes and anatomical structures; the activity domain refers to people's ability to perform activities in their daily life; and the participation domain describes people's interactions with their sociocultural environment .3 Researchers have argued for the use of outcome measures that specifically measure functioning in the activity domain.4–6Research suggests that low back pain (LBP) causes more years lived with disability than any other condition.7–11 PROMs are relatively time saving, easy to administer, and, importantly, include the patient's perspective.12 However, PROMs as used in LBP research have shown both floor and ceiling effects as well as low- to very-low-quality evidence for content validity.14 Clinical experience and scientific evidence also indicate frequent discrepancies between how patients score PROMs and how they actually move and perform activities when observed in the clinic.15–17 Several authors16–18 have therefore recommended the use of physical capacity tasks that measure the capacity qualifier of the ICF activity domain,16–18 defined as “the ability to execute a task or an action in a standardized environment.”3 In a physical capacity task, a patient performs a standardized activity that is administered by an observer using predefined criteria such as repetition counts or task timing.18The ICF activity domain is typically measured with patient-reported outcome measures (PROMs), with which patients rate their perceived ability to perform various activities in their usual environment.20 Physical capacity tasks also appear to be less influenced by education level and language skills compared with PROMs.22Physical capacity tasks are designed to assess what patients actually can do rather than what they think they can do, and can therefore capture important information about functioning that PROMs often do not.23–25 However, to our knowledge, no study has yet summarized the level of evidence of measurement properties of physical capacity tasks for patients with LBP.All outcome measures should have sufficient support for their reliability, validity, and responsiveness in order to be used in research or in clinical practice. Otherwise, there is a significant risk of imprecise or biased results that might lead to incorrect conclusions regarding the patient's level of functioning.The objective of this study was to systematically review the level of evidence of the measurement properties of physical capacity tasks that are designed to assess functioning in patients with LBP.http://www.crd.york.ac.uk/PROSPERO; registration number: CRD42016042011). We followed the working procedure developed by the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) for conducting a systematic review of measurement properties.23 The systematic review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).26The study protocol was registered at the International Prospective Register of Systematic Reviews , CINAHL (EBSCOhost), PsycINFO (Ovid), Scopus (Elsevier), and the Cochrane Library (Wiley). The reference lists of the articles from the electronic data sources that were identified for full-text reading were used as additional data sources.https://academic.oup.com/ptj). The search strategy included 4 main filters, specifically tailored for each electronic information source: target population , the construct of interest , type of outcome measures , and article type . The search strategy was based on a preliminary search strategy as described in the PROSPERO protocol. Improvements of the preliminary search strategy included: (1) adaptation of a validated search filter for measurement properties;27 (2) addition of the specific names of all physical capacity tasks identified by the preliminary search strategy; (3) use of the Ovid interface rather than PubMed for MEDLINE due to the benefit of positional operators; and (4) the addition of supplementary search terms for LBP. The first search with the final search strategy was performed on May 11, 2017 (no limitations for publication period) and an updated search was performed on August 29, 2018 . No restrictions were applied for language. Two authors (M.J. and either A.G. or M.L.) independently performed a hand search of the reference lists of all articles that had been identified for full-text reading.A search strategy was developed in collaboration with 2 medical librarians who also performed the search (Two authors (M.J. and either A.G. or M.L.) independently screened the titles and abstracts of articles from the electronic and hand searches. A third author (R.S.) was consulted to resolve the disagreement if consensus could not be reached on the eligibility of articles for full-text review. Two authors  then independently reviewed the full-text articles for eligibility, and a third author  was consulted if needed for consensus.Articles that met 4 criteria  were included.28 Articles that contained pregnant participants or participants with fibromyalgia, confirmed rheumatic diseases, infections, tumors, osteoporosis, fractures, structural deformities , or cauda equina syndrome were excluded unless data were presented specifically for patients who met the eligibility criteria.Patients in the study population were at least 18 years old and had had LBP for 6 weeks or more.3The test was a measure of “capacity” under the ICF activity domain, defined as the ability to execute a task or an action in a standardized environment.The test was a physical capacity task, defined as a standardized test that is used for an evaluative purpose and that is administered by an observer, includes an activity (as classified by the ICF) that is performed in a standardized setting, and requires readily available, low-cost, and portable equipment. Articles that exclusively investigated test batteries and did not present results for individual physical capacity tasks were excluded. If an article cited an original test manual that could then not be obtained, the test was excluded.29The article presented original data reporting the reliability , validity , or responsiveness of physical capacity tasks.29 but was included in the data extraction form because this measure is necessary to determine the level of evidence for measurement error.30 Data from all included articles were subsequently extracted by 1 author (M.J.) and then independently checked for accuracy by a second author .A pilot version of a data extraction form was developed by the first author (M.J.) and piloted by 3 authors  on 5 randomly selected, included articles. The data extraction form was modified in response to the pilot to include the following 6 data items: (1) patient sample characteristics; (2) eligibility criteria; (3) setting; (4) procedure and equipment for performing the physical capacity tasks; (5) results of the measurement properties, and (6) minimal important change. Minimal important change is not considered a measurement property in the COSMIN taxonomy32 and a third author  was consulted if needed to reach consensus. The COSMIN 4-point checklist is specifically designed to determine methodological quality scores of studies of measurement properties. The scores  are assigned for each measurement property using the “worst score counts method.”32 The item for sample size in the checklist was excluded from the “worst score counts method” as recommended when performing systematic reviews of measurement properties of physical capacity tasks.33 The rating authors (M.J. and M.L.) pretested and then discussed the ratings of the checklist with a third author (L.B.M.) to achieve consistency in scoring, as recommended to ensure the validity of the scoring method.34Two authors (M.J. and M.L.) independently assessed all of the included studies for methodological quality using the COSMIN 4-point checklist,35 This procedure is similar to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE),36 but different in that the best-evidence synthesis determines the level of evidence for the results of measurement properties, rather than the results of clinical trials.23 First, the results of each measurement property for each physical capacity task were rated as “positive,” “negative,” or “indeterminate” according to result rating criteria accepted with consensus in an international Delphi study  used in previous systematic reviews of the reliability, validity, and responsiveness of physical capacity tasks.35A “best-evidence synthesis” approach was performed by consensus of all authors to synthesize the level of evidence of measurement properties per physical capacity task.hi study .30 Then,This criterion encompassed consistent result ratings in at least 2 good-quality articles or at least 1 excellent-quality article, with a total sample size of eligible articles equal to or greater than 100.This criterion encompassed consistent result ratings in at least 2 fair-quality articles or 1 good-quality article, with a total sample size of eligible articles equal to or greater than 50.This criterion encompassed at least 1 fair-, good-, or excellent-quality article, with a total sample size of eligible articles of 25 to 49.This criterion encompassed the following 4 options: indeterminate result ratings, all eligible articles were of poor methodological quality, the total sample size of eligible articles was less than 25, or conflicting result ratings.This criterion encompassed conflicting findings.https://academic.oup.com/ptj).If an article lacked a priori hypotheses for validity and responsiveness, we extracted what the authors had expected in relation to those measurement properties from the description found in the article. We generated our own hypotheses for validity and responsiveness based on these descriptions, which were then added to the data synthesis ,37 whereas the rest included patients with a pain duration of at least 12 weeks (“chronic” LBP28). Eleven articles included patients with back-related diagnoses known to affect walking capacity severely.38–46 Of these, 1 article included patients with lumbar spondylolisthesis and postlaminectomy,38 6 articles included patients with lumbar spinal stenosis,39–43 3 articles included patients with lumbar disk herniation and lumbar spinal stenosis,45 and 1 article included patients with lumbar disk herniation, lumbar spinal stenosis, and spondylolisthesis.46One article included patients with a pain duration of at least 6 weeks , criterion validity, and responsiveness.46–50 Three studies of reliability in 1 article48 were rated as poor for methodological quality and therefore excluded from the best-evidence synthesis. The poor scores were due to the fact that patients received treatment between the first and second administration of the tasks.The results for reliability are shown in With regard to best-evidence synthesis, a strong level of evidence for positive ratings for test-retest reliability was found for 3 tasks . A moderate level of evidence for positive ratings for test-retest reliability was found for 4 tasks . Four tasks were specifically evaluated for patients with back-related diagnoses known to severely affect walking capacity , and all of these had limited evidence for positive ratings for test-retest reliability. Intrarater reliability was assessed for 1 task (30-second chair stand test), which had limited evidence for a positive rating. Most of the tasks investigated for interrater reliability displayed unknown evidence due to small sample sizes.The results for measurement error are shown in 52 Nine studies of measurement error in 3 articles51 were rated as poor and therefore excluded from the best-evidence synthesis. The poor scores were due to the fact that patients in the articles received treatment between the first and second administration of the tasks.Regarding methodological quality, 8 articles investigated measurement error.30 The level of evidence was unknown for 4 tasks , because the minimal important change was not investigated.With regard to best-evidence synthesis, a moderate level of evidence for negative ratings for measurement error was displayed by the 1-minute stair-climbing, 5-minute walk, and Progressive Isoinertial Lifting Evaluation tasks. A strong level of evidence for negative ratings was displayed by 50-ft walk and 5-repetition sit-to-stand tasks. The negative ratings were a consequence of failure to meet the criterion stating that the smallest detectable change must be smaller than the minimal important change.https://academic.oup.com/ptj).The results for construct validity (hypothesis testing) are shown in 17,19,20,41,43,44,47,48,50,53–55 Five studies of construct validity in 2 articles54 were rated as poor and therefore excluded from the best-evidence synthesis. The poor scores were due to an absence of a priori validity hypotheses .With regard to methodological quality, 12 articles investigated construct validity.With regard to best-evidence synthesis, a moderate level of evidence for positive ratings of construct validity was found for 6 tasks . Limited evidence for positive ratings for construct validity was found for 4 walking tasks investigated specifically for patients with back-related diagnoses known to severely affect walking capacity .The results for criterion validity are shown in 42 and was rated as good for methodological quality and was therefore included in the best-evidence synthesis.With regard to methodological quality, 1 article investigated criterion validityAs regards best-evidence synthesis, the treadmill protocol displayed limited evidence for a positive rating for criterion validity for patients with lumbar spinal stenosis.The results for responsiveness are shown in 57 All studies of responsiveness in the articles received either fair or good scores and were therefore included in the best-evidence synthesis.Regarding methodological quality, 7 articles investigated responsiveness.With regard to best-evidence synthesis, a limited level of evidence for positive ratings for responsiveness was found for 3 tasks . A moderate level of evidence for negative ratings was found for 3 tasks . A limited level of evidence for negative ratings was found for 4 tasks . A limited level of evidence for a positive rating for responsiveness was found for 1 task (Timed “Up & Go” task) that was specifically for patients with back-related diagnoses known to severely affect walking capacity.A summary of the level of evidence is shown in The 5-repetition sit-to-stand task was the only physical capacity task that displayed positive ratings for more than 2 measurement properties: test-retest reliability (strong evidence), construct validity (moderate evidence), and responsiveness (limited evidence). The 50-ft walk, 5-minute walk, Progressive Isoinertial Lifting Evaluation, and Timed “Up & Go” tasks displayed moderate to strong evidence for positive ratings for both test-retest reliability and construct validity. The above-mentioned tasks, however, also displayed moderate to strong evidence for negative ratings for measurement error. The 1-minute stair-climbing task and shuttle walking test displayed positive ratings for responsiveness (limited evidence) as well as for test-retest reliability .Of the walking tasks that were specifically investigated for patients with diagnoses known to severely affect walking capacity, the Timed “Up & Go” task and shuttle walking test were the only tasks that displayed positive ratings for more than 1 measurement property.23 A previous systematic review investigated the reliability of physical capacity tasks, but not the validity and responsiveness.58 That review reported similar results for reliability, despite a different method for determining the level of evidence.58To our knowledge, this is the first study to determine the level of evidence for the reliability, validity, and responsiveness of physical capacity tasks designed to assess functioning for patients with LBP. The 5-repetition sit-to-stand, 50-ft walk, 5-minute walk, Progressive Isoinertial Lifting Evaluation, and Timed “Up & Go” tasks displayed moderate to strong evidence for positive ratings for both test-retest reliability and construct validity. These results suggest that a clinician or researcher can be confident that the scores of these tasks have a high degree of reliability and are likely to measure the constructs they are designed to measure.29 However, most of the included articles investigated responsiveness by comparison with global rating scales of constructs such as “LBP-associated disability,”51 “general health improvements,”38 and “return to work,”56 all constructs that are different from those found in the physical capacity tasks. In contrast, several authors have recommended using global rating scales of the same constructs as the outcome measures of interest.23 For instance, the responsiveness of a walking task could preferably be investigated by comparing the results with a global rating scale concerning walking ability.23 Future high-quality studies with a priori hypotheses that include global rating scales of capacity could show clearer evidence for the responsiveness of physical capacity tasks.The 1-minute stair climbing task, 5-repetition sit-to-stand task, shuttle walking test, and Timed “Up & Go” displayed limited evidence for positive ratings for responsiveness. These results suggest that these tasks appear to have the ability to detect changes in functioning after a treatment, although the evidence is limited. In contrast, most included tasks that were investigated for responsiveness displayed limited to moderate evidence for negative ratings. An important aspect of the definition of responsiveness in the COSMIN taxonomy is the ability to detect change over time specifically in the construct to be measured.60 The smallest detectable change  should be smaller than the minimal important change  in order to detect changes that are as small as the minimal important change.61 The data of the systematic review suggest that the smallest detectable change of the investigated tasks appears to be too large to distinguish minimal important change from measurement error. Nevertheless, all negative ratings of measurement error were due to comparisons with minimal important change values determined for 5 tasks in a single article.51 That article investigated minimal important change values with a global rating scale of “LBP-related disability” rather than the constructs that the physical capacity tasks measure. In contrast, minimal important change is recommended to be compared with similar constructs as those in the outcome measures of interest.61 Moreover, the COSMIN 4-point scale is also not designed to assess the quality of studies that investigate minimal important change32 and therefore the methodological quality of the relevant article was undetermined.A moderate to strong level of evidence for negative ratings for measurement error was displayed by 5 tasks because the smallest detectable change was larger than the minimal important change. Similar findings have been reported previously for PROMs of self-efficacy and health-related quality of life.23 The patients in the systematic review comprise a heterogeneous sample, which is partly reflected in the differences in levels of pain and disability seen between the included studies  extracted the data and a second author  double-checked it for accuracy. In contrast, at least 2 authors independently performed all other methodological steps of the review. We decided on the current data extraction procedure because of the high accuracy of the first author in the pilot of this methodological step. We therefore argue that having a second author double-checking all data extracted was almost equivalent to having 2 authors independently performing the data extraction.In conclusion, the 5-repetition sit-to-stand, 5-minute walk, 50-ft walk, Progressive Isoinertial Lifting Evaluation, Timed “Up & Go,” and 1-minute stair-climbing tasks are promising physical capacity tasks for the measurement of functioning in patients with chronic LBP. However, more research on the measurement error and responsiveness of these tasks is needed to be able to fully recommend them as outcome measures in research and clinical practice for patients with LBP.pzy159_Supplemental_eAppendixsClick here for additional data file.


Pregnancy-associated Venous thromboembolism (VTE) is one of the most common causes of maternal morbidity and mortality in developed countries. In this study, we aimed to systematically review and critical appraisal of guidelines to compare the recommendations in pregnancy-associated VTE.Guidelines in English between January 1, 2009 and November 31, 2018 were searched using Medline via PubMed, as well as the guidelines’ website. The guidelines containing the recommendations on pregnancy-associated VTE were included. Through the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument, three reviewers appraised the quality of the included guidelines. The recommendations were also summarized and compared to analyze the consistency.Fifteen guidelines from 13 organizations were included. Ten guidelines from nine organizations, namely, ACCP, ANZJOG, ASH, Australia, ESC, Korea, RCOG, SASTH, SOCC, were regarded as “strongly recommended for use in practice”. Most of the included guidelines scored low in lower scores in domain 3 (Rigor of development) and domain 6 . Recommendations on prevention are contained in ten guidelines while treatment are included in seven. The main conflicting recommendations were mainly at the anticoagulant choice for prevention on pregnant women and prevention after cesarean section. The duration of VTE treatment in pregnant women was also controversial.In summary, the quality of pregnancy-associated VTE guidelines varied widely, especially in Rigor of development and Editorial independence. Recommendations were inconsistent both in prevention and treatment across guidelines. Increased efforts are required to provide high-quality evidence specific to the pregnancy population. Guideline developers should also pay more attention to methodological quality.The online version of this article (10.1186/s12872-019-1183-3) contains supplementary material, which is available to authorized users. Pregnancy-associated Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is one of the most common causes of maternal morbidity and mortality in developed countries . As a prThere are many clinical practice guidelines (CPGs) published for pregnancy-associated VTE patients. Using the method of evidence base, these guidelines attempted to summarize and organize the existing evidence to provide recommendations on clinical decisions. Due to the paucity of related studies of high quality, CPGs are mainly based on observation studies rather than randomized controlled trials (RCTs). Moreover, some studies are not specifically targeted at the pregnancy population, just the extrapolation from results in nonpregnant patients. The lack of RCTs can be explained by the difficulty of conducting RCTs with adequate statistical power due to the low rate of thrombosis among women identified as having a high risk of VTE. The guidelines at high quality are commonly believed to optimize clinical practice and improve patient outcomes , 8; neveTherefore, we aimed to systematically assess the quality of pregnancy-associated VTE guidelines using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument and evaluate the consistency of recommendations. A systematic review was undertaken using the Cochrane methodology .A systematic search was undertaken to search the guidelines related to pregnancy-associated VTE. Briefly, relevant guidelines were obtained by searching MEDLINE and EMBASE. In addition, four guideline-related databases, the Guidelines International Network (G-I-N) International Guideline Library, the National Guidelines Clearinghouse (United States), the Canadian Medical Association Infobase (Canada) and the National Library for Health (United Kingdom), were searched for any guidelines, which might have been missed by systematic searches. We limited the search time from January 1, 2009 to November 31, 2018. Details on the search terms and syntax are provided in Additional file The Institute of Medicine defines CPGs as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” . AccordiThe guidelines were excluded for the following reasons: (1) historical versions of guidelines had been subsequently updated; (2) the topic is only mentioned in the guidelines; (3) unpublished guidelines, conference paper, discussion paper, draft and opinions are excluded.We assessed the quality of each included guideline using the AGREE II instrument . AGREE IThresholds were determined to assess guideline overall quality. We considered a guideline as “strongly recommended for use” if majority of domains of it scored over 60%, as “recommended with modifications” if the majority of domains scored between 30 and 60%, as “not recommended for use” if the majority of domains were below 30%.Data collection and recommendations synthesis.One reviewer (JZ) extracted the information about guideline characteristics, including year of publication, country/region, development team, target population, target users, and funding organization  and domain 4 (Clarity of presentation) obtained relatively high scores, while the scores in domain 3 (Rigor of development) and domain 6  were low. The information about the evidence base was only mentioned in six guidelines , 23–25. The conflicting recommendations might result from the process of guideline development. CPGs are developed to assist the clinician decision under different clinical settings. The proper use of CPGs at high quality is essential to reduce practice variation and improve patient outcome . AlthougAlthough pregnancy-associated VTE is uncommon, it remains a leading cause of maternal morbidity and mortality worldwide , 2, 28. Without the clear-cut evidence, the consistency of recommendations will be more sensitive to the methodological method and conflicts of interest.The strength of this study is a comprehensive literature search. We carefully collected the information about the guideline development process and consideration about the quality by judging each item in the AGREE-II instrument, which is hopeful for enhancing the quality of guidelines. It is of great importance to perform the guideline appraisal, especially for the countries without their own guidelines on managing VTE in pregnancy. Guideline appraisal is essential to determine the guidelines with high quality and the recommendations with agreement from most guidelines, which are useful on the extent to the countries without their own guidelines. However, our study has some potential limitations. First, only guidelines published in English were reviewed, and we might overlook the other guidelines written by other languages. Second, the appraisal of CPGs was merely based on the information reported by the authors. Hence, some items in AGREE II could have a low score because of the lack of related information, even though the authors had the complete process during guideline development. Moreover, most guidelines included did not state the funding sources. It was difficult to evaluate whether there was an influence from the commercial industry. Third, AGREE II is a tool used to access the quality of the guideline development instead of the quality of the evidence. Recommendations from high-score CPGs might be based on weak evidence and vice versa.Fourth, because the number of guidelines on pregnancy VTE is limited, the guideline that is not specifically targeted on the pregnancy population but still with related recommendations was also included in this study . During In summary, the quality of pregnancy-associated VTE guidelines varied widely, especially in Rigor of development and Editorial independence. Recommendations were inconsistent both in prevention and treatment across guidelines. Increased efforts are required to provide high-quality evidence specific to the pregnancy population. Guideline developers should also pay more attention to methodological quality.ACCP ACOG ANZJOG , 15ASH Australia AVTF ESC GTH [2O]JOGNN Korea RCOG , 24SASTH SOGC Additional file 1:Table S1. Search strategies. (DOCX 15 kb)Additional file 2:Tables S2. Structure and content of the AGREE instrument. (DOCX 15 kb)Additional file 3:Tables S3. Data extraction template. (DOCX 14 kb)Additional file 4:Tables S4. Raw Data. (DOCX 16 kb)


Diagnosis of carpal tunnel syndrome is based on clinical symptoms, examination findings, and electrodiagnostic studies. For carpal tunnel syndrome, the most useful of these are nerve conduction studies. However, nerve conduction studie can result in ambiguous or false-negative results, particularly for mild carpal tunnel syndrome. Increasing the number of nerve conduction studie tests improves accuracy but also increases time, cost, and discomfort. To improve accuracy without additional testing, the terminal latency index and residual latency are additional calculations that can be performed using the minimum number of tests. Recently, the median sensory-ulnar motor latency difference was devised as another way to improve diagnostic accuracy for mild carpal tunnel syndrome.The median sensory-ulnar motor latency difference, terminal latency index, and residual latency were compared for diagnostic accuracy according to severity of carpal tunnel syndrome.Diagnostic accuracy study.A total of 657 subjects were retrospectively enrolled. The carpal tunnel syndrome group consisted of 546 subjects with carpal tunnel syndrome according to nerve conduction studie . The control group consisted of 121 subjects with no hand symptoms and normal nerve conduction studie. All statistical analyses were performed using SAS v9.4. Means were compared using one-way ANOVA with the Bonferroni adjustment. Sensitivity, specificity, positive predictive value, and negative predictive value were compared, including receiver operating characteristic curve analysis.For mild carpal tunnel syndrome, the median sensory-ulnar motor latency difference showed higher specificity and positive predictive value rates  than terminal latency index  and residual latency . The area under the receiver operating characteristic was highest for the median sensory-ulnar motor latency difference (0.889), followed by the residual latency (0.829), and lastly the terminal latency index (0.762). Differences were statistically significant (median sensory-ulnar motor latency difference being the most accurate). For moderate carpal tunnel syndrome, sensitivity and specificity rates of residual latency (0.989 and 1.000) and terminal latency index (0.983 and 0.975) were higher than those for median sensory-ulnar motor latency difference (0.866 and 0.958). Differences in area under the receiver operating characteristic curve were not significantly significant, but median sensory-ulnar motor latency difference sensitivity was lower. For severe carpal tunnel syndrome, residual latency yielded 1.000 sensitivity, specificity, positive predictive value, negative predictive value and area beneath the receiver operating characteristic curve. Differences in area under the receiver operating characteristic curve were not significantly different.The median sensory-ulnar motor latency difference is the best calculated parameter for diagnosing mild carpal tunnel syndrome. It requires only a simple calculation and no additional testing. Residual latency and the terminal latency index are also useful in diagnosing mild to moderate carpal tunnel syndrome. Carpal tunnel syndrome (CTS) is a complex syndrome caused by compression of the median nerve beneath the transverse carpal ligament . CTS is However, several studies show that routine electrodiagnostic tests have limited sensitivity and specificity for mild CTS ,6,7,8,9.The aim of this study is to compare the diagnostic accuracy of all of these methods in large study involving patients with CTS of all severities.This diagnostic accuracy study was conducted retrospectively  8 mm in diameter were used. The distance between the recording electrodes was 3-5 cm.The distance between stimulator electrodes was 3 cm. The stimulation intensity was 10-30 mA for sensory nerve conduction studies and 10-50 mA for motor nerve conduction studies. The duration was 0.1-0.2 msec for sensory nerve conduction studies and 0.1-0.5 msec for motor nerve conduction studies. Supramaximal stimulation was achieved by adjusting the duration and intensity of the stimulus.Median sensory nerve conduction studies, digit II (finger)-wrist median and palm-wrist sensory nerve conduction velocities were orthodromically recorded with surface stimulation from digit II and mid palm. Latencies of the sensory nerve action potentials were measured from the onset to the initial negative peak.The median motor compound muscle action potential (CMAP) was recorded with the active recording electrode placed over the midpoint of the abductor pollicis brevis muscle and the reference electrode placed distally over the thumb. The belly-tendon principle was followed, and the ground electrode was placed between the stimulating and recording electrodes. Median motor distal latency (mMDL) was measured from the stimulus onset to the initial CMAP response. Median motor nerve conduction velocity (mMNCV) was determined by dividing the distance between the stimulation points by the difference in conduction times.For the ulnar motor CMAP, the active recording electrode was placed over the belly of the abductor digiti minimi (ADM) midway between the distal wrist crease and the base of digit V. The reference electrode was placed on the proximal phalanx of the digit V. Electrical stimulation of the ulnar nerve was done proximal to the active recording electrode at the wrist crease just lateral to the flexor carpi ulnaris tendon. Ulnar motor distal latency was measured from the stimulus onset to the initial ADM CMAP deflection.Terminal latency index was calculated with Equation 1 and residual latency, with Equation 2. MSUMLD was determined by simple subtraction .Terminal latency index= terminal distance / (mMNCV × mMDL)Residual latency= mMDL -  / mMNCV)Electrodiagnostic data were compared with normal reference values and categorized by our laboratory’s grading system (15):- Extreme CTS ,- Severe CTS ,- Moderate CTS ,- Mild CTS ,- Normal .In extreme CTS, median sensory and motor latencies could not be obtained and hence, were not included in parameter analysis. The MSUMLD requires a median sensory response and hence, could not be determined in severe cases.All statistical analyses were performed using SAS v9.4 . Data were reported as means ± standard deviation. Means were compared using one-way ANOVA with the Bonferroni adjustment. For statistical significance, a probability level of 5% (p<0.05) was required. The sensitivity and specificity were compared using receiver operating characteristic (ROC) curve analysis.According to the standards for the reporting of diagnostic accuracy studies , the chaComparisons of mean values between control and all CTS groups are presented in When the control and mild CTS groups were compared , the cutA comparison of control and moderate CTS is shown in Comparing controls and severe CTS , residuaIn this study, the sensitivity and specificity of terminal latency index, residual latency, and MSUMLD were examined. In CTS, conduction abnormalities are often limited to short segments of the carpal tunnel, so normal conduction in parts of the carpal tunnel can mask the slowing of conduction in mild CTS ,12,17. TPrevious studies showed a higher mean value of terminal latency index in the control group than our study ,23. ThisThe MSUMLD can be a very sensitive and specific test for CTS. It is worth noting that the MSUMLD does not require mid palm stimulation, saving time and increasing patient comfort. For MSUMLD in mild CTS, Bodofsky et al.  found hiThere are some limitations to this study. For severe CTS, MSUMLD could not be compared with residual latency and terminal latency index because the median sensory responses by definition could not be obtained. However, severe cases are easily diagnosed by using standard criteria. There was limited information available for some patients. This was a retrospective study. Diagnostic criteria were primarily electrodiagnostic.There were more female than male subjects in this study. However, CTS incidence is reported to be significantly higher in the female population . TherefoMSUMLD is the best calculated parameter for diagnosing mild CTS using a minimum number of tests. It requires only a simple calculation and no additional testing. Residual latency and terminal latency index are also useful in diagnosing mild to moderate CTS.


In recent years there has been an exponential rise in the professionalism and success of female sports. Practitioners  aim to apply evidence-informed approaches to optimise athlete performance and well-being. Evidence-informed practices should be derived from research literature. Given the lack of research on elite female athletes, this is challenging at present. This limits the ability to adopt an evidence-informed approach when working in female sports, and as such, we are likely failing to maximize the performance potential of female athletes. This article discusses the challenges of applying an evidence base derived from male athletes to female athletes. A conceptual framework is presented, which depicts the need to question the current  evidence base due to the differences of the “female athlete” and the “female sporting environment,” which pose a number of challenges for practitioners working in the field. Until a comparable applied sport science research evidence base is established in female athletes, evidence-informed approaches will remain a challenge for those working in female sport. There is currently a lack of sport science and sport medicine research conducted on elite female athletes, making it challenging to develop an evidence-informed approach to practice.Applying evidence developed in male athletes to female athletes may be erroneous.This article highlights the challenges of applying evidence derived from male athletes and applying it to female athletes and female sporting contexts. It provides considerations of how to apply research to female sport, considering the female athlete and the female sporting environment.In recent years there has been an exponential rise in the professionalism and profile of female sports . Women’sPractitioners  aim to apply evidence-informed approaches to accomplish the goal of optimal athlete performance and well-being. Evidence-informed practice is the application of research findings to the real world . The chaThe purpose of this article is therefore to highlight the challenges of applying evidence developed in a male cohort to a female cohort. Of note, this article will not discuss gender as it is outside the scope of this editorial. The article will provide considerations, supporting the application of evidence into practice, and also support future translational research for female sport.independent variables  on dependent variables . In sports science disciplines, sex should be controlled given the different biological attributes [British Journal of Sports Medicine [Scientific research aims to investigate the effects of tributes . HoweverMedicine . The appDeveloping an applied sports performance evidence base in female sport is also challenging, given the logistical and methodological context . FluctuaContextual factors may also influence the effectiveness and application of sports science interventions in practice. Contextual factors include competition structure, finance allocated to tournaments, access to facilities, or access to expert staff, for example. Sports science and medical provision  are often limited for female athletes in comparison to males and must be considered when trying to apply research to practice. For example, the success of a training or injury prevention intervention is not solely determined by the efficacy of the intervention, but it is also influenced by multiple interrelated contextual factors within the target group and in the community . Specifivs. female youth soccer).Current sports performance and player well-being strategies in female sport are often underpinned by evidence derived from male athletes or male talent development environments. While there are some good practices that can be derived from a male context, in some instances we may be failing to consider the requirements of the female athlete as highlighted above. When aiming to either develop applied sport science practices, adopt an evidence-informed approach, or undertake future research, the first step is to appraise and evaluate the current available evidence. Acknowledging that limited research studies have investigated female athlete cohorts in comparison to male athletes, this may lead to simply identifying the “best available evidence.” For the practitioner, this may mean that the evidence is useful to support decision-making or indeed the findings may not be suitable to translate into practice, due to inherent differences  the female sporting environment, in addition to the typical scientific scrutiny applied to published research literature. This can be used to both apply the current evidence into policy and practice and indeed conceive future research projects specific to the needs of the female athletes, which has direct translation into practice.In Fig. female athlete  is different to the male rugby league player , itAcknowledging that the effective translation of research findings is not solely determined by the efficacy of the intervention , there iusefulness and adoption of the research findings into practice. Adopting such approaches to research as described by Bishop [The application of established research models, considering the female athlete within context, is likely a useful starting point. Bishop  providesy Bishop  and Joney Bishop  with cony Bishop ; thus thfemale athlete and the female sporting environment. Considering the athlete and the environment allows the researcher and practitioner to consider potential differences to published literature in male cohorts. Due to the dearth in female-specific sport science literature, in most cases there is a clear need to start with descriptive research to understand the current level of performance within female elite sport. Once this is achieved, the next challenge will be exploring in the influence of female physiology and the contextual factors which may limit the effectiveness of interventions with high efficacy. Only when this disparity in applied sport science research is addressed will the full potential of adopting an evidence-informed approach be possible in female sport.In summary, all stakeholders need to be cognizant of sexual dimorphism and the disparity in the current sports science literature and consequent challenges of adopting an evidence-informed approach to practice for female athletes. When applying and undertaking research in female sport, the first step is to appraise and evaluate the current available evidence, with consideration for both the


Epidemiologists face two fundamental and interrelated problems when judging causality: knowledge is fallible, and studies are imperfect. In medicine, this will always leave a degree of uncertainty in scientific judgements. From an epistemological point of view, even randomized trials cannot be regarded as the ultimate proof to establish a causal relation. Given this inherent uncertainty it is no surprise that much attention has been drawn to the question how we can move from an association to a valid judgement of causation. It was exactly this question that urged Austin Bradford Hill more than 50 years ago to his well-known and still worth-reading paper, in which his nine viewpoints (often referred to as Hill’s criteria) to judge causality were described .European Journal of Epidemiology, Olsen and Jensen call it a time for revision of Hill’s criteria [In their paper, published in this issue of the criteria . They poVery likely, Hill would have welcomed such discussion about his viewpoints; nowhere in his paper he claims that the presented list to judge causality is final, complete or sufficient. The only condition from Hill’s list that can be regarded as necessary, is temporality, as in medicine causes precede their consequences; however, as a feature to distinguish a mere association from causality, temporality is hardly helpful. Though not included as criterion, the fundamental prerequisite before judging causality is the presence of an association. This fundamental point is mostly disregarded, as the presence of an association is often the starting point for a discussion about causality; it can however be relevant to consider it for refutation of alleged causes, especially in pseudo-scientific debates where seemingly all meanings are equally important. In short: no causation without association.None of the nine criteria is sufficient to judge causality and there is arguably also not a sufficient set or minimum number of Hill’s criteria that suffices for a verdict of causality. Not all criteria are equally important; for example, strength of the association and consistency are more relevant than specificity. How the different criteria have to be weighted in a specific case is also unclear. This issue is further complicated by the fact that many of the criteria are not independent. For example, the existence of experimental evidence , will influence the judgement of another criterion, plausibility. It is thus no surprise that in an empirical study, asking epidemiologists to make explicit reasons for the causality judgment for a specific exposure-outcome association, variation in the reasons, but also in the final judgment, was shown .A major contribution to the field of epidemiology since Hill, is the introduction of a counterfactual framework to judge causality of interventions . This frIn 2015, a Zika epidemic emerged and scientists aimed to assess whether causality was underlying the association of the Zika virus and microcephalia. Upfront, there were arguments in favour (association of a rare exposure with a rare outcome), but also against (no flavovirus had ever been shown to cause birth defects). As no single convincing piece of evidence existed, a group of experts evaluated existing evidence, thereby explicitly using two frameworks for causal inference, one of which Hill’s criteria . The expAs can be seen from the Zika example, applying Hill’s criteria is not an automatic process that generates a correct conclusion; judging causality ultimately requires a verdict that has some degree of uncertainty. The fact that two sets of criteria were used (Hill’s and Shepard’s), does not add largely to the conclusion, as these criteria were partly overlapping. It is unlikely that a counterfactual framework of causality would have been better equipped in this case. Of course, one can think of Zika infection in terms of a hypothetical and unbiassed trial . But eveNo experiments, no (emulated) trials, different lines of evidence and a question that was in urgent need for an answer. In such situation Hill’s framework is likely helpful to judge causality. Mind that the question at stake is broad: is the association between Zika and birth defects causal? For its answer different lines of evidence were combined and weighted. Such an approach, taking into account the total body of evidence, is more recently framed as triangulation . After tLet me turn to the proposal from Olsen and Jensen, that is adding a consequence criterion  to Hill’s list. It was upfront clear in the Zika case, that a verdict of causality would have provided the basis for immediate discussion on public health action(s) to be taken. The potential need for action might even have contributed to the urge of the discussion about the causality. However, the potential for action, did not play a role in the ultimate verdict. Epistemologically, there is no compelling reason to argue that knowing the consequence (in terms of actions) of a casual judgment adds to the knowledge base of causality. It might even be that when judging causality, no certainty about relevant therapeutic options exists. Should we in such case abstain from a verdict of causality?Hill was well aware of the relevance of actions, to which the last few paragraphs in his paper are devoted, as in passing from association to causation ‘we have to consider what flows from that decision’ . He furtFor therapeutic interventions, especially when considering implementation, a general statement about causality is not sufficient. Discussions about interventions require a clear definition of an intervention, and also the magnitude of the effect should be quantified. For causal inference of interventions, the counterfactual framework is clearly better equipped than Hill’s criteria. However, such counterfactual framework does not give us candidate exposures to be used as intervention, nor adds fundamentally to our understanding of why an intervention actually works. Before considering a substance or public health action as an intervention that is worthy of a RCT, this action should be considered as potentially disease reducing. How? By using the whole body of evidence about the condition, or the target, on which this action should work.So, there is indeed room for discussing relevance and limitations of Hill’s criteria. And, if we are reconsidering criteria for causality anyway, I would like to add another urging challenge to the agenda: how to judge causality when data, analyses and probably even conclusions are provided by artificial intelligence.


The Belt and Road Initiative involves many countries and areas. As the introducer, China plays a key role in the initiative. However, the coastal areas in China have frequently been hit by typhoons that lead to huge casualties and economic losses. In order to reduce damages caused by natural disasters, this paper selected the coastal regions of the 21st Century Maritime Silk Road as the study areas, specifically Shanghai, Zhejiang, Guangdong, Fujian, and Hainan, to estimate the vulnerability to typhoon disasters based on the historical data about typhoon disasters and the super-efficiency data envelopment analysis (DEA) evaluation model. Although Shanghai is a low-vulnerable region, it needs to pay close attention to the risk of typhoon disasters due to the outstanding economic influence. In addition, it was found that the vulnerability to typhoons in Zhejiang, Guangdong, and Hainan showed a dramatic fluctuation from 2011 to 2016, and Zhejiang’s vulnerability in 2013 was extremely high compared to other years. Meanwhile, Guangdong and Hainan are highly vulnerable areas, suffering from typhoon disasters heavily. Moreover, the vulnerability to typhoons for Fujian is relatively low. A Silk Road Economic Belt and a 21st Century Maritime Silk Road were proposed by Chinese President Xi Jinping in September and October 2013, respectively . ParticuA standardized and comprehensive hazard vulnerability assessment can help healthcare facilities to identify and stratify potential hazards . VulneraChina’s Belt and Road initiative belongs to the world. Currently, many scholars are discussing the initiative from different perspectives. The Belt and Road initiative of China provides a great opportunity for promoting the Resourcing Future Generations program across much of the Eurasian continent . Under tIn a word, the new Silk Road initiatives create a medium of communication for companies and capital to make a series of investments in other countries by taking advantage of China’s strengths in infrastructure, financial power, and manufacturing capacity . Yet, thAt present, various methods are widely used in research, such as field investigation, the historical recording method, the indicator framework, and the method of analogue function. Among them, field investigation uses questionnaires and face-to-face interviews to conduct sample surveys on the affected individuals that mainly focus on vulnerable individuals with high vulnerability, neglecting the total vulnerability of the affected population and reducing the reliability of the overall measurement. The indicator framework is to establish an evaluation system in advance and then select different kinds of indicators, determine the weights of them through the Delphi method, gray correlation method, analytic hierarchy process, etc., which finally conducts a comprehensive assessment of vulnerability. Unfortunately, due to the lack of consensus about the selection principle and empowerment of indicators, it may lead to the absence of credibility. In addition, the method of analogue function is applied into the risk assessment for accurately and quantitatively assessing disaster vulnerability. However, it needs to assume a functional model in advance and takes a large amount of data as the support. The results are easily affected by the presupposed model.Based on historical data about disaster, the historical recording method is applicable to assess vulnerability at the macro scale. The disaster risk index (DRI) and HOTSPOTS program are representative applications of this method. Specifically, the DRI program uses the ratio of the number of people killed by natural disasters to exposures as an index of relative vulnerability . Meanwhiε is Archimedes infinitesimal, andData envelopment analysis (DEA) is an efficiency evaluation method proposed by American operation researchers . It can The traditional DEA model fails to distinguish the decision-making units with the efficiency value equals to the highest value “1”. To solve the problem, some researchers have proposed the super-efficiency DEA model . In ordeε is Archimedes infinitesimal, while The To estimate the vulnerability to typhoon disasters, the coastal regions of the 21st Century Maritime Silk Road as the case study were selected as the study areas, namely Shanghai, Zhejiang, Guangdong, Fujian, and Hainan. Based on the input–output system, considering the availability of data and referring to ,47, thisThe data were collected from the China Statistical Yearbook, China Meteorological Yearbook (2012–2017), annual climate bulletins of various regions, and information provided by departments. Particularly, due to the lack of a record about Shanghai’s typhoon disaster loss in 2014, the mean of the two years before and after was adopted to replace the missing one.The vulnerability to typhoon disasters of selected areas is shown in In order to further analyze the vulnerability to typhoon disasters of selected areas, this paper compared the exposure, loss, and vulnerability in each region in the past six years in Overall, Zhejiang was in a state of high exposure–medium loss–medium vulnerability from 2011 to 2016. As a coastal, economically developed region, Zhejiang is always in the forefront of five regions in terms of population, economy, and crop sown area. Thus, Zhejiang is a high-exposure area. In the past six years, Zhejiang has ranked among the top three in the vulnerability of typhoon disasters three times. Moreover, Guangdong belongs to the high exposure–high loss–high vulnerability area, and its typhoon disaster vulnerability is always at the top. Among the five research objects, the direct economic losses caused by typhoon disasters in Guangdong, the largest economic aggregation, have remained stable in the top two five times over the years. It can be seen that typhoons have a particularly destructive effect on the Guangdong’s economy. As the core of the Pearl River Delta, it ought to think highly of the system of typhoon disasters, improve the collaboration capability of meteorological, oceanic, transportation, and civil affairs departments to deal with major natural disasters, and build an effective disaster emergency response and rescue system.In addition, the vulnerability of typhoon disasters in Fujian is low generally, and it has low exposure–low loss–low vulnerability. Due to the super typhoons Nepartak, Meranti, and Megi landing in Fujian in 2016, major casualties and property losses caused the rank of vulnerability to rise up to the second spot. Meanwhile, Hainan had the highest vulnerability to typhoon disasters in 2011, 2014, and 2016, ranking first among five regions. Hainan is a region with low exposure–high loss–high vulnerability on the whole. In the face of a typhoon of the same intensity, Hainan may suffer from more serious disaster losses due to its high vulnerability. Based on the historical recording method, this paper took the coastal areas of the 21st Century Maritime Silk Road in China as the research object and used the super-efficiency DEA model to evaluate the vulnerability to typhoon disasters in Shanghai, Zhejiang, Guangdong, Fujian, and Hainan between 2011 and 2016. Furthermore, the exposure of these regions, loss caused by typhoons, and overall vulnerability were analyzed in detail. The results indicated that the vulnerability to typhoons in Zhejiang, Guangdong, and Hainan showed a dramatic fluctuation from 2011 to 2016. Although Shanghai is a low-vulnerable city, it needs to pay close attention to the risk of typhoon disasters, enhance the ability to respond to natural disasters, and prevent sudden-onset disasters because of its large population and production activities. In addition, with it having been hit by typhoons such as Soulik, Kong-Rey, and Fitow, the vulnerability of Zhejiang Province in 2013 was extremely high compared with other years. Meanwhile, Guangdong and Hainan are highly vulnerable areas, and typhoon disasters have caused huge casualties and economic losses. The vulnerability to typhoons for Fujian is relatively low. Hainan is often attacked by typhoons in China, so the rank of vulnerability has always been in the forefront over the past years, especially in 2011, 2014, and 2016.Typhoon disasters have become the main obstacle to the sustainable development of the economy in coastal areas of China. The formulation of disaster prevention and reduction measures is an important guarantee for sustainability. Based on the analysis of our study, suggestions are given in the following part.The successful implementation of prediction about typhoon disasters is inseparable from advanced technology and equipment. Studies about high-accuracy typhoon monitoring instruments are supposed to be improved and enhance the exactitude of meteorological disaster prediction. At the same time, the refined management of disaster prediction systems is carried out, and the responsibilities of each post should be standardized clearly so as to achieve a comprehensive regulatory system. In addition, the establishment of an information sharing platform ought to be pushed on in order to increase the efficiency of typhoon disaster prediction.Improving the emergency response mechanism of typhoon disasters is conducive to reducing losses caused by natural disasters and enhancing the rescue capability of meteorological disasters. It is necessary to strengthen the uniformity of emergency command and rescue work and ensure related information transfer quickly among different departments. In particular, information disclosure should be given great importance, which means the public should have easy access to it. Meanwhile, closely monitoring the condition of typhoons in metropolitan areas and comprehensively assessing the risk of disasters are beneficial to the construction of an emergency support system.The propaganda campaign needs to be enriched and make the public aware of the fatalness of catastrophic weather such as typhoons and heavy rain in order to take proper measures. Uniting available social forces and making full use of resources such as the government, media, and research institutes will comprehensively strengthen the public’s awareness of typhoon so that they can exert themselves to play a part in the process of rescue.