The COVID‐19 pandemic poses a critical global public health crisis. Operating room (OR) best practice in this crisis is poorly defined. This systematic review was performed to identify contemporary evidence relating to OR practice in the context of COVID‐19.MEDLINE was searched systematically using PubMed (search date 19 March 2020) for relevant studies in accordance with PRISMA guidelines. Documented practices and guidance were assessed to determine Oxford Centre for Evidence‐Based Medicine (OCEBM) levels of evidence, and recommendations for practice within five domains were extracted: physical OR, personnel, patient, procedure, and other factors.Thirty‐five articles were identified, of which 11 met eligibility criteria. Nine articles constituted expert opinion and two were retrospective studies. All articles originated from the Far East ; eight of the articles concerned general surgery. Common themes were identified within each domain, but all recommendations were based on low levels of evidence (median OCEBM level 5 (range 4–5)). The highest number of overlapping recommendations related to physical OR (8 articles) and procedural factors (13). Although few recommendations related to personnel factors, consensus was high in this domain, with all studies mandating the use of personal protective equipment.There was little evidence to inform this systematic review, but there was consensus regarding many aspects of OR practice. Within the context of a rapidly evolving pandemic, timely amalgamation of global practice and experiences is needed to inform best practice. This rapid systematic review was performed to identify contemporary evidence relating to operating room (OR) practice during the COVID‐19 pandemic. Evidence underpinning the review was sparse; however, consensus regarding many aspects of OR practice was apparent.High quality evidence needed Coronavirus has killed thousands since emerging in China in December 2019, and compelled many governments to lock down populationsPreliminary data from China and Italy regarding the spectrum of severity and fatality vary. China reported that 80 per cent of those infected reported no or mild, 15 per cent severe, and 5 per cent critical symptoms, with a mortality rate ranging from 0·25 to 3·0 per centFrom an acute surgical perspective, although some patients may present with an acute abdomen secondary to the viral infection, it is more likely that general surgeons will encounter patients with common acute abdominal pathology and undiagnosed COVID‐19 infection, or those who develop nosocomial COVID‐19 infection while an inpatient with a surgical diagnosis. Guidance on perioperative care of surgical patients with suspected or proven coronavirus infection is slender, and operating room (OR) best practice remains unknown.The aim of this study was to perform a systematic review of the literature to identify and collate global experience, practice and recommendations relating to OR practice in the context of the COVID‐19 pandemic.A rapid systematic review of published work was conducted using standard rapid review methodology, as outlined by Schünemann and MojaS1 (supporting information). Further articles were identified by hand search of references and using the PubMed related articles function. Levels of evidence were determined as described by the Oxford Centre for Evidence‐Based Medicine (OCEBM)MEDLINE was searched via PubMed on 19 March 2020 (no date restriction), for articles describing specific practices, or providing recommendations or guidance relating to OR practice, in the context of the COVID‐19 pandemic. No limitation was placed on language or publication type, but non‐English‐language articles without extractable data were excluded. Relevant articles were identified using terms in any field relating to coronavirus  and the OR , and operating room practice . The full search algorithm is shown in a priori: the physical OR factors, personnel factors, patient factors, procedure factors, and other considerations.Nine authors extracted data independently, and two verified a random subsample of seven articles. The following details were extracted: first author, date of publication, study design, country, region, and any description of specific practices, recommendations or guidance in relation to OR practice in the context of the COVID‐19 pandemic. Five domains for data capture were identified Articles reporting specific practices, experience, recommendations or guidance in relation to emergency OR practice, in the context of the COVID‐19 pandemic, were included.Articles were excluded if they did not meet the inclusion criteria, if the full‐text article was unavailable, or if no English version was extractable.Fig. The MEDLINE search yielded a total of 35 articles. Full manuscripts were obtained for all of these, of which 11 articlesTable Table Table All 11 papers contained recommendations relating to the physical OR. Despite wide‐ranging specialty coverage, common themes for preparation of the OR were identified as shown in Both of the case series reported data from patients treated within a single centre. One studyTable The remaining nine papers made suggestions derived from local operative experience during the pandemic. Use of a negative‐pressure OR, along with a number of other practices to minimize intraoperative viral load, was recommended in sixThe use of single‐use/disposable equipment for COVID‐19‐positive patients was recommended in four communicationsTable Of the 11 communications, eightTable Indications for the use of PAPR masks varied Table 4, althTwo articlesTable Ten articlesTable A host of routine blood tests were recommended by Li and colleaguesFour articlesCommunication with patients and families was highlighted. Patients with cancer were described as needing special consideration, with four articlesNine articlesTable Seven focused on individual subspecialty practice, including preoperative considerations. Although each of these concentrated on different surgical circumstances, overlapping themes were apparent, as described in Table The main additional area considered was postoperative management. Most described the importance of altered postoperative practice, eight articlesRecognizing the risks of significant complications, four articlesNutrition was again highlighted in four articlesThis systematic review identified and evaluated evidence of OR best practice in the face of the COVID‐19 pandemic. The research question was deliberately kept broad, to optimize the volume of clinical practice and consequent literature reports available. At the time of the review (19 March 2020), COVID‐19 had been reported in 156 countriesAlthough the epidemiology of COVID‐19 has been well reported10,14 of the 11 articles mandating the use of PAPR during high‐risk procedures such as intubation. The filtering ability of PAPR masks is reported to be marginally better than that of N95 masks , but the clinical significance of this is unknownThe importance of appropriate PPE, both before and during surgery, to protect staff and minimize viral transmission was highlighted in all articles, supported by evidence in reports from previous outbreaks of SARS and MERSThe level of screening necessary for surgical patients differed between hospital units. All recommended health questionnaires or nasopharyngeal swabs as a minimum requirement, with additional thoracic CT recommended by almost half. Evidence‐based consensus regarding patient screening is therefore a priority, based on the balance of risk and sensitivity of individual screening test modalities.The issue of a deliberate pause in elective surgical practice was a common theme, with the justification cited being to minimize further viral transmission, strategically to ration a stretched health resource threatened with an overwhelming burden, and as a response to the risk of unknown potential adverse clinical outcomes of patients developing COVID‐19‐related morbidity and complications after surgery. To mitigate potential surgical and respiratory morbidity, consideration of less invasive procedures such as interventional radiology or endoscopy was recommended, and in those requiring surgical resection the formation of proximal diversion or end stomas to avoid the risk of operative sepsis associated with anastomotic leakageMinimizing intraoperative aerosol generation and the potential for dissemination of viral particles was addressed in a number of the papers included in this review. The use of rapid sequence induction with cuffed endotracheal tubes and limiting energized dissection, as reported, are recognized techniques in the literature; however, high‐quality evidence‐based practices are lackingThere are several limitations to this review. The number of publications available for review was modest. Rapid evaluation of evidence, which has been essential in informing early recommendations in an emerging pandemic, can result in false assumptions and conclusions. The results are subject to the risk of significant bias. The study relied on the inclusion of expert opinion and low‐quality observational studies, owing to the absence of high‐quality clinical trials. In exceptional circumstances, such as the current coronavirus pandemic, a conventional strong evidence‐based approach to healthcare policy development is neither feasible nor safe.Within the constraints of time and resource, clinical practice must be driven by a pragmatic approach to developing evidence‐based practice, and arguably a novel scientific approach to collating global evidence when rigorous research evidence is not available. The widespread professional use of social networking platforms represents a powerful way of sharing such information internationally.This review has highlighted the need for novel methodological approaches. There is a need to assimilate ‘real‐time’ preliminary experiences and evidence, in advance of publication, while recognizing the heightened potential for bias. An ability to transcend geographical and language barriers is essential to facilitate international knowledge‐sharing. The encouragement of wide participation across a range of disciplines, not limited to healthcare professionals, would help to capture the full spectrum of viewpoints and potential solutions. Finally, the ability to recruit a pool of engaged stakeholders, ready to assist, would permit iterative development and re‐evaluation as a situation unfolds.Members of the WSRI Collaborative: T. Abdelrahman, J. Ansell, C. Brown, R. Egan, T. Evans, E. Ryan Harper, R. L. Harries, L. Hopkins, O. James, S. Lewis, W. G. Lewis, O. Luton, K. Mellor, A. G. Powell, D. Robinson, R. Thomas, A. Williams, A. J. Beamish.Appendix S1: Supporting informationClick here for additional data file.


There is consensus that health services commissioning and clinical practice should be driven by scientific evidence. However, workload pressures, accessibility of peer reviewed publications and skills to find, appraise, and synthesise relevant evidence are often cited as barriers to uptake of research evidence by practitioners and commissioners alike. In recent years a growing requirement for rapid evidence synthesis to inform commissioning decisions about healthcare service delivery and provision of care contributed to an increasing popularity of scoping literature reviews (SLRs). Yet, comprehensive guidelines for conducting and reporting SLRs are still relatively scarce.The exemplar review used as a worked example aimed to provide a readily available, comprehensive, and user-friendly repository of research evidence for local commissioners to help them make evidence-informed decisions about redesigning East of England Children and Adolescent Mental Health Services. In conducting the review, we were broadly guided by Arksey and O’Malley’s framework, however some modifications were made at different stages to better reflect the largely pragmatic objective of this review. This paper compares the methodology used with existing methodological frameworks for scoping studies, to add to the existing knowledge base.We proposed the following advancements to the existing SLR frameworks: (i) Assemble a research team with complementary skills and expertise; (ii); Draw on expertise of external partners, particularly practitioners, decision-makers and commissioners who will be translating findings into practice; (iii) Pre-register the review protocol. Keep a detailed record of all steps and decisions and consider how they would impact on generalisability and utility of review findings; (iv) Use systematic procedures for literature searchers, selection of studies, data extraction and analysis; (v) If feasible, appraise the quality of included evidence; (vi) Be transparent about limitations of findings.Despite some methodological limitations, scoping literature reviews are a useful method of rapidly synthesising a large body of evidence to inform commissioning and transformation of CAMHS. SLRs allow researchers to start with a broader questions, to explore the issue from different perspectives and perhaps find more comprehensive solutions that are not only effective, but also accounted for their feasibility and acceptability to key stakeholders. Evidence-based policy requires evidence, yet the policy and research cycles operate on vastly different timescales. There is consensus that health services commissioning and clinical practice should be driven by scientific evidence, but decision-makers often feel that gathering evidence may slow down innovation and overwhelm frontline staff . WorkloaTraditionally, systematic reviews are considered the most robust and reliable evidence synthesis method to inform evidence-based healthcare, answer clinically meaningful questions about treatments , 8, and Despite growing popularity of SLRs  our searFirst, we describe and discuss the methodology used to conduct an SLR. To this end we provide an exemplar SLR and describe how the specific purpose of the exemplar SLR defined and shaped its’ subsequent stages. We describe the steps taken from defining the research questions, charting the evidence, and data analysis to the final presentation of the findings. We highlight additional steps we have taken and describe how our methodology deviated from the original Arksey’s and O’Malley’s framework  to aid tThe SLR used as a worked example in this paper aimed to inform the redesign of East of England Children and Adolescent Mental Health Services (CAMHS) to create more accessible, user-friendly and efficient service for young people and their families. It was conducted as part of a multifaceted research initiative that was undertaken to support local operationalisation of the recommendations outlined in “Future in Mind” – a taskforce report outlining the improvements needed in the way CAMHS are organised, commissioned and provided, to optimise children’s and young people’s mental wellbeing in the UK . The praPredefining research questions, breadth and coverage, and inclusion/exclusion criteria to reflect the key priorities for local CAMHS redesign selected by stakeholders. Rather than being informed by research objectives , this prKeeping a detailed record of every decision made about breadth and coverage of the SLR, inclusion/exclusion criteria and data analysis, noting the rational for it, and considering how it impacts on generalisability and practical applications of SLR findings.Consultations with a broad range of experts at every stage of the review. We primarily relied on guidance from practitioners, commissioners and other decision-makers to ensure that the review is ‘fit for purpose’ i.e. to inform decisions about redesigning existing services and commissioning new ones, and to provide a practical guide on how to implement and evaluate them.We applied rigorous methods used for systematic reviews to maximise robustness and ensure replicability of our methodology. These include using predefined search strategy and inclusion/exclusion criteria, and having two reviewers preform study selection and data extraction.Although we did not undertake it in the exemplar review, we strongly recommend appraising included studies for quality.Include a detailed description of limitations of findings and of their practical applications.In conducting the review, we were broadly guided by Arksey and O’Malley’s framework , howeverWhat are the effective ways of delivering services that were prioritised for CAMHS transformation?What ways of delivering services that were prioritised for CAMHS transformation are feasible and acceptable for CAMHS users?What are the effective procedures for implementing services that were prioritised for CAMHS transformation?What are the effective ways of measuring transformation outcomes?Aims and research questions were formulated to reflect the pragmatic aim of the SLR i.e. guiding the operationalisation of key priorities for local CAMHS transformation. These priorities were identified through Delphi-method consultations  with staThe pragmatic purpose of the SLR determined coverage corresponding with key priorities for local CAMHS transformation identified through the three-stage Delphi study . The proDelphi phase 1 : Following completion of the first round of the Delphi, JKA conducted an “evidence charting” search to understand the amount and type of evidence available for each key priority identified. A systematic search strategy was then developed to reflect key priorities identified through the first round of the Delphi  terms and key words in titles and abstracts were searched . Duplicate records of the same report were removed. Documents retrieved in grey literature searches were filed separately in Excel database and separately screened for relevance.Titles and abstracts of all papers and grey literature documents were examined to remove obviously irrelevant papers .Abstracts/executive summaries of remaining papers were screened against inclusion/exclusion criteria.Full texts of remaining, potentially relevant papers were retrieved and multiple reports of the same study were linked.Full texts were examined for compliance with inclusion/exclusion criteria. After completing abstracts and full text screening another member of the team double screened 10% of papers in each review area. Team discussions allowed disagreements and boundary papers to be included/excluded via consensus. We kept a detailed record of the outcomes of each stage, including rejected papers and reasons for rejection. Additionally, each screening researcher identified and recorded main themes for each paper in the key priority area. , and comments on paper’s relevance if there were doubts whether it should be included or excluded. Results of pilot screening were discussed within the research team with particular focus on applying refined inclusion/exclusion criteria Table  and releAfter completing the last round of the Delphi study, we collated a final list of key priorities for local CAMHS redesign . This liBefore data extraction the lead researcher developed an extraction table to be trialled by members of the research team. Because the review included a variety of evidence types i.e. papers describing qualitative and quantitative studies, process evaluation studies, theory and framework papers, discussion and opinion papers, policy documents, we developed different forms to extract different type of evidence. This aimed to maximise the amount of meaningful information extracted, and to facilitate further narrative synthesis process. Data for each key priority area identified through the Delphi study were organised in a separate table(s). Extracted data were organised under the key themes identified in the previous stage  and review process (e.g. decisions about search strategy), to consider when translating findings from the review into practice.Phase III: Exploring relationships in data. The aim of this is to identify factors explaining differences in direction and size of effects across included studies, and factors that might explain differences in facilitators and barriers to successful implementation. The SLR aimed to provide an evidence-base to guide the transformation of local CAMHS in each identified priority area. In practice we were aiming to develop a robust, credible, yet concise and user-friendly summary of evidence .We applied rigorous processes used in systematic reviews to define search strategy, select papers for inclusion, extract data and analyse data. We kept detailed records documenting every step to ensure our methods are systematic, verifiable and replicable. Initially, we extracted and data and synthesised evidence separately for each key priority area. Subsequently, we explored relationships between data in each area to determine which ways of delivering services were the most feasible, clinically and cost-effective, and acceptable for users in different contexts. We also identified common factors contributing to effectiveness, feasibility and acceptability. Finding these commonalities allowed us to synthesise a very large amount of data relatively quickly an in a succinct manner. Our outputs were concise summaries of findings and recommendations, focusing primarily on practical implications, foregoing methodological considerations  can be quite lengthy, since they require a coordinated input from different groups of experts and stakeholders. If resources are an issue, it might be more feasible to conduct a rapid review, however, considering literature searches restrictions and stringent inclusion/exclusion criteria, the findings are likely to only partially reflect available evidence.Finally, although involving commissioners and decision-makers in defining research questions and scope of a review is very beneficial and useful when it comes to informing practice, there are also downsides that need to be considered. Different decision-makers may have different, often competing priorities that do not always align with those of other stakeholders (e.g. service users and clinicians). Designing a review that addresses all different priorities may be very challenging, and foregoing some to give precedence to others may result in limited practical applications and usefulness of findings.Despite some methodological limitations, SLRs are a useful method of rapidly synthesising a large body of evidence to inform commissioning and transformation of CAMHS. Unlike systematic reviews, SLRs allow researchers to start with broader questions, to explore the issue from different perspectives and perhaps find more comprehensive solutions that are not only effective, but also accounted for their feasibility and acceptability to key stakeholders. Unlike for systematic reviews, there is no strict requirement to rigorously adhere to SLR process and reviewers can skip or modify certain steps as they see fit. However, non-adherence to guidelines is likely to result in significant bias and compromise the reliability of findings. The framework we propose brings together numerous advancements made to SLR methodology, as well as introduces additional protocols to enhance methodological robustness, minimise bias, and ensure reliability of findings. ▪ Assemble a research team with a range of skills and expertise.▪ Draw on expertise of external partners, particularly practitioners, decision-makers and commissioners who will be translating findings into practice.▪ Document in the review process in detail. Note rationale for each decision and consider how it would impact on generalisability and utility of findings.▪ Use systematic procedures for literature searchers, selection of studies, data extraction and reporting. Keep detailed records to ensure replicability.▪ If feasible, appraise the quality of included evidence.▪ Be transparent about limitations of findings.▪ Commit to and embrace open science principles.Additional file 1: Appendix 1. Table 1: Search terms used in evidence charting searches. Table 2. Initial inclusion/exclusion criteria for evidence charting searches. Table 3: Results of evidence charting search. Table 4: Search terms used in final SLR searches.Additional file 2: Appendix 2. Figure 1: CAMHS delivery models – logic map.Additional file 3: Appendix 3. Executive summaries of findings for the exemplar review.


Healthcare settings are complex, and the decision-making process is usually complicated, too. Precise use of best evidence from different sources for increasing the desired outcomes is the result of EBM. Therefore, this study aimed to map the potential facilitators and barriers to EBM in health systems to help the healthcare managers to better implement EBM in their organizations.The present study was a scoping review (SR) conducted in 2020 based on the integration of the frameworks presented by Arksey and O’Malley (2005) and Levac et al. (2010) considering the Joanna Briggs Institute guideline (2015). These frameworks consist of 6 steps. After finalizing the search strategy, 7 databases were searched, and the PRISMA-ScR was used to manage the retrieval and inclusion of the evidence. Microsoft Excel 2013 was used to extract the data, and the graphic description was presented. The summative analysis approach was used applying MAXQDA10.According to the systematic search, 4815 studies were retrieved after eliminating duplicates and unrelated articles, 49 articles remained to extract EBM facilitators and barriers. Six main aspects attitude toward EBM, external factors, contextual factors, resources, policies and procedures, and research capacity and data availability were summarized as EBM facilitators. The barriers to EBM were similarly summarized as attitude toward EBM, external factors, contextual factors, policies and procedures, limited resources, and research capacity and data availability. The streamgraphs describe that the international attention to the sub-aspects of facilitators and barriers of EBM has been increased since 2011.The importance of decision-making regarding complex health systems, especially in terms of resource constraints and uncertainty conditions, requires EBM in the health system as much as possible. Identifying the factors that facilitate the use of evidence, as well as its barriers to management and decision-making in the organization, can play an important role in making systematic and reliable decisions that can be defended by the officials and ultimately lead to greater savings in organization resources and prevent them from being wasted.The online version contains supplementary material available at 10.1186/s13643-021-01595-8. In the last decade of the twentieth century, evidence-based medicine was introduced, which is defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about patient care” . Then, tHealthcare settings are complex; consequently, the types of decisions that must be made are usually complicated too. Often, decisions are based on incomplete and outdated information and personal experiences . TherefoAlthough some studies have shown that health leaders have a generally positive attitude toward EBM , it was Recognizing the facilitators and barriers of EBM is necessary to develop this approach and implement it by the health care managers . HoweverThis was a scoping review conducted in 2020. In order to design the study, the Joanna Briggs Institute’s protocol (2015) was applied, and the integration based on the frameworks presented by Arksey and O’Malley (2005)  and LevaWhat are the facilitators or enablers that help health systems decide according to the evidence?What are the barriers or limitations to evidence-based decision-making or evidence-based management in health systems?In this step according to the Joanna Briggs Institute manual for scoping reviews (2015), the main research question was defined as “what are the EBM/EBDM facilitators and barriers in health systems/organization?” As the nature of the scoping review’s question is iterative, the specific questions were made as follows:In this regard, Levac et al.  have enhFurthermore, the scoping review question guides and directs the development of the specific inclusion criteria for the scoping review. The clarity in the review question assists to develop the protocol, facilitate effectiveness in the literature search, and provide a clear structure for the development of the scoping review report. As with the title, the question should incorporate the PCC elements  . In thisIn this step, the authors have searched the 7 main databases including Cochrane, ISI web of science, PubMed, Scopus, Science Direct, ProQuest, and EMBASE applying related keywords. The search duration was defined from January 01, 2000, up to August 25, 2020. Table The inclusion criteria consisted of those articles in any formats of review, original articles, or dissertations with the English language that had a full text and was determined or identified facilitators or barriers of EBM in health systems. Also, the exclusion criteria were the studies without full text or English language and some types of articles like a book review, opinion articles, or commentaries that had no defined framework for inspecting this study’s intended factors. In addition, the studies that were conducted clinically regarding the various scopes of health, medicine, or diseases were excluded. During this step, it was attempted to inquire about the related gray literature or studies that were not included in the search process as far as possible by reviewing the reference lists of the selected studies or by contacting some experts or the authors of the articles. This complementary search was based on the related articles’ titles in the reference lists of the selected articles conducted in Google scholar.After searching the studies from all databases and eliminating duplicates, the studies were independently reviewed and screened by two members of the research team (TSH and MRAM) in three phases by title, abstract, and then the full text of the articles. At each phase, the final decision to include the evidence was based on agreement, and in case of disagreement, the opinion of the third member (PB) was used. The Mendeley software version 1.19.4) was used to manage the process of systematic search. At the same time, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for Scoping Review (PRISMA-ScR)  was appl.19.4 waswww.plotdb.com.This step is defined as charting the data in the protocol of Arksey and O’Malley and the incorporation of a numerical summary and the qualitative analysis via Levac et al.  approachThen, for qualitative summative analysis, the included data was reviewed several times to be assured of considering all large or small sections of the included texts. The aim of the summative analysis is to cover all the complex subjects and contents of the text associated with the context . Applyinconsensus. These aspects then were defined, clarified, and tabulated as a comprehensive set of all facilitators and barriers to EBM in health systems and organizations  independently integrated and summarized the texts to reach the main and sub-aspects related to the facilitators and barriers of EBM. At the times of probable disagreements, the third person in the research team (PB) who has more reflexivity helped to reach the This step was mentioned optional according to Arksey and O’Malley. Although the revised protocol by Levac et al.  emphasizBased on a systematic search, 4815 studies were found from 7 databases, reaching a total of 2460 articles after duplicates were removed. After excluding studies with unrelated titles, 991 studies remained, and after studying the abstracts and removing unrelated articles, 268 articles were selected for the full-text screening. After studying the full text of the remaining papers, 49 papers were eventually selected to extract facilitators and barriers to EBM in health systems ) conducted between 2011 and 2015, 15 (30%) of them conducted between 2016 and 2020, 8 (16%) of them between 2006 and 2010, and the others (4 (8%)) conducted between 2000 and 2005. Additionally, most of the selected articles were from the USA (16 (32%)), Canada (11 (22%)), and Australia (6 (12%)). Also, there were 5 (10%) studies from Iran, and the rest (11 (22%)) were from other countries. Considering the design of the studies, 24 (48%) were qualitative, 18 (36%) were quantitative, and 7 (14%) were mixed-method researches. A summary of the final selected articles is given in Table 2 in Additional file Results of the summative analysis have shown that six main aspects attitude toward EBM, external factors, contextual factors, resources, policies and procedures, and research capacity and data availability were summarized as EBM facilitators. These six aspects were classified into 24 sub-aspects presented in Table 3 in Additional file Also, the framework of facilitators and barriers of EBM in health systems is illustrated in Fig. In the present study, we provide a comprehensive map of the facilitators and barriers to EBM in health systems that have been classified into six main aspects including “attitudes toward EBP and research,” “external factors,” “contextual factors,” “policies and procedures,” “resources,” and “research capacity and data availability”. In a study, facilitators and barriers to evidence use in program management and decision-making within health care organizations were divided into four distinct groups: informational, organizational, individual, and interactional . AnotherIn this regard, however, several studies were conducted to identify facilitators and barriers of EBM or EBDM in health organizations; they only focused on some aspects of just one or two of these factors and did not present a comprehensive and complete set or framework for them –16.In the following, we discussed the main aspects in two general categories of facilitators and barriers to EBM.In this research, EBM facilitators were categorized into six main aspects and 24 sub-aspects. Humphries et al. divided facilitators into five principal themes , and 15 sub-theme . JessaniIn the “attitudes toward EBM” aspects, four sub-aspects that were identified the most frequent ones based on the previous studies were “use of evidence as an organizational value” (14 (28.5%)) and “desire and political will” (13 (26.5%)). Schleiff et al. in their study explained that EBDM does not take place in a depoliticized vacuum. Political alliances and priorities, knowledge brokers, and other factors have a substantial role to play in applying EBM in health organizations. Hence, after the leaders determined the evidence priorities, they can identify processes for their generation and use them by using political commitments to set up structures to support it .In this aspect, the most mentioned sub-aspects were “interaction between researchers and decision-makers and participatory decision-making” (12 (24.5%)). This interaction assists to create consensus between researchers and managers or decision-makers, which can facilitate and promote evidence use , 25–32. Among six sub-aspects of the “contextual factors” aspect, “strong leadership” (23 (47%)), “organizational/administrative support” (22 (45%)), and “teamwork, collaboration, and communication” (21 (43%)) were the most repeated concepts in the literature. Encouragement of decision-makers to use evidence in their decision-making process can be considered as a change in organizations. Strong leadership and organizational support are the crucial components of a successful change in any organization . On the This aspect included four sub-aspects, and among them, “sufficient infrastructures or structures” was the most mentioned sub-aspect (24 (49%)) in the studies. In this regard, some factors such as information systems , 30, 35 This aspect included four sub-aspects. “Workforce development, empowerment and training leaders/staff” was the most frequent sub-aspect (31 (63%)) in this aspect. Empowering the decision-maker and building capacity to use evidence in the decision-making process can lead to more usage of evidence in an organization. Also, evaluating the implementation of the decisions taken can lead to reinforcing and institutionalizing the use of EBM in the organization. Considering this, some factors such as “executive training programs” , 30, 39,In this aspect, three sub-aspects have existed. Accordingly, “relevance, reliable, interpretable and understandable evidence” was the most mentioned sub-aspect (10 (20%)) in studies. Evidence is the fundamental part of EBM, so the data for use should be real-time, synthesized, and from different agencies , and if Different types of factors were explained which can impede the development of EBM in the organization. In this research, the identified barriers in literature are divided into six main aspects with 27 sub-aspects. Liang et al. identified 12 barriers in three levels including a broader level, organization, and individual manager . Pagoto In this aspect, both the “resistance to change” (14 (28.5%)) and “lack of confidence/interest about the values or the accuracy of research data or the researchers” (13 (26.5%)) were most repeated in previous researches. Adaption to various changes in organizations is unavoidable . ResistaIn the “external factors” aspect, “competing interests and priorities” which is defined as “the need for a hierarchy of approaches that allow to competing for organizational priorities and a balance between reactive and proactive management”  was mostAmong the “contextual factors,” “weak Organizational leadership” (20 (41%)) and “weak culture of decision-making based on evidence” (18 (37%)) were the most repeated sub-aspects in the literature. It is clear that no program or change in the organization will be successful without the commitment and support of the leader and senior officials of the organization. Also, the implementation of any plan and reforms requires the existence of a suitable cultural context and infrastructure. Culture is an important basic element to support changes in an organization, as well as to move toward EBM . OrganizIn this aspect, “limited knowledge and skills to access, interpret, appraise, and synthesize research evidence, or in research methods or foreign language” was the most cited sub-aspect 26 53%)) by the previous studies. According to a previous study, inadequate technical training to enable managers to interpret research findings was a barrier to adequate accessibility to scientific evidence [%) by the3%) by th“Time constraint for collecting and interpretation of information, engaging in research or implementation of an evidence-based decision making” was identified as an important and frequent (33 (67%)) sub-aspect in the “limited resources” aspect. Health workers are overworked, so time constraints are one of the barriers to using evidence. Organizations should provide the essential tools to facilitate quick and easy access to the required research, ensuring appropriate journal subscriptions, and providing relevant links on the organizations’ intranet  to overc“Lack of relevant or high-quality evidence” (24 (49%)) and “inadequate/uneven access to evidence” (22 (45%)) were the sub-aspects that were mentioned in much other literature. Uncertain/unreliable evidence , 42, nonThe importance of decision-making regarding complex health systems, especially in terms of resource constraints and uncertainty conditions, makes it necessary to apply the EBM in the health system organizations as much as possible. Existence and access to credible evidence from a variety of sources can reduce uncertainty and opinion-based decision-making. Therefore, we tried to provide a comprehensive map of EBM facilitators and barriers in health system organizations since we did not find a study that provided a comprehensive synthesis of all facilitating and hindering factors to EBM. We expect that the authorities and managers of health system organizations can make evidence-based decisions in their organizations using the map and the complete set of potential EBM facilitators and barriers presented in this study and by focusing on improving the facilitators and reducing or eliminating the barriers. Such systematic, reliable, and rational decisions can properly justify the stockholders’ demands and at the same time lead to better use of limited resources in the organizations.The most important strength of this study is providing a comprehensive set of EBM facilitators and barriers in health systems and map their trends over years. At the same time, the main novelty and contribution to the knowledge of the study is the integration of two methodologies for conducting the scoping review.However, like any other review, in this scoping review, some relevant sources of information might have been omitted, and the review was dependent on information on the review question and the selected search strategy. Also, for further studies, it might be interesting to survey the factors provided in this study from the healthcare managers’ perspective in different contexts.Additional file 1. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.Additional file 2: Table 2. Summary of characteristics of included studies. Table 3. The facilitators of EBM in health systems. Table 4. The barriers of EBM in health systems management.


A small proportion of chiropractors, osteopaths, and other manual medicine providers use spinal manipulative therapy (SMT) to manage non-musculoskeletal disorders. However, the efficacy and effectiveness of these interventions to prevent or treat non-musculoskeletal disorders remain controversial.We convened a Global Summit of international scientists to conduct a systematic review of the literature to determine the efficacy and effectiveness of SMT for the primary, secondary and tertiary prevention of non-musculoskeletal disorders.The Global Summit took place on September 14–15, 2019 in Toronto, Canada. It was attended by 50 researchers from 8 countries and 28 observers from 18 chiropractic organizations. At the summit, participants critically appraised the literature and synthesized the evidence.We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health, and the Index to Chiropractic Literature from inception to May 15, 2019 using subject headings specific to each database and free text words relevant to manipulation/manual therapy, effectiveness, prevention, treatment, and non-musculoskeletal disorders. Eligible for review were randomized controlled trials published in English. The methodological quality of eligible studies was assessed independently by reviewers using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for randomized controlled trials. We synthesized the evidence from articles with high or acceptable methodological quality according to the Synthesis without Meta-Analysis (SWiM) Guideline. The final risk of bias and evidence tables were reviewed by researchers who attended the Global Summit and 75% (38/50) had to approve the content to reach consensus.We retrieved 4997 citations, removed 1123 duplicates and screened 3874 citations. Of those, the eligibility of 32 articles was evaluated at the Global Summit and 16 articles were included in our systematic review. Our synthesis included six randomized controlled trials with acceptable or high methodological quality (reported in seven articles). These trials investigated the efficacy or effectiveness of SMT for the management of infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. None of the trials evaluated the effectiveness of SMT in preventing the occurrence of non-musculoskeletal disorders. Consensus was reached on the content of all risk of bias and evidence tables. All randomized controlled trials with high or acceptable quality found that SMT was not superior to sham interventions for the treatment of these non-musculoskeletal disorders. Six of 50 participants (12%) in the Global Summit did not approve the final report.Our systematic review included six randomized clinical trials (534 participants) of acceptable or high quality investigating the efficacy or effectiveness of SMT for the treatment of non-musculoskeletal disorders. We found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function. Governments, payers, regulators, educators, and clinicians should consider this evidence when developing policies about the use and reimbursement of SMT for non-musculoskeletal disorders.The online version contains supplementary material available at 10.1186/s12998-021-00362-9. Some evidence-based clinical practice guidelines recommend that spinal manipulative therapy (SMT) be used alone, or in addition to other interventions for the management of back pain, neck pain, and headaches associated with neck pain –5. AlthoThe treatment of non-musculoskeletal disorders has a long tradition among chiropractors and osteopaths. This tradition is based on two foundational concepts. The first concept implies that spinal dysfunctions, or subluxations, can have a negative effect on the body’s innate ability to heal itself, and that these dysfunctions can be rectified through SMT –11. The Laboratory studies of physiological mechanisms report that certain types of manual therapies can indeed affect body functions, such as heart rate variability or inflammatory cytokines in healthy individuals , 19, thuSome clinicians and patients report favorable outcomes when SMT is used to treat a variety of non-musculoskeletal complaints, such as allergies, breathing problems, digestive problems, and tinnitus . MoreoveSeveral previous reviews have evaluated the efficacy and effectiveness of SMT for non-musculoskeletal disorders , 37–41. Compared to sham or placebo interventions, is spinal manipulation, spinal mobilization or spinal traction efficacious for the prevention or management of non-musculoskeletal disorders?Compared to other interventions (including sham intervention when delivered in a pragmatic plan of management or no intervention), is spinal manipulation, spinal mobilization or spinal traction effective in the prevention or management of non-musculoskeletal disorders?The purpose of our study was to systematically review the body of evidence on the efficacy and effectiveness of SMT for the prevention and treatment of non-musculoskeletal disorders. Based on the osteopathic and chiropractic theories described above –14, we aThe primary target audience for our systematic review is policy makers . We targeted policy makers because they are well positioned to facilitate the development of clinical practice guidelines and implement evidence-based policies that will serve and protect the public’s best interest. We also aim to provide educators, researchers and health care providers with the best evidence to inform their contribution to the policy development process.The two research questions were the focus of the Global Summit on the Efficacy and Effectiveness of Spinal Manipulation for the Management of Non-musculoskeletal Disorders . The initiation of the Global Summit was prompted by international public concerns about chiropractic care for the management of non-musculoskeletal disorders –45.The Global Summit was organized by a steering committee which included PC (chair), CLY, IA and JH. The steering committee developed the methodology for the systematic review, oversaw its conduct and implementation, led the evidence synthesis, and published the report. The steering committee was assisted in this work by a research assistant (MC). The final report was drafted by a writing team consisting of the steering committee and senior researchers with expertise and experience in evidence synthesis and scientific writing . The writing team provided ongoing feedback and quality assurance to drafts of evidence tables and sections of the manuscript.The Global Summit brought together researchers who were invited by the steering committee. Participants met the following criteria: 1) chiropractor with a PhD, or a researcher with a PhD (not a chiropractor) with research expertise in chiropractic; 2) actively involved in research (defined as having published at least 5 peer-reviewed papers over the past 5 years); and 3) appointed at an academic or educational institution. In addition, a small group of researchers who did not meet these criteria were invited. These included three chiropractors with a strong publication and scientific editorial record who did not have a PhD  and two early career researchers with an expertise within the area of chiropractic and pseudoscience . Participants were invited by the Steering Committee using purposive and snowball sampling methods.From January 5, 2019 to September 13, 2019, the Steering Committee held regular meetings to organize the Global Summit. The presummit activities included: 1) identification and invitation of participants and observers; 2) design of the systematic review; 3) search of the literature; 4) submission of the review protocol to International Prospective Register of Systematic Reviews (PROSPERO); 5) development of the instruction manual for critical appraisal; 6) screening of articles; 7) creation of three review groups of researchers for studies related to primary, secondary and tertiary prevention; 8) critical appraisal of the literature (first round) conducted by each review group; and 9) preparation of structure and first draft of evidence tables.On September 14–15, 2019, 50 researchers  from eight countries met in Toronto, Canada for the Global Summit. Twenty-eight researchers were from North America, 14 from Europe and eight from Australia. There were no participants from Asia, Africa or South America. In addition, 28 observers from various chiropractic organizations and educational institutions from North America, Europe and Australia were present to observe the meeting. At the Global Summit, researchers worked in their pre-assigned review groups. Each group reviewed the eligibility of RCTs that were deemed to be relevant by participants prior to the Global Summit, rated and discussed the methodological quality of studies, and extracted data from eligible studies. This was one of four phases in the risk of bias assessment, as described in detail below.The steering committee invited representatives from chiropractic organizations to observe the scientific deliberations during the Global Summit. The organizations represented at the Global Summit included 28 representatives from 18 international, national and provincial associations, regulators, one malpractice protective association, and one chiropractic college. We invited chiropractic organizations so that they could witness the scientific discussion and learn about the methods involved in the conduct of systematic reviews. There were no formal criteria to invite observers, but it followed a purposive process. Observers held separate meetings during the Global Summit to discuss the implications of the research. Although they were invited to observe the scientific discussion, they did not participate in or influence the scientific deliberations.Following the Global Summit, the steering committee ensured that all relevant studies were critically re-appraised using a standardized method and finalized the risk of bias assessment and evidence tables. The steering committee also led an online consensus process with all participants of the Global Summit, who were asked to review and approve/reject/modify the final risk of bias tables and evidence tables. These activities are discussed in detail below.We registered our systematic review with PROSPERO (CRD42019140194). We structured our report according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) , the PRIStudies eligible for our systematic review met the following inclusion criteria: 1) English language; 2) published from database inception to May 15, 2019 in a peer-reviewed journal; 3) investigated non-musculoskeletal disorders; 4) randomized controlled trial that investigated the efficacy or effectiveness of spinal manipulation, mobilization, or traction ; 5) study population included all ages; 6) included at least one outcome that is specific to the non-musculoskeletal disorder under investigation and measured at the patient level; and 7) the number of randomized participants per group was ≥20.We did not include the following study types: 1) guidelines, letters, editorials, commentaries, unpublished manuscripts, dissertations, government reports, books or book chapters, conference proceedings, meeting abstracts, lectures and addresses, consensus development statements, or guideline statements; 2) cadaveric or animal studies; 3) non-clinical studies ; 4) pilot studies aimed at demonstrating the feasibility of conducting an RCT; and 5) studies in which the effect of spinal manipulation, mobilization, or traction could not be isolated .Studies of efficacy are designed to investigate the benefits and adverse events of an intervention under ideal and highly controlled conditions. The preferred design for efficacy studies is the RCT using a sham or placebo group as a comparison .Studies of effectiveness seek to examine the outcomes of interventions under circumstances that more closely approximate a real-world setting. Effectiveness studies, therefore, typically use an RCT design, where the new treatment is compared to other interventions (including sham intervention when delivered in a pragmatic plan of management), such as the standard of practice for the patient population being studied . In our Disorders that are not related to the locomotor system, including those not related to disorders of muscles, bones, joints and associated tissues such as tendons and ligaments. These include but are not limited to asthma, stroke, migraine, dysmenorrhea and hypertension.Intervening to prevent disease or injury from ever occurring.Intervening to cure or reduce the impact of a disease or injury that has already occurred.Intervening to improve the impact of a persistent illness or injury that has lasting effects.Manual therapy applied to the spine that involves a high velocity, low amplitude impulse or thrust applied at or near the end of a joint’s passive range of motion . Spinal Manual treatment applied to the spine that incorporates movements, within a joint’s passive range of motion , 51. SpiManual or mechanically assisted application of an intermittent or continuous distractive force , 53.In this report, spinal manipulation, spinal mobilization and spinal traction are referred to collectively as “spinal manipulative therapy”.We developed our search strategy in consultation with a health sciences librarian from the Centre for Disability Prevention and Rehabilitation at Ontario Tech University and CMCC. A second librarian from the Canadian Memorial Chiropractic College reviewed the strategy to ensure accuracy using the Peer Review of Electronic Search Strategies (PRESS) checklist , 55. We All articles retrieved through the literature searches were exported into EndNote X7.0.2 for reference management and tracking of the screening process. Four pairs of trained and experienced reviewers  independently screened all potentially eligible articles in three phases. In phase one screening, titles and abstracts were reviewed and classified as relevant, possibly relevant or irrelevant according to the eligibility criteria. During phase two screening, the full text of possibly relevant articles was reviewed for final determination of eligibility. Pairs of reviewers discussed eligibility to reach consensus for both phases of screening. Finally, in phase three, the eligibility of studies identified in phase two was reviewed and adjudicated at the Global Summit by the primary, secondary and tertiary groups. In cases of disagreement between reviewers during phase one or phase two screening, a third independent reviewer (CLY) was consulted to achieve consensus.p-values (when 95% CI were not reported or could not be computed)). The data were entered directly into evidence tables. Pairs of researchers extracted data during the Global Summit and independent reviewers validated the data extraction following the Global Summit. The steering committee subsequently validated the content of the evidence tables for completeness, accuracy and consistency of reporting. Finally, the content of the evidence tables was submitted to all participants for review and approval through an electronic survey. We used 75% agreement (38/50 participants) as the threshold for consensus.We extracted the following descriptive variables from all relevant studies: First author’s name, year of publication, description of participants, case definition, health care setting where the study was conducted, sampling frame, total number of participants enrolled, treatment and control interventions , duration of follow-up; outcome measurement(s), results  and 95% CI or “The definition of the non-musculoskeletal condition is clear?” (Yes/No)“The participants are free from the non-musculoskeletal condition studied at the beginning of the study?” (Yes/No/Can’t say) (only for studies investigating primary prevention)“The spinal manipulative therapy  intervention is described in sufficient detail?” (Yes/No)“The control intervention (if any) is described in sufficient detail?” (Yes/No)“The follow-up period is sufficient (long enough for the outcome to occur) to answer the research question?” (Yes/No/Can’t say)We critically appraised articles using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for randomized controlled trials . The SIGIn addition, we edited the following item (in the primary prevention form) to ensure that the measurement properties of the method used to identify the non-musculoskeletal condition were clearly captured. The item “Are all outcomes measured in a standard, valid and reliable way?” was split into two questions, “The non-musculoskeletal condition is measured in a reliable way” (Yes/No/Can’t say) and “The non-musculoskeletal condition is measured in a valid way” (Yes/No/Can’t say). Detailed notes accompanied the SIGN generic checklists, and these were also edited to match the purpose of this review.The risk of bias assessment was informed by the items from the SIGN checklists that focused on methodological quality. All risk of bias assessments were conducted by two independent investigators who were unaware of each other’s ratings. The risk of bias items included: clarity of the research question, definition of the non-musculoskeletal condition, randomization procedure, blinding of participants, clinicians and investigators, description of manipulation and control interventions, outcome measurements, drop-outs, co-interventions, intention-to-treat analysis and follow-up period.The risk of bias assessment was conducted in four sequential steps. Prior to the Global Summit, independent pairs of reviewers  critically appraised relevant RCTs to determine their methodological quality. At the Global Summit, the quality was discussed and agreed upon by the respective group. After the summit, all RCTs were critically appraised a third time by two independent experienced methodologists  to ensure that the SIGN criteria were interpreted and applied in a similar manner across reviewers and review groups. Two participants  then performed quality assurance by reviewing all SIGN forms and risk of bias tables developed from the third round of reviews to ensure their accuracy and standard application.A study was rated as low risk of bias  if reviewers judged that potential sources of selection bias, information bias and confounding were minimal or acceptable . In partFinally, all researchers involved in the systematic review of the literature reviewed the risk of bias tables and were asked to vote on the outcome of the critical appraisal through an electronic survey. We used 75% agreement (38/50 participants) as the threshold for consensus. One researcher (CLY) was not involved in the systematic review at the Global Summit but was, in case of problems, available as referee, to thereafter participate in the validation process and therefore also in the two voting sessions.We used RR and between-group difference in means to quantify the effect of interventions. We reported the intervention-specific incidence of adverse events. When these summary measurements were not reported in the published article, we used data reported in the paper to attempt to compute these statistics.p < 0.05) for the observed between-group difference in the primary outcome [We synthesized the evidence from acceptable or high-quality RCTs according to the SWiM Guideline and reported them in evidence tables . We used outcome . Second,We restricted our synthesis to RCTs with acceptable/high methodological quality because low/unacceptable quality trials are more likely to yield biased estimates of effect sizes –61. To uWe tabulated disease-specific outcomes as reported in the individual papers by comparing the outcomes for SMT to the outcomes for control interventions. These comparisons informed the development of an evidence statement for each non-musculoskeletal disorder. Because the studies were clinically heterogeneous, we did not assess for statistical heterogeneity of effects across studies.We present our main results in a series of tables. First, we report our consensus methodological quality assessment in the risk of bias table. Second, the study characteristics and key study results are presented in the evidence table. Finally, we provide a succinct evidence table, which summarizes the key characteristics and results of all studies to facilitate the comparison of study results according to study quality. We examined the direction and magnitude of effect sizes across RCTs according to methodological quality by comparing studies rated as high/acceptable quality versus those rated as low/unacceptable quality.We developed a consensus-based, narrative evidence statement for each non-musculoskeletal disorder. However, since the rationale for treatment is the same across conditions, these statements synthesize the evidence about the efficacy and effectiveness of SMT for the prevention and management of the specific non-musculoskeletal disorder in general, in accordance with our research questions.clinicaltrials.gov.We did not assess publication bias. We checked reporting of outcomes for the acceptable- and high-quality trials against registered protocols by 1) scrutinizing the papers for mentioning of published or registered protocols; 2) searching for protocol papers in PubMed; and 3) accessing The final manuscript was submitted to all participants to the Global Summit for review. Participants were asked to vote electronically on whether they approved the final version of the paper and whether they wanted to co-author the published paper. Participants who declined authorship were asked to provide the reason for their decision. This process was repeated after the submitted manuscript had been reviewed by the journal.Our search retrieved 4997 citations Fig. . No addiOf the 14 included RCTs, three were rated as high quality , 81, 84,Differences in the methodological quality between RCTs rated as high/acceptable quality and those rated as low/unacceptable quality were mainly related to the method of randomization, concealment of treatment allocation, successful blinding of participants (inability to identify the treatment), and blinding of outcome assessors and investigators (those who collected outcome data and investigators were unaware of the treatment received by participants) Table .Our qualitative synthesis therefore includes three high quality RCTs , 81, 84 clinicaltrials.gov [Of the six trials of acceptable-or high-quality, two had been registered in ials.gov , 82 and Six RCTs were rated as high or acceptable quality Table . Of thosNine RCTs were rated as low or unacceptable quality Table . Two of None of the six RCTs of high or acceptable quality demonstrated that SMT is efficacious or effective for the secondary or tertiary prevention of non-MSK disorders Tables -4 and thOne high quality RCT by Balon et al.  comparedOne RCT of acceptable quality by Olafsdottir et al.  comparedIn one high quality RCT, Hondras et al.  comparedOne acceptable quality RCT  and one An RCT of acceptable quality by Chaibi et al.  comparedAll studies of low or unacceptable quality reported some positive results Table . Eight RThe risk of bias table was approved by 98.0% (49/50) of participants Table . SimilarEighty-eight percent of Global Summit participants approved the final paper and agreed to be co-authors. However, six participants declined authorship because they did not agree with the overall conclusion.Our systematic review of the best available evidence suggests that SMT is not effective or efficacious for treating infantile colic, childhood asthma, hypertension, primary dysmenorrhea, or migraine. Collectively, the evidence from six high and acceptable quality RCTs casts doubt on the hypothesis that SMT is efficacious or effective for the management of non-musculoskeletal disorders , 84, 87 Our conclusions agree with several previous reviews. Clar et al., who comprehensively reviewed the literature on the clinical effectiveness of spinal manipulation for the management of musculoskeletal and non-musculoskeletal disorders, only found evidence for the effectiveness for the treatment of some musculoskeletal disorders . Similarn = 3) and acceptable (n = 3) quality randomized clinical trials. Second, the literature search was conducted by an expert librarian and independently reviewed by a second librarian to minimize errors. Third, our critical appraisal of the literature included four sequential steps to ensure that the risk of bias assessment was conducted in a transparent, standardized, and rigorous manner. Fourth, the evidence synthesis included only high and acceptable quality RCTs and was conducted according to the SWiM Guideline and reported in transparent evidence tables [Our systematic review has several strengths. First, our research questions focused on determining the efficacy and effectiveness of SMT for both the prevention and management of non-musculoskeletal disorders. These questions required that we focus our review on evidence from high Implications for healthcare delivery systems and regulatory agenciesThe findings from the Global Summit call for the development and implementation of evidence-based policies regarding the use of SMT in the treatment of non-MSK disorders at several levels, as explained below. We anticipate that system-level polices will eventually impact clinical practice and change clinical behaviours. Policies should be based on the best available evidence with consideration of its strength and limitations.ii)Implications for educational institutions and educational regulatorsOur systematic review highlights the need for healthcare delivery systems and regulatory agencies to consider the lack of evidence supporting the prevention and treatment of non-musculoskeletal disorders using SMT when developing policies.Educational institutions for the chiropractic, osteopathic and other manual medicine health professions have the opportunity to implement our findings into their curricula to train their students as modern, evidence-based clinicians. This will ensure that students’ future clinical activities are consistent with the best available evidence and viable within modern healthcare systems. Implementing our findings will require significant changes in curriculum in some institutions where there is a need to communicate to students when their teaching content is not supported by valid evidence. It is of utmost importance that educational institutions educate students to be competent consumers of research, thereby enabling the next generation of clinicians to differentiate high from low quality research. This should be a priority because, as we have demonstrated, sometimes very different conclusions can be drawn from high versus low quality research.Educational regulators, who oversee the educational quality of practitioners of manual medicine, should also align their standards with best evidence and ensure consistency across educational institutions and, ultimately, of practitioners of manual medicine around the world. According to the Council for Higher Education Accreditation (CHEA) International Quality Group (CIQG)  this couiii)Implications for clinical practiceFinally, the findings from the Global Summit should be incorporated into continuing education programs and disseminated to clinicians, and professional organizations should align their policies and communications with the current evidence.Our systematic review helps clinicians by providing them with necessary knowledge to deliver evidence-based care to their patients. Even though non-musculoskeletal disorders make up a small proportion of patients in chiropractic and osteopathic practice , 8, impliv)Implications for future researchImportantly, clinicians need to be aware that low- and poor-quality studies can lead to deceptive results. This was the case in our review; all low-quality studies reported “good” results whereas high-quality studies all reported null results. Therefore, studies with poor methodological quality should not be used to inform clinical practice.Although we found consistent evidence that SMT is not efficacious or effective for the management of non-MSK conditions, our conclusions are based on a limited number of high and acceptable quality RCTs. Therefore, more and better RCTs should be conducted if the management of non-musculoskeletal disorders with SMT is a priority for patients, clinicians and decision-makers. However, this will require that the preliminary research leading to the design and conduct of an RCT follows a sequential and logical approach, where adequate pre-trial data allows for the formulation of rational inclusion criteria, power calculations and interventions that have a clear biological target .Our research brought together an international group of researchers who used established methods to search, screen, critically appraise, and synthesize the literature. We ensured that our methods and deliberations were transparent by inviting chiropractic stakeholder organisations to attend and observe the Global Summit proceedings. The observers are, therefore, able to testify to the rigor and the transparency of the work conducted at the Global Summit proceedings. Including these observers in our process was important due to the considerable debate in the chiropractic and other manual medicine professions about the efficacy and effectiveness of SMT to prevent and treat non-MSK disorders.The Global Summit was a unique and historic event. Never in the history of chiropractic or any manual medicine profession has such a large international group of active researchers collaborated to produce such a comprehensive scientific report. Representatives from professional organizations observed the scientific process and discussions, and they were able to interact with the scientists during breaks and provided all participants with the opportunity to discuss scientific, professional and political issues in an informal and friendly atmosphere. In spite of involving a large group of researchers and the complicated logistics of the Summit, we were able to strictly adhere to our pre-determined methods. It is also noteworthy that 88% of all researchers who attended the Global Summit agreed with the final conclusions of this comprehensive review. The six participants, who chose to abstain from authorship, did so because they did not agree that the overall conclusion represented the results of the review.Our systematic review included six randomized clinical trials (534 participants) of acceptable or high quality investigating the efficacy or effectiveness of SMT for the treatment of non-musculoskeletal disorders. We found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function. Governments, payers, regulators, educators, and clinicians should consider this evidence when developing policies about the use and reimbursement of SMT for non-musculoskeletal disorders.Additional file 1.