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Table 2 Summary of the quality of evidence and strength of recommendation according to Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria

From: Technology-assisted rehabilitation following total knee or hip replacement for people with osteoarthritis: a systematic review and meta-analysis

Certainty assessment № of (events/) participants Quality Importance
№ of studies Risk of bias Inconsistency Indirectness Imprecision Publication bias Intervention Control Overall certainty of evidence Importance of outcomesa
Pain (follow up: from 2 weeks to 3 months; assessed with: Visual Analogue Scale)
 3 RCTs [27, 32, 37] Seriousf Not serious Not serious Not serious Nonem 204 205 Moderate Critical
Function (follow up: range from 2 weeks to 3 months; assessed with: Timed Up and Go test)
 2 RCTs [32, 37] Seriousf Serioush Not serious Seriousi Nonem 103 104 Very low Critical
Mobility (follow up: range from 2 months to 3 months; assessed with: Six-Minute Walk Test)
 2 RCTs [31, 41] Seriousf Serioush Seriousg Very seriousi, l Nonem 128 130 Very low Critical
Serious adverse eventsb (follow up: range 6 weeks to 4 months)
 3 RCTs [29,30,31] Not serious Not serious Seriousj Not serious Nonem 38/334 (11.4%) 27/333 (8.1%)d Moderate Critical
Treatment-related adverse eventsc (follow up: range 6 weeks to 4 months)
 2 RCTs [29, 31] Not serious Not assessedk Not serious Not assessedk Nonem 9/251 (3.1%) 8/256 (3.6%)e Moderate Critical
  1. Abbreviations: GRADE Grading of recommendations assessment, development and evaluation, RCT Randomised controlled trial
  2. GRADE Working Group grades of evidence
  3. High certainty: We are very confident that the true effect lies close to that of the estimate of the effect
  4. Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
  5. Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effectVery low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
  6. Explanation
  7. aThe level of importance for patient-relevant outcome measures
  8. bSerious adverse events include: hospital readmission for leg blister, manipulation under aesthesia for poor knee range of motion, prostate check and cataract surgery (Han 2015); death, hospitalization, manipulation under aesthesia, degradation of the general condition, hip fracture due to fall, gastrointestinal disorder, rheumatologic disorder, cardiac arrhythmia, thrombophlebitis, spinal surgery, inguinal hernia surgery, cystocele surgery, retinal detachment surgery, total knee arthroplasty on contralateral side (Moffet 2016)
  9. cTreatment-related adverse events include: operated knee swelling and/or extreme knee pain; excess wound leakage or bleeding (Han et al., 2015)
  10. dRisk difference with intervention: 33 more per 1000 (from 9 fewer to 100 more)
  11. eRisk difference with intervention: 6 more per 1000 (from 17 fewer to 67 more)
  12. fMore than 25% of participants from studies with low methodological quality (Physiotherapy Evidence Database score < 7 points)
  13. gDifferent technologies were analysed together (Moffet 2016 – telerehabilitation; Li 2014 – game-based therapy)
  14. hI2 > 50%; substantial heterogeneity
  15. iSmall sample size: < 400 participants in the pooling.
  16. jA mixed population of hip and knee replacement: 10% of patients have total hip replacement (Vesterby 2016 – hip replacement-only study)
  17. kZero events were reported in one of the trials.
  18. l95% CI overlaps no effects (i.e. fails to exclude important benefit or important harm)
  19. mThe possibility of publication bias is not excluded but it was not considered as sufficient to downgrade the quality of evidence