Non-Cochrane · intervention · PM41696072
Extended reality interventions for health and procedural anxiety: An overview of reviews.
Arthur Tom, Robinson Sophie, Harris David, et al. · Digital health · 2026 · PubMed · doi:10.1177/20552076251411512
Findings
32 findings
| Population | ||||
|---|---|---|---|---|
| Patients undergoing acute medical operations and surgery | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | Procedural anxiety Included review: Simonetti et al. (2022) | PL -0.34 [-0.62, -0.11] GRADE not reported 6 studies |
| Patients undergoing acute medical operations and surgery | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | Procedural anxiety Included review: Chen et al. (2023) | SMD -0.91 [-1.43, -0.39] GRADE not reported 5 studies |
| Patients undergoing acute medical operations and surgery | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | Procedural anxiety Included review: Koo et al. (2020) | SMD -0.64 [-1.08, -0.20] GRADE not reported 10 studies |
| Patients undergoing acute medical operations and surgery | Virtual reality exposure | Control conditions (usual care, other technology, conventional education or distraction) | Procedural anxiety Included review: Tas et al. (2022): VR exposure | SMD -0.58 [-1.15, -0.01] GRADE not reported 4 studies |
| Patients undergoing acute medical operations and surgery | Virtual reality distraction | Control conditions (usual care, other technology, conventional education or distraction) | Procedural anxiety Included review: Tas et al. (2022): VR distraction | SMD -0.74 [-1.00, -0.48] GRADE not reported 10 studies |
| Patients receiving cancer treatment (chemotherapy support) | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | Procedural anxiety Included review: Cheng et al. (2022) | SMD -1.47 [-2.46, -0.48] GRADE not reported 5 studies |
| Patients receiving cancer treatment (chemotherapy support) | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | Procedural anxiety Included review: Czech et al. (2023) | SMD -1.86 [-2.98, -0.73] GRADE not reported 4 studies |
| Patients undergoing dental procedures | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | Procedural anxiety Included review: Yan et al. (2023) | SMD -1.74 [-2.46, -1.02] GRADE not reported 11 studies |
| Patients undergoing dental procedures | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | State anxiety (procedural, dental) Included review: Chen et al. (2021) | SMD -1.44 [-2.12, -0.78] GRADE not reported 2 studies |
| Patients undergoing dental procedures | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | Procedural anxiety Included review: Lopez-Valverde et al. (2020) | SMD -1.75 [-3.06, -0.43] GRADE not reported 7 studies |
| Patients undergoing dental procedures | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | Procedural anxiety Included review: Custodio et al. (2020) | MD -3.37 [-4.57, -2.18] GRADE not reported 2 studies |
| Patients undergoing miscellaneous healthcare procedures | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | Procedural anxiety Included review: Eijlers et al. (2019) | SMD -1.32 [-2.44, -0.21] GRADE not reported 7 studies |
| Patients undergoing needle-related procedures | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | Procedural anxiety Included review: Wang et al. (2022a) | MD -2.79 [-4.07, -1.54] GRADE not reported 6 studies |
| Patients undergoing needle-related procedures | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | Procedural anxiety Included review: Saliba et al. (2022) | SMD -0.89 [-1.63, -0.16] GRADE not reported 6 studies |
| Patients undergoing needle-related procedures | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | Procedural anxiety Included review: Lluesma-Vidal et al. (2022) | SMD -1.26 [-1.89, -0.63] GRADE not reported 5 studies |
| Patients undergoing needle-related procedures | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | Procedural anxiety Included review: Gao et al. (2023) | SMD -0.61 [-1.02, -0.20] GRADE not reported 10 studies |
| Patients undergoing wound care procedures | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | Procedural anxiety Included review: Lan et al. (2023) | SMD -0.73 [-1.35, -0.11] GRADE not reported 5 studies |
| Patients in cancer treatment and rehabilitation (general health anxiety) | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | General health anxiety Included review: Zeng et al. (2019) | SMD -3.03 [-6.20, 0.15] GRADE not reported 4 studies |
| Patients in cancer treatment and rehabilitation (general health anxiety) | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | General health anxiety Included review: Tian et al. (2022) | MD -4.93 [-8.00, -1.87] GRADE not reported 6 studies |
| Patients in cancer treatment and rehabilitation (general health anxiety) | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | General health anxiety Included review: Obrero-Gaitan et al. (2022) | SMD -1.79 [-2.70, -0.91] GRADE not reported 3 studies |
| Patients in cancer treatment and rehabilitation (general health anxiety) | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | General health anxiety Included review: Hao et al. (2023) | MD -6.99 [-9.73, -4.25] GRADE not reported 3 studies |
| Patients in cancer treatment and rehabilitation (general health anxiety) | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | General health anxiety Included review: Bu et al. (2022) | MD -6.47 [-7.21, -5.73] GRADE not reported 4 studies |
| Patients in cancer treatment and rehabilitation (general health anxiety) | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | General health anxiety Included review: Zhang et al. (2022) | SMD -2.07 [-3.81, -0.34] GRADE not reported 3 studies |
| Patients in cancer treatment and rehabilitation (general health anxiety) | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | General health anxiety Included review: Wu et al. (2023) | SMD -0.83 [-1.25, -0.42] GRADE not reported 7 studies |
| Patients with chronic pain (general health anxiety) | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | General health anxiety Included review: Cortes-Perez et al. (2021) | SMD -0.47 [-0.91, -0.03] GRADE not reported 3 studies |
| Patients with chronic pain (general health anxiety) | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | General health anxiety Included review: Gava et al. (2022) | SMD 0.03 [-0.40, 0.46] GRADE not reported 2 studies |
| Patients with chronic pain (general health anxiety) | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | General health anxiety Included review: Huang et al. (2022) | MD -1.30 [-1.86, -0.75] GRADE not reported 10 studies |
| Patients in cardiac rehabilitation (general health anxiety) | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | General health anxiety Included review: Chen et al. (2022) | SMD -0.35 [-0.70, 0.01] GRADE not reported 3 studies |
| Patients in cardiac rehabilitation (general health anxiety) | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | General health anxiety Included review: Turan-Kavradim et al. (2023) | SMD -0.85 [-1.55, -0.14] GRADE not reported 8 studies |
| Patients in cardiac rehabilitation (general health anxiety) | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | General health anxiety Included review: Bashir et al. (2023) | SMD -0.32 [-0.61, 0.03] GRADE not reported 4 studies |
| Maternity patients (general health anxiety) | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | General health anxiety Included review: Baradwan et al. (2022) | SMD -1.15 [-2.18, -0.12] GRADE not reported 3 studies |
| Maternity patients (general health anxiety) | Extended reality (virtual reality) interventions | Control conditions (usual care, other technology, conventional education or distraction) | General health anxiety Included review: Xu et al. (2022) | SMD -1.39 [-1.99, -0.78] GRADE not reported 7 studies |
Included primary studies 63
Open in Studies| Study | Year | Also included by | Outcomes it informs here | Trial data |
|---|---|---|---|---|
| Chen et al. (2021) matched by author and year (probable) | NR | 7 other reviews | State anxiety (procedural, dental) | not extracted yet |
| Zhang et al. (2023) matched by author and year (probable) | NR | 5 other reviews | not stated | not extracted yet |
| Zhang et al. (2022) matched by author and year (probable) | NR | 2 other reviews | General health anxiety | not extracted yet |
| Addab et al. (2022) Use of virtual reality in managing paediatric procedural pain and anxiety: An integrative literature review. PMID:35068011 | 2022 | this review only | not stated | not extracted yet |
| Ahmad et al. (2020) Virtual Reality Technology for Pain and Anxiety Management among Patients with Cancer: A Systematic Review. PMID:32423641 | 2020 | this review only | not stated | not extracted yet |
| Alqudimat et al. (2021) State of the Art: Immersive Technologies for Perioperative Anxiety, Acute, and Chronic Pain Management in Pediatric Patients. PMID:34276254 | 2021 | this review only | not stated | not extracted yet |
| Baradwan et al. (2022) The impact of virtual reality on pain management during normal labor: A systematic review and meta-analysis of randomized controlled trials. PMID:35381438 | 2022 | this review only | PM41696072-P14-O1 | not extracted yet |
| Bashir et al. (2023) The impact of Virtual Reality on Anxiety and Functional Capacity in Cardiac Rehabilitation: A Systematic Review and Meta-analysis. PMID:36736604 | 2023 | this review only | PM41696072-P13-O1 | not extracted yet |
| Bu 2022 The Effectiveness of Virtual Reality-Based Interventions in Rehabilitation Management of Breast Cancer Survivors: Systematic Review and… PMID:35225817 | 2022 | this review only | not stated | not extracted yet |
| Cataldo et al. (2023) Use of virtual reality for MRI preparation and technologist education: A scoping review. PMID:36588009 | 2023 | this review only | not stated | not extracted yet |
| Chen et al. (2022) Effectiveness of virtual reality in cardiac rehabilitation: A systematic review and meta-analysis of randomized controlled trials. PMID:35870329 | 2022 | this review only | PM41696072-P13-O1 | not extracted yet |
| Chen et al. (2023) Effects of virtual reality on preoperative anxiety in children: A systematic review and meta-analysis of randomised controlled trials. PMID:35672942 | 2023 | this review only | Procedural anxiety | not extracted yet |
| Cheng et al. (2022) Virtual reality for pain and anxiety of pediatric oncology patients: A systematic review and meta-analysis. PMID:36389624 | 2022 | this review only | Procedural anxiety | not extracted yet |
| Chow et al. (2021) Effect of Virtual Reality Therapy in Reducing Pain and Anxiety for Cancer-Related Medical Procedures: A Systematic Narrative Review. PMID:32822755 | 2021 | this review only | not stated | not extracted yet |
| Comparcini et al. (2023) Immersive and Non-Immersive Virtual Reality for Pain and Anxiety Management in Pediatric Patients with Hematological or Solid Cancer: A… PMID:36765945 | 2023 | this review only | not stated | not extracted yet |
| Cortes-Perez et al. (2021) Virtual Reality-Based Therapy Reduces the Disabling Impact of Fibromyalgia Syndrome in Women: Systematic Review with Meta-Analysis of… PMID:34834518 | 2021 | this review only | General health anxiety | not extracted yet |
| Cunningham et al. (2021) A systematic review of the use of virtual reality or dental smartphone applications as interventions for management of paediatric dental… PMID:33962624 | 2021 | this review only | not stated | not extracted yet |
| Custodio et al. (2020) Effectiveness of Virtual Reality Glasses as a Distraction for Children During Dental Care. PMID:32276674 | 2020 | this review only | Procedural anxiety | not extracted yet |
| Czech et al. (2021) Virtual Reality Interventions for Needle-Related Procedural Pain, Fear and Anxiety-A Systematic Review and Meta-Analysis. PMID:34362032 | 2021 | this review only | not stated | not extracted yet |
| Czech et al. (2023) Virtual reality in chemotherapy support for the treatment of physical functions, fear, and quality of life in pediatric cancer patients: A… PMID:37124795 | 2023 | this review only | Procedural anxiety | not extracted yet |
| Desmet et al. (2021) matched by author and year (probable) | NR | this review only | not stated | not extracted yet |
| Eijlers et al. (2019) Systematic Review and Meta-analysis of Virtual Reality in Pediatrics: Effects on Pain and Anxiety. PMID:31136330 | 2019 | this review only | Procedural anxiety | not extracted yet |
| Fardin et al. (2020) Non-pharmacological interventions for anxiety in burn patients: A systematic review and meta-analysis of randomized controlled trials. PMID:32147030 | 2020 | this review only | not stated | not extracted yet |
| Gaina et al. (2022) State-of-the-Art Review on Immersive Virtual Reality Interventions for Colonoscopy-Induced Anxiety and Pain. PMID:35329993 | 2022 | this review only | not stated | not extracted yet |
| Gao et al. (2023) Effectiveness of virtual reality intervention on reducing the pain, anxiety and fear of needle-related procedures in paediatric patients:… PMID:36330583 | 2023 | this review only | Procedural anxiety | not extracted yet |
| Gava 2022 Effects of Gaming on Pain-Related Fear, Pain Catastrophizing, Anxiety, and Depression in Patients with Chronic Musculoskeletal Pain: A… PMID:35613404 | 2022 | this review only | not stated | not extracted yet |
| Gava et al. (2022) matched by author and year (probable) | NR | this review only | General health anxiety | not extracted yet |
| Gomez-Busto & Ortiz (2020) Virtual Reality and Psychedelics for the Treatment of Psychiatric Disease: A Systematic Literature Review. PMID:34909015 | 2020 | this review only | not stated | not extracted yet |
| Grilo et al. (2023) Using virtual reality to prepare patients for radiotherapy: A systematic review of interventional studies with educational sessions. PMID:36873800 | 2023 | this review only | not stated | not extracted yet |
| Hajesmaeel-Gohari et al. (2021) Virtual reality applications to assist pregnant women: a scoping review. PMID:33765969 | 2021 | this review only | not stated | not extracted yet |
| Hao et al. (2023) Effects of virtual reality on physical, cognitive, and psychological outcomes in cancer rehabilitation: a systematic review and… PMID:36633695 | 2023 | this review only | General health anxiety | not extracted yet |
| Huang et al. (2022) Using Virtual Reality Exposure Therapy in Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. PMID:35094802 | 2022 | this review only | General health anxiety | not extracted yet |
| Kilic et al. (2021) Using Virtual Technology for Fear of Medical Procedures: A Systematic Review of the Effectiveness of Virtual Reality-Based Interventions. PMID:33821879 | 2021 | this review only | not stated | not extracted yet |
| Koo et al. (2020) The Effect of Virtual Reality on Preoperative Anxiety: A Meta-Analysis of Randomized Controlled Trials. PMID:33003411 | 2020 | this review only | Procedural anxiety | not extracted yet |
| Lan et al. (2023) Use of Virtual Reality in Burn Rehabilitation: A Systematic Review and Meta-analysis. PMID:36030891 | 2023 | this review only | General health anxiety | not extracted yet |
| Leggiero et al. (2020) Use of virtual reality for symptom management in solid-tumor patients with implications for primary brain tumor research: a systematic… PMID:33014388 | 2020 | this review only | not stated | not extracted yet |
| Lluesma-Vidal 2022 Effect of Virtual Reality on Pediatric Pain and Fear During Procedures Involving Needles: Systematic Review and Meta-analysis. PMID:35943776 | 2022 | this review only | not stated | not extracted yet |
| Lluesma-Vidal et al. (2022) matched by author and year (probable) | NR | this review only | Procedural anxiety | not extracted yet |
| Lopez-Valverde et al. (2020) Retraction: López-Valverde, N.; et al. Use of Virtual Reality for the Management of Anxiety and Pain in Dental Treatments: Systematic… PMID:32731319 | 2020 | this review only | Procedural anxiety | not extracted yet |
| Martinez-Bernal et al. (2023) The Use of Virtual Reality to Reduce Pain and Anxiety in Surgical Procedures of the Oral Cavity: A Scoping Review. PMID:36572388 | 2023 | this review only | not stated | not extracted yet |
| Obrero-Gaitan et al. (2022) Digital and Interactive Health Interventions Minimize the Physical and Psychological Impact of Breast Cancer, Increasing Women's Quality… PMID:36077670 | 2022 | this review only | General health anxiety | not extracted yet |
| Rutkowski et al. (2021) Virtual reality as a chemotherapy support in treatment of anxiety and fatigue in patients with cancer: A systematic review and… PMID:34403772 | 2021 | this review only | not stated | not extracted yet |
| Saliba et al. (2022) The use of virtual reality in children undergoing vascular access procedures: a systematic review and meta-analysis. PMID:34052954 | 2022 | this review only | Procedural anxiety | not extracted yet |
| Scapin et al. (2018) Virtual Reality in the treatment of burn patients: A systematic review. PMID:29395400 | 2018 | this review only | not stated | not extracted yet |
| Simonetti et al. (2022) Effectiveness of virtual reality in the management of paediatric anxiety during the peri‑operative period: A systematic review and… PMID:34781118 | 2022 | this review only | Procedural anxiety | not extracted yet |
| Smith 2020 The Effectiveness of Virtual Reality in Managing Acute Pain and Anxiety for Medical Inpatients: Systematic Review. PMID:33136055 | 2020 | this review only | not stated | not extracted yet |
| Smith 2021 Impact of Virtual Reality Technology on Pain and Anxiety in Pediatric Burn Patients: A Systematic Review and Meta-Analysis. PMID:36247202 | 2022 | this review only | not stated | not extracted yet |
| Smith et al. (2020) matched by author and year (probable) | NR | this review only | not stated | not extracted yet |
| Smith et al. (2022) matched by author and year (probable) | NR | this review only | not stated | not extracted yet |
| Tas et al. (2022) Virtual reality in pediatrics, effects on pain and anxiety: A systematic review and meta-analysis update. PMID:35993398 | 2022 | this review only | Procedural anxiety | not extracted yet |
| Tian 2023 The Efficacy of Virtual Reality-Based Interventions in Breast Cancer-Related Symptom Management: A Systematic Review and Meta-analysis. PMID:37607378 | 2023 | this review only | not stated | not extracted yet |
| Tian et al. (2022) matched by author and year (probable) | NR | this review only | General health anxiety | not extracted yet |
| Turan-Kavradim et al. (2023) Effectiveness of virtual reality interventions on physiological and psychological outcomes of adults with cardiovascular disease: A… PMID:36942847 | 2023 | this review only | PM41696072-P13-O1 | not extracted yet |
| van der Linde-van den Bor et al. (2022) The use of virtual reality in patient education related to medical somatic treatment: A scoping review. PMID:35000833 | 2022 | this review only | not stated | not extracted yet |
| Wang et al. (2022a) Effects of Virtual Reality-Based Distraction of Pain, Fear, and Anxiety During Needle-Related Procedures in Children and Adolescents. PMID:35519646 | 2022 | this review only | Procedural anxiety | not extracted yet |
| Wang et al. (2022b) Virtual reality interventions and the outcome measures of adult patients in acute care settings undergoing surgical procedures: An… PMID:34633112 | 2022 | this review only | not stated | not extracted yet |
| Wu 2023 Effectiveness of Virtual Reality in Symptom Management of Cancer Patients: A Systematic Review and Meta-Analysis. PMID:36758907 | 2023 | this review only | not stated | not extracted yet |
| Xu 2022 The Effects of Virtual Reality in Maternal Delivery: Systematic Review and Meta-analysis. PMID:36416881 | 2022 | this review only | not stated | not extracted yet |
| Yan et al. (2023) Effectiveness of virtual reality distraction interventions to reduce dental anxiety in paediatric patients: A systematic review and… PMID:36842625 | 2023 | this review only | Procedural anxiety | not extracted yet |
| Yu 2023 Impact of Virtual Operating Room Tours on Relieving Perioperative Anxiety in Adult Patients: A Systematic Review. PMID:36697345 | 2023 | this review only | not stated | not extracted yet |
| Zeng et al. (2019) Meta-Analysis of the Efficacy of Virtual Reality-Based Interventions in Cancer-Related Symptom Management. PMID:31441352 | 2019 | this review only | General health anxiety | not extracted yet |
| Zhang 2022 Efficacy of virtual reality-based interventions for patients with breast cancer symptom and rehabilitation management: a systematic review… PMID:35301201 | 2022 | this review only | not stated | not extracted yet |
| Zhang 2023 The impact of extended reality on surgery: a scoping review. PMID:36645474 | 2023 | this review only | not stated | not extracted yet |
Overlap with other reviews
Reviews that include the same primary studies are not independent evidence. Shared counts match studies by PMID, DOI or NCT, and otherwise by author and year (a probable match). Only the non-Cochrane dental reviews have study lists, so overlap with Cochrane reviews is not counted yet.
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | Patients of any age with health anxiety or procedural anxiety; no restriction on population | Children (19 reviews), adults (20), both (17); procedural anxiety (38 reviews: surgery, needle, wound care, chemotherapy, imaging, dental) and general health anxiety (18: cancer, chronic pain, cardiac rehabilitation, maternity) |
| Intervention | Patient-directed extended reality (virtual, mixed, augmented reality) interventions | Mostly virtual reality (distraction, exposure, education, combined); no dedicated augmented or mixed reality analyses; 48/56 reviews pooled immersive and non-immersive devices or did not specify |
| Comparison | Not restricted (any comparison condition) | Usual care, other technology applications, conventional education or distraction methods |
| Outcomes | Anxiety (general health anxiety and procedural anxiety); reviews could also address patient experience, implementation or economic outcomes | Patient anxiety (state, trait, physiological); implementation outcomes (acceptability, usability, adverse effects) |
| Study designs | Systematic reviews published as full texts in peer-reviewed journals, 2013 onwards (umbrella review) | 56 systematic reviews (35 with meta-analysis, 16 narrative syntheses, 5 scoping reviews) published 2018 to 2022; 46 appraised with AMSTAR-2 |
| Timing | Not specified | Not specified |
AMSTAR 2 items
Two independent extractors rated each item. Their ratings are shown side by side because they have not been reconciled yet. The overall rating follows Shea et al. 2017: one critical flaw gives Low, more than one gives Critically Low.
| Item | Extractor A | Extractor B | Agree |
|---|---|---|---|
| 1Research question includes PICO components | Yes | Yes | yes |
| 2Protocol established before the reviewcritical | Partial Yes | Partial Yes | yes |
| 3Choice of study designs explained | Yes | No | no |
| 4Comprehensive literature searchcritical | Partial Yes | Partial Yes | yes |
| 5Study selection in duplicate | Yes | Yes | yes |
| 6Data extraction in duplicate | Yes | Yes | yes |
| 7List of excluded studies with reasonscritical | Yes | Yes | yes |
| 8Included studies described in detail | Partial Yes | Partial Yes | yes |
| 9Risk of bias assessed satisfactorilycritical | RCT: Yes · NRSI: Yes | NRSI: N/A · RCT: Yes | no |
| 10Funding of included studies reported | No | No | yes |
| 11Appropriate meta-analysis methodscritical | RCT: N/A · NRSI: N/A | NRSI: N/A · RCT: N/A | no |
| 12Impact of risk of bias on the pooled results | N/A | N/A | yes |
| 13Risk of bias accounted for in interpretationcritical | Yes | Yes | yes |
| 14Heterogeneity explained | Yes | Yes | yes |
| 15Publication bias investigatedcritical | N/A | N/A | yes |
| 16Conflicts of interest reported | Yes | Yes | yes |
| Overall | High | Moderate | no |