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With regards to the methodological quality of the studies considered, only a few of the studies adhered to recognised standards of methodological quality, which utilised a transparent methodology, and thus provided credible results.
We also used methods to assess methodological quality which are not the most recent and valid ones.
Second, the included trials are of variable methodological quality, which introduced the risk of bias (Table 3).
These databases are sources of systematic reviews that tend to be of higher methodological quality, which may reflect better reporting and hence better indexing.
For high-quality comparative studies, Newcastle-Ottawa scale (NOS) was adopted to assess methodological quality, which was mainly based on patients selection, baseline comparability, and outcome measure [ 11].
Furthermore, no a priori quality criteria were imposed on studies included for review in terms of sample size or methodological quality which may explain some of the heterogeneity.
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Observers were blind to the period, the journal, the authors, the method (meta-analysis, randomized, non randomized), and the methodological quality from which each conclusion was derived.
Research evidence is commonly assessed by the methodological quality by which it is generated.
However, heterogeneity was low (I=12%) in the sensitivity analysis including only higher methodological quality studies, which confirms the small and similar incidence of major bleeding in both treatment arms already suggested by the forest plot that included all studies.
38 Thus, taking into account the fact that studies of low methodological quality in which the estimate of quality is incorporated into the meta-analyses can alter the interpretation of the benefit of the intervention, 38 this meta-analysis has a major strength in that it separately considered the effect of treatment among high quality and low quality trials.
The aims of this review were, first to rate the methodological quality of studies which investigate the reliability of manual tests for cervical spine dysfunctions by applying a new quality assessment tool; secondly to compare the outcomes of these studies.
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