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array:21 [ "pii" => "S2666506924000233" "issn" => "26665069" "doi" => "10.1016/j.apunsm.2024.100455" "estado" => "S300" "fechaPublicacion" => "2024-10-01" "aid" => "100455" "copyrightAnyo" => "2024" "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:16 [ "pii" => "S2666506924000324" "issn" => "26665069" "doi" => "10.1016/j.apunsm.2024.100464" "estado" => "S300" "fechaPublicacion" => "2024-10-01" "aid" => "100464" "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Epidemiological analysis of injuries in soccer referees: A systematic review" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "en" ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 1 "multimedia" => array:6 [ "identificador" => "fig0002" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "ga1.jpeg" "Alto" => 886 "Ancho" => 1860 "Tamanyo" => 274009 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alttx001" "detalle" => "Image, graphical abstrac" "rol" => "short" ] ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sebastián Rodríguez, Angie Natalia Suarez-Cuervo, Catalina León-Prieto, María Fernanda Rodríguez-Jaime" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Sebastián" "apellidos" => "Rodríguez" ] 1 => array:2 [ "nombre" => "Angie Natalia" "apellidos" => "Suarez-Cuervo" ] 2 => array:2 [ "nombre" => "Catalina" "apellidos" => "León-Prieto" ] 3 => array:2 [ "nombre" => "María Fernanda" "apellidos" => "Rodríguez-Jaime" ] ] ] ] "resumen" => array:1 [ 0 => array:3 [ "titulo" => "Graphical abstract" "clase" => "graphical" "resumen" => "<span id="abss0006" class="elsevierStyleSection elsevierViewall"><p id="spara019" class="elsevierStyleSimplePara elsevierViewall"><elsevierMultimedia ident="fig0002"></elsevierMultimedia></p></span>" ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666506924000324?idApp=UINPBA00004N" "url" => "/26665069/0000005900000224/v2_202410292108/S2666506924000324/v2_202410292108/en/main.assets" ] "itemAnterior" => array:16 [ "pii" => "S2666506924000208" "issn" => "26665069" "doi" => "10.1016/j.apunsm.2024.100452" "estado" => "S300" "fechaPublicacion" => "2024-10-01" "aid" => "100452" "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Bidirectional relationship between mental health and sport injuries: a review of reviews" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0002" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1260 "Ancho" => 2250 "Tamanyo" => 124305 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0002" "detalle" => "Fig " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spara002" class="elsevierStyleSimplePara elsevierViewall">Databases consulted. Own elaboration.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Laura Gil-Caselles, Roberto Ruiz Barquín, José María Giménez Egido, Aurelio Olmedilla-Zafra" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Laura" "apellidos" => "Gil-Caselles" ] 1 => array:2 [ "nombre" => "Roberto Ruiz" "apellidos" => "Barquín" ] 2 => array:2 [ "nombre" => "José María Giménez" "apellidos" => "Egido" ] 3 => array:2 [ "nombre" => "Aurelio" "apellidos" => "Olmedilla-Zafra" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666506924000208?idApp=UINPBA00004N" "url" => "/26665069/0000005900000224/v2_202410292108/S2666506924000208/v2_202410292108/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Incidence of injuries per 1000 hours of refereeing or training in soccer referees: A mini-review" "tieneTextoCompleto" => true "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Sebastián Rodríguez, María Fernanda Rodríguez-Jaime, Angie Natalia Suarez-Cuervo, Catalina León-Prieto" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Sebastián" "apellidos" => "Rodríguez" "email" => array:1 [ 0 => "srodriguezja@unal.edu.co" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0001" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0001" ] ] ] 1 => array:3 [ "nombre" => "María Fernanda" "apellidos" => "Rodríguez-Jaime" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0002" ] ] ] 2 => array:3 [ "nombre" => "Angie Natalia" "apellidos" => "Suarez-Cuervo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0001" ] ] ] 3 => array:3 [ "nombre" => "Catalina" "apellidos" => "León-Prieto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0003" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Facultad de Medicina, Departamento de Movimiento Corporal Humano, Maestría en Fisioterapia del Deporte y la Actividad Física, Universidad Nacional de Colombia, Sede Bogotá, Bogotá, Colombia" "etiqueta" => "a" "identificador" => "aff0001" ] 1 => array:3 [ "entidad" => "Universidad Santiago de Compostela – Santiago de Compostela, Spain" "etiqueta" => "b" "identificador" => "aff0002" ] 2 => array:3 [ "entidad" => "Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia" "etiqueta" => "c" "identificador" => "aff0003" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0001" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0002" "etiqueta" => "Fig 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1241 "Ancho" => 2500 "Tamanyo" => 144111 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0004" "detalle" => "Fig " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spara002" class="elsevierStyleSimplePara elsevierViewall">Estimation of the incidence of injuries per 1000 h of exposure related to refereeing and training in soccer referees.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Introduction</span><p id="para0001" class="elsevierStylePara elsevierViewall">As a highly competitive team sport, soccer demands that athletes possess a wide range of physical skills, ranging from the ability to perform quick changes of direction to explosive jumps, repeated sprints, and remarkable endurance, among other skills. Improving these aspects is crucial to enhance performance during the game.<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a> However, due to the intense physical demands in both training and competitive matches, injuries are a recurrent problem among soccer players.<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> Considering this reality and given that the amount of exposure may influence the development of more injuries, several reviews have elucidated the injury incidence rate per 1000 h of exposure in soccer players.<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a></p><p id="para0002" class="elsevierStylePara elsevierViewall">On the other hand, referees, like players, must possess exceptional physical qualities, as they are also submitted to considerable physical exertion. In fact, it has been shown that referees can cover distances of up to 12 kms and run at speeds in excess of 18 kms per hour.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> It is therefore not surprising that they also suffer a high number of injuries, mainly to the lower limbs<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a>. However, to date, there is no review that compiles and synthesizes the injury incidence rate per 1000 h of exposure, implying a lack of knowledge about injury risk in relation to exposure time in soccer referees. That being said, the objective of this mini-review is to systematically examine the literature on the incidence of injury per 1000 h of exposure related to refereeing and training in soccer referees.</p></span><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0004">Methods</span><span id="sec0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0005">Search strategy and procedure</span><p id="para0003" class="elsevierStylePara elsevierViewall">A systematic search for original studies (prospective cohort studies and randomized controlled trials) was carried out with a deadline of February 28, 2024, using the PubMed, Web of Science and ScienceDirect databases. For this purpose, the following search terms were used: Epidemiology, Epidemiologic, Epidemiological, Epidemiological, Incidence, Prevalence, Injury, Injuries, Injured and Soccer referees. These terms were combined in the following search equation: ((((((“Epidemiology”) OR (“Epidemiologic”)) OR (“Epidemiological”)) OR (“Incidence”)) OR (((“Prevalence”)))) AND (((“Injury”) OR (“Injuries”))) OR (“Injured”)))) AND (Soccer Referees). Detailed search history in each of the databases used, along with the number of records identified, is provided in the supplementary material.</p></span><span id="sec0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0006">Criteria for the evaluation of studies for this review</span><p id="para0004" class="elsevierStylePara elsevierViewall">Prospective cohort studies and clinical trials were selected to reduce recall bias inherent in retrospective studies. No language restrictions were imposed in order to avoid linguistic bias and to collect more information on the incidence of injury per 1000 h of exposure, either during training or refereeing, or in both contexts. The target population considered was eleven-a-side soccer referees, regardless of gender.</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0007">Identification of studies and data extraction</span><p id="para0005" class="elsevierStylePara elsevierViewall">For article selection, first, the preliminary manuscripts obtained during the searches in each database were uploaded to the collaborative web application Rayyan<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a>. Then, two reviewers conducted an independent selection after analyzing the title and abstract of each found text. Subsequently, the reviewers conducted a second independent selection process after reading the full texts that had been selected in the first phase. During these two stages of selection, in the event of discrepancies between the reviewers, a third reviewer was involved to facilitate reaching a consensus and reaching an agreement.</p><p id="para0006" class="elsevierStylePara elsevierViewall">Once the texts that were included in this review were selected, the following data were extracted from each of them: title, authors, year of publication, journal of publication, type of study, follow-up period, injury definition, population, total injuries and injury incidence rate per 1000 h of exposure during training, refereeing or both, with their respective confidence intervals when available. These data were extracted by two reviewers independently and stored in an Excel spreadsheet. Subsequently, the extracted data were cross-checked to verify the accuracy of the extraction. In case of discrepancies, a third reviewer intervened to verify the information and reach a consensus on the final data.</p></span><span id="sec0006" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0008">Quality of studies</span><p id="para0007" class="elsevierStylePara elsevierViewall">The quality of the studies was assessed using the cohort study checklist and the clinical trial checklist provided by the Scottish Intercollegiate Guidelines Network (SIGN)<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a>. The application of these scales to the texts selected in this review was performed by two investigators. If disagreements appeared, a third reviewer intervened to facilitate consensus.</p></span><span id="sec0007" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0009">Synthesis of results</span><p id="para0008" class="elsevierStylePara elsevierViewall">The results are presented both qualitatively and quantitatively, using tables and figures that provide a visual representation of the data collected and the results obtained. The injury incidence rate per thousand hours of exposure during refereeing, training or both activities, together with their respective 95% confidence intervals, were used to estimate the overall incidence rate by meta-analysis. In cases where the studies did not provide the confidence intervals and the raw data did not allow their calculation, it was necessary to contact the authors of the articles via e-mail and the social network for researchers ResearchGate<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a>, requesting the missing data. The I2-squared statistic was used to determine heterogeneity among the included studies, and the random-effects model was used.</p></span></span><span id="sec0008" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0010">Result</span><span id="sec0009" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0011">Study selection characteristics</span><p id="para0009" class="elsevierStylePara elsevierViewall">Initially, 299 manuscripts were identified. After eliminating duplicates, the number was reduced to 266. Afterwards, a review of titles and abstracts was conducted, resulting in the selection of 13 articles for comprehensive review.<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">10–21</span></a> During this process, 7 articles were excluded due to their retrospective nature,<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRefs" href="#bib0017"><span class="elsevierStyleSup">17–21</span></a> as well as an additional one that lacked specific data relevant to soccer referees.<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a> This left a total of 5 articles for final selection and synthesis.<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRefs" href="#bib0017"><span class="elsevierStyleSup">17–18</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0021"><span class="elsevierStyleSup">21</span></a> A flowchart that visually summarizes the search and article selection process is presented in <a class="elsevierStyleCrossRef" href="#fig0001">Fig. 1</a>.</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0012">Data analysis and description of the studies</span><p id="para0010" class="elsevierStylePara elsevierViewall">An analysis was conducted involving a total of 625 referees, of whom 621 were men and only 4 were women. The age range of the referees was between 27 and 40 years. In terms of study designs, 4 prospective cohort studies<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a> and 1 randomized clinical trial<a class="elsevierStyleCrossRef" href="#bib0021"><span class="elsevierStyleSup">21</span></a> were identified. A notable aspect across the studies was the consistency in the definition of injury used, as all 5 studies adopted the definition provided by the consensus on injury definitions and data collection procedures in soccer studies.<a class="elsevierStyleCrossRef" href="#bib0022"><span class="elsevierStyleSup">22</span></a> The characteristics of the studies are detailed in <a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>.</p><elsevierMultimedia ident="tbl0001"></elsevierMultimedia></span><span id="sec0011" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0013">Quality of studies</span><p id="para0011" class="elsevierStylePara elsevierViewall">After evaluating the quality of the studies, it was determined that the clinical trial reached an acceptable level. However, regarding the prospective cohort studies, it was found that two met the criteria for acceptable quality, while the other two exhibited significant deficiencies and were rated as low quality. The main deficiencies were related to the lack of consideration of the probability that some eligible subjects already had the outcome at the time of enrollment, the absence of blinding or acknowledgment of it when it was impossible to implement, suggesting that knowledge of exposure status could have biased the outcome assessment and identification of key confounding factors. A detailed summary of the quality assessment of the studies included in this review is provided in <a class="elsevierStyleCrossRef" href="#tbl0002">Table 2</a>.</p><elsevierMultimedia ident="tbl0002"></elsevierMultimedia></span><span id="sec0012" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0014">Incidence of injuries per 1000 h of exposure</span><p id="para0013" class="elsevierStylePara elsevierViewall">One study reported the incidence rate of injuries per thousand exposure hours during refereeing and training<a class="elsevierStyleCrossRef" href="#bib0021"><span class="elsevierStyleSup">21</span></a>. However, it did not provide confidence intervals or the necessary data to calculate them, so it could not be included in the overall analysis. This study stood out among the others as a clinical trial, in which the FIFA 11+ program was used as a preventive measure for injuries. It was observed that the control group, which did not implement the program, had an incidence rate of 1.45 injuries per 1000 exposure hours, while the group that followed the program twice a week showed an injury incidence rate of 0.50 injuries per 1000 exposure hours.</p><p id="para0014" class="elsevierStylePara elsevierViewall">Another cohort study also did not provide the necessary confidence intervals for the overall analysis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a> In this study, the injury rate during refereeing was 37.8 injuries per 1000 exposure hours, and for training, it was 39.9 injuries per 1000 exposure hours. It is important to note that attempts were made to contact the authors of these two studies, but no response was received.</p><p id="para0015" class="elsevierStylePara elsevierViewall">Regarding the studies in which it was possible to obtain confidence intervals, weighted estimates revealed that the incidence rate of injuries is higher during refereeing matches, at 14.43 injuries per 1000 exposure hours, compared to training, which was 8.59 injuries per 1000 exposure hours. The overall weighted incidence rate of injuries during both refereeing and training was 11.66 injuries per 1000 exposure hours (<a class="elsevierStyleCrossRef" href="#fig0002">Fig. 2</a>).</p><elsevierMultimedia ident="fig0002"></elsevierMultimedia></span></span><span id="sec0013" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0015">Discussion</span><p id="para0016" class="elsevierStylePara elsevierViewall">The present review, to the best of our knowledge, represents the first compendium synthesizing available information on the incidence rate of injuries in soccer referees per 1000 h of exposure. The compiled data reveal that the incidence rate of injuries per 1000 h of exposure is notably higher during refereeing activities than during soccer referee training sessions. These findings align with previous discoveries in soccer players, such as those documented by Robles-Palazón et al.,<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> where an incidence rate of 14.43 injuries/1000 h of exposure was observed during matches for men and 14.97 injuries/1000 h of exposure for women, whereas during training, the rate significantly dropped to 2.77 injuries/1000 h of exposure for men and 2.62 injuries/1000 h of exposure for women. Similarly, Owoeye et al.'s umbrella review<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> found similar data in elite soccer players, with rates during matches ranging from 9.5 to 48.7 injuries/1000 h of exposure and during training from 3.7 to 11.4 injuries/1000 h of exposure.</p><p id="para0017" class="elsevierStylePara elsevierViewall">These findings from the literature, in contrast with those of this study, are likely due to the fact that during competition, not only is maximum physical performance demanded of football players and referees, but multiple external factors also challenge cognitive performance and can increase the number of injuries.<a class="elsevierStyleCrossRef" href="#bib0023"><span class="elsevierStyleSup">23</span></a> Therefore, it is imperative to integrate preventive measures, such as the FIFA 11+ program for referees, which one of the studies included in this review found to be highly effective.<a class="elsevierStyleCrossRef" href="#bib0021"><span class="elsevierStyleSup">21</span></a> However, this program focuses on exercises for the lower limbs and does not include exercises for other parts of the body. This aspect is crucial because, according to Kordi et al.<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a> and Bizzini et al.,<a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a> while upper limb and trunk injuries are less frequent, they still occur. In one year, 4.35% of injuries to main referees involve hands and wrists, and 2.17% involve the head. Among assistant referees, 3.57% of total injuries affect hands and wrists.<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a></p><p id="para0018" class="elsevierStylePara elsevierViewall">Therefore, it is essential to conduct more research in this field to validate and establish injury prevention protocols that encompass all potential risk areas for referees. Since, as far as is known, the FIFA program is the only one available for referees, it may be necessary to consider alternatives in some situations.</p><p id="para0019" class="elsevierStylePara elsevierViewall">Finally, considering that the incidence rate of injuries per 1000 h of exposure is higher during matches, it is fundamental that decision-makers at local, national, and international levels reinforce warm-up programs to prevent injuries before each soccer match, and implement all necessary preventive measures to reduce the number of injuries during refereeing.</p></span><span id="sec0014" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0016">Limitations</span><p id="para0020" class="elsevierStylePara elsevierViewall">It is crucial to acknowledge the limitations of this review. Firstly, it is evident that this field of study has not yet been deeply explored, which limits the analyses presented due to a scarcity of data from primary studies. Furthermore, there is significant heterogeneity among the included studies, necessitating a cautious interpretation of the presented data. This statistical heterogeneity, along with observable differences in incidence rates, may be explained by the specific contexts in which the studies were conducted, where the pace of play in each league and competition could exert greater demands on referees and result in more injuries. For instance, a higher injury rate was evident among referees officiating in the 2006 FIFA World Cup compared to those in the Irish professional league,<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a> suggesting that dynamics within each setting could pose varying risks to referees.</p><p id="para0021" class="elsevierStylePara elsevierViewall">Moreover, it is important to note that due to underrepresentation, findings may be limited to male referees and cannot be extrapolated to female referees, as only four women were included in the analysis. Additionally, while the data obtained in the meta-analysis pertain to studies conducted on professional referees, providing clarity on incidence rates among them, the sole study on amateur referees was conducted by Attar et al.,<a class="elsevierStyleCrossRef" href="#bib0021"><span class="elsevierStyleSup">21</span></a> who implemented the FIFA 11+ referees program for preventive measures. Therefore, these data are not generalizable to amateur referees, and the reported incidence rate of injuries is likely influenced by various confounding variables inherent to the study context where an intervention was applied.</p><p id="para0022" class="elsevierStylePara elsevierViewall">Furthermore, it is relevant to point out that while some studies presented combined data for main referees and assistant referees, others presented them separately, indicating a disparity in injury incidence rates during refereeing, with higher rates in main referees than in assistants.<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a> This difference could be explained by the greater distances covered and the higher physical demands during the game by main referees.<a class="elsevierStyleCrossRef" href="#bib0024"><span class="elsevierStyleSup">24</span></a> Additionally, there is still a lack of data on injury rates during fitness assessment tests, where the level of physical demand is also considerably high.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">25</span></a></p><p id="para0023" class="elsevierStylePara elsevierViewall">In light of the above, it is imperative that researchers address the epidemiology of injuries in soccer referees more rigorously, given the existing imbalance between the study of players and the refereeing body. This will enable a more comprehensive understanding of the issue and facilitate the implementation of appropriate preventive measures, in an area where studies on injury prevention are also scarce.<a class="elsevierStyleCrossRef" href="#bib0021"><span class="elsevierStyleSup">21</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0026"><span class="elsevierStyleSup">26</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0017">Conclusion</span><p id="para0024" class="elsevierStylePara elsevierViewall">Injuries among soccer referees are a recurring issue that warrants attention. Studies have shown that referees are more likely to sustain injuries during matches than during training sessions, with an injury incidence rate of 14.43 injuries per 1000 h of officiating compared to 8.59 injuries per 1000 h of training. Therefore, it is crucial to implement preventive measures and educational programs to reduce the incidence rate of injuries among referees. An example of such a program is the FIFA 11+ for referees, which is especially recommended before matches, as this is when the highest number of injuries occur.</p></span><span id="sec0016" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0018">Statements</span><p id="para9001" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="celist0001"><li class="elsevierStyleListItem" id="celistitem0001"><span class="elsevierStyleLabel">•</span><p id="para0026" class="elsevierStylePara elsevierViewall">That it is an original work.</p></li><li class="elsevierStyleListItem" id="celistitem0002"><span class="elsevierStyleLabel">•</span><p id="para0027" class="elsevierStylePara elsevierViewall">That it has not been previously published in whole or in part.</p></li><li class="elsevierStyleListItem" id="celistitem0003"><span class="elsevierStyleLabel">•</span><p id="para0028" class="elsevierStylePara elsevierViewall">That it is not under evaluation in any other publication.</p></li><li class="elsevierStyleListItem" id="celistitem0004"><span class="elsevierStyleLabel">•</span><p id="para0029" class="elsevierStylePara elsevierViewall">That all authors are responsible for the final version of this article, to the preparation of which they have contributed.</p></li><li class="elsevierStyleListItem" id="celistitem0005"><span class="elsevierStyleLabel">•</span><p id="para0030" class="elsevierStylePara elsevierViewall">That the fact of being accepted for publication implies that all authorship rights are transferred.</p></li><li class="elsevierStyleListItem" id="celistitem0006"><span class="elsevierStyleLabel">•</span><p id="para0031" class="elsevierStylePara elsevierViewall">That there was not and will not be any economic benefit for the preparation of this manuscript.</p></li><li class="elsevierStyleListItem" id="celistitem0007"><span class="elsevierStyleLabel">•</span><p id="para0032" class="elsevierStylePara elsevierViewall">That there was no source of funding for the development of the manuscript.</p></li></ul></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres2284111" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abss0001" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1900307" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0001" "titulo" => "Introduction" ] 3 => array:3 [ "identificador" => "sec0002" "titulo" => "Methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0003" "titulo" => "Search strategy and procedure" ] 1 => array:2 [ "identificador" => "sec0004" "titulo" => "Criteria for the evaluation of studies for this review" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Identification of studies and data extraction" ] 3 => array:2 [ "identificador" => "sec0006" "titulo" => "Quality of studies" ] 4 => array:2 [ "identificador" => "sec0007" "titulo" => "Synthesis of results" ] ] ] 4 => array:3 [ "identificador" => "sec0008" "titulo" => "Result" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0009" "titulo" => "Study selection characteristics" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Data analysis and description of the studies" ] 2 => array:2 [ "identificador" => "sec0011" "titulo" => "Quality of studies" ] 3 => array:2 [ "identificador" => "sec0012" "titulo" => "Incidence of injuries per 1000 h of exposure" ] ] ] 5 => array:2 [ "identificador" => "sec0013" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0014" "titulo" => "Limitations" ] 7 => array:2 [ "identificador" => "sec0015" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0016" "titulo" => "Statements" ] 9 => array:2 [ "identificador" => "xack784730" "titulo" => "Acknowledgments" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-04-14" "fechaAceptado" => "2024-06-10" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1900307" "palabras" => array:4 [ 0 => "Epidemiology" 1 => "Injury" 2 => "Soccer" 3 => "Soccer referees" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abss0001" class="elsevierStyleSection elsevierViewall"><p id="spara006" class="elsevierStyleSimplePara elsevierViewall">Soccer referees, same as players, face intense physical exertion, exposing them to a high risk of injury. However, to date, no review has been conducted that synthesizes the injury incidence rate per 1000 h of exposure. Therefore, the purpose of this mini-review was to systematically examine the literature on the incidence of injury per 1000 h of exposure related to refereeing and training in soccer referees. A search was conducted in PubMed, Web of Science and ScienceDirect, resulting in the identification of 299 articles, of which 5 met the established inclusion criteria. The quality of the selected studies was assessed using the checklists provided by SIGN. In total, a group of 625 soccer referees was analyzed. The injury incidence rate during refereeing was found to be 14.43 injuries per 1000 h of exposure, while for training it was 8.59 injuries per 1000 h of exposure.</p></span>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="para0025a" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="ecom0001"></elsevierMultimedia></p>" "etiqueta" => "Appendix" "titulo" => "Supplementary materials" "identificador" => "sec0018" ] ] ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0001" "etiqueta" => "Fig 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2846 "Ancho" => 2500 "Tamanyo" => 367581 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0001" "detalle" => "Fig " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">PRISMA flow diagram suggested by Page et al.,<a class="elsevierStyleCrossRef" href="#bib0026"><span class="elsevierStyleSup">26</span></a>.</p>" ] ] 1 => array:8 [ "identificador" => "fig0002" "etiqueta" => "Fig 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1241 "Ancho" => 2500 "Tamanyo" => 144111 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0004" "detalle" => "Fig " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spara002" class="elsevierStyleSimplePara elsevierViewall">Estimation of the incidence of injuries per 1000 h of exposure related to refereeing and training in soccer referees.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0001" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0002" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0001"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">First Author \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0002"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Year \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0003"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Journal \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0004"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Design \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0005"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Population \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0006"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Follow-up period \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0007"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Wilson et al. \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0008"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">2012<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0009"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Irish Medical Journal \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0010"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Prospective Cohort \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0011"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">n: 31 professional referees [27 male and 4 female (33.2 ± 6.2 years)] \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0012"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1 year \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0013"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Vieira et al. \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0014"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">2019<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0015"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Revista Brasileira de Medicina do Esporte \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0016"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Prospective Cohort \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0017"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">n: 257 male professional referees (32,9 ± 5,0 years) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0018"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">3 years \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0019"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Kordi et al. \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0020"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">2013<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0021"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Sports Health \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0022"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Prospective Cohort \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0023"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">n: 74 male professional referees [(30 main referees (37.30 ± 3.20 years) y 44 assistant referees (36.30 ± 4.30 years)] \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0024"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1 year \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0025"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Bizzini et al. \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0026"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">2009<a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0027"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">British Journal of Sports Medicine \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0028"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Prospective Cohort \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0029"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">n: 63 male professional referees [(21 main referees (37.30 ± 3.20 years) y 42 assistant referees (37.30 ± 3.20 years)] \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0030"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1 month \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0031"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="top">Al Attar et al.</td><a name="en0032"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="top">2021<a class="elsevierStyleCrossRef" href="#bib0021"><span class="elsevierStyleSup">21</span></a></td><a name="en0033"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="top">Scandinavian Journal of Medicine & Science in Sports</td><a name="en0034"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="top">Randomized Controlled Trial</td><a name="en0035"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Experimental group= <span class="elsevierStyleItalic">n</span>: 100 male amateur referees (31.6 ± 4.1 years) \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0036"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="top">6 months</td></tr><tr title="table-row"><a name="en0041"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Control group= <span class="elsevierStyleItalic">n</span>: 100 male amateur referees (31.6 ± 4.1 years) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3704305.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spara003" class="elsevierStyleSimplePara elsevierViewall">Characteristics of the included studies.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0002" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "alt0003" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spara005" class="elsevierStyleSimplePara elsevierViewall">Note = ✔: Compliant; X: Does not comply; NA: Not applicable. The percentages shown in item 1.5 and 1.8 correspond to the percentage of subjects who abandoned the study before it ended.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0043"></a><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Studies</th><a name="en0044"></a><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="16" align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">Items</span></th></tr><tr title="table-row"><a name="en0046"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">1.1 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0047"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">1.2 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0048"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">1.3 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0049"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">1.4 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0050"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">1.5 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0051"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">1.6 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0052"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">1.7 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0053"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">1.8 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0054"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">1.9 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0055"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">1.10 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0056"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">1.11 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0057"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">1.12 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0058"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">1.13 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0059"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">1.14 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0060"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">2.1 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><a name="en0061"></a><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="top" scope="col" style="border-bottom: 2px solid black">2.2 \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0062"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Wilson et al.<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0063"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0064"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0065"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0066"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0067"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0% \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0068"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0069"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0070"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0071"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0072"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0073"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0074"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0075"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0076"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0077"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Acceptable \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0078"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0079"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Vieira et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0080"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0081"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0082"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0083"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0084"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">0% \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0085"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0086"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0087"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0088"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0089"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0090"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0091"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0092"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0093"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0094"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Low quality \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0095"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0096"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Kordi et al.<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0097"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0098"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0099"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0100"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0101"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1.3% \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0102"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0103"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0104"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0105"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0106"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0107"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0108"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0109"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0110"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0111"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Low quality \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0112"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0113"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Bizzini et al.<a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0114"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0115"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0116"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0117"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0118"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">4.54% \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0119"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0120"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0121"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0122"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0123"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0124"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0125"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0126"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0127"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0128"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Acceptable \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0129"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><a name="en0130"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="17" align="center" valign="top">Clinical Trial Checklist provided by SIGN</td></tr><tr title="table-row"><a name="en0131"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="top">Studies</td><a name="en0132"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="16" align="left" valign="top"><span class="elsevierStyleItalic">Items</span></td></tr><tr title="table-row"><a name="en0134"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1.1 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0135"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1.2 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0136"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1.3 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0137"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1.4 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0138"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1.5 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0139"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1.6 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0140"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1.7 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0141"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">1.8 \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0142"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="top">1.9</td><a name="en0143"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="top">1.10</td><a name="en0144"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="top">2.1</td><a name="en0145"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="top">2.2</td></tr><tr title="table-row"><a name="en0146"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">Al Attar et al.<a class="elsevierStyleCrossRef" href="#bib0021"><span class="elsevierStyleSup">21</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0147"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0148"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0149"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0150"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">X \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0151"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0152"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0153"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0154"></a><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="top">3.5% \t\t\t\t\t\t\n \t\t\t\t</td><a name="en0155"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="top"></td><a name="en0156"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="top">NA</td><a name="en0157"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="top">Acceptable</td><a name="en0158"></a><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" 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