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Xiao N, Bagayi V, Yang D, Huang X, Zhong L, Kiselev S, Bolkov MA, Tuzankina IA, Chereshnev VA. Effectiveness of animal-assisted activities and therapies for autism spectrum disorder: a systematic review and meta-analysis. Front Vet Sci 2024; 11:1403527. [PMID: 38895710 PMCID: PMC11184216 DOI: 10.3389/fvets.2024.1403527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 05/15/2024] [Indexed: 06/21/2024] Open
Abstract
Background Given the rising interest in complementary therapeutic strategies for autism spectrum disorder (ASD), this research aims to provide a comprehensive analysis of the impact of animal-assisted activities and therapies (AAAT) on various ASD symptoms. Methods A meticulous search of databases, including Scopus and PubMed, was conducted to gather relevant research on AAAT for ASD. This process led to the selection of 45 studies encompassing 1,212 participants. The chosen studies were then subjected to a meta-analysis to evaluate the efficacy of AAAT in alleviating core ASD symptoms. Results The meta-analysis revealed significant improvements in several core ASD symptoms due to AAAT. Notably, there were improvements in social communication (MD = -4.96, 95% CI [-7.49, -2.44]), irritability (MD = -2.38, 95% CI [-4.06, -0.71]), hyperactivity (MD = -4.03, 95% CI [-6.17, -1.89]), and different word usage skills (MD = 20.48, 95% CI [7.41, 33.55]). However, social awareness (MD = -1.63, 95% CI [-4.07, 0.81]), social cognition (MD = -3.60, 95% CI [-9.36, 2.17]), social mannerisms (MD = -0.73, 95% CI [-2.55, 1.09]), social motivation (MD = -1.21, 95% CI [-2.56, 0.13]), lethargy (MD = -1.12, 95% CI [-3.92, 1.68]), and stereotypical behaviors (MD = -0.23, 95% CI [-1.27, 0.80]) did not significantly improve. Conclusion The study demonstrates the potential of AAAT in improving certain core symptoms of ASD, such as social communication, irritability, hyperactivity, and word usage skills. However, the effectiveness of AAAT in other ASD symptom domains remains uncertain. The research is limited by the absence of long-term follow-up data and a high risk of bias in existing studies. Therefore, while the findings indicate the promise of AAAT in specific areas, caution is advised in generalizing its efficacy across all ASD symptoms.
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Affiliation(s)
- Ningkun Xiao
- Department of Immunochemistry, Institution of Chemical Engineering, Ural Federal University, Yekaterinburg, Russia
- Laboratory for Brain and Neurocognitive Development, Department of Psychology, Institution of Humanities, Ural Federal University, Yekaterinburg, Russia
| | - Vaishnavi Bagayi
- Laboratory for Brain and Neurocognitive Development, Department of Psychology, Institution of Humanities, Ural Federal University, Yekaterinburg, Russia
| | - Dandan Yang
- Guang’an District Women and Children’s Hospital, Guangan, China
| | - Xinlin Huang
- Laboratory for Brain and Neurocognitive Development, Department of Psychology, Institution of Humanities, Ural Federal University, Yekaterinburg, Russia
| | - Lei Zhong
- Doctoral Department, Russian Sports University, Moscow, Russia
| | - Sergey Kiselev
- Laboratory for Brain and Neurocognitive Development, Department of Psychology, Institution of Humanities, Ural Federal University, Yekaterinburg, Russia
| | - Mikhail A. Bolkov
- Institute of Immunology and Physiology of the Ural Branch of the Russian Academy of Sciences, Yekaterinburg, Russia
| | - Irina A. Tuzankina
- Institute of Immunology and Physiology of the Ural Branch of the Russian Academy of Sciences, Yekaterinburg, Russia
| | - Valery A. Chereshnev
- Department of Immunochemistry, Institution of Chemical Engineering, Ural Federal University, Yekaterinburg, Russia
- Institute of Immunology and Physiology of the Ural Branch of the Russian Academy of Sciences, Yekaterinburg, Russia
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Shahmoradi L, Rezayi S. Cognitive rehabilitation in people with autism spectrum disorder: a systematic review of emerging virtual reality-based approaches. J Neuroeng Rehabil 2022; 19:91. [PMID: 35982460 PMCID: PMC9389666 DOI: 10.1186/s12984-022-01069-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 08/12/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Emerging virtual technologies and cognitive rehabilitation methods are two new treatment approaches that can be used to strengthen cognitive functions in Autism Spectrum Disorder (ASD). The main aim of this study was to examine the effect of using virtual reality-based approaches on cognitive disorders of children and adults with ASD. Methods This systematic review was conducted on scientific papers to determine the effects of virtual reality-based technologies on the cognitive functions of children and adults with ASD. We identified 688 studies related to this topic and filtered them down to 17 articles, and then extracted the effects of interventions on cognitive outcomes. Results A total of 17 studies met the inclusion criteria, in which 226 persons with ASD had taken place. The sample size in the selected studies ranged from 1 to 56 participants (Median: 8, Q1: 3.5, Q3: 15.5). Four of the studies were case–control studies, ten were pre-test/post-test studies, and three were Randomized Control Trials (RCTs). Results of 16 studies showed significant progress in various cognitive indexes, such as task learning, attention, executive functioning, and daily skills in people with ASD. In most studies, virtual technologies had beneficial effects on reducing cognitive problems, but existing limitations could reduce their effectiveness. These limitations included the cost of virtual reality devices, inappropriate size of software, the weight of devices, potential addiction, intolerance of wearing glasses or headsets by people with autism (especially in children), and the possibility of eye injury. Conclusion Applying appropriate virtual-based approaches could improve cognitive indexes in people with ASD. However, further studies are needed to investigate the real effects of these technologies in the long run.
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Affiliation(s)
- Leila Shahmoradi
- Health Information Management and Medical Informatics Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Sorayya Rezayi
- Health Information Management and Medical Informatics Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran.
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Moreno Escobar JJ, Morales Matamoros O, Aguilar del Villar EY, Tejeida Padilla R, Lina Reyes I, Espinoza Zambrano B, Luna Gómez BD, Calderón Morfín VH. Non-Parametric Evaluation Methods of the Brain Activity of a Bottlenose Dolphin during an Assisted Therapy. Animals (Basel) 2021; 11:ani11020417. [PMID: 33562006 PMCID: PMC7914889 DOI: 10.3390/ani11020417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 11/23/2022] Open
Abstract
Simple Summary Dolphin Assisted Therapies (DAT) can be used with any person or group with specific needs and it can be as disparate as people at risk of social exclusion, eating disorders, terminally ill, mental health disorders, among many others. This paper is focused on measuring and analyzing dolphins brain activity when DAT is taking place, in order to identify if there is any differences in female dolphin’s neuronal signal when it is interacting with control or intervention subjects. In addition, we designed a wireless and portable electroencephalographic single-channel signal capture device to monitor the brain activity of a female bottle-nose dolphin. Our findings also validate the evidence that the interaction between a patient with a certain disease or disorder and undergoes to a DAT modifies usual brain activity behavior of a female bottle-nose dolphin. Abstract Dolphin-Assisted Therapies (DAT) are alternative therapies aimed to reduce anxiety levels, stress relief and physical benefits. This paper is focused on measuring and analyzing dolphins brain activity when DAT is taking place in order to identify if there is any differences in female dolphin’s neuronal signal when it is interacting with control or intervention subjects, performing our research in Delfiniti, Ixtapa, Mexico facilities. We designed a wireless and portable electroencephalographic single-channel signal capture sensor to acquire and monitor the brain activity of a female bottle-nose dolphin. This EEG sensor was able to show that dolphin activity at rest is characterized by high spectral power at slow-frequencies bands. When the dolphin participated in DAT, a 23.53% increment in the 12–30 Hz frequency band was observed, but this only occurred for patients with some disease or disorder, given that 0.5–4 Hz band keeps it at 17.91% when there is a control patient. Regarding the fractal or Self-Affine Analysis, we found for all samples studied that at the beginning the dolphin’s brain activity behaved as a self-affine fractal described by a power-law until the fluctuations of voltage reached the crossovers, and after the crossovers these fluctuations left this scaling behavior. Hence, our findings validate the hypothesis that the participation in a DAT of a Patient with a certain disease or disorder modifies the usual behavior of a female bottle-nose dolphin.
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Affiliation(s)
- Jesús Jaime Moreno Escobar
- Escuela Superior de Ingeniería Mecánica y Eléctrica, Instituto Politécnico Nacional, 07340 Ciudad de México, Mexico; (O.M.M.); (E.Y.A.d.V.); (I.L.R.); (B.E.Z.); (B.D.L.G.)
- Correspondence: ; Tel.: +52-55-5729-6000 (ext. 54639)
| | - Oswaldo Morales Matamoros
- Escuela Superior de Ingeniería Mecánica y Eléctrica, Instituto Politécnico Nacional, 07340 Ciudad de México, Mexico; (O.M.M.); (E.Y.A.d.V.); (I.L.R.); (B.E.Z.); (B.D.L.G.)
| | - Erika Yolanda Aguilar del Villar
- Escuela Superior de Ingeniería Mecánica y Eléctrica, Instituto Politécnico Nacional, 07340 Ciudad de México, Mexico; (O.M.M.); (E.Y.A.d.V.); (I.L.R.); (B.E.Z.); (B.D.L.G.)
| | - Ricardo Tejeida Padilla
- Escuela Superior de Turismo, Instituto Politécnico Nacional, 07630 Ciudad de México, Mexico;
| | - Ixchel Lina Reyes
- Escuela Superior de Ingeniería Mecánica y Eléctrica, Instituto Politécnico Nacional, 07340 Ciudad de México, Mexico; (O.M.M.); (E.Y.A.d.V.); (I.L.R.); (B.E.Z.); (B.D.L.G.)
| | - Brenda Espinoza Zambrano
- Escuela Superior de Ingeniería Mecánica y Eléctrica, Instituto Politécnico Nacional, 07340 Ciudad de México, Mexico; (O.M.M.); (E.Y.A.d.V.); (I.L.R.); (B.E.Z.); (B.D.L.G.)
| | - Brandon David Luna Gómez
- Escuela Superior de Ingeniería Mecánica y Eléctrica, Instituto Politécnico Nacional, 07340 Ciudad de México, Mexico; (O.M.M.); (E.Y.A.d.V.); (I.L.R.); (B.E.Z.); (B.D.L.G.)
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Marino L, Lilienfeld SO. Third time's the charm or three strikes you're out? An updated review of the efficacy of dolphin-assisted therapy for autism and developmental disabilities. J Clin Psychol 2021; 77:1265-1279. [PMID: 33482038 DOI: 10.1002/jclp.23110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 12/11/2020] [Accepted: 12/20/2020] [Indexed: 12/17/2022]
Abstract
CONTEXT Dolphin-assisted therapy (DAT) is a popular form of animal-assisted therapy for autism spectrum disorders and other psychological conditions. OBJECTIVE In this review, our third, we analyze the most recent DAT studies in terms of construct and internal validity criteria to determine if there is empirical support for DAT. METHOD To ensure a systematic review, we searched for peer-reviewed studies on DAT by submitting relevant search terms to Google Scholar from 2007 to 2020, conducted a further search of all DAT papers in several peer-reviewed journals, and reviewed reference sections of DAT articles to ensure a thorough review of the literature between 2007 and the present. RESULTS The DAT literature continues to be marked by several weaknesses in both internal and construct validity that preclude confident inferences regarding the intervention's efficacy. CONCLUSION There is still insufficient evidence that DAT has therapeutic value.
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Affiliation(s)
- Lori Marino
- Whale Sanctuary Project, Kimmela Center for Animal Advocacy, Kanab, Utah, USA
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Chakraborti B, Verma D, Guhathakurta S, Jaiswal P, Singh AS, Sinha S, Ghosh S, Mukhopadhyay K, Mohanakumar KP, Rajamma U. Gender-Specific Effect of 5-HT and 5-HIAA on Threshold Level of Behavioral Symptoms and Sex-Bias in Prevalence of Autism Spectrum Disorder. Front Neurosci 2020; 13:1375. [PMID: 31998058 PMCID: PMC6961535 DOI: 10.3389/fnins.2019.01375] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 12/04/2019] [Indexed: 12/27/2022] Open
Abstract
Platelet hyperserotonemia in a subset of Autism Spectrum Disorder (ASD) probands, efficacy of selective serotonin reuptake inhibitors (SSRIs) in reducing behavioral deficits and gender-bias in normal serotonin (5-hydroxy tryptamine or 5-HT) synthesis suggest disruption in stringent regulation of serotonin metabolism in ASD. Therefore, we investigated the changes in 5-HT and 5-hydroxy indole acetic acid (5-HIAA) in ASD probands to assess its effect on the behavior of male and female probands. ASD cases (n = 215) were examined using childhood autism rating scale (CARS). Platelet 5-HT (104 cases and 26 controls) and platelet/plasma 5-HIAA (73 cases and 17 controls) were estimated using high performance liquid chromatography coupled with electrochemical detector (HPLC-ECD). In male probands, we observed increase in platelet 5-HT content in association with increase in the score for adaptive responses and increase in platelet 5-HIAA levels with concomitant decline in the score for intellectual response. Age did not influence the neurochemical parameters, but imitation, listening responses and nonverbal communication scores decreased with age. Conversely in female probands, plasma 5-HIAA level significantly attenuated with age, when platelet 5-HT content remained unchanged. Interestingly, platelet/plasma 5-HT and plasma 5-HIAA were higher in female controls. Female probands displayed severe autism-associated behaviors. Overall results indicate gender-bias in 5-HT and 5-HIAA regulation, which probably increases the threshold level of ASD phenotypes in the females, thereby affecting ASD prevalence in a sex-specific manner.
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Affiliation(s)
- Barnali Chakraborti
- Manovikas Biomedical Research and Diagnostic Centre, Manovikas Kendra, Kolkata, India
| | - Deepak Verma
- Manovikas Biomedical Research and Diagnostic Centre, Manovikas Kendra, Kolkata, India
| | - Subhrangshu Guhathakurta
- Manovikas Biomedical Research and Diagnostic Centre, Manovikas Kendra, Kolkata, India.,Division of Neuroscience, Burnett School of Biomedical Sciences, University of Central Florida, Orlando, FL, United States
| | - Preeti Jaiswal
- Manovikas Biomedical Research and Diagnostic Centre, Manovikas Kendra, Kolkata, India
| | - Asem Surindro Singh
- Manovikas Biomedical Research and Diagnostic Centre, Manovikas Kendra, Kolkata, India.,Department of Pathology, University of Mississippi Medical Center, Jackson, MS, United States
| | - Swagata Sinha
- Out Patient's Department, Manovikas Kendra, Kolkata, India
| | - Saurabh Ghosh
- Human Genetics Unit, Indian Statistical Institute, Kolkata, India
| | - Kanchan Mukhopadhyay
- Manovikas Biomedical Research and Diagnostic Centre, Manovikas Kendra, Kolkata, India
| | - Kochupurackal P Mohanakumar
- Cell Biology & Physiology Division, Indian Institute of Chemical Biology, Kolkata, India.,Inter University Centre for Biomedical Research and Super Speciality Hospital, Mahatma Gandhi University,, Kottayam, India
| | - Usha Rajamma
- Manovikas Biomedical Research and Diagnostic Centre, Manovikas Kendra, Kolkata, India.,Inter University Centre for Biomedical Research and Super Speciality Hospital, Mahatma Gandhi University,, Kottayam, India
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Evaluating Animal-Assisted Interventions: An Empirical Illustration of Differences between Outcome Measures. Animals (Basel) 2019; 9:ani9090645. [PMID: 31484309 PMCID: PMC6770002 DOI: 10.3390/ani9090645] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/19/2019] [Accepted: 08/29/2019] [Indexed: 11/18/2022] Open
Abstract
Simple Summary This study compares and contrasts several outcome measures to assess the effect of an equine-assisted intervention for a child with Autism Spectrum Disorder. Before and after the equine-assisted sessions, we conducted a semi-structured interview with the participant’s parents, asked parents to fill out a general screening instrument separately, and observed the participant’s social and communication skills during five equine-assisted sessions. We found differences between the interview and questionnaire with regard to parents’ perceptions of aggression regulation and interacting with peers. Differences with regard to parental reports and observations were found for play development and anxiety. The observations provided a detailed view of the child’s development during the intervention, which yielded an interesting hypothesis in terms of the current dose–response discussion in AAI for children with Autism Spectrum Disorder. Abstract Multiple authors have called for strong empirical evaluations to strengthen the foundation of Animal-Assisted Interventions. Carefully choosing the outcome measures of these studies is important, as choosing the wrong outcomes may lead to a failure to detect effects. The current study therefore compares and contrasts the use of several outcome measures, to assess the effect of an equine-assisted intervention for a child with Autism Spectrum Disorder: (1) a semi-structured interview with both parents, specifically designed for children with cognitive disabilities, (2) a general screening instrument filled out by both parents separately, which can be used to assess children’s psycho-social problems, and (3) systematic observations of social and communication skills during the equine-assisted sessions. All instruments indicated an improvement in the participant’s social and communication skills. We found differences between the interview and questionnaires with regard to parents’ perception of aggression regulation and interacting with peers. Differences with regard to parental reports and observations were found for play development and anxiety. The observations provided a detailed view of the child’s development during the intervention, which yielded an interesting hypothesis in terms of the current dose–response discussion in AAI for children with Autism Spectrum Disorder.
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O'Haire M. Research on animal-assisted intervention and autism spectrum disorder, 2012-2015. APPLIED DEVELOPMENTAL SCIENCE 2017; 21:200-216. [PMID: 31080343 DOI: 10.1080/10888691.2016.1243988] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Including animals in autism intervention is growing in both research and practice. A systematic literature review was conducted to collate and synthesize all empirical research on animal-assisted intervention (AAI) for autism published from 2012 to 2015. Findings from 28 included studies revealed that AAI programs generally include one animal per participant with a total contact time of approximately 10 hours over the course of 8 to 12 weeks. Research methodology is diverse and though limited in many cases, has improved over the last few years. The most commonly reported outcome was increased social interaction, which was unanimously significant across 22 studies. The need for further research is highlighted, calling for a focus on refining AAI techniques, identifying optimal circumstances for positive change as well as individuals who may not benefit, and independent replication of high quality studies to move AAI from an enrichment activity to an evidence-based practice for autism.
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Affiliation(s)
- Marguerite O'Haire
- Purdue University, Comparative Pathobiology, College of Veterinary Medicine, CPB/VPTH, 725 Harrison Street, West Lafayette, 47907 USA
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Yap E, Scheinberg A, Williams K. Attitudes to and beliefs about animal assisted therapy for children with disabilities. Complement Ther Clin Pract 2016; 26:47-52. [PMID: 28107849 DOI: 10.1016/j.ctcp.2016.11.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 11/21/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study assessed the attitudes and beliefs surrounding animal-assisted therapy (AAT) for the rehabilitation of children with disabilities at the Royal Children's Hospital (RCH), focusing specifically on cerebral palsy (CP), autism spectrum disorder (ASD) and acquired brain injury (ABI). This was an initial step to inform future AAT research and to understand the feasibility of interventions. DESIGN/SETTING/OUTCOME MEASURES An online survey asking participants their opinions about the inclusion of AAT, and potential barriers to its introduction in a tertiary hospital setting was advertised on the RCH Intranet from 3 March 2015 to 3 April 2015. RESULTS A total of 128 participants responded to the survey request, from a range of specialties and departments. Almost all survey respondents reported that animal-assisted therapy would be helpful in the physical or behavioral management of children affected by CP (98%), ASD (99%) and ABI (96%), and 98% of survey respondents supported the inclusion of AAT in the RCH. Ninety-two percent recommended AAT in the inpatient setting and 52% of the respondents suggest that it should be administered as a pre-determined program with set activities. Additionally, qualitative responses provided suggestions that AAT should be used to provide comfort in high stress environments such as prior to medical and surgical procedures. CONCLUSIONS The majority of staff are supportive of the inclusion of AAT in the RCH, indicating more research is needed to establish whether AAT is acceptable to children and families as part of their care.
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Affiliation(s)
| | - Adam Scheinberg
- Victorian Paediatric Rehabilitation Service at Royal Children's Hospital, Murdoch Childrens Research Institute, Department of Paediatrics, Monash University, Australia.
| | - Katrina Williams
- Developmental Medicine, Royal Children's Hospital, Melbourne APEX Australia Chair of Developmental Medicine, University of Melbourne, Honorary Research Fellow, Murdoch Childrens Research Institute, Australia.
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Abstract
Zusammenfassung. Delfintherapien weltweit werden von deutschen Familien rege in Anspruch genommen, bislang aber kaum von der Fachwelt diskutiert. Dieser Beitrag bietet einen Einblick in konzeptionelle Unterschiede verschiedener Anbieter und einen vollständigen Überblick zu den Wirksamkeitsstudien. Von den insgesamt 32 Studien werden die Ergebnisse der 13 kontrollierten Studien unter Berücksichtigung weiterer methodischer Eckdaten erläutert. Für Kinder mit unterschiedlichen Behinderungen sind Effekte auf die kognitive und motorische Entwicklung sowie nachhaltige Effekte auf kommunikative und soziale Kompetenzen bestätigt. Für andere Zielgruppen ist die Befundlage noch sehr eingeschränkt. Es werden Schlussfolgerungen für die zukünftige Forschung und für die Beratung von Familien gezogen.
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Chandramouleeswaran S, Russell PSS. Complementary psychosocial interventions in child and adolescent psychiatry: pet assisted therapy. Indian J Psychol Med 2014; 36:4-8. [PMID: 24701004 PMCID: PMC3959016 DOI: 10.4103/0253-7176.127240] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pet assisted therapy (PAT) is a form of complementary psychosocial intervention used in the field of mental health and disability. The form of therapy has the potential to augment the other forms of psychotherapies and pharmacotherapy. This article is an overview of history and clinical origins of PAT, classification and therapy models, scientific basis, the current use in specific disorders, preventive and diagnostic role as well as the potential risks among children and adolescents with mental health needs with a special focus on the Indian needs. A systematic electronic search strategy was undertaken to identify the intervention effectiveness of PAT in MedLine (PubMed), cochrane database of systematic reviews, high-wire press and Google Scholar. We augmented our electronic search with a search of additional articles in reference lists of retrieved articles, as well as a hand search available journals that were not indexed in any electronic database in consultation with colleagues and experts. To qualify for inclusion, studies were required to meet predetermined criteria regarding study design, study population, interventions evaluated and outcome measured to reduce the publication bias.
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