Critical evaluation of the cost-effectiveness and clinical effectiveness of continuity of midwifery care models for women experiencing complex pregnancy is an important consideration in the review and reform of maternity services. Most studies either focus on women who experience healthy pregnancy or mixed risk samples. These results may not be generalised across the childbearing continuum to women with risk factors. This review critically evaluates studies that measure the cost of care for women with complex pregnancies, with a focus on method and quality.To critically appraise and summarise the evidence relating to the combined cost-effectiveness, resource use and clinical effectiveness of midwifery continuity models for women who experience complex pregnancies and their babies in developed countries.Structured review of the literature utilising a matrix method to critique the methods and quality of studies.A search of Medline, CINAHL, MIDIRS, DARE, EMBASE, OVID, PubMed, ProQuest, Informit, Science Direct, Cochrane Library, NHS Economic Evaluation Database (NHSEED) for the years 1994 – 2018 was conducted.Nine articles met the inclusion criteria. The review identified four areas of economic evaluation that related to women who experienced complex pregnancy and continuity of midwifery care. (1) cost and clinical effectiveness comparisons between continuity of midwifery care versus obstetric-led units; (2) cost of continuity of midwifery care and/or team midwifery compared to Standard Care; (3) cost-effectiveness of continuity of midwifery care for Australian Aboriginal women versus standard care; (4) patterns of antenatal care for women of high obstetric risk and comparative provider cost.Cost savings specific to women from high risk samples who received continuity of midwifery care compared with obstetric-led standard care was stated for only one study in the review. Kenny et al. 1994 identified cost savings of AUS $29 in the antenatal period for women who received the midwifery team model from a stratified sub-set of high-risk pregnant woman within a mixed risk sample of 446 women. One systematic review relevant to the UK context, Ryan et al. (2013), applied sensitivity analysis to include women of all risk categories. Where risk ratio for overall fetal/neonatal death was systematically varied based on the 95% confidence interval of 0.79 to 1.09 from pooled studies, the aggregate annual net monetary benefit for continuity of midwifery care ranged extremely widely from an estimated gain of £472 million to a loss of £202 million. Net health benefit ranged from an annual gain of 15 723 QALYs to a loss of 6 738 QALYs. All other studies in this review reported cost savings narratively or within mixed risk samples where risk stratification was not clearly stated or related to the midwifery team model only.Studies that measure the cost of continuity of midwifery care for women with complex pregnancy across the childbearing continuum are limited and apply inconsistent methods of economic evaluation. The cost and outcomes of implementing continuity of midwifery care for women with complex pregnancy is an important issue that requires further investigation. Robust cost-effectiveness evidence is essential to inform decision makers, to implement sustainable systems change in comparative maternity models for pregnant women at risk and to address health inequity. Review and transformation of maternity service models have been on the policy agenda of the Australian Government for the past decade , 2. An iInternationally, and in Australia, strong clinical and cost evidence already exist to support systemic implementation of continuity of midwifery care for women with healthy pregnancies –10. HoweNo previous systematic reviews have focused on women with complex pregnancies. To date, most systematic reviews of midwifery care have been conducted in the United Kingdom (UK) for low risk pregnancies. These reviews provide strong evidence for clinical and cost effectiveness of continuity of midwifery care (including birthing centres and home birth), as compared to obstetric - led units, but discrete economic analysis of outcomes and cost for pregnant women with risk factors were not included , 18–23. Econometric models that applied productivity / efficiency frontiers and standard international resource ingredient approaches to develop predictive cost models, or other methods, for example, Net Benefit, were similarly limited , 25. TheCapacity to improve maternity services to women with complicated pregnancy continues to pose a major challenge for the Australian health system –28. ThisThe aim of this review is to critically appraise available literature and summarise the evidence related to cost, resource use, and clinical outcomes of care for women with complex pregnancies who received care in a continuity of midwifery care model compared with other maternity models.This structured, integrated review will examine the available evidence for cost-effectiveness of antenatal, intrapartum and postnatal care in continuity of midwifery care. It will critically evaluate the methods of these studies. This includes their capacity to support public health policy through expanded implementation and access to continuity of midwifery care for women who experience complications of pregnancy and childbearing and their babies.This review used a stepped structured approach to documenting the search strategy . The MatTable Inclusion criteria were primary research articles published in English language, peer-reviewed journals between the years 1994–2018. The 24-year time - frame marked the emergence of studies on the cost-effectiveness of continuity of midwifery care, including the first Australian studies , 37, 38.The classification of included studies within the evidence hierarchy is documented in Table This review identified three systematic reviews that examined the cost and clinical effectiveness of continuity of midwifery care and obstetric-led maternity models. All three of these reviews were undertaken in the UK Table .Table 3SA summary of the six primary studies included in this review, including study design is provided in Table Results of these primary studies are reported in table Economic evaluations undertaken alongside randomised controlled trials (RCT) constituted the most robust evidence for economic analysis of continuity of midwifery care models available. Importantly, four RCTs included in the systematic review by Sandall et al.  were conThe quality of cost, resource use and clinical effectiveness evidence in the primary studies included in this review therefore is high as they include mainly RCT evidence and also incorporated results from Levels III & IV of the evidence hierarchy. However, of the four RCT studies, three involved team midwifery models, as contrasted with continuity of care with a named midwife. In a team midwifery model a small group of midwives (up to 6 and no more than 8) provide care for identified women and the degree of continuity is not as high as in continuity of care with a named midwife. Other study designs considered cost evidence with varying levels of quality. Based on the NHMRC evidence hierarchy, the studies, in order of decreasing quality included cost analysis , and cosWhile a number of studies were identified that used internationally validated ratios to model predictive costs for mode of birth and other interventions, these studies were excluded as they were not directly applied to continuity of midwifery care or women with identified pregnancy risk factors –45.Comparisons of midwife-led versus obstetric consultant-led units for cost and clinical effectivenessFour areas of economic evaluation that relate to women who experienced complex pregnancy were identified from the review:2.Cost of continuity of midwifery care and/or team midwifery compared to Standard Care Two studies had data relevant to this theme. While cost models were based on trials that recruited women with low pregnancy risk, sensitivity analysis modelled cost for women of mixed pregnancy risk classification based on UK population data. In the two systematic reviews from the UK where continuity of midwifery care and obstetric consultant-led maternity models are common, an estimated mean cost saving for each eligible woman of £12.38 was found in the continuity of midwifery care model overall. This provided aggregate health savings of £1.16 million per year for the health system if only half of all eligible women received continuity of midwifery care . HoweverOver the past two decades economic evaluations conducted alongside RCTs in several Australian states have demonstrated cost saving and clinical effectiveness of continuity of midwifery care models compared with standard hospital care in the same setting –39, 46. The most recent mixed-risk Australian trial identified a median cost saving of A$566 for women who received continuity of midwifery care compared to standard hospital care services, these savings cannot be generalised to high risk groups . This tr3.Cost-effectiveness of continuity of midwifery care for Aboriginal women versus standard careEarlier team midwifery RCT studies identified reduced levels of birth intervention in addition to modest cost savings for women of all-risk. One study identified as a cost-effectiveness study used Australian Diagnostic Related Groups ‘top-down costing’ that showed a mean cost reduction for birth of 4.5% for women in the midwifery group, . The othTwo studies attempted to measure the cost of continuity of midwifery care in identified Australian populations with higher pregnancy risk status. Gao et al.  used a r4.Patterns of antenatal care for women of high obstetric risk and comparative provider costsAn earlier cost analysis of a metropolitan, Aboriginal-controlled, continuity of midwifery care service  estimated direct program costs and downstream savings in the health sector of A$1,200 per woman . DownstrIn this review antenatal care provided by midwives for high risk and mixed risk samples showed reduced cost in three RCT studies , 37, 39 This is consistent with a cochrane review of patterns of antenatal care which showed, among different providers of antenatal care , primary outcome measures of low birthweight, pre-eclampsia/eclampsia, severe postpartum anaemia, and treated urinary tract infection  demonstrate similar clinical effectiveness , 52.Increasingly health services need to justify quality outcomes as well as value for money –56. QualThis review demonstrated that there are few studies specific to evaluating cost-effectiveness of midwifery continuity of care models for women who experience high-risk pregnancy relative to other models of maternity care, including standard and traditional obstetric led models. Of the studies included, significant limitations and caveats apply. Inter-country comparison of cost and models of maternity care between health systems that do not share the same features prohibit comparative generalisability of both outcomes and models of care, including the costs attributable to different models and systems. The costs and outcomes may vary widely according to structural factors such as funding model and workforce arrangements and the influence of demographic features and characteristics of woman who experience high - risk pregnancy within the study samples.A strong international evidence base supports woman’s early access to antenatal care, pre-natal education and health promotion strategies provided by midwives as an effective intervention to improve maternal and neonatal outcomes when integrated with other specialised health and social support services , 58, 60.Two studies included in this review identified higher antenatal costs associated with increased frequency of visits for women identified with higher pregnancy risks who may otherwise experience increased morbidity and mortality in pregnancy and childbearing , 41. ConWith respect to intrapartum care, while studies show resource inputs and cost ratios for mode of birth to be relatively consistent among countries over time, recent comparison of the costs of childbirth show significant cross-country variation. Factors that have been associated with inter-country cost increases relate specifically to workforce salary rates and provider charges in fee-based health systems . FurtherPlace of birth is strongly associated with cost , 23, 67.In different maternity models and among different provider groups, increased rates of surgical birth, especially caesarean section, and other routine medical practices associated with the cascade of intervention in childbirth increase cost and morbidity , 43. LonMost published studies have focused on women considered low risk for developing complications and receiving midwifery-led care. Robust evidence from international and Australian studies demonstrates improved cost and clinical outcomes for these women and their babies across a number of key areas, notably physiological vaginal birth , 20.Significantly, midwifery models for low risk women have shown a trend to variable cost saving in health service models where volume is sufficient to achieve efficiency and economies of scale , 20. SavIn the limited studies examined in this review, diversity in study design and variation in the quality of the results generated often negate reliable comparison of cost results. Where studies include women of mixed pregnancy risk, variation and inconsistency of both study design and the methods applied precluded reliable, comprehensive cost comparisons across the maternity care continuum for woman with pregnancy risk factors. Robust economic evaluations conducted alongside a RCT were considered to have high validity and reliability. None, however, focused exclusively on women with complicated pregnancy. This was in contrast to non-randomised retrospective audit studies , 41. StuMethodological challenges were identified in this review. The first of these was selective risk sampling. Of studies included in this review some used “mixed risk” pregnancy samples that did not stratify clinical results or cost specific to the high-risk sub-set within the sample, thereby limiting generalisability of results. A second challenge included the variables selected for measurement in each study. The variables selected showed significant variation. Accurate measurement of variables depended on the data available and the reliability of the data sources. The data sources of studies included in this review demonstrated wide fluctuation in reliability and quality across different time horizons making comparison of outcomes and cost unreliable.Inconsistencies that compounded the methodological challenges outlined above also were identified in relation to the various type of economic evaluations of maternity care identified in this review – cost-effectiveness, cost consequences analysis, and economic synthesis. These included the use of varying cost methodology and study assumptions. For example, ‘top-down’ costing approaches that used diagnostic related groups cost weights reflected activity-based funding models , 38, as Robust evaluation and comparative cost performance of alternative models of maternity care is an important consideration in the provision of safe, quality maternity services for women who experience complicated pregnancy. While it is well known that poor outcomes at start to life contribute to long-term chronic disease states that is costly for the health system, optimising clinical effectiveness outcomes and cost efficiency for care of women who experience complex pregnancy requires higher prioritisation. This review found limited evidence to support the cost-effectiveness of midwifery continuity of care for women with complex pregnancy. Further evaluation of cost, resource use and clinical outcomes comparative to other models of maternity care is critical. Further, this review shows that those studies that have attempted to measure these costs demonstrate a range of inconsistencies. The application of inconsistent method undermines valid cost comparison of maternity models in developed countries. This remains an ongoing challenge for policy makers and service providers in implementing system change.Equitable access to continuity of midwifery care is an important issue for women with pregnancy complication. Evidence on the comparative cost-effectiveness resource use and clinical outcomes delivered through new maternity services is essential to the development of sustainable maternity models. This issue has relevance in an increasing number of settings in Australia and other high resource countries in which services that address healthy start to life are critical to reduce current maternal newborn health inequity, and to meet the needs and expectations of women and their families.


The effective utilization of slag fertilizer in agriculture to neutralize soil acidity, improve crop productivity, mitigate greenhouse gas emissions, and stabilize heavy metals in contaminated soils turns it into a high value added product in sustainable agriculture. These effects could be due to the shift in microbial metabolism and/or modification of microbial habitats. At the system level, soil microorganisms play an integral role in virtually all ecosystem processes. There is a growing interest to reveal the underlying mechanisms of slag-microbe interactions and the contribution of soil biota to ecosystem functioning. In this perspective, we discuss the possible driving mechanisms of slag-microbe interactions in soil and how these slag-microbe interactions can affect crop yield, greenhouse gas emissions, soil carbon sequestration, and heavy metal stabilization in contaminated soils. In addition, we discuss the problems and environmental concerns in using slag in agriculture. Emphasis has been given for further research to validate the proposed mechanisms associated with slag-microbe interactions for increasing soil quality, crop productivity, and mitigating environmental consequences. While evaluating the slag amendment, effects on agriculture and environment, the potential risks, socio-economics, techno-economics, and ethics should be assessed. Over the past decades, with the rapid growth of industrialization, the higher volume of byproducts (slag) generated from iron/steel production draw attention to the need for its recycling in an increasingly efficient way. With the increase in population, the available land to dispose of large amounts of slag in landfill sites is reduced and the disposal cost is becoming increasingly higher. Moreover, the land filled with disposed slag has become an important source of pollution of air, water, and soil, which further adversely affects vegetation and human health . The entsilicon, sulfur, phosphorus, and aluminum, and products formed in their reactions with furnace linings and fluxing substances such as limestone (2), phosphoric acid (P2O5), magnesia (MgO), Mn, and Fe, these properties of the slag can be exploited to make use of fertilizer , which modify soil properties and soil microbial habitats. With advances in omic techniques, soil microbial communities and community-level molecular characteristics have been exploited as early indicators of ecosystem processes for sustainable soil management and agricultural productivity . In receper se, but also enriches soil microorganisms that have a beneficial role in nutrient mobilization . Identification and elucidation of functional roles of keystone soil microbes that sustain plant health and productivity under slag fertilization could provide a technological breakthrough for a sustainable use of slag in agricultural productivity.Among fertilizers made from slag, the use of silicate fertilizer, particularly in rice cropping systems has been gaining awareness and demand . Rice is4) and nitrous oxide (N2O), which are two of the most important greenhouse gases responsible for global warming  with biochar (8 Mg ha−1) reduced CH4 emission up to 38.6% in early rice in China; however, 4 emissions in green manure amended paddy soils probably due to the enhanced decomposition of added organic matter by the silicate liming effect. Elucidation of methanogen and methanotroph diversity and their functional changes in response to slag fertilizer amendment will improve our mechanistic understanding of CH4 dynamics in relation to slag fertilization.Agriculture significantly contributes to the emission of methane  Si fertilization acting to lower soil C decomposition, which would alleviate immobilization of fertilizer N thereby making more mineral N available to nitrification and denitrification; and (2) Si fertilization improving soil pH and Eh, which are two factors important to N2O emissions  occurs spontaneously on geological time scales and has a high potential for CO2 sequestration . Mineral carbonation reactions require combining CO2 with metals to form stable carbonate minerals. With few exceptions, the required metals are divalent cations, including Ca2+, Mg2+, and Fe2+, and the most abundant cation source are silicate minerals. Although mineral carbonation is thermodynamically favorable, it proceeds very slowly (2 emissions. It is well recognized that the enzyme carbonic anhydrase (CA) participates in silicate weathering and carbonate formation and thus plays an important role in the biomemetic CO2 sequestration  bioavailability in contaminated soil. The technique is based on amendments to change the soil physicochemical properties through adsorption, precipitation, ion-exchange techniques, redox potential technology, and pH control technology that change the existing forms and speciation of heavy metals/metalloids and thus, reduce their toxicity . There a2, repeated application of slag may make the soil excessively alkaline, which may decrease the bioavailability and uptake of macronutrients such as P and micronutrients such as Fe, Cu, and Zn by the plant and likely hinder plant growth and productivity  will no doubt be imperative to uncover the hidden dimensions of slag-microbe interactions in ecosystem functioning.SD wrote the manuscript. All authors contributed to the intellectual input and provided assistance to the manuscript preparation.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Waterlogging remains a significant constraint to cereal production across the globe in areas with high rainfall and/or poor drainage. Improving tolerance of plants to waterlogging is the most economical way of tackling the problem. However, under severe waterlogging combined agronomic, engineering and genetic solutions will be more effective. A wide range of agronomic and engineering solutions are currently being used by grain growers to reduce losses from waterlogging. In this scoping study, we reviewed the effects of waterlogging on plant growth, and advantages and disadvantages of various agronomic and engineering solutions which are used to mitigate waterlogging damage. Further research should be focused on: cost/benefit analyses of different drainage strategies; understanding the mechanisms of nutrient loss during waterlogging and quantifying the benefits of nutrient application; increasing soil profile de-watering through soil improvement and agronomic strategies; revealing specificity of the interaction between different management practices and environment as well as among management practices; and more importantly, combined genetic, agronomic and engineering strategies for varying environments. Waterlogging is one of the focal abiotic stresses, which affects crop growth . It has Waterlogging is also a matter of worldwide concern affecting 16% of the soils in the United States, 10% of the agricultural lands of Russia and irrigated crop production areas of India, Pakistan, Bangladesh, and China . GloballAppropriate soil and crop management practices improve soil quality and crop productivity, through improved ecological and economical flexibility by reducing the need for additional agricultural land . ImproveWaterlogging impedes the ability of soil to provide an optimum medium for plant growth and alters its physical, chemical, electro-chemical and biological characteristics as summarized in 2 deficiency and toxicity caused by excess CO2 or other gases such as ethylene and methane  is a management system to control extensive unsystematic trafficking by farm machinery/vehicles and protect soil structure from indiscriminate change . CTF Fi is a croRandom traffic farming or disorganized traffic causes increases in the soil bulk density resulting in increases in strength limiting soil porosity further leading to soil compaction . RTF hasThe advantages of CTF have been well documented. These include reduced incidence of waterlogging, soil compaction, erosion, tillage, water and nutrient losses and thus increased crop yield . AdoptioStrategic deep tillage (SDT) is a single or occasional practice with a deep ripper, rotary, spader, mouldboard plow or disk plow to help sustain the long-standing productivity of the no-till system . Deep tiDeep ripping loosens hard layers of soil by using sturdy tines to 35–50 cm depth. It is not suitable for all soils and crops, therefore season, timing, soil type, tine spacing, shallow leading tines, soil moisture content, and working depth are all factors that need to be taken into consideration. The benefit of combined CTF and SDT may last for three seasons but can be as long as ten seasons with average wheat yield increase in Western Australia being 0.6 t/ha and 0.5 t/ha at 12 sites and 16 sites, respectively . SchneidThere are, however, several disadvantages of deep ripping including its short-term nature , effectiveness in hostile sub-soils, such as acidity, sodicity or subsoil salinity, and its implementation on a large scale . In thisAnother way of reducing waterlogging is through a similar practice where large volume of organic matter with high N levels are placed within and above the heavy clay layers. This practice is referred to as sub-soil manuring . In soutThe increase in water extraction by roots also provides a greater buffer for subsequent waterlogging events. However, adoption on a commercial scale has remained low due to a combination of high upfront costs (up to $1200/ha) to implement, variable yield responses and logistical constraints such as the limited availability of suitable organic matter sources and access to appropriate machinery .Land drainage is one of the main approaches to improve yields per unit of accessible agricultural area . ReducinDrainage is used to alleviate waterlogging not only in some parts of Australia , but alsSurface drainage is defined as the safe removal of excess water through constructed channels from the land surface . SurfaceThe use of raised beds  is an imWhen seasonal conditions are appropriate, raised beds can significantly increase grain yield under waterlogged conditions compared with crops grown conventionally on flat ground . In AustWhile raised beds have had a positive impact on alleviating the effects of waterlogging they also have a number of disadvantages. These include the cost of adapting and modifying machinery, greater difficulty in controlling sowing depth and seed placement on beds, management of drainage water, limited use where the water table is too high, stubble handling and fodder conservation, firefighting and mustering livestock, the possibility of pesticide contamination into waterways and leaching into the water table and inefficiencies of machinery and weed control in furrows . When raPoor subsurface water movement occurs due to the inability of water to move through soil as a result of heavy soil texture, compacted layers and naturally created or induced hard pans as well as water moving downhill from upper slopes or from springs, raising the water table . SubsurfSubsurface pipe drains are the main forms of subsurface drainage found in the HRZ of Australia . UsuallyAlthough, subsurface deep drains (depth > 1.75 m) are recommended in India , these dHorizontal subsurface  drainageBesides water table control, horizontal drainage controls soil salinity in the root zone of the soil by leaching out the concentrated and harmful salt solutions . This isVertical drainage (VD)  is used Glycine max) and wheat (Triticum aestivum) in Madhya Pradesh, India .Crop management options to increase crop water use and decrease the incidence of waterlogging include early sowing and higher sowing rates . Early sEarly crop vigor can be another important trait for waterlogging tolerance in the field . TilleriMelilotus siculus) adapted to waterlogging and inundation into cropping systems has been suggested to reduce waterlogging  concentration in the rhizosphere, to enable thermodynamically passive uptake  have been reported, most of them are focused around oxygen availability and largely ignore other constraints imposed by waterlogged soils.For improved mitigation strategies, further research should be focused on the following aspects:-Comparison of the cost/benefit analyses of different drainage strategies;-Understanding the mechanisms of nutrient loss during waterlogging and quantifying the benefits of nutrient application;-Increasing soil profile de-watering through soil improvement and agronomic strategies;-Increased specificity of the interaction between different management practices and environment  as well as among management practices.-Discovering new (non-oxygen-associated) QTLs; the effectiveness of these mechanisms/QTL (and combined) on improving waterlogging tolerance in paddocks with soils with multiple constraints; the effect of these QTL on other agronomic, yield and quality traits, as well as management packages for varieties with diverse waterlogging tolerance genes.SM and GP prepared the draft. GD supervised the project. GP, GD, BF, SS, and MZ reviewed and revised the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Positive associations exist between physical activity, cognition, and academic performance in children and adolescents. Further research is required to examine which factors underpin the relationships between physical activity and academic performance. This systematic review aimed to identify, critically appraise, and synthesize findings of studies examining relationships between motor proficiency and academic performance in mathematics and reading in typically developing school-aged children and adolescents. A systematic search of electronic databases was performed to identify relevant studies. Fifty-five eligible articles were critically appraised and key data was extracted and synthesized. Findings support associations between several components of motor proficiency and academic performance in mathematics and reading. There was evidence that fine motor proficiency was significantly and positively associated with academic performance in mathematics and reading, particularly during the early years of school. Significant positive associations were also evident between academic performance and components of gross motor proficiency, specifically speed and agility, upper-limb coordination, and total gross motor scores. Preliminary evidence from a small number of experimental studies suggests motor skill interventions in primary school settings may have a positive impact on academic performance in mathematics and/or reading. Future research should include more robust study designs to explore more extensively the impact of motor skill interventions on academic performance. Early childhood curriculum and pedagogical approaches aim to promote holistic attitudes to teaching and learning which recognise the important contribution a child’s physical, cognitive, social, and emotional development has on their learning and readiness to start school . HoweverThe importance of PA is widely recognized, with regular and adequate levels of PA leading to improvements in muscular and cardiorespiratory fitness (CRF) and bone health, along with a reduction in levels of cardiovascular disease, cancer, and diabetes ,5. FurthThe majority of studies investigating the impact of PA on cognition and academic performance in school-aged children have measured either overall levels of PA  protocol . Firstly(1)The study population had to include typically developing school children aged between four and 18 years.(2)For observational studies, at least one component of motor proficiency had to have been objectively measured and reported. Motor proficiency, as described by Bruininks , incorpo(3)For observational studies, associations between an objective measure of fine or gross motor proficiency AND an objective measure of academic performance  had to have been reported. Appropriate statistical analyses for reporting associations included correlations and regression or structural equation modelling. For experimental studies, the pre-test and post-test values of motor proficiency and academic outcomes in mathematics and reading for both control and experimental groups or a measure of treatment effect on academic performance needed to be reported.(4)Studies had to be either observational or experimental in design.(5)Studies had to have been published after January 2000, due to the methodological limitations in studies published prior to 2000 previously described ,19.Following removal of duplicates, the titles and abstracts of the remaining studies identified in the database searches were screened with reference to pre-determined inclusion and exclusion criteria to assess their potential eligibility for inclusion in this review. Studies in which the abstract clearly indicated the study would be ineligible for inclusion in the review were eliminated, but studies for which any doubt regarding eligibility existed and those considered likely to be eligible were retained; full text copies of these studies were subsequently obtained. The full text copies of these remaining studies were then independently assessed for eligibility for inclusion in the review by one of the reviewers (K.M.), using the pre-determined inclusion and exclusion criteria described below. For inclusion in this review, studies were required to meet the following criteria:(1)Studies involving a population of school-aged children diagnosed with either an intellectual disability or a neurodevelopmental disorder , as defined by the Diagnostic and Statistical Manual of Mental Disorders (5th Edition) .(2)or motor proficiency-related interventions that were implemented outside school hours.For experimental studies, intervention(s) focused on health-related fitness  or general physical activity rather than an intervention specifically focused on motor proficiency (3)Studies reporting motor outcomes that included only an overall fitness score .(4)Studies reporting academic outcomes in terms of an overall academic performance score only  but not an individual score for mathematics and/or reading.(5)Studies published in a language other than English, where a translated version could not be sourced.Following application of these inclusion criteria, five exclusion criteria were applied in the study selection process, these being:Eligible studies were retained and included in the review and were subject to subsequent quality assessment, data extraction, and synthesis. Reference lists of all eligible articles were also reviewed, and potentially eligible studies not previously identified were sourced in full text and subjected to the same selection process.Two authors  independently assessed the methodological quality of included studies using the Downs and Black checklist . The cheTo address the first aim of the current review, which was to determine whether a relationship exists between motor proficiency and academic performance in mathematics and reading in typically developing school-aged children, the methodological quality of included observational studies was assessed. However, items 4, 8, 13, 14, 15, 19, 23, and 24 of the Downs and Black checklist  were notTo address the second aim of the review, to determine whether motor proficiency-related interventions impact academic performance in mathematics and reading in typically developing school-aged children and adolescents, the methodological quality of eligible experimental studies was assessed using all items of the Downs and Black checklist . To provTo determine the level of agreement between the critical appraisal scores derived by the two independent reviewers (K.M. and N.M.) when applying the modified Downs and Black checklist, a kappa coefficient was calculated by a third author (R.O.) and graded using methods previously reported by Viera and Garrett . FollowiKey data from each of the eligible studies was extracted by a single reviewer (K.M.) into a Microsoft Excel spreadsheet constructed to standardize the data extraction. Another reviewer (R.P.) checked the extracted data. The data elements included: (1) author and study design; (2) characteristics of the study sample; (3) the objective outcome measures used to assess fine or gross motor proficiency; (4) the objective outcome measures used to assess academic performance in mathematics and reading; (5) any covariates (confounding factors) included in analyses; (6) characteristics of the intervention (where relevant); and (7) summary of main findings from each study. The data elements that were extracted from observational studies are depicted in the headings of The first aim of the review was to examine the relationships between motor proficiency and academic performance in mathematics and reading, and thus associations between these variables in each included study (when reported) were extracted and considered in a critical narrative synthesis of key findings from the included studies. For the purposes of the synthesis, motor proficiency, as described by Bruininks , was catDuring the synthesis of key findings, interpretation of the strengths of the correlations (r) between the different areas of motor proficiency and academic performance in mathematics and reading was guided by a rating scale described by Evans  as folloTo address the second aim of the review, a critical narrative synthesis was also undertaken to synthesize the key findings from the included experimental studies that investigated whether motor proficiency-related interventions impacted academic performance in typically developing school-aged children and adolescents. Given the heterogeneity between studies in their design, outcome measures and study quality, a meta-analysis was not conducted.The PRISMA diagram  in FigurAs noted in The critical appraisal percentage (CAP) for each of the studies is shown in The mean (±SD) methodological quality score of the four experimental studies included in the review was 14 (±5.35) out of a possible 28 points, equating to a CAP of 50% (±19.12), with a CAP range of 25–71% . One  of the observational studies  from the present review investigated the relationship between fine motor proficiency and academic performance in mathematics. Most studies (86%) examining these variables reported findings from participants in pre-kindergarten to year 2, with only three (11%) studies ,44,45 re% of the A total of five studies ,55,56,66When taking into consideration all studies that examined associations between fine motor integration  and mathematics performance variables , 15 of tp < 0.05).The relationship between manual dexterity and academic performance in mathematics was examined by nine studies ,62,66,68Two other studies ,45 conduA total of nine studies ,67,70,72A total of 24 47%) observational studies  from the review investigated the relationship between gross motor proficiency and academic performance in mathematics. A summary of the data extracted from these studies can be found in % observap < 0.05) found between a dribbling task assessed in grade 7 and maths for boys only, with no significant associations found between these variables for girls. Overall, despite inconsistent findings, summary coding suggests there was sufficient evidence to support a significant very weak to moderate positive association between upper limb coordination and mathematical skills  between a finger-to-nose test and a standardized mathematics test. However, a study by Van Niekerk [p < 0.05) found between a task involving tapping feet and fingers and teacher-reported maths results for boys and girls, but no significant association found between a jumping-in-place task (same sides synchronized) and teacher-reported maths results. Overall, summary coding suggests the level of evidence to support a significant relationship between bilateral coordination and mathematics was uncertain, due to a limited number of studies examining these variables  observational studies  from the present review investigated the relationship between fine motor proficiency and academic performance in reading. A summary of the data extracted from these studies can be found in % observaA total of four studies ,55,66,86The relationship between fine motor integration skills and academic performance in reading was examined most often, with 17 ,86,87,88A total of seven ,68,82,86Finally, all six studies ,59,67,86A total of 21 41%) studies  from the present review investigated the relationship between gross motor proficiency and academic performance in reading. A summary of the data extracted from these studies can be found in % studiesp < 0.05) were found between a dribbling task and marks in Finnish language for girls in grade 7 but not for boys. Overall, despite some inconsistencies in findings, summary coding suggests there was a strong level of evidence to support a significant weak positive association between upper limb coordination and reading performance . Another study [Only two studies ,75 categer study  found thAssociations between speed and agility and reading performance were examined by six studies ,75,76,89p < 0.01) was found between distance measured on the standing broad jump and scores on a standardized reading test; however, no significant association was found between the number of sit-ups performed and the same standardized reading test. Overall, summary coding suggests the level of evidence to support a significant association between strength and reading performance was uncertain, due to a limited number of studies examining these variables  between total motor proficiency and academic achievement in reading; however, a structural equation modelling analysis found that the mechanism appeared to be through an indirect path, via cognitive ability. Another study [Finally, four studies ,61,80,84A total of four experimental studies ,90,91,92The interventions described in each study were delivered in the primary school setting, with participants in the early year levels of schools (pre-kindergarten to Year 2). Interventions ranged in duration from 6 weeks  to 3 yeap < 0.012, Cohen’s effect size d = 1.13). However, improvements in the number concept subtest were not significantly better than the control group following the intervention (controlling for differences in pre-test scores) [All four experimental studies ,90,91,92 scores) .Each of the four experimental studies in the review incorporated gross motor skills into their interventions to examine their effect on academic performance ,90,91,92In summary, a limited number of experimental studies with varied study designs, intervention parameters, and methodological quality have examined whether motor proficiency-related interventions impact academic performance in mathematics and reading. However, there were findings of a statistically significant effect of the motor skill interventions on academic performance that warrants further investigation.The overall objective of this systematic review was to identify, critically appraise, and synthesize the findings of studies examining the relationship between motor proficiency and academic performance in mathematics and reading in typically developing school-aged children and adolescents.To address the first aim of the review, 51 observational studies were examined to determine whether there was evidence for significant associations between components of motor proficiency and academic performance in mathematics and reading. In summary, based on the findings from observational studies, of which 74% were classified as having fair to good methodological quality, there was sufficient evidence to support significant very weak to strong positive associations between all components of fine motor proficiency and academic performance in mathematics. Although fewer studies in the review examined the relationship between the components of gross motor proficiency and academic performance in mathematics, sufficient evidence also emerged to support significant very weak to weak positive associations between gross motor proficiency  and academic performance in mathematics. There was also sufficient evidence to support no significant association between balance and mathematics performance. A similar trend of significant associations was evident in studies examining the relationship between motor proficiency and academic performance in reading, although there were more inconsistencies reported between studies. Overall, there was evidence to support a significant very weak to strong relationship between fine motor proficiency  and academic performance in reading. There was also sufficient evidence to support a significant very weak to weak positive association between academic performance in reading and upper limb coordination, as well as total gross motor scores.To address the second aim of the review, the findings from four experimental studies were synthesized to determine whether motor proficiency-related interventions impact academic performance in mathematics and/or reading in typically developing school-aged children and adolescents. Based on the findings from one cluster randomized controlled trial and three quasi-experimental studies, there was evidence for a statistically significant effect of the motor skill intervention on academic performance compared to the control group in each study for students in the early years of school (pre-kindergarten to year 2). However, several methodological limitations relating to the external and internal validity (bias and confounding) of studies were apparent; thus, it is difficult to infer the exact underlying mechanisms for the effects of the interventions, and results should be interpreted with caution.There was consistency in findings among studies included in the review that a relationship exists between motor proficiency and academic performance in mathematics and reading; however, this association differed between the components of fine and gross motor proficiency. There was evidence from observational studies for significant positive associations between the majority of components of fine motor proficiency and academic performance in mathematics and reading. This was with the exception of the components of fine motor precision and manual dexterity and their associations with reading performance as there was either an insufficient number of studies in the review examining these variables or inconsistent evidence.Differences in associations between motor proficiency and academic variables for children and adolescents were also apparent, consistent with those reported by van der Fels et al. . InteresIt is worth noting that many studies examining the relationship between fine motor proficiency and academic performance in mathematics and reading in the present review conducted statistical analyses that accounted for other covariates, in addition to correlational analyses. For example, regression analyses accounting for key cognitive confounders  were performed in several studies investigating the relationship between fine motor proficiency and mathematics and found that fine motor integration remained independently predictive of academic performance in mathematics. However, when examining the relationship between fine motor proficiency and reading performance, it was often reported that in the presence of other predictors , fine motor integration and manual dexterity did not uniquely contribute to reading performance ,62,83,85The relationships between the components of gross motor proficiency and academic performance in mathematics and reading have been investigated less frequently in the literature. For example, four or less studies in the review investigated associations between academic performance in mathematics and reading and the components bilateral coordination and strength, along with total motor proficiency scores. Consequently, the evidence to support associations between these variables was uncertain, despite several significant positive associations reported by the studies examining them. There was sufficient evidence to suggest there was no association between balance and academic performance in mathematics, with similar trends reported for reading, though this was based on findings from a limited number of studies. However, there was sufficient evidence to support a significant very weak to weak positive association between academic performance in mathematics and reading and upper limb coordination, with promising findings also found for speed and agility. Interestingly, these relationships were assessed in several studies involving high school participants. This warrants further investigation to determine whether more complex gross motor skill training may impact the academic performance of students in both primary and high school.Several findings from the present review appear to be consistent with those reported in the systematic review by van der Fels et al.  in that Collectively, the findings from the four experimental studies included in the review provide results of a statistically significant effect of motor skill interventions on the mathematics and reading performance of children, particularly in the early years of school. These results add to the growing body of literature investigating the impact of classroom-based PA on the educational outcomes of school students. However, to date, studies on this topic have generally been unable to consistently provide sufficient detail regarding whether the type of PA used in classroom-based interventions involves aerobic, motor, or strength-based activities, or a combination of all types of PA . This inThe interventions outlined in the studies by Beck et al.  and CallClassroom-based PA can also involve incorporating PA into the regular school day routine, without an academic focus. In the present review, the intervention described in the study by Erasmus et al.  involvedThe intervention outlined in the study by Ericsson  in the pCollectively the authors from reviews on this topic ,13,23,24The present review had several key strengths. Firstly, this review systematically synthesized the findings of 55 peer-reviewed studies including a large sample of typically developing school-aged participants from over 20 different countries. Secondly, to minimize reporting bias, a comprehensive search of health and education databases was conducted in accordance with the PRISMA guidelines , followeHowever, it is important to acknowledge there were also several key limitations in this review. Firstly, a limited number of experimental studies with robust study designs  were eligible for inclusion in the present review, with findings synthesized from predominantly cross-sectional, longitudinal studies and quasi-experimental designs. Secondly, there was considerable heterogeneity of the outcome measures used between studies to assess motor proficiency and academic performance in mathematics and reading, making it difficult to clearly compare and interpret the findings across studies.The approach used to classify different motor skills measured by studies into components of motor proficiency may also be a potential limitation in the current review. For example, it was the authors’ discretion to determine the most appropriate category of motor proficiency for each motor skill measured, based on Bruininks’ definitions of motor proficiency subtests . AdditioThe search strategy in this review was limited to including studies specifically examining associations between motor proficiency and academic performance in mathematics and reading. However, it was evident that numerous covariates may also impact the findings reported in studies when examining typically developing school-aged children and adolescents. These covariates included demographic factors , cognitive factors , and physical factors . Although the covariates reported by each eligible study were extracted and recorded, their potential contribution to the overall findings were not discussed in detail as this was beyond the scope of the review.There was variation in the parameters for the motor skill interventions reported among the four experimental studies included in the review; thus, factors such as type and intensity of motor skill training, along with the duration and frequency of lessons per week, differed in each study, making it difficult to determine the most effective dose. Given the strict inclusion/exclusion criteria for the present review, several experimental studies reporting motor skill interventions were ineligible for inclusion in the review. These studies were ineligible as they did not report findings for academic performance in mathematics or reading separately, often combining scores of multiple academic areas to provide an overall academic achievement score ,96. OtheThis systematic review adds considerably to the rapidly expanding body of literature examining associations between PA, fitness, cognition, and academic performance. The present review found evidence to support significant positive associations between several components of motor proficiency and measures of academic performance in mathematics and reading. There was evidence that all components of fine motor proficiency were significantly and positively associated with academic performance in mathematics, particularly during the early years of school. Similar evidence was found to support a significant positive relationship between fine motor proficiency  and academic performance in reading. There was also evidence for significant positive associations between academic performance in mathematics and reading and components of gross motor proficiency, specifically upper limb coordination and speed and agility, along with overall gross motor proficiency scores. There was also evidence that balance was not significantly associated with academic performance in mathematics and reading. However, there was either inconsistent or insufficient evidence to support associations between the other components of gross motor proficiency along with total motor proficiency scores and academic performance. Finally, there was some preliminary evidence from a small number of experimental studies that the implementation of motor skill interventions in the school setting may have a positive impact on academic performance in mathematics and/or reading; however, further research is needed to confirm this possibility. Due to the varying levels of methodological quality found in the studies included in the review, further investigation is warranted, using more robust study designs to explore further the impact of motor skill interventions on academic performance.To allow more accurate comparisons of findings between studies in the future, researchers should consider consistently using valid and reliable, standardized instruments to assess both fine and gross motor proficiency and academic performance variables. Furthermore, to better understand and explain the underlying mechanisms of the associations between motor proficiency and academic performance, studies should be designed to provide adequate evidence of causality through robust experimental designs that compare the effects of both health-related and performance-related physical fitness (motor proficiency) interventions on the academic performance of school students. Ideally, study designs will also aim to control for known demographic, cognitive, and physical confounders. Future findings from experimental studies may then be able to ascertain whether motor skill training, aerobic fitness, or a combination of both impact cognitive and academic outcomes. Finally, given that students with neurodevelopmental disorders attend mainstream schools, future research should also examine relationships between motor, cognitive, and academic skills in this population to inform potential intervention pathways.Findings from future high-quality experimental studies aimed at enhancing the PA levels, physical fitness, and academic performance of school students may inform school wellbeing policies and pedagogical approaches to teaching and learning, particularly during the early years of school. This topic is relevant to both education and paediatric health professionals  through their role in the early identification of children experiencing difficulty with motor skills, as this may also impact their academic performance. Furthermore, given that gross motor skills may be linked to academic performance in high school, school policy makers should consider prioritizing, from school entry, students’ acquisition of motor skills.


Historically in Thailand, access to poison antidotes was limited and antivenom stock management was inefficient.In 2010, the country established a national antidote programme, which created national and subnational antidote stocks, managed their distribution and trained health-care providers on clinical management and antidote use. In 2013, the programme incorporated antivenoms to improve stock management and avoid wastage due to stock expiry.Before the programme, health-care providers consulted poison centres on clinical management of poisoning and some antidotes were not available. Individual hospitals stocked antivenoms, which often expired before use.Today, the National Health Security Office finances and manages the centralized procurement of antidotes and antivenoms and all Thai patients have a right to antidotes regardless of health insurance. National and subnational stock levels are determined based on demand, treatment urgency and cost. A web-based system, which incorporates geographical information, was introduced for requesting antidotes and antivenoms. Poison centres provide training, 24-hour consultation services and outcome monitoring. Antidotes and antivenoms are now readily available and used correctly and clinical management has improved. Moreover, better stock and distribution control has helped avoid antivenom wastage and reduced antivenom costs, from US$ 2.23 million United States dollars (US$) to US$ 1.2 million.The programme’s success depended on strong and sustained policy support, adequate funding, improved operational capacity, training for health-care professionals and the provision of 24-hour online consultation services. A web-based centralized procurement and distribution ensured these essential medicines were available, minimized costs, reduced waste and saved lives. Consequently, the pharmaceutical industry has little incentive to develop and market these medicines, even though they are used for life-threatening conditions. Moreover, antidotes are expensive and have a short shelf life, which discourages individual hospitals from keeping large stocks. The World Health Organization (WHO) recommends establishing a central bank of antidotes as an effective and efficient way of ensuring prompt access to these drugs, thereby saving lives.,In 2002, the National Health Security Office in Thailand set up a special system to improve access to high-cost medicines.In 2010, the National Health Security Board established a national antidote programme to ensure equitable access to antidotes for the whole population, not only members of the Universal Health Coverage Scheme. The programme made extensive use of information and communications technology, not only to support procurement and supply chain management, but also for teleconsultations, which enabled frontline health professionals, particularly those in remote areas, to get advice on the proper use of antidotes and on clinical management.Under the programme, national and subnational stocks of antidotes were established as hubs for supplies. The hubs content is based on three criteria: (i) demand in the local area; (ii) whether an antidote had to be provided urgently; and (iii) cost. Today hospitals request antidotes through a web-based system with a high level of data integrity and security. This system includes data on real-time inventories at all hubs and on expiry dates. The distribution of antidotes to hospitals that request them is managed by the stocking centres and responsibility for replenishing stocks has been outsourced by the Government Pharmaceutical Organization to the private sector. The programme is also involved in training health-care providers on the appropriate use of antidotes: manuals and clinical guidelines have been circulated and in-service training is organized annually .Box 1Continued political support ensured that the National Health Security Office received full funding for antidotes and antivenoms for the whole population, thereby protecting against financial risks and saving lives.Antidotes and antivenoms were stocked nationally and subnationally, as guided by epidemiological evidence.Procurement and supply chain management became more efficient: antidotes and antivenoms were provided rapidly following web-based requests and delivered through vendor-managed inventory systems.Efficient procurement and management of antivenoms resulted in substantial cost savings compared with the previous system in which individual hospitals purchased and stocked antivenoms, with the danger of stock expiring.Staff capacity was increased through: (i) the circulation of manuals and guidelines; (ii) annual in-service training for health-care professionals; (iii) the establishment of a 24-hour, online, real-time, clinical consultation service to support case management remotely; and (iv) outcome monitoring.The programme involves close collaboration between several agencies: (i) the National Health Security Office allocates the annual budget and steers and monitors the programme; (ii) the Queen Saovabha Memorial Institute produces antivenom and some antidotes; (iii) the Government Pharmaceutical Organization is responsible for procurement and for managing the supply chain; (iv) the Thai Food and Drug Administration registers medical products; (v) the Thai Society of Clinical Toxicology provides clinical expertise and training; (vi) poison centres at Siriraj and Ramathibodi Hospitals provide clinical consultations; and (vii) the Ramathibodi Poison Center is responsible for monitoring treatment outcomes.Initially, six antidotes were selected using epidemiological data from the Ramathibodi Poison Center: sodium nitrite, sodium thiosulfate, methylene blue, dimercaprol, succimer and glucagon. Succimer, dimercaprol and glucagon were procured from abroad by the Government Pharmaceutical Organization. Methylene blue, sodium nitrite and sodium thiosulfate were mainly manufactured by the Queen Saovabha Memorial Institute at a price per vial 30 times lower than imported equivalents.Antidotes were divided into four categories: (i) critical antidotes, which must be administered in less than 1 hour; (ii) emergency antidotes, to be administered within 1 to 6 hours; (iii) urgent antidotes, to be administered within 6 to 24 hours; and (iv) non-urgent antidotes. In 2018, botulinum antitoxin was held at the Ramathibodi Poison Center only as demand was small and the antidote is very expensive (i.e. up to US$ 12 500 per treatment course). Whereas cyanide antidotes were held in subnational stocks since demand was homogenous throughout the country and dimercaprol was held at only a few subnational centres because demand was low and patients were treated in well-equipped hospitals.Before the programme, individual hospitals procured and stocked snake antivenom themselves without adequate data on poisonous snakes in their localities. Consequently, supply exceeded demand and antivenom was wasted. In response, antivenom was integrated into the programme in 2013 and subnational stocks were adjusted in accordance with local epidemiological data on snake bite cases. This improved the efficiency of stock management and minimized waste. The Queen Saovabha Memorial Institute plays a principal role in producing antivenoms.General and regional hospitals were invited to serve as subnational centres for stocks of antidotes and antivenoms. In addition, these drugs were included in the national list of essential medicines, which means they are covered by all three public health insurance schemes and their cost is incorporated into annual budgets. As clinical management is as important as the availability of antidotes, annual training for health-care professionals on the use of antidotes was initiated and guidelines on antidote use were distributed. Importantly, poison centres were made responsible for supervising treatment with antidotes and for monitoring clinical outcomes. The operation of the programme is continually being improved with the help of evaluations and reviews. Currently, the programme covers nine antidotes and seven antivenoms.Since the programme was implemented in 2011, there has been no shortage of any antidote or antivenom covered. Previously, almost no antidotes were available and deaths occurred. Between 2011 and 2017, 1800 patients who were poisoned benefited from the programme. In addition, 25 636 patients exposed to snake venom had access to the appropriate antivenom and lives were saved. Adjusting the subnational stocking and distribution of antivenom to match the local prevalence of snakebite cases resulted in more efficient stock management and reduced costs: the average annual procurement budget for antivenom decreased from US$ 2.23 million in 2012 when all hospitals purchased their own antivenom to US$ 1.2 million between 2013 and 2017, a 46% cost saving despite relatively constant demand . The effThe programme ensured timely access to essential antidotes and antivenoms, which saved lives even though the production and supply of these orphan drugs were limited and there were few clinical toxicologists in the country. Three factors contributed to the programme’s success .Box 2Strong and sustained policy support and full funding from the national budget ensured adequate supplies of essential antidotes and antivenoms.Improvements in operational capacity, which included central procurement, national and subnational antidote and antivenom stocks, and distribution aided by information and communication technologies, ensured these medicines were rapidly available for patients and minimized waste due to expired products.In-service training and 24-hour online consultations provided by poison centres improved clinical management and helped ensure antidotes and antivenoms were used correctly.First, government policy was strong and sustained across different administrations, annual national budgets allocated full funding to the National Health Security Office for antidotes and antivenoms, which ensured an adequate supply of these essential medicines.Second, the availability of antidotes and antivenoms was improved operationally by: (i) the use of central procurement; (ii) direct delivery from suppliers to national and subnational stocks; (iii) the creation of a management information system that included the number of doses available and their expiry dates; (iv) use of a web-based system to deal with requests from hospitals; and (v) timely delivery from stocks. These factors combined to ensure the timely use of antidotes and antivenoms and saved lives, even in very remote areas. In addition, the programme discouraged individual hospitals from purchasing and stocking these medicines, thereby decreasing wastage and substantially reducing costs.Third, the manuals and clinical guidelines produced by poison centres and the annual training provided for clinicians improved case management and confidence in the use of antidotes and antivenoms. In addition, these centres provided 24-hour online consultation services to support case management remotely; therefore clinical toxicologists at the centres could observe patients’ clinical symptoms in real time.


Globally, low back pain (LBP) is one of the greatest causes of disability. In people with LBP, dysfunction of muscles such as the gluteus medius have been demonstrated to increase spinal loading and reduce spinal stability. Differences in gluteus medius function have been reported in those with LBP compared to those without, although this has only been reported in individual studies. The aim of this systematic review was to determine if adults with a history, or current LBP, demonstrate differences in measures of gluteus medius function when compared to adults without LBP.MEDLINE, EMBASE, AMED, PsycINFO, PubMED, Pro Quest Database, CINAHL and SPORTDiscus were searched from inception until December 2018 for published journal articles and conference abstracts. No language restrictions were applied. Only case-control studies with participants 18 years and over were included. Participants could have had any type and duration of LBP. Studies could have assessed gluteus medius function with any quantifiable clinical assessment or measurement tool, with the participant non-weight bearing or weight bearing, and during static or dynamic activity. Quality appraisal and data extraction were independently performed by two authors.The 24 included articles involved 1088 participants with LBP and 998 without LBP. The gluteus medius muscle in participants with LBP tended to demonstrate reduced strength and more trigger points compared to the gluteus medius muscle of those without LBP. The level of activity, fatigability, time to activate, time to peak activation, cross sectional area, and muscle thickness showed unclear results. Meta-analysis was not performed due to the heterogeneity of included studies.Clinically, the findings from this systematic review should be considered when assessing and managing patients with LBP. Future studies that clearly define the type and duration of LBP, and prospectively assess gluteus medius muscle function in those with and without LBP are needed.CRD42017076773).PROSPERO ( Low back pain (LBP) has been identified as the leading contributor of disability and was ranked sixth largest contributor to the burden of global disease, costing individuals and governments billions of dollars in both direct and indirect costs annually . The preDysfunction of muscles of the lumbopelvic-hip complex is a hallmark of LBP . At the The gluteus medius is one of the main pelvic stabiliser muscles and plays a significant role in controlling transverse and frontal plane motion of the femur and hip , providiIndividual studies have found differences in the activation, strength, and number of trigger points in the gluteus medius muscle between those with and without LBP , 16–18. This systematic review aims to determine, by review of case-control studies, if adults with a history of, or current LBP, demonstrate differences in measures of gluteus medius function when compared to adults without LBP. A secondary aim is to investigate if there is a difference in gluteus medius muscle function between types and durations of LBP.This systematic review was registered with PROSPERO CRD42017076773) and has been reported in accordance with the PRISMA statement . MEDLINE7076773 aCase-control studies including participants 18 years and older with LBP of any type (specific or non-specific) and of any duration  were eligible for inclusion. Studies measuring gluteus medius function in any way, for example, strength, flexibility, fatigability, percentage of maximum voluntary contraction, cross-sectional area, timing or extent of contraction, or other unidentified measurement were eligible for inclusion. Studies could assess gluteus medius with any quantifiable clinical assessment or measurement tool, with the participant non-weight bearing or weight bearing, and during static or dynamic activity.Studies were excluded if they included participants that were pregnant, had a history of low back surgery, or were solely investigating the effect of an intervention on the gluteus medius muscle.One reviewer conducted the electronic searches (SS). Two reviewers (SC/SS) independently screened citations at title and abstract level. One reviewer (SS) retrieved potentially eligible full text articles and these were assessed independently by two reviewers (SC and SS). Authors were contacted where clarification was required for assessing eligibility for inclusion. There were no disagreements so there was no need to seek arbitration by a third reviewer (VC). Data were independently extracted by two reviewers (SC and BP), using a standardised data extraction form, and cross checked by a third reviewer (SS). For the purposes of study classification we defined duration of back pain as: Acute (< 6 weeks), subacute (6- < 12 weeks), and chronic (≥12 weeks) . Due to Two reviewers (SC/BP) independently appraised eligible full text articles using the CASP tool for case-control studies. The results of quality appraisal were checked by a third reviewer (SS) and no disagreements occurred.Searches retrieved 1942 citations of which 94 were eligible for full text review. After review, 24 full text articles of mixed methodological quality , indicating reduced gluteus medius muscle strength.Two studies , 23 measOne study  measuredp < .001).Four studies , 35, 36 p = .025).One study  used ultThe other two studies investigated the cross sectional muscle area of the gluteus medius muscle using magnetic resonance imaging , 37 Tab. Both stThis systematic review included 24 case-control studies investigating gluteus medius function in people with and without LBP. The findings for gluteus medius muscle activity , 34, 38,The majority (9 out of 11) of studies using EMG to assess gluteus medius muscle function did so in either non-weight bearing , 30, 34 The reduction in gluteus medius strength reported by the majority of studies is consistent with previously reported theoretical links between biomechanical dysfunction of the lumbopelvic-hip complex and lower limb, and the development of LBP . During The consistent finding of increased numbers of active gluteus medius trigger points, as well as latent trigger points, in those with LBP , 27, 36 The secondary aim of this review was to investigate differences in gluteus medius function between types and durations of LBP. However, this was hampered by inconsistent definitions of LBP and the lack of detail of LBP type and duration reported in studies. Further differences between studies, such as the method for diagnosing LBP, the tool used to assess the severity of LBP, assessment techniques, and whether or not LBP participants had pain present at the time of assessment Table  are addiThis review was designed to be robust and comprehensive however it is possible that not all studies were identified. The likelihood of this occurring was reduced by a robust search strategy and independent title and abstract screening by two researchers. The generalisability of the review’s findings also needs to be considered. Only studies that measured gluteus medius function in participants over the age of 18 were included. This coupled with the small number of studies per measurement outcome, differences in study methodology and population, and the unclear or inconsistent definitions of the type and duration of LBP has precluded more sophisticated methods of analysis. These differences may, in part, explain some of the insignificant findings between cases and controls within studies and could also have diluted the findings of this review, perhaps explaining why our findings are unclear for some outcome measures. In addition, differing reliability of measures used may have affected the outcomes of the included studies. Although it was not the purpose of this review to determine measurement reliability, only ten of the included studies reported measurement reliability, with large variability between studies for the same measurement outcome –37, 39. In summary, we found that in those with LBP the gluteus medius muscle had reduced strength and more trigger points compared to those without LBP. Findings for the level of muscle activity, fatigability, time to onset, time to peak amplitude, cross sectional area, and muscle thickness were mixed. When interpreting these findings in context of the management of LBP patients, significant caution is recommended because the aim of this review was not to investigate intervention effectiveness. However, strengthening the gluteus medius muscle and eliminating trigger points may form an important part of the multidisciplinary management of LBP patients, although further research is needed before this can be confidently recommended. To help reduce inconsistencies in future research, the authors recommended following the standardised eligibility criteria outlined by Amundsen et al. . AdditioAdditional file 1. Key word search. Additional file 2. Quality appraisal. Additional file 3. Table of excluded full text articles.


Fluorescent carbon dots (CDs) including carbon quantum dots (CQDs) and graphene quantum dots (GQDs) have drawn great interest because of their low cost and low toxicity, and they represent a new class of carbon materials prepared by simple synthetic routes. In particular, the optical properties of CDs can be easily tuned by the surface passivation of the organic layer and functionalization of the CDs. Based on the advantages of these carbon materials, CQDs and GQDs have been applied in various fields as nanoplatforms for sensing, imaging, and delivery. In this review, we discuss several synthetic methods for preparing CQDs and GQDs, as well as their physical properties, and further discuss the progress in CD research with an emphasis on their application in heavy metal sensing. The discovery of fluorescent carbon dots (CDs), also known as carbon quantum dots (CQDs), has attracted tremendous interest from many researchers because of their versatile applications in optoelectronics, biomedical applications, and chemical biosensors –3. All n2+, Pb2+, and Cd2+, are detrimental to humans, even in trace amounts. These toxic metals are easily accumulated in the body and coordinate with biological components, such as enzymes and nucleic acids, hindering normal biological interactions and functions. In this respect, CDs are good candidate components for metal sensors because they are biocompatible. In addition, the fluorescence quantum yield of CDs can be enhanced by modifying the CD surface by adjusting the intrinsic components and surface groups .Fig.Fig2+ an2+ can be gradually recovered upon the concentration of l-ascorbic acid (AA)with a detection limit of 105 nM and this fluorescent “on-off-on” system can be practically used for the excellent detection to Cd2+ and AA in lake water and in human serum, respectively [Zhang et al. reported an efficient CQD-gold nanocluster (CQDs/AuNCs) nanohybrid prepared by a one-step hydrothermal treatment with alanine and histidine. The hybrid materials were used for ratiometric fluorescent probe for sensitive and selective sensing of CD (II) ions with a detection limit of 32.5 nM. Interestingly, the quenched fluorescence by Cdectively .Much research into carbon-based quantum dots has been reported in the last few decades, and a wide range of synthetic methods and characterization techniques have been used. In most cases, studies of these fluorescent materials have focused on their bioimaging applications. Although some heavy metals are essential in the human body, excess heavy metals cause disease, for example, Minamata disease and Itai-itai disease. Thus, recent progress in fluorescent CDs has opened the possibility of developing portable detectors for dangerous heavy metals, and we have outlined recent studies related to surface materials that will enable the development of heavy metal sensors as a portable device . Moreove