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Review authors face great challenges in demonstrating convincingly that the result of a Cochrane review of NRS can give anything close to a definitive answer about the likely effect of an intervention (Deeks 2003). In many situations, reviews of NRS are likely to conclude that calculating an ‘average’ effect is not helpful (Siegfried 2003), that evidence from NRS is inadequate to prove effectiveness or harm (Kwan 2004) and that randomized trials should be undertaken (Taggart 2001).


Challenges arise at all stages of conducting a review of NRS: deciding which study designs to include, searching for studies, assessing studies for potential bias, and deciding whether to pool results. A review author needs to satisfy the reader of the review that these challenges have been adequately addressed, or should discuss how and why they cannot be met. In this section, the challenges are illustrated with reference to issues raised in the different sections of this chapter. The Discussion section of the review should address the extent to which the challenges have been met.