Evidence Quality

Client-reported outcomes include improved sleep, stress handling, fewer triggers, reduced emotional reactivity, confidence, calmness, relaxation, and belief in oneself. No study in the meta-analysis reported allocation concealment. Substantial overlap among primary studies (corrected covered area of 28.9%) prevented quantitative pooling and required narrative synthesis. The primary reasons for downgrading evidence certainty were risk of bias, imprecision, and heterogeneity. Because all findings are based on low-certainty evidence with wide confidence intervals, the results do not support strong clinical guideline recommendations at this time. Publication bias could not be formally assessed because fewer than 10 studies contributed to any single outcome, and only visual funnel plot inspection was possible. All outcomes in this meta-analysis were rated as low certainty by the GRADE framework, meaning true effects may differ substantially from observed estimates. Evidence was downgraded primarily due to performance bias from lack of blinding, as only one of 18 studies was double-blind. Only six systematic reviews and meta-analyses met inclusion criteria, limiting the breadth of the u…