Realist synthesis in sport and exercise medicine: ‘Time to get real’ - Adam Gledhill - Dale Forsdyke

Sep 2, 2026

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Sport and exercise medicine requires decisions grounded in context: what works, for whom, how, and under what circumstances. Traditional evidence hierarchies often prioritise randomised controlled trials, systematic reviews, and meta-analyses, yet these approaches may omit implementation context in dynamic sporting environments. This editorial argues for realist synthesis as a complement, explaining how and why interventions work by mapping context–mechanism–outcome relationships and strengthening practical, real-world recommendations.

LanguageEnglish

CategoryLetters

FormatDOCX

Pages9

Reading Time3 min

AccessFree to download

Realist synthesis and the need for context

Beyond levels of evidence in dynamic sport environments

What is a realist synthesis review?

Benefits of realist syntheses for practice decisions

Summary

Realist synthesis in sport and exercise medicine: ‘Time to get real’ *Adam Gledhill1; Dale Forsdyke2 1Leeds Beckett University, Carnegie School of Sport; Leeds, UK 2York St. John University; School of Sport, York, UK *Corresponding author: HYPERLINK "mailto:Adam.Gledhill@LeedsBeckett.ac.uk" Adam.Gledhill@LeedsBeckett.ac.uk Competing interests: AG is an Associate Editor with BJSM Contributorship AG produced the concept for the editorial, drawing on existing work from AG and DF. DF provided critical debate and revisions on the first version of the work, with AG and DF both producing the final version. Acknowledgements: N/A Funding info: There are no funders to report for this submission Ethical approval information: Not applicable Data sharing statement: Not applicable 825 In sport and exercise medicine (SEM), context is key. By context we mean: What works? For whom? How? And under what circumstances? These are 4 key questions for clinicians who aim to prevent injuries, treat patients, and guide return to sport with athletes. To answer real-world challenges, clinicians will often bow to the Oxford levels of evidence and rely on findings of randomised controlled trials, (RCTs), systematic reviews (SRs) or meta-analyses. These methods are gold standards, recent debate1 notwithstanding. However, in dynamic, changeable and less-controlled sports environments (e.g., soccer; rugby) where we strive to achieve optimal performance and health gains, we should challenge our own thinking and traditions to meet the demands of this unique environment. Recognising a shift to a greater need for implementation science2, we should consider looking beyond the accepted gold standard. Typically, SRs the focus on solely measuring and reporting intervention efficacy,4 they omit implementation context.3 The purpose of this editorial is to promote the value of Realist Synthesis—as a method that complements clinicians’ use of the traditional levels of evidence. What is a realist synthesis review and how does it differ from systematic reviews? Realist Syntheses are based on realist philosophy of science, which has the specific aim of understanding the context—mechanism—outcome relationship, by considering their interactions. Realist synthesis can help to explain the success or failure of interventions within a given context.2 Realist syntheses report on the how and why an intervention works, as opposed to simply whether or not it works? It is common for SRs to only include RCTs.1,5 A Realist Synthesis may complement the scope of knowledge of SRs by including a wider range of study designs to explain why and how interventions might work. Table 12,4,6,7,8,9 outlines key differences between SR and Realist Synthesis; Table 22,4,6,7 provides tips on how to undertake a Realist Synthesis. What are the potential benefits of including realist syntheses when deciding on sport and exercise medicine practice? Consider this scenario: Four RCTs with football teams that examine the FIFA 11+ exercises/program have been included as part of a SR. Two studies show that the FIFA 11+ reduced injury rates, two show a smaller reduction. A traditional SR would use these findings to report efficacy; the study might report an effect size calculated via meta-analysis. However, the studies where the FIFA 11+ program was less effective were coach-led, with the delivery supported by FIFA 11+ videos and posters. Where the FIFA11+ was more effective, the program was coach-led, with their delivery supported by videos and posters and coaches took the lead in delivering the FIFA 11+ after being trained in the delivery of the FIFA11+ programme expert clinicians. Whilst being trained in the FIFA 11+ delivery by clinicians, coaches had the opportunity to take part in the exercises and receive feedback from sports medicine staff. They also had the opportunity to observe each other performing the training programme and provide feedback to each other on movement quality etc. What we see

FAQs

Why does sport and exercise medicine need a context-focused approach?

Because clinical decisions depend on what works, for whom, how, and under what circumstances. Context shapes intervention effectiveness in real-world settings like soccer and rugby.

How does realist synthesis differ from systematic reviews?

Realist syntheses focus on context–mechanism–outcome relationships, explaining how and why interventions work. Systematic reviews often prioritise intervention efficacy and may exclude implementation context.

What example is used to illustrate benefits of realist synthesis?

Four RCTs on FIFA 11+ are compared within a broader evidence base. Differences in coach-led delivery, support materials, training, and feedback are highlighted as mechanisms that influence effectiveness beyond statistical outcomes.

Sep 2, 2026

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