90
W.-J. Kim et al.
Rehabilitation for survivors of BT can be challen-
ging, as they can present with various combinations
of problems, which may fluctuate, with unpredictable
prognoses, and often the disease itself has a progres-
sive nature (3, 8, 9). There is evidence to support
comprehensive multidisciplinary rehabilitation for
functional improvement and psychosocial adjustment
(10, 11). Previous reports suggest that patients with
malignant BT can make functional gains equivalent
to those with stroke and traumatic brain injury in in-
patient rehabilitation settings (9, 12). There remains,
however, an unmet need in the BT population, as only
a limited proportion of survivors receive appropriate
rehabilitation intervention (13).
Clinical practice guidelines (CPGs) are systema-
tically developed evidence-based recommendations
to optimize the quality of healthcare and to guide
clinicians in making appropriate decision making for
improved clinical outcomes (14, 15). The worldwide
published CPGs for BT vary considerably in terms of
scope, developing process, search methods for evi-
dence, strength of evidence used in formulating recom-
mendations, etc. There is variation in the quality and
consistency of recommendations amongst CPGs, as
they are developed by different organizations, making
it difficult for practitioners to choose the appropriate
recommendations (16). Therefore, critical appraisal
and evaluation of these guidelines is important (17).
To our knowledge, published BT guidelines have
not been systematically and qualitatively appraised to
date, especially for their recommendations regarding
rehabilitation. The aims of this study are to critically
appraise published CPGs for the management of BT,
and to synthesize the evidence-based recommendations
provided from the rehabilitation perspective in order
to guide treating clinicians.
METHODS
Literature search
A review of the literature for published CPG on the manage-
ment of persons with BT was undertaken on 21 March 2018
using a multipronged approach. A comprehensive search of the
following health science databases was undertaken: Cochrane
Library, PubMed, EMBASE, and CINAHL. The search strategy
included combinations of multiple search terms (both MeSH
and keyword text terms) for 2 themes: BT and guidelines (see
Appendix 1). Various CPG clearinghouse websites and CPG
developer websites were explored for potential CPGs (Table
I). A search of grey literature was conducted using different
internet search engines and websites: such as System for In-
formation on Grey Literature in Europe; New York Academy
of Medicine Grey Literature Collection and Google Scholar.
In addition, various healthcare institutions; and governmental
and non-governmental organizations associated with BT were
explored. The bibliographies of identified CPGs were scrutini-
www.medicaljournals.se/jrm
Table I. List of organizations searched
Organization Country
Agency for Healthcare Research and Quality (AHRQ)
National Guideline Clearinghouse
National Health and Medical Research Council (NHMRC)
Guidelines International Network
National Institute for Health and Clinical Excellence (NICE)
National Health Service (NHS) Evidence-National Library
of Guidelines
New Zealand Guidelines Group
Scottish Intercollegiate Guidelines Network
European Association for Neuro-Oncology (EANO)
Brain Cancer Foundations
World Health Organization (WHO)
International Society of Physical Medicine and
Rehabilitation (ISPRM)
World Federation of Neurorehabilitation (WFNR) USA
USA
Australia
Canada
UK
UK
New Zealand
Scotland
Austria
Various countries
Switzerland
Switzerland
UK
zed, and authors and known experts in the field were contacted
for further information if required.
Selection criteria
CPGs were included if they focused on the management of BT
and met the following criteria:
• The scope of the CPG focused specifically on treatment of BT
with systematically developed recommendations, strategies,
or other information for rehabilitation.
• The CPG was produced under the auspices of a relevant
professional organization.
• The development process included a verifiable, systematic
literature search and review of existing evidence published in
peer-reviewed journals (the Appraisal of Guidelines, Research
and Evaluation (AGREE II) Instrument item 8); and defines
an explicit link between the recommendations and supporting
evidence (AGREE II Instrument item 12).
• CPG developed, reviewed, or revised within the last 15 years
(2003 onwards).
• CPG targets adult participants (> 18 years of age).
Exclusion criteria included: CPGs focused solely on the
management of other cancers; BT in the paediatric population;
CPG does not include or explicitly describe the rehabilitation
component; non-English publications.
Where a single CPG was reported and/or published in several
different formats with varying degree of detail, only the original
and latest update version with the most detailed description of
its development was included.
Evaluation of included clinical practice guidelines
Three authors (JK, KN, BA) independently appraised the
included CPGs using the structured AGREE II Instrument de-
veloped by the AGREE collaboration (http://www.agreetrust.
org/?o=1397). The AGREE II Instrument contains 23 items
organized in 6 domains: scope and purpose; stakeholder invol-
vement; rigour of development; clarity and presentation; appli-
cability; and editorial independence. All authors independently
scored each item of the instrument on a 7-point Likert scale:
from 1vstrongly disagree to 7 = strongly agree. Furthermore, 2
overall appraisal items assessed the overall quality of the guide-
lines and whether it should be recommended for practice. Fleiss’
kappa statistic was used to determine the inter-rater reliability
amongst the authors’ scores. Any disagreement or discrepancies
were resolved with the fourth author (FK) and by a final group