92
W.-J. Kim et al.
Table IV. Ratings of the included clinical practice guidelines
according to the AGREE II Instrument
Domain and items
NICE, ACN,
2006 2009
(26)
(25)
1. Overall objective(s)
6
2. Health question(s)
3
3. Target patient population
5
4. Development group representative
7
5. Patient views and preferences
6
6. Target users defined
5
7. Systematic method for evidence search
3
8. Criteria for selecting evidence
2
9. Strengths and limitations of body of evidence
2
10. Formulation of recommendations explicit 6
6
11. Benefits, side-effects, and risks described
5
12. Explicit link between evidence and recommendations
6
13. External review
3
14. Procedure for updating guidelines
6
15. Specific and unambiguous recommendations
5
16. Different treatment options
4
17. Key recommendations easily identified
6
18. Facilitators and barriers to implementation are discussed
5
19. Advice and/or tools on recommendations
6
20. Resource implications are discussed
6
21. Review/monitoring criteria defined
3
22. Editorial independent from funding body
6
23. Conflicts of interest are stated
1
TOTAL SCORE
107
Global score (1 = lowest quality, 7 = highest quality)
5
Applicability to practice (y = yes, M = yes with modification, N = no)
M
6
3
5
7
6
5
2
2
3
6
5
6
6
6
7
4
7
6
6
1
4
6
6
115
5
M
AGREE II: Appraisal of Guidelines, Research and Evaluation Instrument;
NICE: National Institute for Health and Clinical Excellence; ACN: Australian
Cancer Network.
Domain 2: Stakeholder involvement (AGREE Items
4–6). Both CPGs included individuals from all relevant
professional groups in the guideline development,
including patient advocacy groups, community group
representatives, and specific details including their
roles. Although the views and preferences of the target
population were stated adequately, the description of
relevant target-users was not sufficiently reported in
either guideline.
Domain 3: Rigour of development (AGREE Items
7–14). The strength and limitations of the body of
evidence, consideration of health benefits, side-effects
and risks when formulating the recommendations were
not well described. There were explicit links between
the recommendations and the supporting evidence in
both CPGs, as well as procedures for updating the gui-
delines. However, NICE does not provide information
on the external review process, while ACN does not
report the process of reviewers’ selection.
Domain 4: Clarity of presentation (AGREE Items
15–17). Recommendations in both CPGs were specific
and unambiguous, with key recommendations clearly
stated. However, different options were not sufficiently
described for different BT populations. The importance
of the rehabilitation process was highlighted in both
CPGs, but without clear recommendations concerning
treatment options.
www.medicaljournals.se/jrm
Domain 5: Applicability (AGREE Items 18–21). Both
guidelines failed to describe clearly the barriers and
facilitators for implementation of the CPG in practice;
only a few items were mentioned vaguely. Implications
of resources and associated costs were not mentioned in
the ACN guidelines; however, the NICE made attempts
to describe costs related to hiring specialized medical
staff. Both guidelines briefly mentioned tools and
advice on how to apply recommendations in clinical
practice; however, reviewing and monitoring criteria
were not comprehensively well-defined by either of
the guidelines.
Domain 6: Editorial independence (AGREE Items
22–23). The influence of the funding body on the
content of the guidelines was described clearly by
both CPGs. However, the conflict of interest was not
provided in the NICE guidelines.
A summary of the guidelines assessment AGREE II
scores is given in Table IV.
Summary of rehabilitation interventions in the
clinical practice guidelines
Despite the recognition of rehabilitation as an integral
component of management of BT survivors in both in-
cluded CPGs, recommendations for specific rehabilita-
tion interventions were described ambiguously in both.
The best-evidence synthesis for various rehabilitation
interventions for the management of BT provided in the
included CPGs are summarized below and in Table V.
Multidisciplinary rehabilitation. Both guidelines re-
commend a comprehensive multidisciplinary approach
with individually selected goals for the longer-term
management of BT. The ACN outlines rehabilitation
programmes as associated with improved mobility,
cognitive-communication and participation. NICE
states effective and timely provision rehabilitation
services in optimizing function and participation; ho-
wever, without specific recommendations.
Physiotherapy (PT) and occupational therapy (OT).
ACN recommends PT for patients with residual motor
deficits (strength, coordination, balance) and occupa-
tional therapy for residual problems in personal care
and independent activities of daily living (Level III
evidence). ACN describes steroid-induced myopathy,
characterized by proximal muscle weakness, as a pos-
sible negative side-effect of treatment, which can be
improved with a combination of PT exercise and OT.
NICE mentions that PT and OT should be involved as
a part of rehabilitation team; however, without specific
recommendations or evidence.
Exercise. ACN recommends aerobic and resistance
training for all patients with BT to enhance muscle