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guidelines provided a comprehensive description of
recommendations for rehabilitation interventions with
a supporting level of evidence. The ACN extensively
described more specific and detailed recommendations
on specific problems in patients with BT, justifying the
level of evidence accordingly.
The key outcome measurements for evaluation of
rehabilitation recommended by these 2 guidelines va-
ried. ACN recommends the Barthel Index or Functional
Independence Measure for motor function, activities
of daily living, and cognitive-communication skills.
The NICE guidelines did not recommend any spe-
cific assessment tools. It vaguely recommends QoL,
functional status and patients/family satisfaction as
patient-outcome measures.
The overall scope of the 2 included CPGs was di-
verse: the NICE CPG informs non-specialist readers
about BT and management, whereas the ACN CPG
was developed to provide information to medical
practitioners and interested community members.
There is considerable scope to improve the quality of
both CPGs by highlighting aspects of applicability, the
rigour of development, and the editorial independence.
More detailed and specified implementation in practice
and monitoring criteria should be considered in future
CPGs. Evidence-based best-practice guidelines speci-
fic to BT rehabilitation should be developed further and
incorporated into routine management programmes for
patients with BT.
Evidence to support brain tumour rehabilitation
In recent years, therapeutic advances have prolonged
survival rates in BT (6, 22). Despite these advances,
there are often residual concerns in the post-acute and
longer-term phases (24) (regarding physical, cognitive,
behavioural and psychosocial problems) (6, 8, 23).
These can have a cumulative effect over time and
cause considerable distress to the cancer survivor,
their families, and reduce QoL (24). Furthermore,
treatment regimens are associated with adverse effects
(4, 31) and the disease course itself can alter outco-
mes due to a combination of physical, cognitive, and
communication deficits. There is evidence to support
interdisciplinary rehabilitation for improved functional
independence, mental and emotional state, QoL and
participation (7). Furthermore, inpatient rehabilitation
can result in functional improvement and going-home
rates are on par with individuals with stroke or trauma-
tic brain injury (7). Studies have shown that participa-
tion in multidisciplinary rehabilitation, significantly
improved function (27, 32–35), with some gains in BT
survivors maintained for up to 6 months (10).
www.medicaljournals.se/jrm
Limitations of the methodological quality appraising
process
The AGREE-II Instrument is a useful tool used world-
wide for evaluating the quality of guidelines. Howe-
ver, it has some limitations; especially regarding the
assignment of scores, as there are no clear definitions
for different scores (36). Hence, at times scoring may
be influenced by subjectivity (37). Nonetheless, the
AGREE-II Instrument remains the most widely ac-
cepted method and validated tool available for this pur-
pose. A clinimetric appraisal of the AGREE II tool was
beyond the scope of this review. The AGREE-II tool
focuses on methodological issues related to the guide-
line development process and reporting, and which is
explicitly insufficient to ensure that recommendations
are valid and appropriate (36, 37). The tool itself cannot
appraise the quality of evidence supporting the recom-
mendations. This is clearly reflected in the findings
of this review, with included CPGs applying multiple
sources for generating the evidence underlying the
recommendations. The authors employed 3 reviewers
per guideline for the critical appraisal, with input from
others in case of discordance, and extensive consulta-
tions with experts in the field to minimize these short-
falls. Despite multiple attempts, we did not receive
a comprehensive report on the methodological CPG
development process from the guideline developers.
Therefore, the raters’ judgement was based explicitly
on the information stated in the guidelines and/or in-
formation obtained from developers’ websites.
Study limitations
Some limitations of this study in terms of methodo-
logy and completeness of the literature retrieval and
review process cannot be ruled out. First, since only
published CPGs in the specific searched health-science
databases and guideline-publishing organizations were
searched, there is a possibility that relevant CPGs from
other sources may have been missed. Nevertheless, our
comprehensive systematic search strategy of prominent
databases in the medical literature and grey literature
and search of prominent CPG developing organiza-
tions; and manual screening of bibliographies, mean
that it is unlikely that any important CPGs were mis-
sed. Furthermore, only guidelines published in English
language were retrieved, therefore there is a likelihood
of CPGs published in other languages being missed.
However, a comprehensive search of guidelines clea-
ringhouses was conducted, which includes information
on all published guidelines without language restric-
tion. This review included only adult populations