Posts Tagged clinical practice guidelines

[ARTICLE] Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury



Individuals with acute-onset central nervous system (CNS) injury, including stroke, motor incomplete spinal cord injury, or traumatic brain injury, often experience lasting locomotor deficits, as quantified by decreases in gait speed and distance walked over a specific duration (timed distance). The goal of the present clinical practice guideline was to delineate the relative efficacy of various interventions to improve walking speed and timed distance in ambulatory individuals greater than 6 months following these specific diagnoses.


A systematic review of the literature published between 1995 and 2016 was performed in 4 databases for randomized controlled clinical trials focused on these specific patient populations, at least 6 months postinjury and with specific outcomes of walking speed and timed distance. For all studies, specific parameters of training interventions including frequency, intensity, time, and type were detailed as possible. Recommendations were determined on the basis of the strength of the evidence and the potential harm, risks, or costs of providing a specific training paradigm, particularly when another intervention may be available and can provide greater benefit.


Strong evidence indicates that clinicians should offer walking training at moderate to high intensities or virtual reality–based training to ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance. In contrast, weak evidence suggests that strength training, circuit (ie, combined) training or cycling training at moderate to high intensities, and virtual reality–based balance training may improve walking speed and distance in these patient groups. Finally, strong evidence suggests that body weight–supported treadmill training, robotic-assisted training, or sitting/standing balance training without virtual reality should not be performed to improve walking speed or distance in ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance.


The collective findings suggest that large amounts of task-specific (ie, locomotor) practice may be critical for improvements in walking function, although only at higher cardiovascular intensities or with augmented feedback to increase patient’s engagement. Lower-intensity walking interventions or impairment-based training strategies demonstrated equivocal or limited efficacy.


As walking speed and distance were primary outcomes, the research participants included in the studies walked without substantial physical assistance. This guideline may not apply to patients with limited ambulatory function, where provision of walking training may require substantial physical assistance.


The guideline suggests that task-specific walking training should be performed to improve walking speed and distance in those with acute-onset CNS injury although only at higher intensities or with augmented feedback. Future studies should clarify the potential utility of specific training parameters that lead to improved walking speed and distance in these populations in both chronic and subacute stages following injury.


These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for persons with chronic stroke, incomplete spinal cord injury, and traumatic brain injury to improve walking speed and distance.



Summary of Action Statements………………………………………………..53

Levels of Evidence and Grade of Recommendations…………………54



Action Statements…………………………………………………………………..63



Summary of Research Recommendations……………………………….83





Table 1: Levels of Evidence for Studies……………………………………54

Table 2: Standard and Revised Definitions for Recommendations………………..54

Table 3: Example of PICO Search Terms for Strength Training………………….58

Table 4: Survey Results………………………………………………….59

Figure 1: Flow chart for article searches and appraisals…………………….60

Table 5: Final Recommendations for Clinical Practice Guideline on Locomotor Function…..79


Appendix Table 1: Walking Training at Moderate to High Aerobic Intensities…….91

Appendix Table 2: Walking Training With Augmented Feedback/Virtual Reality…….92

Appendix Table 3: Strength Training……………………………………….93

Appendix Table 4: Cycling and Recumbent Stepping Training……………………94

Appendix Table 5: Circuit and Combined Exercise Training…………………….95

Appendix Table 6A: Balance Training: Sitting/Standing With Altered Feedback/Weight Shift……..96

Appendix Table 6B: Balance Training: Augmented Feedback With Vibration………..97

Appendix Table 6C: Balance Training: Augmented Visual Feedback……………….98

Appendix Table 7: Body Weight–Supported Treadmill Walking………………99

Appendix Table 8: Robotic-Assisted Walking Training………………………..100



Continue —-> Clinical Practice Guideline to Improve Locomotor Function Fo… : Journal of Neurologic Physical Therapy

, , , , , , , ,

Leave a comment

[WEB SITE] Connecting Care for Stroke Patients – Rehab Managment



by Meri K. Slaugenhaupt, MPT, and Valerie Bucek, MA, CCC-SLP/L

According to the Centers for Disease Control and Prevention, someone in the United States has a stroke every 40 seconds. Someone dies from a stroke every 4 minutes. It is a leading cause of long-term disability. A stroke occurs when there is a disruption in blood flow to the brain. The most common kind of stroke, ischemic stroke, occurs when a clot or mass obstructs a blood vessel. A hemorrhagic stroke occurs when a weakened blood vessel ruptures.

This article follows the treatment of stroke survivor Greg Myers, who was finishing his workday when he suddenly became confused and had difficulty walking and talking. A co-worker called Emergency Medical Services, and Myers was transported to the nearest acute care primary stroke center for treatment. Myers had suffered a right cerebellar hemorrhage. His hospital course was complicated by the need for evacuation of the hematoma, post-occipital craniotomy, and wound dehiscence. After several days of acute medical care and monitoring, it was determined that Myers would benefit from intensive multidisciplinary rehabilitation services to address his residual physical deficits and cognitive needs. To begin his stroke rehabilitation journey, Myers chose HealthSouth Harmarville Rehabilitation Hospital (which will be known as Encompass Health Rehabilitation Hospital of Harmarville beginning January 1, 2019).

Evidence-Based Rehabilitation

Since 2002, HealthSouth Harmarville has been certified as a Joint Commission Disease-Specific Care Stroke Program. The team follows evidence-based Clinical Practice Guidelines (CPG) for treatment of individuals with stroke. By following these guidelines, the team has confidence that treatments are based upon the most current evidence-based research and philosophies.

Comprehensive rehabilitation services, such as those provided at HealthSouth Harmarville, are found to be one of the most effective ways to achieve functional recovery and independence after a stroke. Intensive rehabilitation services facilitates neuroplasticity and recovery of motor function. Neuroplasticity is the ability for the brain to “rewire” or adapt to new circumstances by reorganizing synaptic connections. By engaging in therapy that is challenging, repetitive, and task specific, motor pathways that have been disrupted by the stroke can be rewired and strengthened.

Reducing Complications of Stroke

One of the goals of the clinical practice guidelines is to reduce the complications of stroke. One of the most frequent complications following a stroke is difficulty swallowing, or dysphagia. Stroke survivors with dysphagia have an increased risk of pneumonia, dehydration, and malnutrition. Instrumental assessment in the form of a Modified Barium Swallow study (MBS) or Fiber-Optic Endoscopic Evaluation of Swallowing (FEES) determine an appropriate, safe diet and the course of treatment. Swallowing difficulty is treated by exercise, diet modification, and technology, such as neuromuscular electrical stimulation.

Early therapy intervention is also important to maximize motor recovery in our stroke patients. Deconditioning and non-use are a hurdle to restoring function, especially with the elderly stroke population. Physiological changes and complications as a result of prolonged bedrest can lead to additional loss of muscle mass, contractures, skin breakdown, and deep vein thrombosis, all of which further hinder the stroke-recovery process.

Technology and the Path to Walking

Being able to walk again is a common goal shared by most stroke survivors, and Myers was no exception. Studies show that stroke affects mobility in greater than half of stroke survivors. Those suffering from gait disturbances often have further difficulties with balance and cardiovascular endurance, and are subsequently more likely to fall. Therefore, improvements achieved with gait function frequently carry over to improvements in many other aspects of daily living.

In the past decade, technology has moved to the forefront of therapeutic intervention as an adjunct to conventional practice. This is true for all disciplines and ranges from Vital Stimulation in the treatment of dysphagia to robotics in the treatment of movement disorders.

Body weight-supported technology is one such area of technological advancement being utilized for gait training. Partial body weight (PBW)-supported devices are designed to use a harness and/or suspension system to assist with standing and safety during ambulation. When partial body weight devices are used over a treadmill, the therapist is able to change gait speed and work on gait quality under controlled, safe conditions. However, many PBW devices do not require use of a treadmill and can be used over the ground while providing similar training benefits to patients.

Automated technology incorporates the use of robotics, using attachments to the patient’s hip, knees, and ankles. These robotics guide the patient’s lower-extremity movement and promote normal movement throughout the entire gait cycle. Robotic body weight support is generally used with more involved patients who have significant difficulty with lower extremity movement. These devices allow the therapist to gradually decrease the support provided as gait improves.

Fall Protection and Balance

A clinical advantage that these technologies have over other conventional gait training is the reduced support required by the therapist. When asked about using a PBW support device, Tammy Whitlinger, a physical therapist assistant at HealthSouth Harmarville for 28 years, states, “I am able to safely initiate gait training earlier, and my patients are less anxious about the training because they know that they can’t fall.”

Balance deficits resulting from a stroke can also be very debilitating and frustrating for individuals. Since Myers had a stroke that affected the cerebellar part of his brain, balance training was also a major component of his therapy program. Myers’s balance program included a variety of approaches including altering visual feedback and multi-surface challenges. Equipment utilized for balance deficits can be as simple as carpet or foam. More complex devices are designed to use interactive technology and visual feedback to further analyze a patient’s posture and balance deficits.

Treadmills are another piece of technology commonly found in the clinic that are used to improve motor recovery after stroke. Treadmill training can be used with or without partial body weight support. When used along with conventional therapy, treadmill training has been shown to improve gait quality and efficiency, strength, and cardiovascular fitness. Other adjunct modalities are also utilized by physical therapists to address aerobic fitness and reciprocal movements of the lower extremities, such as stepper machines, elliptical trainers, and stationary/recumbent bikes.

Upper Extremity Dysfunction

Advanced technology used for the treatment of upper extremity dysfunction has also impacted stroke rehabilitation. Improving deficits in fine motor control, coordination, and weakness are often a focus of treatment in stroke recovery. Electrical stimulation, biofeedback, or robotics are utilized in many technologies to retrain arm movements and hand function. Some of these devices are even coupled with gaming to provide motivation and entertainment for the patient while exercising.

Family/caregiver involvement early on is very beneficial to a successful inpatient rehabilitation stay and transition to home. Our Clinical Practice Guidelines recommend that patients and caregivers be educated throughout the entire stay to learn about disease process, expected outcomes, treatment goals, and follow-up support services available in the home and community. As part of our discharge planning and preparation for a safe transition home, we completed a home visit for Myers. This is when the physical and occupational therapist team takes the patient home in order to problem-solve accessibility issues and to perform caregiver training in their own environment. By doing this, Myers and his wife were less anxious and fearful about their transition home.

Neuro-Focused Outpatient Rehab

Quality inpatient rehabilitation is a vital step in the journey of returning to community participation. Many patients choose to receive home health services after inpatient rehabilitation to assist with the transition to home. Myers briefly utilized home health before initiating the next stage of his recovery, which was a neuro-focused outpatient program found at HealthSouth Harmarville. Outpatient therapy provides an opportunity for stroke survivors to build endurance and to practice skills in higher levels of difficulty. Concerns and issues that have arisen from community integration can be incorporated into treatment and resolved. Instrumental activities of daily living are also a focus of the outpatient program. Participation in activities such as disease-specific support groups and wellness programs can help to facilitate return to the community.

HealthSouth Harmarville offers the entire continuum of care for patients, ranging from inpatient rehabilitation to home health to outpatient services to community support groups. Myers’s wife, Cathy, has become an active participant in the hospital’s Stroke Support Group, attending the educational programs and interacting with families of other stroke survivors. Myers, himself, continues to make gains in physical functioning, daily living skills, communication, and cognitive skills in outpatient therapy. He has returned to some of the leisure activities he enjoyed before his stroke. The couple took another step toward normalcy by going on a vacation to Aruba in August.

Additionally, Greg Myers was honored at the hospital’s National Rehabilitation Awareness Week celebration in September as one of five Rehab Champions treated in the last year who displayed determination, a positive attitude, and the ability to overcome obstacles in order to be successful. RM

Meri K. Slaugenhaupt, MPT, has served on the HealthSouth Harmarville Rehabilitation Hospital team since 1993, beginning as a physical therapist and now serves as the team’s program champion of the stroke program. In this role, Slaugenhaupt has obtained Stroke Joint Commission Disease Specific Certification, making HealthSouth Harmarville the first rehabilitation hospital to achieve this status in 2002. Under Slaugenhaupt’s leadership the hospital has achieved its 8th Joint Commission disease-specific care certification in 2017 for the stroke program. She earned her bachelor’s degree in physiology with a minor in exercise science from Penn State University in 1991. She then earned her master’s in physical therapy at the University of Pittsburgh.

Valerie Bucek, MA, CCC-SLP/L, has been a member of the HealthSouth Harmarville Rehabilitation Hospital team for more than 25 years. She began her work there as a staff speech pathologist and a speech therapy supervisor prior to her current role as the hospital’s therapy manager. Bucek received a bachelor’s degree in speech pathology from Duquesne University and a master’s degree in communication disorders from the University of Pittsburgh. She is one of the leaders of the hospital’s stroke and Parkinson’s disease programs, is founder and facilitator of the HealthSouth Harmarville Community Stroke Support Group, and is an affiliate for the ASHA Special Interest Division-Adult Neurogenic Communication Disorders. For more information,

via Connecting Care for Stroke Patients – Rehab Managment

, , , , , , , ,

Leave a comment

[ARTICLE] Clinical practice guidelines for the management of brain tumours: A rehabilitation perspective – Full Text



Objective: To critically appraise published clinical practice guidelines (CPGs) for brain tumours, and to synthesize evidence-based recommendations from a rehabilitation perspective.

Methods: A comprehensive literature search included: health science databases, CPG clearinghouse/developer websites, and grey literature up to March 2018. All brain tumour CPGs that reported systematic methods for evidence search, and clearly defined recommendations supporting evidence for rehabilitation interventions were included. Three authors independently selected potential CPGs and assessed their methodological quality using the Appraisal of Guidelines, Research and Evaluation (AGREE-II) Instrument. Recommendations from included CPGs were categorized from a rehabilitation perspective.

Results: Of the 11 CPGs identified, only 2, developed by the National Institute for Health and Clinical Excellence (NICE) and the Australian Cancer Network (ACN), included rehabilitation components for the management of brain tumours. Both CPGs were of moderate quality. The recommendations reported were generic, and only the ACN guidelines provided detailed recommendations for rehabilitation interventions. Both guidelines recommend a comprehensive multi-disciplinary care approach. Detailed comparison, however, was not possible due to inconsistent recommendations, making it difficult to summarize rehabilitative care.

Conclusion: Despite rehabilitation being an integral component of the management of brain tumours, only a limited number of CPGs have incorporated recommendations for specific rehabilitation interventions. In order to improve clinical outcomes in this population future CPGs should incorporate rehabilitation interventions.


Lay abstract

Brain tumours cause significant disability and morbidity. There are numerous published clinical practice guidelines (CPGs) for the management of brain tumours, and rehabilitation is recognized as an integral component of management of brain tumours. However, only limited numbers of these CPGs incorporate recommendations for specific rehabilitation interventions. To establish understanding of the issues of rehabilitation needs in brain tumours survivors, and synthesise evidence-based recommendations from rehabilitation perspective, published CPGs for brain tumours were critically appraised. Gaps in current literature were identified, and need of incorporation of rehabilitation interventions are highlighted. This is for  future direction/recommendations in developing new CPGs to guide clinicians and to improve clinical outcomes in this population.



Brain tumours (BT) comprise 2% of all cancers, affecting 7 per 100,000 population annually worldwide (1). Overall incidence of BT is increasing, especially in the population over 60 years of age (2). In Australia, there are an estimated 1,400 new cases per annum, which account for 1,200 deaths annually (3). BT can have a devastating impact on patients (carers/family) and are associated with significant costs and socioeconomic implications, with increased demand for healthcare, social and vocational services (3, 4). In Australia, the estimated mean overall healthcare system cost of BT is 5 times higher than for patients with breast or prostate cancer (5).

Recent therapeutic advances have improved the survival rates of persons with BT. However, many have residual neurological deficits, leading to physical, cognitive, psychosocial and behavioural impairments, which limit everyday activity and participation (6, 7). Furthermore, many treatments for BT, such as radio-therapy, chemotherapy and surgery are associated with adverse events. Therefore, patients require integrated and coordinated long-term management, including rehabilitation, for improvements in their functional, mental and emotional state, and quality of life (QoL) (7).

Rehabilitation for survivors of BT can be challenging, as they can present with various combinations of problems, which may fluctuate, with unpredictable prognoses, and often the disease itself has a progressive 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 inpatient 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 systematically 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 evidence, strength of evidence used in formulating recommendations, 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.



Literature search

A review of the literature for published CPG on the management 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 Information 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 scrutinized, and authors and known experts in the field were contacted for further information if required.

Appendix 1. Search terms

Table I. List of organizations searched

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 developed by the AGREE collaboration ( The AGREE II Instrument contains 23 items organized in 6 domains: scope and purpose; stakeholder involvement; rigour of development; clarity and presentation; applicability; 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 guidelines 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 consensus. Furthermore, as aggregate scoring across domains is not recommended by the AGREE Enterprise, the AGREE II-Global Rating Scale (AGREE II-GRS) was used to rate overall quality on a 7-point scale (from 1 = lowest quality to 7 = highest quality) and categorized as: “excellent quality”= score 7/7, “high quality”  =  5–6/7, “moderate quality”  =  4/7 and “poor quality” = 0–3/7. The AGREE-II instrument is a validated appraisal tool for thorough quality assessment of guidelines and is widely used (18–24).

Data extraction and classification of recommendations

A standard pro-forma was used for data extraction from all CPGs. The form included: publication and search date, objectives/scope, methodology used, evidence-supported recommendation, and limitations. Three authors (JK, KN, BA) extracted the evidence-based recommendations, specifically for the rehabilitation, and categorized them into the following groups: (i) initial clinical assessment, (ii) observation and management, (iii) triage and discharge planning, and (iv) patient information and patient follow-up.


The searches retrieved 458 published titles and abstracts. Ten titles met the inclusion criteria and were selected for closer scrutiny. Full texts of these articles/reports were retrieved and 3 reviewers (JK, KN, BA) performed the final selection. One report that met inclusion criteria was identified from bibliographies of relevant articles. The search did not identify any specific guidelines for rehabilitation of persons with BT. Of the 11 CPGs identified, only the following 2 generic CPGs for management of BT which included different rehabilitation interventions, fulfilled the inclusion criteria for this review (Table II):

  • Australian Cancer Network. Adult Brain Tumour Guidelines Working Party. CPGs for the Management of Adult Gliomas: Astrocytomas and Oligodendrogliomas. Cancer Council Australia, Australian Cancer Network and Clinical Oncological Society of Australia Inc., Sydney 2009 (hereafter referred as “ACN” guidelines) (25).
  • National Institute for Health and Clinical Excellence (NICE) (UK). Improving outcomes for people with brain and other CNS tumours: the Manual, National Collaborating Centre for Cancer, London June 2006 (hereafter referred as “NICE” guidelines) (26).

A detailed description of the included guidelines and a list of excluded guidelines are given in Table III.

Table II. Characteristics of the included clinical practice guidelines

Table III. List of excluded clinical practice guidelines

Quality assessment of included clinical practice guidelines

The 2 included CPGs were critiqued qualitatively using the AGREE-II tool, with a global rating score of 5 out of 7. Overall, the ACN CPG scored better than the NICE CPG (total score = 115 vs 107). All 3 authors rated the guidelines “Moderate”, indicating the need for some modification for clinical applicability. The kappa level of agreement between the authors for AGREE II assessment was 0.81. A summary of the guidelines’ assessment AGREE II scores is shown in Table IV. An overview of the quality assessment of the included CPGs for each of the 6 AGREE-II domains is set out below.

Domain 1: Scope and purpose (AGREE Items 1–3). In general, both CPGs outlined the objectives and overall aim, the specific health questions, and the target population. However, both CPGs failed to provide clear or concise information on interventions, and outcomes; and did not specifically describe the state of disease, clinical condition and exclusion criteria for the target population.

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 guidelines. 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.

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.

Table IV. Ratings of the included clinical practice guidelines according to the AGREE II Instrument

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 included CPGs, recommendations for specific rehabilitation 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.

Table V. Recommendations for rehabilitation interventions in the clinical practice guidelines

Multidisciplinary rehabilitation. Both guidelines recommend 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; however, without specific recommendations.

Physiotherapy (PT) and occupational therapy (OT). ACN recommends PT for patients with residual motor deficits (strength, coordination, balance) and occupational 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 possible 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 strength and endurance. However, no specific recommendations with regards to timing, dose and intensity are provided. ACN advocates for resistance training of unaffected muscles to compensate for impaired coordination for those with ataxia and cerebellar dysfunction. There is no description of exercise therapy in the NICE guidelines.

Neuropsychological management. ACN recommends neuropsychological assessment for behavioural changes, and organic personality change in patients with BT for cognitive deficits. It recommends that depression and anxiety can interfere with a person’s capacity to make treatment decisions and should be treated with a combination of psychotherapy and cognitive behavioural therapy, together with relaxation therapy or guided imaginary to help deal with stressful situations. The NICE guidelines recommend psychological assessment and support as an integral part of comprehensive care; however, the guidelines fail to provide any specific description or evidence.

Communication and swallowing. Speech and language therapy are offered to those with communication and/or swallowing dysfunction, for aspiration intervention and adjustments to food consistency. However, NICE only mentions involvement of a speech therapist as a part of the rehabilitation team, without specific recommendations or evidence.

Compensatory aids. Both NICE and ACN recommend immediate access to specific orthoses (ankle-foot orthoses), walking sticks or walkers, and wheelchairs for BT patients with gait impairment. Neither of the 2 CPGs provides specific recommendations and/or level of evidence.


This review comprehensively evaluates and assesses the methodological quality of the published CPGs for management of BT and summarizes recommendations for applicability from the rehabilitation perspective. Despite the challenges and complexity of delivering healthcare to BT survivors, there is well-documented evidence advocating the integral role of rehabilitation (10, 11) in restoring function, minimizing complications, reducing morbidity and improving QoL (9, 27–29). This review identifies several CPGs for the management of BT published in the last decade. However, majority focus on acute radiological, surgical and medical treatments, and rehabilitation approaches are neglected. Of the 11 published CPGs identified, only 2 provide recommendations for rehabilitation interventions. Both of these CPGs (published by NICE and ACN) describe rehabilitation approaches ambiguously and provide limited information about various rehabilitation modalities. With improved survival of patients with cancer, the role of rehabilitation must be emphasized.

Comparison between the guidelines

The overall quality of the included 2 CPGs was “moderate”. Despite increasing evidence for rehabilitation in improved physical (6, 9, 28), psychosocial wellbeing and QoL (7, 29, 30), the included CPGs failed to incorporate and provide detailed evidence-based information on many specific rehabilitation recommendations. The overall recommendations in the NICE guidelines on rehabilitation approaches is too generic, failing to provide specific description and a supporting body of evidence behind the recommendations. Only the ACN 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 varied. 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 specific 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 diverse: 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 specific 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 outcomes 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 traumatic brain injury (7). Studies have shown that participation in multidisciplinary rehabilitation, significantly improved function (27, 32–35), with some gains in BT survivors maintained for up to 6 months (10).

Limitations of the methodological quality appraising process

The AGREE-II Instrument is a useful tool used worldwide for evaluating the quality of guidelines. However, 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 accepted method and validated tool available for this purpose. 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 guideline 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 recommendations. 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 consultations with experts in the field to minimize these shortfalls. 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 information obtained from developers’ websites.

Study limitations

Some limitations of this study in terms of methodology 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 organizations; and manual screening of bibliographies, mean that it is unlikely that any important CPGs were missed. 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 clearinghouses was conducted, which includes information on all published guidelines without language restriction. This review included only adult populations with BT; the paediatric BT population was beyond the scope of the review and expertise of the research team. Interestingly, the majority of published CPGs on BT were generally more attentive to the medical, surgical and radiological treatments, and only 2 CPGs included information on rehabilitation approaches. The underlying evidence for the recommendations in both of the included CPGs (NICE and ACN) appears outdated and old (> 10 years) (update of the NICE guidelines is currently in progress; personal communication with the developers). To our knowledge, a large body of evidence (clinical trials, systematic reviews) is now available since the development of these 2 CPGs. Examination of this evidence will be critical in formulating the recommendations in future updates or development of new CPGs in this area.

Implications for clinical practice

BT have a significant effect on both survivors and their caregivers/family (5). In the community patients are often confronted by new care demands, personal relationship, financial constraints, relationship stress, relapse, recurrence, etc., requiring integrated multidisciplinary care, including rehabilitation (38). However, there is lack of awareness about the integral role of rehabilitation amongst many healthcare professionals, as surgical, medical, and radiological treatments are considered a priority. The aim of BT rehabilitation is not only management of disability and/or minimizing symptoms and treatment-related complication effects, but also enhancing participation. Interventions such as physical therapy, psychological interventions (psychotherapy, cognitive behaviour training) and others can reduce disability, and improve participation.

This review was unable to synthesize rehabilitation-related recommendations sufficiently from the publi-shed CPGs, due to the limited numbers of BT CPGs with rehabilitation management, and the inconsistency in reporting underlying evidence to support these recommendations. The 2 included CPGs (NICE and ACN), were moderate in quality, and the overall recommendations formulated were generic. This resulted in difficulty in comparing and summarizing recommendations for rehabilitation approaches. However, both CPGs recommend comprehensive assessment of functional limitations and the various levels of disability in this population at regular intervals in order to establish a better care model and to optimize physical independence and participation (12).


Implications for research

Despite evidence to support rehabilitation interventions in patients with BT (2, 11), literature evaluating rehabilitation interventions is scarce (2, 11). There is lack of robust studies evaluating the effectiveness of many rehabilitation interventions. The findings from this review highlight the need for systematic data collection in clinical practice and research into the course of BT, including long-term follow-up outcomes. Although randomized controlled trials (RCTs) are considered the “gold standard” for high-level evidence, they are less appropriate in studying rehabilitation interventions. Patients’ (and/or caregivers’) perspective must be incorporated into rehabilitation programmes. Outcome measures should reflect activity and restriction in participation. There is a need for a suitable battery of measures to capture change in physical ability, symptoms and longer-term outcomes relating to psychosocial adjustment and QoL.



This study reviews CPGs for the management of persons with BT from the rehabilitation perspective. Delivery of rehabilitation interventions in patients with BT should not differ from other neurological conditions, such as stroke or traumatic brain injury; however, owing to the disease characteristics, rehabilitation is often overlooked in this patient cohort. Current CPGs for the management of BT do not provide consistent and detailed information on rehabilitation management; thus it is challenging to synthesize recommendations for rehabilitation approaches specific to BT survivors. Both of the guidelines included in this review provide generic recommendations regarding rehabilitation modalities. Developers of future CPGs should comprehensively evaluate and incorporate rehabilitation modalities in the management of patients with BT, so that these interventions can be integrated into routine clinical practice in order to improve patient outcomes.


  1. Parkin DM, Whelan SL, Ferlay J, Teppo L, Thomas DB. Cancer incidence in five continents. Vol VIII. IARC Scientific Publication No. 155. Lyon: International Agency for Research on Cancer; 2002.
    View article    Google Scholar
  2. Flowers A. Brain tumors in the older person. Cancer Control 2000; 7: 523–538.
    View article    Google Scholar
  3. Khan F, Amatya B. Use of the International Classification of Functioning, Disability and Health (ICF) to describe patient-reported disability in primary brain tumour in an Australian community cohort. J Rehabil Med 2013; 45: 434–445.
    View article    Google Scholar
  4. Tang V, Rathbone M, Park Dorsay J, Jiang S, Harvey D. Rehabilitation in primary and metastatic brain tumours: impact of functional outcomes on survival. J Neurol 2008; 255: 820–827.
    View article    Google Scholar
  5. Barton M, Hovey E, Reeve T. Clinical Practice Guidelines for the management of adult gliomas: astrocytomas and oligodendrogliomas. Asia-pacific J Clin Oncol 2009; 5: A170.
    View article    Google Scholar
  6. Huang ME, Sliwa JA. Inpatient rehabilitation of patients with cancer: efficacy and treatment considerations. PM&R 2011; 3: 746–757.
    View article    Google Scholar
  7. Andrejeva J, Volkova OV. Physical and Psychological Rehabilitation of Patients with Intracranial Glioma. Progress Neurolog Surg 2018; 31: 210–228.
    View article    Google Scholar
  8. Ownsworth T, Hawkes A, Steginga S, Walker D, Shum D. A biopsychosocial perspective on adjustment and quality of life following brain tumor: a systematic evaluation of the literature. Disabil Rehabil 2009; 31: 1038–1055.
    View article    Google Scholar
  9. Shahpar S, Wong AW, Keeshin S, Eickmeyer S, Semik P, Kocherginsky M, et al. Functional Outcomes of an Interdisciplinary Outpatient Rehabilitation Program for Patients with Malignant Brain Tumors. PM&R 2018; 10: 926–933.
    View article    Google Scholar
  10. Khan F, Amatya B, Drummond K, Galea M. Effectiveness of integrated multidisciplinary rehabilitation in primary brain cancer survivors in an Australian community cohort: a controlled clinical trial. J Rehabil Med 2014; 46: 754–760.
    View article    Google Scholar
  11. Khan F, Amatya B, Ng L, Drummond K, Galea M. Multidisciplinary rehabilitation after primary brain tumour treatment. Cochrane Database Syst Rev 2015; 8: CD009509.
    View article    Google Scholar
  12. Vargo M, Henriksson R, Salander P. Rehabilitation of patients with glioma. Handb Clin Neurol 2016; 134: 287–304.
    View article    Google Scholar
  13. Pace A, Villani V, Parisi C, Di Felice S, Lamaro M, Falcicchio C, et al. Rehabilitation pathways in adult brain tumor patients in the first 12 months of disease. A retrospective analysis of services utilization in 719 patients. Supp Care Cancer. 2016; 24: 4801–4806.
    View article    Google Scholar
  14. Field M, Lohr K. Institute of Medicine Committee to Advise the Public Health Service on Clinical Practice Guidelines. Clinical practice guidelines: directions for a new program. Washington, DC: National Academy Press; 1990.
    View article    Google Scholar
  15. Vecchio AL, Giannattasio A, Duggan C, De Masi S, Ortisi MT, Parola L, et al. Evaluation of the quality of guidelines for acute gastroenteritis in children with the AGREE instrument. J Ped Gastroenterol Nutri 2011; 52: 183.
    View article    Google Scholar
  16. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282: 1458–1465.
    View article    Google Scholar
  17. March L, Amatya B, Osborne RH, Brand C. Developing a minimum standard of care for treating people with osteoarthritis of the hip and knee. Best Pract Res Clin Rheumatol 2010; 24: 121–145.
    View article    Google Scholar
  18. Brouwers M, Kho M, Browman G, Burgers J, Cluzeau F, Feder G, et al. on behalf of the AGREE Next Steps Consortium: Performance, usefulness and areas for improvement: development steps towards the AGREE II-Part 1. Can Med Assoc J 2010; 182: 1045–1052.
    View article    Google Scholar
  19. Brouwers M, Kho M, Browman G, Burgers J, Cluzeau F, Feder G, et al. on behalf of the AGREE Next Steps Consortium: Validity assessment of items and tools to support application: Development steps towards the AGREE II-Part 2. Can Med Assoc J 2010; 182: E472–E478.
    View article    Google Scholar
  20. Zhang Z-w, Liu X-w, Xu B-c, Wang S-y, Li L, Kang Y-y, et al. Analysis of quality of clinical practice guidelines for otorhinolaryngology in China. PLoS One 2013; 8: e53566.
    View article    Google Scholar
  21. Barriocanal AM, López A, Monreal M, Montané E. Quality assessment of peripheral artery disease clinical guidelines. J Vascular Surg 2016; 63: 1091–1098.
    View article    Google Scholar
  22. Cartabellotta A. [AGREE II: assessing the quality of practice guidelines.] Recenti Progressi Medicina 2011; 102: 217–219 (in Italian).
    View article    Google Scholar
  23. Poggi G, Liscio M, Pastore V, Adduci A, Galbiati S, Spreafico F, et al. Psychological intervention in young brain tumor survivors: the efficacy of the cognitive behavioural approach. Disabil Rehabil 2009; 31: 1066–1073.
    View article    Google Scholar
  24. Ness KK, Morris EB, Nolan VG, Howell CR, Gilchrist LS, Stovall M, et al. Physical performance limitations among adult survivors of childhood brain tumors. Cancer 2010; 116: 3034–3044.
    View article    Google Scholar
  25. Australian Cancer Network – Adult Brain Tumour Guidelines Working Party. Clinical Practice Guidliness for the management of adult gliomas: astrocytomas and oligodendrogliomas. Sydney Cancer Council Australia, Australian Cancer Network and Clinical Oncological Society of Australia Inc., 2009.
    View article    Google Scholar
  26. National Institute for Health and Clinical Excellence (NICE). Improving outcomes for people with brain and other CNS tumours: the manual. London National Collaborating Centre for Cancer, June 2006.
    View article    Google Scholar
  27. Marciniak CM, Sliwa JA, Heinemann AW, Semik PE. Functional outcomes of persons with brain tumors after inpatient rehabilitation. Arch Phys Med Rehabil 2001; 82: 457–463.
    View article    Google Scholar
  28. Hansen A, Sogaard K, Minet LR, Jarden JO. A 12-week interdisciplinary rehabilitation trial in patients with gliomas – a feasibility study. Disabil Rehabil 2018; 40: 1379–1385.
    View article    Google Scholar
  29. McCarty S, Eickmeyer SM, Kocherginsky M, Keeshin S, Shahpar S, Semik P, et al. Health-Related Quality of Life and Cancer-Related Symptoms During Interdisciplinary Outpatient Rehabilitation for Malignant Brain Tumor. Am J Phys Med Rehabil 2017; 96: 852–860.
    View article    Google Scholar
  30. Baima J, Omer ZB, Varlotto J, Yunus S. Compliance and safety of a novel home exercise program for patients with high-grade brain tumors, a prospective observational study. Supp Care Cancer 2017; 25: 2809–2814.
    View article    Google Scholar
  31. Aziz NM, Rowland JH. Trends and advances in cancer survivorship research: challenge and opportunity. Sem Radiat Oncol 2003; 13: 248–266.
    View article    Google Scholar
  32. Bartolo M, Zucchella C, Pace A, Lanzetta G, Vecchione C, Bartolo M, et al. Early rehabilitation after surgery improves functional outcome in inpatients with brain tumours. J Neuro-Oncol 2012; 107: 537–544.
    View article    Google Scholar
  33. Fu JB, Parsons HA, Shin KY, Guo Y, Konzen BS, Yadav RR, et al. Comparison of functional outcomes in low-and high-grade astrocytoma rehabilitation inpatients. Am J Phys Med Rehabil 2010; 89: 205–212.
    View article    Google Scholar
  34. Geler-Kulcu D, Gulsen G, Buyukbaba E, Ozkan D. Functional recovery of patients with brain tumor or acute stroke after rehabilitation: a comparative study. J Clin Neurosci 2009; 16: 74–78.
    View article    Google Scholar
  35. Greenberg E, Treger I, Ring H. Rehabilitation outcomes in patients with brain tumors and acute stroke: comparative study of inpatient rehabilitation. Am J Phys Med Rehabil 2006; 85: 568–573.
    View article    Google Scholar
  36. Harris SR, Schmitz KH, Campbell KL, McNeely ML. Clinical practice guidelines for breast cancer rehabilitation. Cancer 2012; 118: 2312–2324.
    View article    Google Scholar
  37. Hoffmann-Eßer W, Siering U, Neugebauer EA, Brockhaus AC, Lampert U, Eikermann M. Guideline appraisal with AGREE II: Systematic review of the current evidence on how users handle the 2 overall assessments. PloS One 2017; 12: e0174831.
    View article    Google Scholar
  38. Khan F, Amatya B. Factors associated with long-term functional outcomes, psychological sequelae and quality of life in persons after primary brain tumour. J Neuro-Oncol 2013; 111: 355–366.
    View article    Google Scholar

via Journal of Rehabilitation Medicine – Clinical practice guidelines for the management of brain tumours: A rehabilitation perspective – HTML

, , , ,

Leave a comment

%d bloggers like this: