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Replicability of recommended exercise interventions for knee osteoarthritis: a descriptive systematic review of current clinical guidelines and recommendations

      Purpose: Exercise is strongly recommended as treatment of choice in current clinical guidelines about management of knee osteoarthritis (OA). However, for successful uptake of clinical guidelines complete intervention reporting is essential in order for recommended interventions to be replicated in clinical practice. The purpose of this systematic review was to examine the completeness of the descriptions of exercise interventions for knee OA in the published scientific studies that are used to inform current recommendations.
      Methods: We searched PubMed and EMBASE for current (2006-2016) clinical practice guidelines relevant to knee OA management, including guidelines that includes exercise. From the guidelines we identified and retrieved the original studies used to inform guideline recommendations about exercise. In the original studies, the completeness of the descriptions of the exercise interventions were assessed using a combination of the Template for Intervention Description and Replication (TIDieR) and Consensus on Exercise Reporting Template (CERT) checklists to evaluate 12 items: 1. Name; 2. Why; 3. What (materials); 4. What (procedure); 5. Who provided; 6. How; 7. Where; 8. When and how much (dose); 9. Tailoring/Progression; 10. Modifications; 11. How well (planned); 12. How well (actual). Items 6 (How) and 8 (When and how much [dose]) were assessed in their sub-components to include essential elements of exercise delivery and dose. Each item was scored ‘Yes’ or ‘No’ for completeness of reporting at a minimal form to allow clinical replication. The scoring sheet for each intervention is shown in Table 1.
      Each item was summarised across included interventions as the proportion (%) of interventions with complete descriptions, and each intervention’s completeness was summarised across the 12 items as the percentage of completely described items.
      The methods were pre-specified in a protocol that was registered in the PROPERO database (Prospero Registration Number: CRD42016039742) before any study activities commenced.
      Results: From 10 clinical guidelines published between 2006 and 2016, we identified 103 original studies of which 100 were retrievable (133 interventions with 6926 patients allocated to exercise) published from 1982 to 2012 and used to inform recommendations about exercise for management of knee OA. No interventions (0%) were completely described on all 12 items (median 33% of items complete; range 17%−75%). Name and rationale of intervention (items 1 & 2) were consistently reported (complete for 98% and 99% of interventions, resp.) and general procedures (item 4) were completely described in 80% of interventions (Figure 1). However, complete descriptions of essential elements of exercise delivery and dose (items 6 & 8) were missing for 97% and 84% of interventions, resp. (Figure 2). Between 8% and 40% of interventions had complete descriptions of items 3, 5, 7, 9, 10, 11, and 12 (Figure 1).
      Conclusions: Inadequate description of recommended interventions for knee OA is a substantial problem. This precludes replication of effective interventions in clinical practice, which limits the relevance and usability of clinical guideline documents and original study reports. Further it may cause significant uncertainty among clinicians. It is surprising that essential details of exercise interventions are so unclear yet exercise is unanimously recommended as treatment of choice for knee OA across international guidelines. There is a need for efforts to address this problem of poor description of exercise interventions.
      Figure thumbnail fx1
      Figure 1Proportion of interventions (n = 133) with complete reporting of each of the TIDieR/CERT items.
      Figure thumbnail fx2
      Figure 2Proportion of interventions with complete reporting of sub-components of the TIDieR/CERT items 6 and 8.
      Table 1Intervention description completeness scoring sheet
      TIDieR /CERT item no. and nameItem descriptionCompletely described (y/n)
      1. Brief NameA name or a phrase that describes the exercise intervention
      2. WhyDescribes the rationale, theory, or goal of the elements essential to the intervention
      3. What: MaterialsDescribes any physical or informational materials provided to participants or used in the exercise intervention delivery or in training of exercise intervention providers
      4. What: ProceduresDescribes each of the procedures, activities, and processes used in the intervention, including any enabling or support activities
      5. Who: ProviderDescribes the intervention provider and their expertise, background, and any specific training given
      6. HowDescribes the mode of delivery (e.g. face-to-face) of the intervention and whether it was provided individually or in a group. This item is only complete if all sub-items are completely reported
      • a.
        Whether exercises are performed individually or in a group.
      • b.
        Whether exercises are supervised or unsupervised
      • c.
        Measurement and reporting of adherence to exercise
      • d.
        Decision rules for progressing the exercise program
      • e.
        Each exercise is described so that it can be replicated
      • f.
        Content of any home program component
      7. WhereDescribes the type(s) of location(s) where the intervention occurred, including any necessary infrastructure or relevant features.
      8. When and how muchDescribes the dose/scheduling of the intervention. This item is only complete if all sub-items are completely reported
      • a.
        The intensity of the exercise
      • b.
        The frequency of the exercise sessions
      • c.
        The duration of each individual exercise session
      • d.
        The overall duration of the exercise intervention
      9. Tailoring/ProgressionDescribes the what, why, when, and how of intervention titration, personalisation, or progression
      10. ModificationsDescribes any modification to the intervention during the course of the study
      11. How well: PlannedDescribes strategies used to maintain or improve fidelity (how and by whom)
      12. How well: ActualDescribes the extent to which the intervention was delivered as planned (if adherence and fidelity was assessed)