The Appraisal of Guidelines for REsearch and Evaluation II (AGREE II) tool was used to critique the guidelines.10 AGREE II is a guideline quality appraisal tool that has been found to have high construct validity.11 It consists of 23 items arranged into 6 domains: CH5424802 in vitro scope and purpose (3 items), stakeholder involvement (3 items), rigor of development (8 items), clarity of presentation (3 items), applicability (4 items), and editorial independence (2 items). Each item is scored between strongly

agree (4) and strongly disagree (1). The items scores within a domain were then added and calculated as a percentage. A domain was determined to be effectively addressed if its score was ≥60%, as has been used in other critical appraisals of arthritis guidelines.12 and 13 Before selleckchem a full critique of the guidelines, all members of the research team undertook a training review process to ensure consistency and reliability in grading. All guidelines were then reviewed independently to ensure sufficient reliability as suggested by previous authors.11 Differences in scoring were resolved through discussions and consensus between all 4 authors. Where guidelines were not clear, the identified author was contacted for clarification if possible. Finally, based on their

overall domain scores, the guidelines received an overall assessment from the research team of “recommended,” “recommended with modifications,” or “not recommended.”10 Following the AGREE II appraisal of the guidelines, recommendations that were specific to the physical management of OA were identified for data extraction. This analysis involved categorizing recommendations Vorinostat ic50 by intervention (eg, exercise, education) with their associated level of evidence (LOE) and strength of recommendation (SOR). For the purposes of this review, the interventions have been grouped for

similarity into 12 interventions. For each guideline recommendation, the associated interventions were scored on an individual weighting scale from +4 to −4 (table 1) on the basis of their LOE and SOR values. The levels of the scale were derived from LOE and SOR values found in each guideline. There was variation in how individual guidelines provided grading scales for both LOE and SOR. A list of individual guideline scales is provided in appendix 2. Guidelines based on MA, systematic reviews, and definitive randomized controlled trials (RCTs) that were strongly recommended were weighted highest (individual weighting=4), whereas expert opinion with a weak SOR was weighted low (individual weighting=1). Where a guideline provided a recommendation against an intervention, this was weighted negatively (individual weighting=−1 to −4). There were 2 exceptions to this process. First, the recommendations from the National Health and Medical Research Council guideline14 were already graded on a 4-point scale on the basis of LOE and SOR.