The Consensus on Exercise Reporting Template (CERT) applied to exercise interventions in musculoskeletal trials demonstrated good rater agreement and incomplete reporting

PEMOCS: Evaluating the effects of a concept-guided, PErsonalised, MOtor-Cognitive exergame training on cognitive functions and gait in chronic Stroke-study protocol for a randomised controlled trial

BACKGROUND

Many stroke survivors remain with residual cognitive and motor impairments despite receiving timely acute and sub-acute rehabilitation. This indicates that rehabilitation following stroke should be continuous to meet the needs of individual stroke patients. Both cognitive and motor functions are essential for mastering daily life and, therefore, should be aimed at with rehabilitation. Exergames, motor-cognitive exercises performed using video games, are an auspicious method to train both motor and cognitive functions and at the same time may foster the long-term motivation for training. This study aims to assess the effect of concept-guided, personalised, motor-cognitive exergame training on cognitive and motor functions in chronic stroke survivors.

METHODS

This study is a single-blinded, randomised controlled trial. Assessments are performed at baseline, after a 12-week intervention, and at a 24-weeks follow-up. Chronic stroke patients (≥ 18 years old, ≥ 6 months post-stroke) able to stand for 3 min, independently walk 10 m, follow a two-stage command, and without other neurological diseases apart from cognitive deficits or dementia are included. Participants in the intervention group perform the exergame training twice per week for 30 (beginning) up to 40 (end) minutes additionally to their usual care programme. Participants in the control group receive usual care without additional intervention(s). Global cognitive functioning (total Montreal Cognitive Assessment (MoCA) score) is the primary outcome. Secondary outcomes include health-related quality of life, specific cognitive functions, single- and dual-task mobility, and spatiotemporal gait parameters. The target sample size for this trial is 38 participants. Linear mixed models with the post-outcome scores as dependent variables and group and time as fixed effects will be performed for analysis.

DISCUSSION

Superior improvements in global cognitive functioning and in the abovementioned secondary outcomes in the intervention group compared to the control group are hypothesised. The results of this study may guide future design of long-term rehabilitation interventions after stroke.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05524727). Registered on September 1, 2022.

Competency in Robotic Surgery: Standard Setting for Robotic Suturing Using Objective Assessment and Expert Evaluation

OBJECTIVE

Surgical skill assessment tools such as the End-to-End Assessment of Suturing Expertise (EASE) can differentiate a surgeon's experience level. In this simulation-based study, we define a competency benchmark for intraoperative robotic suturing using EASE as a validated measure of performance.

DESIGN

Participants conducted a dry-lab vesicourethral anastomosis (VUA) exercise. Videos were each independently scored by 2 trained, blinded reviewers using EASE. Inter-rater reliability was measured with prevalence-adjusted bias-adjusted Kappa (PABAK) using 2 example videos. All videos were reviewed by an expert surgeon, who determined if the suturing skills exhibited were at a competency level expected for residency graduation (pass or fail). The Contrasting Group (CG) method was then used to set a pass/fail score at the intercept of the pass and fail cohorts' EASE score distributions.

SETTING

Keck School of Medicine, University of Southern California.

PARTICIPANTS

Twenty-six participants: 8 medical students, 8 junior residents (PGY 1-2), 7 senior residents (PGY 3-5) and 3 attending urologists.

RESULTS

After 1 round of consensus-building, average PABAK across EASE subskills was 0.90 (Range 0.67-1.0). The CG method produced a competency benchmark EASE score of >35/39, with a pass rate of 10/26 (38%); 27% were deemed competent by expert evaluation. False positives and negatives were defined as medical students who passed and attendings who failed the assessment, respectively. This pass/fail score produced no false positives or negatives, and fewer JR than SR were considered competent by both the expert and CG benchmark.

CONCLUSIONS

Using an absolute standard setting method, competency scores were set to identify trainees who could competently execute a standardized dry-lab robotic suturing exercise. This standard can be used for high stakes decisions regarding a trainee's technical readiness for independent practice. Future work includes validation of this standard in the clinical environment through correlation with clinical outcomes.

Sexual Disability in Low Back Pain: Diagnostic and Therapeutic Framework for Physical Therapists

BACKGROUND

The literature shows a relationship between sexual activity and low back pain (LBP). The aim of this work is to provide a theoretical framework and practical proposal for the management of sexual disability in individuals with LBP.

METHODS

Based on a literature review, a team of specialized physical therapists developed a pattern for the management of LBP-related sexual disability.

RESULTS

A patient reporting LBP-related sexual disability may be included in one of four clinical decision-making pathways corresponding to one of the following: #1 standard physical therapy (PT); #2 psychologically informed physical therapy (PIPT); #3 PIPT with referral; or #4 immediate referral. Standard PT concerns the management of LBP-related sexual disability in the absence of psychosocial or pathological issues. It includes strategies for pain modulation, stiffness management, motor control, stabilization, functional training, pacing activities comprising education, and stay-active advice. PIPT refers to patients with yellow flags or concerns about their relationship with partners; this treatment is oriented towards a specific psychological approach. "PIPT with referral" and "Immediate referral" pathways concern patients needing to be referred to specialists in other fields due to relationship problems or conditions requiring medical management or pelvic floor or sexual rehabilitation.

CONCLUSIONS

The proposed framework can help clinicians properly manage patients with LBP-related sexual disability.

Content reporting and effectiveness of therapeutic exercise in the management of massive rotator cuff tears: A systematic review with 490 patients

Background

Massive rotator cuff tears (MRCT) account for a substantial fraction of tears above the age of 60 years. However, there are no clear criteria for prescription parameters within therapeutic exercise treatments. The aim of this study was to evaluate the effects and characteristics of therapeutic exercise treatments in patients with MRCT.

Methods

A systematic search was conducted in MEDLINE/PubMed, Web of Science, SPORTDiscus, SciELO, Scopus and EMBASE from inception to August 2022. Studies were included if they evaluated the effects of exercise on patients with MRCT. The risk of bias was evaluated and the Consensus on Exercise Reporting Template (CERT) was also used. A narrative synthesis without meta-analysis was performed.

Results

One randomized controlled trial, two non-randomized studies, six non-controlled studies, one case series and four retrospective studies were included. They ranged from serious to moderate risk of bias. The CERT reflected a poor description of the exercise programmes. Studies showed a pattern of improvements in most patient-reported outcome measures (PROM) surpassing the MCID, and active elevation range of motion.

Conclusions

There is limited evidence that exercise and co-interventions are effective in the management of some patients with MRCT, based on a systematic review without meta-analysis. Future research should improve content reporting.

Level of evidence

IV.

Effect of resistance exercise dose components for tendinopathy management: a systematic review with meta-analysis

OBJECTIVE

To investigate potential moderating effects of resistance exercise dose components including intensity, volume and frequency, for the management of common tendinopathies.

DESIGN

Systematic review with meta-analysis and meta-regressions.

DATA SOURCES

Including but not limited to: MEDLINE, CINAHL, SPORTDiscus, ClinicalTrials.gov and ISRCTN Registry.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised and non-randomised controlled trials investigating resistance exercise as the dominant treatment class, reporting sufficient information regarding ≥2 components of exercise dose.

RESULTS

A total of 110 studies were included in meta-analyses (148 treatment arms (TAs), 3953 participants), reporting on five tendinopathy locations (rotator cuff: 48 TAs; Achilles: 43 TAs; lateral elbow: 29 TAs; patellar: 24 TAs; gluteal: 4 TAs). Meta-regressions provided consistent evidence of greater pooled mean effect sizes for higher intensity therapies comprising additional external resistance compared with body mass only (large effect size domains: β BodyMass: External = 0.50 (95% credible interval (CrI): 0.15 to 0.84; p=0.998); small effect size domains (β BodyMass: External = 0.04 (95% CrI: -0.21 to 0.31; p=0.619)) when combined across tendinopathy locations or analysed separately. Greater pooled mean effect sizes were also identified for the lowest frequency (less than daily) compared with mid (daily) and high frequencies (more than once per day) for both effect size domains when combined or analysed separately (p≥0.976). Evidence for associations between training volume and pooled mean effect sizes was minimal and inconsistent.

SUMMARY/CONCLUSION

Resistance exercise dose is poorly reported within tendinopathy management literature. However, this large meta-analysis identified some consistent patterns indicating greater efficacy on average with therapies prescribing higher intensities (through inclusion of additional loads) and lower frequencies, potentially creating stronger stimuli and facilitating adequate recovery.

Can patients and clinicians find conservative management protocols of anterior cruciate ligament injuries online? A systematic review

OBJECTIVE

To systematically search the internet for conservative rehabilitation protocols for people with an anterior cruciate ligament (ACL) injury and critically appraise the websites and exercise protocols.

DESIGN

Systematic review of online rehabilitation protocols.

SEARCH

We searched four online search-engines (Google, Yahoo, Bing, DuckDuckGo).

SELECTION CRITERIA

Rehabilitation protocols on active, English language websites aimed at conservative (non-surgical) management of an ACL injury.

DATA SYNTHESIS

We extracted descriptive information and assessed quality of the websites using the Journal of the American Medical Association (JAMA) benchmark criteria, the Health on the Net Code (HONcode) certificate, and the Flesch-Kincaid Reading Ease (FKRE). We assessed completeness of exercise protocol reporting using the Consensus on Exercise Reporting Template (CERT). We performed a descriptive analysis.

RESULTS

We found 14 websites that met our selection criteria. The protocols varied between 10 and 26 weeks duration, nine were from the United States, five targeted patients, and 13 used multiple phases with a variety of different criteria for progression. Three protocols scored good quality with the JAMA, two were HonCode certified, and ten had good readability according to the FKRE. Completeness of exercise protocol reporting in all but one protocol was poor according to the CERT.

CONCLUSION

Few rehabilitation protocols for conservative management of ACL injuries were available online. Most of the websites showed good readability, but poor quality and credibility with inadequate description of exercise protocols.

Healthcare Professionals' Perceptions of and Attitudes towards a Standardized Content Description of Interdisciplinary Rehabilitation Programs for Patients with Chronic Pain-A Qualitative Study

Interdisciplinary pain rehabilitation (IPR) is a recommended treatment for people with chronic pain. An inadequate description of the content of IPR programs makes it difficult to draw conclusions regarding their effects. The purpose of this study was to describe the perceptions and attitudes of healthcare professionals toward a content description of IPR programs for patients with chronic pain. Individual interviews with healthcare professionals (n = 11) working in IPR teams in Sweden were conducted between February and May 2019. Analysis of the interviews resulted in a theme: interdisciplinary pain rehabilitation is a complex intervention, with three categories: limitations in the description of IPR programs; lack of knowledge about IPR and chronic pain; and facilitating and hindering factors for using the content description of IPR programs. Conclusion: Healthcare professionals perceived that IPR programs could be described through a general content description. A general content description could enhance the quality of IPR programs through a better understanding of their content and a comparison of different IPR programs. Healthcare professionals also expressed the importance of a content description being a guide rather than a steering document.

High-Intensity Training for Knee Osteoarthritis: A Narrative Review

Knee osteoarthritis (OA) is the most common joint disease worldwide. Exercise therapy has been identified as a first-line treatment option in patients suffering from knee OA. High-intensity training (HIT) is an innovative exercise modality with potential in improving various disease-related outcomes. The purpose of this review is to explore the impact of HIT on knee OA symptoms and physical functioning. A comprehensive search of scientific electronic databases was conducted to identify articles on the effects of HIT on knee OA. Thirteen studies were included in this review. Ten compared the effects of HIT with those of low-intensity training, moderate-intensity continuous training, or a control group. Three evaluated the effects of HIT alone. Eight reported a decrease in knee OA symptoms (especially pain), and eight reported an increase in physical functioning. HIT was shown to improve knee OA symptoms and physical functioning, but also aerobic capacity, muscle strength, and quality of life with minimal or no adverse events. However, compared with other exercise modalities, no clear superiority of HIT was found. HIT is a promising exercise strategy in patients with knee OA; nonetheless, the actual quality of evidence remains very low, and more high-quality studies are needed to confirm these promising outcomes.

Exercise therapy reporting in clinical trials for chronic neck pain: A systematic review

OBJECTIVE

The aim of this systematic review was to assess the reproducibility of exercise therapy used in clinical trials for chronic neck pain (CNP) based on reported items from the Template for Intervention Description and Replication (TIDieR) and the Consensus on Exercise Reporting Template (CERT) checklists.

METHODS

Two researchers systematically searched, screened, and selected trials that assessed exercise therapy for CNP between 2000 and 2021 from PubMed, CINAHL, and Ovid Medline. Included studies were published in English, and study participants experienced neck pain for longer than 3 months. Thoroughness of reporting of exercise therapy was assessed using the TIDierR and CERT checklists. Methodological quality of each study was screened with the Revised Cochrane Risk of Bias Tool. Data analysis was performed for descriptive and correlational statistics.

RESULTS

Sixty-three clinical trials using exercise therapy for treatment of CNP met the inclusion criteria. No study reported all TIDieR or CERT items. The mean number of items reported was 5.44 (SD 2.40, range of 1-11) on the TIDieR, and 8.27 (SD 4.14, range of 0-17) for the CERT. Risk of bias was high for 30 studies (47.6%), somewhat concerning for 20 studies (31.7%), and low for 13 studies (21.7%). Higher risk of bias was associated with a lower number of TIDieR and CERT items reported.

DISCUSSION & CONCLUSION

The majority of exercise therapy trials for CNP lack proper reporting, limiting reproducibility of the interventions in real world clinical practice and follow-on research. After checklists were published, reporting did not improve.

Exercise Interventions During Hospitalization for Stem Cell Transplantation: An Integrative Review

Exercise interventions may influence adverse effects experienced during hospitalization for hematopoietic stem cell transplantation (HSCT). Adherence to exercise interventions is challenging. This review aimed to synthesize the literature to identify exercise interventions implemented during hospitalization for HSCT, including intervention characteristics, adherence, barriers and facilitators, and behavior change techniques using the behavior change technique taxonomy. A review of PubMed, CINAHL, PsycINFO, and Embase was completed. The sample included 19 studies. Exercise interventions demonstrated heterogeneity in prescription components, definitions, measures, and reporting of adherence. Barriers and facilitators of adherence to exercise were reported infrequently. Behavior change techniques most frequently used in studies reporting adherence rates of ≥75% included instruction on how to perform the behavior, graded tasks, and adding objects to the environment. The heterogeneity in definitions and measures of adherence limit forming conclusions to identify barriers and facilitators and determine which behavior change techniques increase adherence to exercise during HSCT.

Exercise as effective as surgery in improving quality of life, disability, and pain for large to massive rotator cuff tears: A systematic review & meta-analysis

QUESTIONS

To report the characteristics of exercise interventions and ascertain their effectiveness compared to surgery on quality of life, disability, and pain for people with large to massive rotator cuff tendon tears (L-MRCTTs).

DESIGN

Systematic review with meta-analysis of randomised controlled trials (RCTs).

PARTICIPANTS

Adults with L-MRCTTs defined as; >5 cm, 2 or more tendons.

INTERVENTION

Exercise as an intervention for L-MRCTTs.

OUTCOME MEASURES

Primary: quality of life, disability, and pain. Secondary: range of motion (ROM). The Consensus on Exercise Reporting Template (CERT) was used to extract data on the individual characteristics of each exercise intervention. The Cochrane Risk of Bias Tool V2 was used to assess study quality with the certainty of evidence assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

RESULTS

Five trials (n = 297 participants, average age 66.7 years, 55% male) were included in analysis. Three trials compared exercise to another non-surgical intervention and 2 trials compared exercise to surgery. At 12 months a significant improvement in pain of 0.47 (95% CI 0.07-0.88, I² = 53%, REM) favoured the surgical group and a significant improvement in shoulder external rotation ROM of 9° (95% CI 2.16-16.22, I² = 0%, FEM) favoured the exercise group. The median CERT score was 7/19 (range 4-12). The certainty of evidence was low or very low across all outcomes.

CONCLUSION

A paucity of high-quality research on the role of exercise in the management of L-MRCTTs exists with substantial discrepancies in the reporting of the exercise interventions in the published research.

Active Pregnancy: A Physical Exercise Program Promoting Fitness and Health during Pregnancy-Development and Validation of a Complex Intervention

Physical activity during pregnancy is a public health issue. In the view of reproducibility and the successful implementation of exercise interventions, reporting the quality of such study design must be ensured. The objective of this study was to develop and validate a physical exercise program promoting fitness and health during pregnancy. A qualitative methodological study was carried out. For the description of the exercise program, the Consensus on Exercise Reporting Template (CERT) was used. For the validation of the program, the revised guideline of the Criteria for Reporting the Development and Evaluation of Complex Interventions in Health Care (CReDECI2) was followed and went through three stages of development, piloting, and evaluation. The customizable exercise program was designed and validated by exercise and health specialists based on evidence-based, international recommendations and supported by different educational tools to be implemented by qualified exercise professionals in health and fitness settings. A 12-week testing intervention addressing a group of 29 pregnant women was carried out. The program's feasibility was subsequently evaluated by all the pregnant women. The CReDECI2 process guides practitioners and researchers in developing and evaluating complex educational interventions. The presented intervention may assist exercise specialists, health professionals, and researchers in planning, promoting, and implementing a prenatal exercise program.

Poor Reporting of Exercise Interventions for Hamstring Strain Injury Rehabilitation: A Scoping Review of Reporting Quality and Content in Contemporary Applied Research

OBJECTIVE

To review the quality of reporting and identify the content of exercise interventions prescribed for hamstring strain injury (HSI) rehabilitation in the scientific literature from 2010 to 2020.

DESIGN

Scoping review.

LITERATURE SEARCH

We searched the bibliometric databases Web of Science, CINAHL, SPORTDiscus, Scopus, Cochrane Library, MEDLINE, and Embase.

STUDY SELECTION CRITERIA

Original research articles (randomized controlled trials and cohort studies) published from 2010 to 2020 that described an exercise rehabilitation intervention for participants with acute HSIs were included. Injuries must have been confirmed within 7 days of occurrence via clinical assessment and/or diagnostic imaging.

DATA SYNTHESIS

The quality of reporting, in terms of completeness of exercise intervention description, was evaluated using the Consensus on Exercise Reporting Template (CERT), and the content of interventions was categorized into exercise types.

RESULTS

Fourteen studies were included; exercise intervention quality of reporting was moderate in 3 studies and low in 11 studies. Using the 19-item CERT, an average of 8.8 items (range, 4-14) were reported across all studies. Two studies reported sufficient exercise content and progression information to allow replication. Exercises categorized as hamstring flexibility, hamstring strength, running related, and non-hamstring specific were prescribed in 13, 11, 10, and 10 studies, respectively. Half of the included studies incorporated all 4 exercise types in their exercise interventions.

CONCLUSION

There is a wide variety of exercise interventions applied in published research that has addressed HSI rehabilitation. Researchers must improve reporting quality to support other professionals in replicating exercise interventions and help practitioners to effectively implement research in practice. J Orthop Sports Phys Ther 2022;52(3):130-141. Epub 21 Sep 2021. doi:10.2519/jospt.2022.10641.

If exercise is medicine, why don't we know the dose? An overview of systematic reviews assessing reporting quality of exercise interventions in health and disease

OBJECTIVE

To determine how well exercise interventions are reported in trials in health and disease.

DESIGN

Overview of systematic reviews.

DATA SOURCES

PubMed, EMBASE, CINAHL, SPORTDiscus and PsycINFO from inception until June 2021.

ELIGIBILITY CRITERIA

Reviews of any health condition were included if they primarily assessed quality of exercise intervention reporting using the Consensus on Exercise Reporting Template (CERT) or the Template for Intervention Description and Replication (TIDieR). We assessed review quality using a modified version of A MeaSurement Tool to Assess systematic Reviews.

RESULTS

We identified 7804 studies and included 28 systematic reviews. The median (IQR) percentage of CERT and TIDieR items appropriately reported was 24% (19%) and 49% (33%), respectively. TIDieR items 1, Brief name (median=100%, IQR 4) and 2, Why (median=98%, IQR 6), as well as CERT item 4, Supervision and delivery (median=68%, IQR 89), were the best reported. For replication of exercise interventions, TIDieR item 8, When and how much, was moderately well reported (median=62%, IQR 68) although CERT item 8, Description of each exercise to enable replication (median=23%, IQR 44) and item 13, Detailed description of the exercise intervention (median=24%, IQR 66) were poorly reported. Quality of systematic reviews ranged from moderate to critically low quality.

CONCLUSION

Exercise interventions are poorly reported across a range of health conditions. If exercise is medicine, then how it is prescribed and delivered is unclear, potentially limiting its translation from research to practice.

PROSPERO REGISTRATION NUMBER

CRD42021261285; Open Science Framework: osf.io/my3ec/.

Examining Clinical Practice Guidelines for Exercise and Physical Activity as Part of Rehabilitation for People with Stroke: A Systematic Review

BACKGROUND

Stroke is the leading cause of chronic physical disability in Western industrialised nations. Despite clear guidelines for exercise in individuals with many non-communicable diseases, the guidance for people with stroke (PwS) who frequently present with multiple comorbidities is less clear. A systematic review of exercise guidelines was undertaken to synthesise themes and patterns.

METHODS

The review was completed according to the PRISMA statement. Guideline-specific databases were searched for worldwide clinical practice guidelines (CPGs). All included papers underwent quality assessment using the AGREE II protocol. Content synthesis and analysis of the guidelines was undertaken using CERT.

RESULTS

Searching identified 2184 papers. After duplicate removal and screening by title and abstract, 22 CPGs remained for review. Seven guidelines identified three key roles for exercise interventions: (1) promoting a healthy lifestyle, (2) prevention of further strokes and (3) rehabilitation. Of concern, many CPGs fail to recommend appropriate safety measures and standards, pre-, during and post-exercise or tailor for specific needs.

CONCLUSIONS

Global guidelines for exercise in PwS lack in-depth and technical information on the exercise delivery methods, application and dosage required to progress exercise interventions for PwS.

Application of the Templates TIDieR and CERT Reveal Incomplete Reporting and Poor Replicability of Exercise Interventions for Type 2 Diabetes Mellitus

BACKGROUND

Exercise is strongly recommended for the management of type 2 diabetes mellitus (T2DM). However, incomplete intervention reporting in clinical trials limits the replication of exercise protocols. As previously demonstrated by us for exercise and hypertension, the reporting quality might also be insufficient in studies with respect to T2DM and exercise.

OBJECTIVE

The aim of the study was to assess the completeness of exercise intervention reporting in randomized controlled trials (RCTs) for T2DM.

METHODS

Two independent reviewers applied the Consensus on Exercise Reporting Template (CERT) and the template for intervention description and replication (TIDieR) to 23 exercise trials obtained from the most recent and frequently cited meta-analysis in current guidelines. The completeness of reporting was evaluated, focusing on the F.I.T.T. components (frequency, intensity, time, type). Interrater agreement and associations with publication year and journal impact factor were examined.

RESULTS

Mean CERT score was 11/19 (range 5-17), and 8/12 (range 4-12) for TIDieR. F.I.T.T. components were almost completely described, whereas overall completeness of exercise reporting was 60% and 68% (CERT and TIDieR). Replication of each exercise of the respective program was not possible in 52% of interventions. The majority of items had shown excellent agreement. No associations with publication year or impact factor were found.

CONCLUSION

Exercise interventions were not found to be sufficiently reported in RCTs that currently guide clinical practice in T2DM. Replication in further studies or clinical practice is limited due to poor exercise description. We suggest the use of more specific CERT for reporting results of exercise interventions. Further refinement for internal diseases is needed to better describe exercise interventions.

Attention to principles of exercise training: an updated systematic review of randomized controlled trials in cancers other than breast and prostate

BACKGROUND

The primary objective of this systematic review was to update our previous review on randomized controlled trials (RCTs) of exercise in cancers other than breast or prostate, evaluating: 1) the application of principles of exercise training within the exercise prescription; 2) reporting of the exercise prescription components (i.e., frequency, intensity, time, and type (FITT)); and 3) reporting of participant adherence to FITT. A secondary objective was to examine whether reporting of these interventions had improved over time.

METHODS

MEDLINE, EMBASE, CINAHL and SPORTDiscus databases were searched from 2012 to 2020. Eligible studies were RCTs of at least 4 weeks of aerobic and/or resistance exercise that reported on physiological outcomes relating to exercise (e.g., aerobic capacity, muscular strength) in people with cancer other than breast or prostate.

RESULTS

Eighty-six new studies were identified in the updated search, for a total of 107 studies included in this review. The principle of specificity was applied by 91%, progression by 32%, overload by 46%, initial values by 72%, reversibility by 7% and diminishing returns by 5%. A significant increase in the percentage of studies that appropriately reported initial values (46 to 80%, p < 0.001) and progression (15 to 37%, p = 0.039) was found for studies published after 2011 compared to older studies. All four FITT prescription components were fully reported in the methods in 58% of all studies, which was higher than the proportion that fully reported adherence to the FITT prescription components in the results (7% of studies). Reporting of the FITT exercise prescription components and FITT adherence did not improve in studies published after 2011 compared to older studies.

CONCLUSION

Full reporting of exercise prescription and adherence still needs improvement within exercise oncology RCTs. Some aspects of exercise intervention reporting have improved since 2011, including the reporting of the principles of progression and initial values. Enhancing the reporting of exercise prescriptions, particularly FITT adherence, may provide better context for interpreting study results and improve research to practice translation.

Reporting of post-operative rehabilitation interventions for Total knee arthroplasty: a scoping review

Objective

The aim of this study was to evaluate the completeness of reporting of exercise adherence and exercise interventions delivered as part of clinical trials of post-operative total knee replacement (TKA) rehabilitation.

Design: Scoping review

Literature search

A literature search was conducted in PubMed, EMBASE, AMED, CINAHL, SPORTDiscus and Cochrane Library.

Study selection criteria

All randomized controlled trials (RCT) that examined post-operative exercise-based interventions for total knee arthroplasty were eligible for inclusion. Studies that were multifactorial or contained exercise interventions for both hip and knee arthroplasty were also included.

Data synthesis

The definition, type of measurement used and outcome for exercise adherence were collected and analyzed descreptively. Quality of reporting of exercise interventions were assessed using the Consensus for Exercise Reporting Tool (CERT) and the Cochrane Risk of Bias Tool.

Results

There were a total of 112 RCTs included in this review. The majority of RCTs (63%, n = 71) did not report exercise adherence. Only 23% (n = 15) of studies provided a definition of adherence. RCTs were of poor quality, with 85% (n = 95) of studies having high or unclear risk of bias. Reporting of exercise interventions was poor, with only 4 items (of 19) (21%) of the CERT adequately reported (88–99%), with other items not fulfilled on at least 60% of the RCTs. There were no RCTs that had fulfilled all the criteria for the CERT.

Conclusion

The RCTs included in this study poorly reported exercise adherence, as well as description of the post-operative TKA rehabilitation intervention. Future RCTs should use valid and reliable measures of adherence and a proper tool for reporting of exercise interventions (e.g., CERT, TiDER).

Pre-registration

OSF:https://osf.io/9ku8a/

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04460-w.

Exercise interventions for low back pain are poorly reported: a systematic review

OBJECTIVE

To assess the reporting quality of exercise interventions from clinical trials of low back pain (LBP).

STUDY DESIGN AND SETTING

We conducted a systematic review to assess the reporting quality of randomised controlled trials (RCTs) that investigated the effectiveness of exercise interventions for patients with LBP. Five online databases and Clinical Trial Registries were searched (October 2018). We included RCTs that reported interventions for LBP, containing at least 50% exercise. The Template for Intervention Description and Replication (TIDieR) and the Consensus on Exercise Reporting Template (CERT) reporting checklists were then used to assess quality of reporting.

RESULTS

582 trials were eligible for inclusion. Due to the large number of eligible studies, 100 studies were randomly selected for data extraction and coding with the TIDieR and CERT checklists. The random sample was representative of the 582 eligible trials. The overall completeness of reporting (median (IQR)) of TIDieR items was 59.2% (45.5%-72.7%) and CERT was 33.3% (22.2%-52.6%).

CONCLUSIONS

We found poor overall reporting with both checklists, which has not improved over time or since the introduction of the checklists. More dedicated work is required to address poor reporting of exercise interventions in clinical trials.

Completeness of exercise reporting among randomized controlled trials on pelvic floor muscle training for women with pelvic organ prolapse: A systematic review

AIMS

This systematic review aimed to assess the completeness of exercise reporting in randomized controlled trials (RCTs) on pelvic floor muscle training (PFMT) for women with pelvic organ prolapse (POP).

METHODS

MEDLINE, Cochrane Central, CINHAL, Embase, SCOPUS, and PEDro databases were searched up to October 2020. Full-text RCTs comparing PFMT to any type of intervention among women with any type and stage of POP were eligible for inclusion. Completeness of intervention was evaluated with t20he template for intervention description and replication (TIDieR) and the consensus on exercise reporting template (CERT). Inter-rater agreement for each item of the tools was calculated.

RESULTS

Twenty-six RCTs were included. None of the studies completely reported all intervention descriptors. On average 57.1% (6.8 ± 2.4; out of 12) of the overall TIDieR items and 35.3% (6.7 ± 2.9; out of 19) of the CERT were well described. In particular, 7 and 5 items were completely reported more than 50% of the time for the TIDieR and CERT, respectively. Frequent shortcomings were the undetailed reporting of information regarding tailoring and modifications of exercises and their adherence. Detailed descriptions of exercise repetitions to enable replication were missing in 53.8%. According to the CERT, only 11.5% of the RCTs sufficiently described the main providers' characteristics.

CONCLUSION

The completeness of PFMT reporting for women with POP is still below desirable standards and it is insufficient to ensure transferability into practice. The present results may add relevant knowledge and contribute to improving adequate reporting of exercise.

Analysis of Movement-Based Mind-Body Interventions to Guide the Implementation of Osteoarthritis Exercise Programs: A Descriptive Review of Randomized Controlled Trials

Background: Clear and complete reporting of the components of complex interventions is required in clinical trials to ensure that research can be reliably replicated and successfully translated into clinical practice. Movement-based mind-body exercises, such as Tai Chi, qigong, and Yoga (TQY), are considered complex interventions and recommended for individuals with osteoarthritis in the latest guidelines of the American College of Rheumatology. This review analyzes the intervention reporting of randomized controlled trials of TQY to guide the implementation in osteoarthritis exercise programs. Methods: We searched PubMed, Cochrane Central Register of Controlled Trials, and EMBASE for TQY exercise trials in osteoarthritis between 2000 and 2020. Pairs of researchers independently screened the records, extracted study characteristics, and assessed 19 items on the Consensus on Exercise Reporting Template (CERT) checklist. For each of these items, the numbers of studies that clearly reported the item were calculated. We then identified the items in the studies that are key to delivering home-based exercises for further analysis. Results: We included 27 publications reporting 22 TQY interventions in the analysis. None of the studies reported sufficient details on all the 19 CERT items. The median completeness of reporting score was 11 and ranged from 6 to 15 of 19. The most frequently incompletely reported items (number reporting and percentage of studies) were "starting level rule" (n = 1, 5%) and "progression rule" (n = 1, 5%). Other incompletely reported items included "fidelity or adherence (planned)" (n = 9, 41%), "motivations" (n = 9, 41%), and "progression description" (n = 5, 23%). Conclusions: The content analysis highlights motivational strategies for long-term adherence to home-based exercises, which may help clinicians develop interventions for their patients. Details of TQY exercises interventions for osteoarthritis are incompletely reported in the included studies. The study suggests that improvements in content reporting are especially needed on items related to exercise intensity and program progression decisions, and motivational strategies in future implementation.

Efficacy of Prehabilitation Including Exercise on Postoperative Outcomes Following Abdominal Cancer Surgery: A Systematic Review and Meta-Analysis

Objectives: This systematic review set out to identify, evaluate and synthesise the evidence examining the effect of prehabilitation including exercise on postoperative outcomes following abdominal cancer surgery. Methods: Five electronic databases (MEDLINE 1946-2020, EMBASE 1947-2020, CINAHL 1937-2020, PEDro 1999-2020, and Cochrane Central Registry of Controlled Trials 1991-2020) were systematically searched (until August 2020) for randomised controlled trials (RCTs) that investigated the effects of prehabilitation interventions in patients undergoing abdominal cancer surgery. This review included any form of prehabilitation either unimodal or multimodal that included whole body and/or respiratory exercises as a stand-alone intervention or in addition to other prehabilitation interventions (such as nutrition and psychology) compared to standard care. Results: Twenty-two studies were included in the systematic review and 21 studies in the meta-analysis. There was moderate quality of evidence that multimodal prehabilitation improves pre-operative functional capacity as measured by 6 min walk distance (Mean difference [MD] 33.09 metres, 95% CI 17.69-48.50; p = <0.01) but improvement in cardiorespiratory fitness such as preoperative oxygen consumption at peak exercise (VO2 peak; MD 1.74 mL/kg/min, 95% CI -0.03-3.50; p = 0.05) and anaerobic threshold (AT; MD 1.21 mL/kg/min, 95% CI -0.34-2.76; p = 0.13) were not significant. A reduction in hospital length of stay (MD 3.68 days, 95% CI 0.92-6.44; p = 0.009) was observed but no effect was observed for postoperative complications (Odds Ratio [OR] 0.81, 95% CI 0.55-1.18; p = 0.27), pulmonary complications (OR 0.53, 95% CI 0.28-1.01; p = 0.05), hospital re-admission (OR 1.07, 95% CI 0.61-1.90; p = 0.81) or postoperative mortality (OR 0.95, 95% CI 0.43-2.09, p = 0.90). Conclusion: Multimodal prehabilitation improves preoperative functional capacity with reduction in hospital length of stay. This supports the need for ongoing research on innovative cost-effective prehabilitation approaches, research within large multicentre studies to verify this effect and to explore implementation strategies within clinical practise.

Comprehensive reporting of pelvic floor muscle training for urinary incontinence: CERT-PFMT

AIM

To produce a pelvic floor muscle training variation of the Consensus on Exercise Reporting Template (CERT-PFMT).

METHODS

Qualitative methods were used to explore the perspectives of physiotherapists who have postgraduate continence and pelvic floor rehabilitation qualifications on using research evidence to implement pelvic floor muscle training for urinary incontinence. The same experienced facilitator guided the discussions with questions derived from systematic reviews and content experts. The face-to-face focus groups were audio-recorded and verbatim transcripts were thematically analysed. For each CERT item the authors collated participant quotations that identified required explanation or elaboration for the CERT-PFMT. Systematic reviews of pelvic floor muscle training for urinary incontinence were searched by the research team for examples of good reporting.

RESULTS

Twenty- nine continence physiotherapists participated in one of seven focus groups. Participants agreed that all key elements they needed for replicating pelvic floor muscle training interventions from a research report were provided in the published CERT checklist. CERT items 2 (qualifications), 6 (motivation), 7 (progression rules), 8 (exercise description), 13 (intervention description) and 15 (starting level) required additional explanations for pelvic floor muscle training. Clinicians reported that original CERT explanations for items 1, 3-5, 8-12, 14 and 16 could be used without modification.

CONCLUSIONS

The CERT-PFMT reporting guideline has been designed with clinician input to inform how to document pelvic floor muscle training to enable replication in clinical practice. It can be used for research protocols, to construct manuscripts reporting pelvic floor muscle training for urinary incontinence and by journal editors and reviewers.

Effect of an additional health-professional-led exercise programme on clinical health outcomes after hip fracture

PURPOSE

To examine the effect of an additional 2-week health professional-led functional exercise programme compared to usual care for patients after hip fracture during a short-term nursing home stay directly after hospital discharge.

METHOD

One hundred and forty participants, 65 years or older with hip fracture, admitted to a short-term nursing home stay were randomised to an intervention group or control group. Participants in the intervention group (n = 78) received the experimental programme consisted of functional exercises, performed by health care professionals up to four times a day, 7 days a week, in addition to usual care during a 2-week short-term nursing home stay. Participants in the control group (n = 62) received usual care alone. Primary outcome was Short Physical Performance Battery (SPPB). Secondary outcomes were Timed Up & Go, New Mobility Score, The University of California, Los Angeles Activity Scale, Fall Efficacy Scale International, The EuroQol five dimension five-level questionnaire, and Numeric Rating Scale for pain. Outcome measures were assessed after 2 weeks in a short-term nursing home stay and 3 months after hip fracture surgery. The activity monitor ActivPal registered activity during the 2-week short-term nursing home stay.

RESULTS

No statistically significant differences between groups was found in any outcomes after 2 weeks or 3 months (p > 0.05). There were statistically significant within-group improvements in primary outcome SPPB and in most secondary outcomes at all time points in both groups (p > 0.05).

CONCLUSIONS

A 2-week health professional-led functional exercise programme in addition to usual care demonstrated no difference in clinical outcomes compared to usual care alone up to 3 months after hip fracture. The patients with hip fracture are fragile and vulnerable in this early phase, and usual physiotherapy may be sufficient to improve their physical function.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02780076.

i-CONTENT tool for assessing therapeutic quality of exercise programs employed in randomised clinical trials

OBJECTIVE

When appraising the quality of randomised clinical trial (RCTs) on the merits of exercise therapy, we typically limit our assessment to the quality of the methods. However, heterogeneity across studies can also be caused by differences in the quality of the exercise interventions (ie, 'the potential effectiveness of a specific intervention given the potential target group of patients')-a challenging concept to assess. We propose an internationally developed, consensus-based tool that aims to assess the quality of exercise therapy programmes studied in RCTs: the international Consensus on Therapeutic Exercise aNd Training (i-CONTENT) tool.

METHODS

Forty-nine experts (from 12 different countries) in the field of physical and exercise therapy participated in a four-stage Delphi approach to develop the i-CONTENT tool: (1) item generation (Delphi round 1), (2) item selection (Delphi rounds 2 and 3), (3) item specification (focus group discussion) and (4) tool development and refinement (working group discussion and piloting).

RESULTS

Out of the 61 items generated in the first Delphi round, consensus was reached on 17 items, resulting in seven final items that form the i-CONTENT tool: (1) patient selection; (2) qualified supervisor; (3) type and timing of outcome assessment; (4) dosage parameters (frequency, intensity, time); (5) type of exercise; (6) safety of the exercise programme and (7) adherence to the exercise programme.

CONCLUSION

The i-CONTENT-tool is a step towards transparent assessment of the quality of exercise therapy programmes studied in RCTs, and ultimately, towards the development of future, higher quality, exercise interventions.

The management of lower back pain using pilates method: assessment of content exercise reporting in RCTs

PURPOSE

To evaluate the quality of the reporting of exercise interventions with Pilates method for the treatment of lower back pain (LBP) in adults.

MATERIALS AND METHODS

Two independent evaluators selected randomized controlled trials (RCTs) of moderate and high methodological quality included in a Cochrane Systematic Review (SR) and from an additional updated search in the following databases: CENTRAL, MEDLINE, EMBASE, CINAHL, PEDro and SPORTDiscus. Three assessment tools (Consensus on Therapeutic Exercise Training (CONTENT) scale, Template for Intervention Description and Replication (TIDieR) checklist and Consensus on Exercise Reporting Template (CERT) checklist) were utilized by three pairs of two independent researchers trained. The scales' concordance was measured using the Kappa coefficient.

RESULTS

Ten RCTs were included. The CONTENT scale score was 5.3 (± 1.33) out of 9 points; the TIDieR checklist was 8.5 (± 1.71) out of 12 points and the CERT checklist was 9.5 (± 3.62) out of 19 points. The CONTENT and CERT had moderate concordance, while there was fair concordance between the other tools.

CONCLUSIONS

The overall reporting quality for the Pilates exercises in ten moderate-to-high quality RTCs for the management of LBP was low according to CONTENT scale and CERT checklist and high according to TIDieR checklist.Implications for RehabilitationReporting of Pilates exercise program in moderate-to-high quality RCTs for the management of lower back pain remains incomplete.Pilates exercise program should be personalized and contextualized to individual participants.There may be a need to consider adding to or combining the information available from various trials.

Smartphone Apps Targeting Physical Activity in People With Rheumatoid Arthritis: Systematic Quality Appraisal and Content Analysis

BACKGROUND

Rheumatoid arthritis (RA) is a disabling, inflammatory joint condition affecting 0.5%-1% of the global population. Physical activity (PA) and exercise are recommended for people with RA, but uptake and adherence tend to be low. Smartphone apps could assist people with RA to achieve PA recommendations. However, it is not known whether high quality, evidence-informed PA apps that include behavior change techniques (BCTs) previously identified as effective for PA adherence are available for people with RA.

OBJECTIVE

This study aims to systematically identify apps that include goals to facilitate PA for adults with RA and assess app quality and content for the inclusion of relevant BCTs against recommendations for cardiorespiratory, resistance, flexibility, and neuromotor PA and exercise.

METHODS

A systematic search of the Apple App Store and Google Play Store in the United Kingdom was conducted to identify English language apps that promote PA for adults with RA. Two researchers independently assessed app quality (mobile app rating scale [MARS]; range 0-5) and content (BCT Taxonomy version 1, World Health Organization, the American College of Sports Medicine, and the European League against Rheumatism recommendations for PA). The completeness of reporting of PA prescription was evaluated using a modified version of the Consensus on Exercise Reporting Template (CERT; range 0-14).

RESULTS

A total of 14,047 apps were identified. Following deduplication, 2737 apps were screened for eligibility; 6 apps were downloaded (2 on the Apple App Store and 4 on the Google Play Store), yielding 4 unique apps. App quality varied (MARS score 2.25-4.17). Only 1 app was congruent with all aspects of the PA recommendations. All apps completely or partially recommended flexibility and resistance exercises, 3 apps completely or partially advised some form of neuromotor exercise, but only 2 offered full or partial guidance on cardiorespiratory exercise. Completeness of exercise reporting was mixed (CERT scores 7-14 points) and 3-7 BCTs were identified. Two BCTs were common to all apps (information about health consequences and instruction on how to perform behavior). Higher quality apps included a greater number of BCTs and were more closely aligned to PA guidance. No published trials evaluating the effect of the included apps were identified.

CONCLUSIONS

This review identifies 4 PA apps of mixed quality and content for use by people with RA. Higher quality apps were more closely aligned to PA guidance and included a greater number of BCTs. One high-quality app (Rheumatoid Arthritis Information Support and Education) included 7 BCTs and was fully aligned with PA and exercise guidance. The effect of apps on PA adherence should be established before implementation.

Measurement and reporting of physical rehabilitation interventions in pediatric critical care: a scoping review

Purpose: To describe and evaluate physical rehabilitation research in critically ill children, including physical rehabilitation intervention reporting.Methods: We searched five electronic databases to 31 December 2018 for prospective physical rehabilitation studies conducted in pediatric intensive care units (PICU). Screening was conducted independently in duplicate. Study characteristics, outcomes, and interventions were extracted from included studies. Quality of study reporting was assessed using standardized tools. Completeness of physical rehabilitation intervention reporting was assessed using the Consensus on Exercise Reporting Template (CERT).Results: We included 20 studies enrolling a total of 2644 patients. Median (Q1,Q3) sample size was 57 (44,104). Seven studies (35%) were randomized controlled trials. Eleven studies (55%) evaluated respiratory interventions, most commonly multicomponent chest physiotherapy (73%). Nine studies (45%) evaluated physical activity interventions, most commonly progressive mobility (56%). The majority of stated outcomes (92.5%) were limited to the PICU setting. Median [Q1,Q3] quality of study reporting was good (77.2% [66.7%,87.4%]), and completeness of physical rehabilitation intervention reporting was moderate (61.9% [45.9%,71.5%]).Conclusion: Physical rehabilitation studies in critically ill children were small, and focused on evaluating respiratory-based interventions and short-term PICU-based outcomes. Reporting of physical rehabilitation interventions was suboptimal. Use of CERT may improve design and reporting in future studies.Implications for rehabilitationWhile physical rehabilitation research in critically ill children is a growing field, there are currently few studies evaluating physical rehabilitation interventions in this population.Physical rehabilitation studies to date have been small, focused on evaluating respiratory-based interventions and short-term outcomes limited to the PICU setting.The reporting of physical rehabilitation interventions in this population is suboptimal, making it challenging for clinicians to reproduce interventions and appraise their efficacy or safety.

Content reporting of exercise interventions in rotator cuff disease trials: results from application of the Consensus on Exercise Reporting Template (CERT)

Background

Exercise interventions are frequently recommended for patients with rotator cuff disease, but poor content reporting in clinical trials of exercise limits interpretation and replication of trials and clinicians’ ability to deliver effective exercise protocols. The Consensus on Exercise Reporting Template (CERT) was developed to address this problem.

Objective

To assess completeness of content reporting of exercise interventions in randomised controlled trials for patients with rotator cuff disease and the inter-rater reliability of the CERT.

Design

Critical appraisal.

Methods

Independent pairs of reviewers applied the CERT to all 34 exercise trials from the most recent Cochrane Review evaluating the effect of manual therapy and exercise for patients with rotator cuff disease. We used the CERT Explanation and Elaboration Statement to guide assessment of whether each of the 19-item criteria were clearly described (score 0–19; higher scores indicate better reporting). Percentage agreement and the prevalence and bias adjusted kappa (PABAK) coefficient were used to measure inter-rater reliability.

Results

The median CERT score was 5 (range 0–16). Percentage agreement was high for 15 items and acceptable for 4 items. The PABAK coefficient indicated excellent (5 items), substantial (11 items) and moderate (3 items) inter-rater agreement.

Conclusion

The description of exercise interventions for patients with rotator cuff disease in published trials is poorly reported. Overall, the inter-rater reliability of the CERT is high/acceptable. We strongly encourage journals to mandate use of the CERT for papers reporting trial protocols and results investigating exercise interventions.

The Consensus on Exercise Reporting Template (CERT) in a systematic review of exercise-based rehabilitation effectiveness: completeness of reporting, rater agreement, and utility

BACKGROUND

Rehabilitation interventions are diverse - making decisions about pooling data in meta-analyses challenging. Intervention reporting templates such as the Consensus on Exercise Reporting Template (CERT) may help reviewers document intervention variability.

AIM

To assess inter-rater agreement and utility of CERT used to assess completeness of reporting of one rehabilitation exercise intervention: pelvic floor muscle training (PFMT).

DESIGN

A non-experimental agreement study.

SETTING

Update of the Cochrane systematic review comparing different approaches to PFMT for urinary incontinence in women.

POPULATION

Two PFMT arms from 21 newly identified trials.

METHODS

Five raters independently used CERT to assess sufficiency of reporting of each arm (experimental PFMT and control PFMT) of each trial. One rater, PFMT non-expert, rated all trials. Four raters, all PFMT experts, assessed a mutually exclusive subgroup of the trials. In addition to rating sufficiency - "Yes" compared to No" or "Uncertain" - raters also reported on CERT utility. Expert ratings were used to determine the proportion of CERT items rated as sufficiently reported. Rater agreement was estimated using coefficient kappa and McNemar's test.

RESULTS

The range of CERT items rated as sufficiently reported was 0 to 15 of 19 items, and the mean for both trial arms was 5.5. For agreement, 11 of 19 items had sufficient data to estimate coefficient kappa and only 3 of 11 had a kappa >0.4 (moderate agreement). From the 12 of 19 items for which McNemar's test could be performed, five had evidence that PFMT experts more often rated the reporting as sufficient than the non-expert. Raters reported the CERT template was comprehensive but not complete and needed contextualizing for PFMT.

CONCLUSIONS

Completeness of reporting was poor for this example of a rehabilitation exercise intervention, and equally poor in both trial arms. Inter-rater agreement of completeness of reporting was also poor. Using a data extraction tool with poor rater-agreement may add unnecessary burden in a review. However, using a data extraction tool that enables assessment of intervention homogeneity has benefits in making decisions about which data to pool or not.

CLINICAL REHABILITATION IMPACT

Researchers reporting clinical trials must pay more attention to completeness of rehabilitation exercise reporting.

Evidence of stabilizing exercises for low back- and pelvic girdle pain - a critical review

BACKGROUND

Pregnancy-related low back pain (LBP) and pelvic girdle pain (PGP) have been associated with an alteration in the strategy for lumbopelvic stabilization. Different core stabilization approaches exist, the evidence is however controversial.

METHODS

This paper discusses how to improve the evidence of exercises for women suffering from LBP and PGP during and after pregnancy. Exercises should be understood in a context, where the bio-psycho-social perspective directs the prescription of exercises, targeting both psychological and physical factors. The type of exercise probably should be individually tailored to the needs and capability of the individual and it is not only about the most appropriate exercise, it is about dosage and delivery of the exercises, and it is about performance. To promote adherence the use of patient preferences, with self-defined movement goals, may be a motivational basis for behavior change. Communication skills may facilitate positive beliefs and provide a motivational foundation for empowerment, self-efficacy and for self-management. To learn by discovery where the patient learns through their own experiences, might motivate the patients to active engagement and to behavioral change. Adherence probably will increase when the patients understand the aim and the rationale behind the exercises they are prescribed. However, with high adherence to exercises that maintains an inappropriate motor pattern, LBP and PGP possibly could proceed into chronicity.

CONCLUSION

Exercises need to be meaningful to the patient, relevant for daily activities, individualized according to patient preferences, guided and supervised to secure performance and quality.