Comparing the reporting and conduct quality of exercise and pharmacological randomised controlled trials: a systematic review

[DNVF Memorandum: Objectives and Methods of Physical Activity-Related Health Services Research]

The DNVF Memorandum: Objectives and Methods of Physical Activity-Related Health Services Research summarizes, for the first time, the highly interdisciplinary and interprofessional field of physical activity-based health care in the German healthcare system. In addition to providing a conceptual framework and definition of key measures and concepts in physical activity-related health care research, existing research gaps and needs are identified, and methods for advancing this relatively young field of research are described. A particular focus of this study is the relevant outcome parameters and their standardized assessment using established and valid measurement tools. The memorandum aims to establish a general understanding of the complex subject of promoting physical activity and sports therapy in the context of healthcare, to give an impulse to new research initiatives, and to integrate the currently available strong evidence on the effectiveness of physical activity and exercise into healthcare.

How completely are randomized controlled trials of non-pharmacological interventions following concussion reported? A systematic review

PURPOSE

The study aimed to examine the reporting completeness of randomized controlled trials (RCTs) of non-pharmacological interventions following concussion.

METHODS

We searched MEDLINE, Embase, PsycInfo, CINAHL, and Web of Science up to May 2022. Two reviewers independently screened studies and assessed reporting completeness using the Template for Intervention Description and Replication (TIDieR), Consensus on Exercise Reporting Template (CERT), and international Consensus on Therapeutic Exercise aNd Training (i-CONTENT) checklists. Additional information was sought my study authors where reporting was incomplete. Risk of bias (ROB) was assessed with the Cochrane ROB-2 Tool. RCTs examining non-pharmacological interventions following concussion.

RESULTS

We included 89 RCTs (n = 53 high ROB) examining 11 different interventions for concussion: sub-symptom threshold aerobic exercise, cervicovestibular therapy, physical/cognitive rest, vision therapy, education, psychotherapy, hyperbaric oxygen therapy, transcranial magnetic stimulation, blue light therapy, osteopathic manipulation, and head/neck cooling. Median scores were: TIDieR 9/12 (75%; interquartile range (IQR) = 5; range: 5-12), CERT 17/19 (89%; IQR = 2; range: 10-19), and i-CONTENT 6/7 (86%; IQR = 1; range: 5-7). Percentage of studies completely reporting all items was TIDieR 35% (31/89), CERT 24% (5/21), and i-CONTENT 10% (2/21). Studies were more completely reported after publication of TIDieR (t87 = 2.08; p = 0.04) and CERT (t19 = 2.72; p = 0.01). Reporting completeness was not strongly associated with journal impact factor (TIDieR: rs = 0.27; p = 0.01; CERT: rs = -0.44; p = 0.06; i-CONTENT: rs = -0.17; p = 0.48) or ROB (TIDieR: rs = 0.11; p = 0.31; CERT: rs = 0.04; p = 0.86; i-CONTENT: rs = 0.12; p = 0.60).

CONCLUSION

RCTs of non-pharmacological interventions following concussion demonstrate moderate to good reporting completeness, but are often missing key components, particularly modifications, motivational strategies, and qualified supervisor. Reporting completeness improved after TIDieR and CERT publication, but publication in highly cited journals and low ROB do not guarantee reporting completeness.

Developing an international consensus Reporting guideline for intervention Fidelity in Non-Drug, non-surgical trials: The ReFiND protocol

BACKGROUND

Inadequate reporting of fidelity to interventions in trials limits the transparency and interpretation of trial findings. Despite this, most trials of non-drug, non-surgical interventions lack comprehensive reporting of fidelity. If fidelity is poorly reported, it is unclear which intervention components were tested or implemented within the trial, which also hinders research reproducibility. This protocol describes the development process of a reporting guideline for fidelity of non-drug, non-surgical interventions (ReFiND) in the context of trials.

METHODS

The ReFiND guideline will be developed in six stages. Stage one: a guideline development group has been formed to oversee the guideline methodology. Stage two: a scoping review will be conducted to identify and summarize existing guidance documents on the fidelity of non-drug, non-surgical interventions. Stage three: a Delphi study will be conducted to reach consensus on reporting items. Stage four: a consensus meeting will be held to consolidate the reporting items and discuss the wording and structure of the guideline. Stage five: a guidance statement, an elaboration and explanation document, and a reporting checklist will be developed. Stage six: different strategies will be used to disseminate and implement the ReFiND guideline.

DISCUSSION

The ReFiND guideline will provide a set of items developed through international consensus to improve the reporting of intervention fidelity in trials of non-drug, non-surgical interventions. This reporting guideline will enhance transparency and reproducibility in future non-drug, non-surgical intervention research.

Exercise training improves blood pressure reactivity to stress: a systematic review and meta-analysis

Blood pressure (BP) reactivity to stress is associated with cardiovascular events and the incidence of hypertension, therefore, tolerance to stressors is important for better management of cardiovascular risks. Exercise training is among the strategies that have been investigated as blunting the peak response to stressors, however, its efficacy is poorly explored. The aim was to explore the effects of exercise training (at least four weeks) on BP responses to stressor tasks in adults. A systematic review was performed in five electronic databases (MEDLINE, LILACS, EMBASE, SPORTDiscus, and PsycInfo). Twenty-three studies and one conference abstract was included in the qualitative analysis, totaling 1121 individuals, and k = 17 and 695 individuals in the meta-analysis. Favorable results (random-effects) for exercise training were found, with attenuated peak responses in systolic (standardized mean difference (SMD) = -0.34 [-0.56; -0.11], representing average reductions of 2.5 ± 3.6 mmHg) and null effects on diastolic BP (SMD = -0.20 [-0.54; 0.14], representing average reductions of 2.0 ± 3.5 mmHg). The analysis removing outliers' studies improved the effects for diastolic (SMD = -0.21 [-0.38; -0.05]) but not systolic BP (SMD = -0.33 [-0.53; -0.13]). In conclusion, exercise training seems to lower stress-related BP reactivity, therefore has the potential to improve patients' ability to better respond to stressful situations.

Methodological consideration for a physical activity intervention in breast cancer population: An umbrella review

Objective

Breast cancer patients and survivors are increasing in the last years such as their mean age. A feasible and useful complementary intervention to improve physical and psychological health, and decrease some disease symptoms seems to be physical activity. Consequently, this umbrella review wanted to analyze the protocols of different physical activity interventions and to eventually propose a standard operating procedure for possible exercise training in breast cancer patients.Design, Data sources, Eligibility criteria. The electronic databases PubMed, Scopus, and Web of Science were searched till 25 March 2022 to detect all systematic review and meta-analysis of randomized controlled trials on this topic. The studies were analyzed narratively and evaluated with a scale to assess their quality.

Results

The studies presented heterogeneity in their population included in terms of disease stage and treatments, intervention protocols and outcomes evaluated. This made difficult to synthesize the findings.

Conclusion

It was not possible to propose a standard operating procedure but some indications were proposed to provide feedback for future studies. Ideally, an intervention should be composed of combined training (aerobic and resistance training) with a component of a mindfulness intervention, with an intensity from moderate to high, and 3 times a week. The intervention should be supervised in the first period and then it could be home-based. Exercise training should be personalized to the patients treated.

Harms of exercise training in patients with cancer undergoing systemic treatment: a systematic review and meta-analysis of published and unpublished controlled trials

Background

Exercise is recommended for people with cancer. The aim of this study was to evaluate the harms of exercise in patients with cancer undergoing systemic treatment.

Methods

This systematic review and meta-analysis included published and unpublished controlled trials comparing exercise interventions versus controls in adults with cancer scheduled to undergo systemic treatment. The primary outcomes were adverse events, health-care utilization, and treatment tolerability and response. Eleven electronic databases and trial registries were systematically searched with no date or language restrictions. The latest searches were performed on April 26, 2022. The risk of bias was judged using RoB2 and ROBINS-I, and the certainty of evidence for primary outcomes was assessed using GRADE. Data were statistically synthesised using pre-specified random-effect meta-analyses. The protocol for this study was registered in the PROESPERO database (ID: CRD42021266882).

Findings

129 controlled trials including 12,044 participants were eligible. Primary meta-analyses revealed evidence of a higher risk of some harms, including serious adverse events (risk ratio [95% CI]: 1.87 [1.47-2.39], I2 = 0%, n = 1722, k = 10), thromboses (risk ratio [95% CI]: 1.67 [1.11-2.51], I2 = 0%, n = 934, k = 6), and fractures (risk ratio [95% CI]: 3.07 [3.03-3.11], I2 = 0%, n = 203, k = 2) in intervention versus control. In contrast, we found evidence of a lower risk of fever (risk ratio [95% CI]: 0.69 [0.55-0.87], I2 = 0% n = 1109, k = 7) and a higher relative dose intensity of systemic treatment (difference in means [95% CI]: 1.50% [0.14-2.85], I2 = 0% n = 1110, k = 13) in intervention versus control. For all outcomes, we downgraded the certainty of evidence due to imprecision, risk of bias, and indirectness, resulting in very low certainty of evidence.

Interpretation

The harms of exercise in patients with cancer undergoing systemic treatment are uncertain, and there is currently insufficient data on harms to make evidence-based risk-benefits assessments of the application of structured exercise in this population.

Funding

There was no funding for this study.

Practical suggestions for harms reporting in exercise oncology: the Exercise Harms Reporting Method (ExHaRM)

The volume of high-quality evidence supporting exercise as beneficial to cancer survivors has grown exponentially; however, the potential harms of exercise remain understudied. Consequently, the trade-off between desirable and undesirable outcomes of engaging in exercise remains unclear to clinicians and people with cancer. Practical guidance on collecting and reporting harms in exercise oncology is lacking. We present a harms reporting protocol developed and refined through exercise oncology trials since 2015.Development of the Exercise Harms Reporting Method (ExHaRM) was informed by national and international guidelines for harms reporting in clinical trials involving therapeutic goods or medical devices, with adaptations to enhance applicability to exercise. The protocol has been adjusted via an iterative process of implementation and adjustment through use in multiple exercise oncology trials involving varied cancer diagnoses (types: breast, brain, gynaecological; stages at diagnosis I-IV; primary/recurrent), and heterogeneous exercise intervention characteristics (face to face/telehealth delivery; supervised/unsupervised exercise). It has also involved the development of terms (such as, adverse outcomes, which capture all undesirable physical, psychological, social and economic outcomes) that facilitate the harms assessment process in exercise.ExHaRM involves: step 1: Monitor occurrence of adverse outcomes through systematic and non-systematic surveillance; step 2: Assess and record adverse outcomes, including severity, causality, impact on intervention and type; step 3: Review of causality by harms panel (and revise as necessary); and step 4: Analyse and report frequencies, rates and clinically meaningful details of all-cause and exercise-related adverse outcomes.ExHaRM provides guidance to improve the quality of harms assessment and reporting immediately, while concurrently providing a framework for future refinement. Future directions include, but are not limited to, standardising exercise-specific nomenclature and methods of assessing causality.

What is the believability of evidence that is read or heard by physical therapists?

BACKGROUND

Physical therapists obtain information from a variety of sources. The sources may influence their believability and use in clinical practice.

OBJECTIVES

In this hypothesis-based study, we queried physical therapists (PTs) on the believability of evidence across six musculoskeletal treatment domains and analyzed variables that predicted the strength of beliefs.

METHODS

This international survey included six different language portals and used a snowball dispensation strategy. PTs who were credentialed, licensed, or who practiced in the field, were queried on the believability of six treatment domains (i.e., exercise, manual therapy, psychologically-informed practice, sports/occupational performance, thermal/electrical agents, and pain science/patient education) and potential predictors of believability (i.e., social media use, years of practice, time and access to literature, specialization, confidence in reviewing literature and attributions of the researcher).

RESULTS

In total, 1098 PTs from 36 countries completed the survey. PTs had strong beliefs in what they read or hear about exercise, sports/occupational performance, pain science/patient education, and psychologically-informed interventions. There was only moderate believability regarding manual therapy treatment and weak believability associated with thermal/electrical agents. Multiple linear regression analyses revealed that the most robust predictor to outcome relationships included time and access to literature and believability of pain science/patient education, years of clinical practice and believability of psychologically informed practice, and believability of thermal/electrical agents.

CONCLUSION

An important takeaway from this study is that believability was influenced by several factors (primarily by years of practice, attributions of the researcher, and time and access to literature) and appeared to vary across treatment domains.

Research Quality and Impact of Cardiac Rehabilitation in Cancer Survivors

Background

Cardiac rehabilitation (CR) is endorsed to improve cardiovascular outcomes in cancer survivors. The quality of CR-based research in oncology has not been assessed.

Objectives

The aim of this study was to evaluate the quality of reporting and evidence from CR-based intervention studies in oncology and to explore associations between intervention participation and outcomes.

Methods

Systematic searches of 5 databases were conducted (January 2020) and updated (September 2021). Randomized and nonrandomized studies evaluating CR-based interventions in adult cancer survivors during and after treatment were eligible. Independent reviewers extracted data using 2 reporting guidelines (Template for Intervention Description and Replication and Consolidated Standards for Reporting Trials Harms extension), risk of bias (ROB) assessment tools (Cochrane ROB 2.0 and Cochrane Risk of Bias in Non-Randomized Studies of Interventions), and a combined inventory (Tool for the Assessment of Study Quality and reporting in Exercise). A meta-analysis was used to explore pre-intervention/post-intervention differences for commonly assessed outcomes.

Results

Ten studies involving data from 685 survivors were included. The mean quality scores for intervention reporting (Template for Intervention Description and Replication) and harms (Consolidated Standards for Reporting Trials Harms extension) were 62% and 17%, respectively. There was moderate-to-high ROB across nonrandomized (Cochrane Risk of Bias in Non-Randomized Studies of Interventions score: 25%) and randomized (ROB 2.0 score: 50%) studies. The mean standardized cardiorespiratory fitness was higher (0.42; 95% CI: 0.27-0.57), fatigue was lower (−0.45; 95% CI: −0.55 to −0.34), and percent body fat (0.07; 95% CI: −0.23 to 0.38) was not different in survivors completing CR compared with those not completing CR.

Conclusions

CR-based studies in oncology have low-to-moderate reporting quality and moderate-to-high ROB limiting interpretation, reproducibility, and translation of this evidence into practice.

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/.