title: Evidence-based clinical guidelines: a new system to better determine true strength of recommendation.
abstract: OBJECTIVE
  Clinical practice guidelines often grade the 'strength' of their recommendations according to the robustness of the supporting research evidence. The existing methodology does not allow the strength of recommendation (SOR) to be upgraded for recommendations for which randomized controlled trials are impractical or unethical. The purpose of this study was to develop a new method of determining SOR, incorporating both research evidence and expert opinion.
  
  
  METHODS
  A Delphi technique was employed to produce 10 recommendations for the role of exercise therapy in the management of osteoarthritis of the hip or knee. The SOR for each recommendation was determined by the traditional method, closely linked to the category of research evidence found on a systematic literature search, and on a visual analogue scale (VAS). Recommendations were grouped A-D according to the traditional SOR allocated and the mean VAS calculated. Difference across the groups was assessed by one-way ANOVA variance analysis.
  
  
  RESULTS
  Mean VAS scores for the traditional SOR groups A-D and one proposition which was 'not recommended' showed significant linearity on one-way ANOVA. However, certain recommendations which, for practical reasons, could not assessed in randomized controlled trials and therefore could not be recommended strongly by the traditional methodology, were allocated a strong recommendation by VAS.
  
  
  CONCLUSIONS
  This new system of grading strength of SOR is less constrained than the traditional methodology and offers the advantage of allowing SOR for procedures which cannot be assessed in RCTs for practical or ethical reasons to be upgraded according to expert opinion.
authors.affiliation: Academic Rheumatology, Clinical Sciences Building, Nottingham City Hospital, Hucknall Road, Nottingham, UK. edward.roddy@nottingham.ac.uk
authors.forename: Edward
authors.initials: E
authors.lastname: Roddy
authors.forename: Weiya
authors.initials: W
authors.lastname: Zhang
authors.forename: Michael
authors.initials: M
authors.lastname: Doherty
authors.forename: Nigel K
authors.initials: NK
authors.lastname: Arden
authors.forename: Julie
authors.initials: J
authors.lastname: Barlow
authors.forename: Fraser
authors.initials: F
authors.lastname: Birrell
authors.forename: Alison
authors.initials: A
authors.lastname: Carr
authors.forename: Kuntal
authors.initials: K
authors.lastname: Chakravarty
authors.forename: John
authors.initials: J
authors.lastname: Dickson
authors.forename: Elaine
authors.initials: E
authors.lastname: Hay
authors.forename: Gillian
authors.initials: G
authors.lastname: Hosie
authors.forename: Michael
authors.initials: M
authors.lastname: Hurley
authors.forename: Kelsey M
authors.initials: KM
authors.lastname: Jordan
authors.forename: Christopher
authors.initials: C
authors.lastname: McCarthy
authors.forename: Marion
authors.initials: M
authors.lastname: McMurdo
authors.forename: Simon
authors.initials: S
authors.lastname: Mockett
authors.forename: Sheila
authors.initials: S
authors.lastname: O'Reilly
authors.forename: George
authors.initials: G
authors.lastname: Peat
authors.forename: Adrian
authors.initials: A
authors.lastname: Pendleton
authors.forename: Selwyn
authors.initials: S
authors.lastname: Richards
mesh_terms: D000704:Analysis of Variance; D003661:Decision Support Techniques; D003697:Delphi Technique; D019317:Evidence-Based Medicine; D005081:Exercise Therapy; D006801:Humans; D015207:Osteoarthritis, Hip / Q000503:physiopathology / Q000534:rehabilitation; D020370:Osteoarthritis, Knee / Q000503:physiopathology / Q000534:rehabilitation; D010147:Pain Measurement; D017410:Practice Guidelines as Topic