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10.1136/bmjopen-2024-086301
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Original Research
Rehabilitation Medicine
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Clinical practice guidelines and expert consensus statements on rehabilitation for patients with COVID-19: a systematic review
http://orcid.org/0000-0003-0081-1658
Zhang Yue 1002395737501@qq.com

http://orcid.org/0000-0002-6451-7311
Li Yuxi 100liyuxi620@126.com

http://orcid.org/0000-0003-4606-925X
Zhong Dongling 100417934055@qq.com

Li Huijing 22272051760@qq.com

Liu Xiaobo 11258644767@qq.com

Tang Wenjing 12238553739@qq.com

Chen Yuan 1614611286@qq.com

Pan Dongchuan 3*506755058@qq.com

Jin Rongjiang 1*cdzyydxjrj@126.com

http://orcid.org/0000-0002-8530-9001
Li Juan 14785939016@qq.com

1 School of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
2 School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
3 Department of rehabilitation medicine, Santai County People's Hospital, Mianyang, China
4 Affiliated Sichuan Provincial Rehabilitation Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

None declared.

DrJuanLi; 785939016@qq.com
DrRongjiangJin; cdzyydxjrj@126.com
DrDongchuanPan; 506755058@qq.com
YZ, YL and DZ contributed equally.

YZ, YL and DZ are joint first authors.

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Abstract

Objectives

To appraise the quality of clinical practice guidelines (CPGs) and expert consensus statements on rehabilitation for patients with COVID-19, summarise recommendations of rehabilitation assessments and interventions and evaluate the heterogeneity of the recommendations.

Design

Systematic review.

Data sources

PubMed and Embase databases and five online guideline repositories: The National Guideline Clearinghouse, Guidelines International Network, Scottish Intercollegiate Guidelines Network, National Institute for Health and Clinical Excellence and WHO were searched from their inception to August 2024. In addition, we reviewed reference lists of eligible citations and searched the grey literature on the relevant websites.

Eligibility criteria for selecting studies

We included CPGs and expert consensus statements which provided information about rehabilitation of patients with COVID-19. To be eligible, the CPGs and expert consensus statements were issued in English by a nationally or internationally recognised government authority, medical/academic society or organisation. If there were multiple versions of the guidelines, we included the latest one. The translations, interpretations and abstracts of guidelines were excluded.

Data extraction and synthesis

All recommendations on rehabilitation assessments and interventions for COVID-19 were extracted and summarised. Two reviewers independently evaluated the methodological quality with the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, and two other reviewers assessed the reporting quality using the Reporting Items for Practice Guidelines in Healthcare (RIGHT) statement of included CPGs and expert consensus statements. We used the Measurement Scale of Rate of Agreement to evaluate the heterogeneity of the recommendations in different CPGs and expert consensus statements.

Results

A total of 31 CPGs and expert consensus statements were included. 14 guidelines provided recommendations for rehabilitation assessments. At the early, development, critical and recovery stages of COVID-19, the most frequently recommended were exercise therapy (25.8%, 35.5%, 25.8% and 58.1%, respectively). According to AGREE II, 17 included guidelines were assessed as low methodological quality (35%–56%), 10 guidelines were rated as moderate quality (46%– 62%) and four had high quality (69%–79%). Among 31 eligible guidelines, the reporting rate of 22 items in the RIGHT checklist ranged from 10% to 100%. The included guidelines were consistent with the reference guidelines (80%–100%). Only one guideline existed minor (60%–80%) disagreements in respiratory muscle training relative to the reference guideline.

Conclusions

Rehabilitation assessments and interventions should be implemented consistently throughout the entire process of COVID-19. The recommendations should be tailored to each stage of COVID-19. The methodological and reporting qualities of several guidelines remain suboptimal. Therefore, developers should adhere strictly to the AGREE II standard and RIGHT checklist to formulate and publish CPGs and expert consensus statements with high quality.

PROSPERO registration number

CRD42020190761.

COVID-19
systematic review
SARS-CoV-2 infection
protocols and guidelines
rehabilitation medicine
Department of Science and Technology of Sichuan Province 2019YFS0019
==== Body
pmcSTRENGTHS AND LIMITATIONS OF THIS STUDY

This systematic review summarised rehabilitation recommendations for patients with COVID-19 in the present clinical practice guidelines (CPGs) and expert consensus statements and assessed the heterogeneity of recommendations using a Measurement Scale of Rate of Agreement.

This systematic review rigorously followed the Appraisal of Guidelines for Research and Evaluation II tool and the Reporting Items for Practice Guidelines in Healthcare statement to comprehensively evaluate the methodological quality and reporting quality of CPGs and expert consensus statements.

The present study included CPGs and expert consensus statements published in English; the language bias was inevitable.

The effectiveness of rehabilitation recommendations for patients with COVID-19 cannot be assessed, and further research and clinical trials are required.

Introduction

The WHO declared the COVID-19 pandemic on 11 March 2020.1 The epidemic had become a major global public health event, which had been affecting >223 countries and territories worldwide.2 Globally, over 775 million cases and 7 million deaths have been reported.3 To date, COVID-19 vaccinations have high effectiveness in preventing hospitalisation and death.4 5 However, there may be different degrees of lung infection, respiratory dysfunction, physical and mental impairment and limitation of activities of daily living (ADL) at different stages of COVID-19 (the early, development, critical and recovery stages).611 Patients with COVID-19 may suffer from respiratory, cardiovascular, gastrointestinal, renal, musculoskeletal and neurological dysfunctions.12 13 ‘Long COVID’ is commonly used to describe the symptoms and signs that persist or develop after acute coronavirus infection.14 The common symptoms include fatigue or muscle weakness (63%), sleep difficulties (26%) and anxiety or depression (23%).15 Huang et al documented that about half of patients with COVID-19 (650/1190) still had symptoms of long COVID at 2 years, which led to the decline in quality of life, decreased exercise ability, abnormal mental health and increased use of medical care.16 Studies suggested that rehabilitation interventions were beneficial for patients with COVID-19, and rehabilitation interventions could improve exercise capacity, lower limb muscle strength and physical quality of life of patients with COVID-19.1719

Rehabilitation guidance for patients with COVID-19 mainly concentrated on respiratory rehabilitation, exercise guidance, dietary guidance, physical factor therapy, living guidance, psychological intervention and traditional Chinese medicine (TCM) rehabilitation.172023 Several rehabilitation guidelines for patients with COVID-19 have been published with various quality. Guidelines with low quality could cause confusion for users of guidelines, waste medical resources and endanger patients’ care and health. Therefore, the purpose of this study is to evaluate the quality of clinical practice guidelines (CPGs) and expert consensus statements on rehabilitation for patients with COVID-19, summarise the recommendations of rehabilitation assessments and interventions and evaluate the heterogeneity of recommendations, so as to provide basis and reference for the application of these recommendations.

Methods

The systematic review was registered in the International Prospective Register of Systematic Reviews (CRD42020190761) and was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The study protocol has been published in advance (DOI: 10.1136/bmjopen-2022–0 60 767). The full PRISMA 2020 checklist is provided in online supplemental appendix 1.

Eligibility criteria

We included CPGs and expert consensus statements which provided information about rehabilitation of patients with COVID-19. To be eligible, the CPGs and expert consensus statements were issued in English by a nationally or internationally recognised government authority, medical/academic society or organisation after December 2019. If there were multiple versions of the guidelines, we included the latest one. The translations, interpretations and abstracts of guidelines were excluded.

Search strategy

We searched the PubMed and Embase databases from their inception to August 2024. We also retrieved five online guideline repositories: The National Guideline Clearinghouse, Guidelines International Network, Scottish Intercollegiate Guidelines Network, National Institute for Health and Clinical Excellence and WHO. In addition, we reviewed reference lists of eligible guidelines and searched the grey literature on the relevant websites. Search terms included rehabilitation, COVID-19, guidelines and expert consensus statements. The search strategies for each database are presented in the online supplemental appendix 2.

Study selection

We used Endnote X9 for literature management. Two reviewers (YZ and YL) independently reviewed all titles and/or abstracts to identify potential records. Then, the full texts were downloaded to determine eligible studies. Discrepancies were solved by a third reviewer (DP).

Data extraction

Two reviewers (DZ and XL) extracted the following data using a standardised form: (1) the characteristics of CPGs and expert consensus statements: title, source of guideline/ consensus and publication year; (2) stages of COVID-19; (3) recommended rehabilitation assessments; (4) recommended rehabilitation interventions and (5) related contents of methodological quality and reporting quality. The extracted data were cross-examined and any disagreement was solved via consultation with a third reviewer (RJ).

Quality assessment

We used the Appraisal of Guidelines for Research & Evaluation (AGREE II) tool and Reporting Items for Practice Guidelines in Healthcare (RIGHT) statement to evaluate the methodological quality and reporting quality of included CPGs and expert consensus statements, respectively. The assessors preassessed and discussed the samples of eligible records. We calculated the intraclass correlation coefficient (ICC) to examine the consistency between reviewers. Quality evaluation was conducted when ICC >0.8. Then, two assessors (HL and YZ) independently evaluated the methodological quality and two independent assessors (WT and YC) appraised the reporting quality. Discrepancies were arbitrated by a third reviewer (JL).

Methodological quality

AGREE II instrument has become an internationally accepted methodological quality appraisal tool for guidelines.24 The AGREE II consists of two overall assessments and 23 items involving six domains: (1) scope and purpose (items 1–3), (2) stakeholder involvement (items 4–6), (3) rigour of development (items 7–14), (4) clarity of presentation (items 15–17), (5) applicability (items 18–21) and (6) editorial independence (items 22–23). Each item is ranked on a seven-point scale (1: strongly disagree to 7: strongly agree). The standardised score is calculated using the AGREE II formula ((obtained score from all raters—minimum possible score from all raters)/(maximum possible score for all raters—minimum possible score for all raters))×100. Based on the scores of all domains, the assessors made an overall evaluation of the guidelines, including ‘recommended’, ‘recommended with modifications’ or ‘not recommended’. The scores of five or six domains >60% are usually considered as high quality, three or four domains >60% are regarded as moderate quality, two or fewer domains >60% are taken as low quality.25

Reporting quality

The RIGHT statement provides users and evaluators a clear, explicit description of the guideline development process and is also used to assess the reporting quality of the CPGs and expert consensus statements.26 A total of 22 items cover seven domains: (1) basic information (items 1–4), (2) background (items 5–9), (3) evidence (items 10–12), (4) recommendations (items 13–15), (5) review and quality assurance (items 16–17), (6) funding, declaration and management of interest (items 18–19) and (7) other information (items 20–22). Each item is judged as ‘Yes’ (relevant information is sufficiently reported) or ‘No’ (relevant information is lacking).

Heterogeneity assessment in rehabilitation entries

We used the Measurement Scale of Rate of Agreement (MSRA) to investigate the heterogeneity of recommendations which were mentioned in at least four CPGs and expert consensus statements. The scoring criteria of MSRA are 0%–20%: radically different; 20%–40%: numerous major differences; 40%–60%: some major differences; 60%–80%: only minor differences and 80%–100%: essentially identical.27 28

Data analysis

The ICC was calculated using Statistical Package for Social Sciences 25.0 to examine the consistency between reviewers. According to the ICC, the consistency is defined as poor 0.0–0.2, fair 0.21–0.4, moderate 0.41–0.6, good 0.61–0.8 and very good 0.81–1.00.29 All results were summarised and analysed with Microsoft Excel 2019. We narratively described the general characteristics of the included CPGs and expert consensus statements and summarised the recommendations of rehabilitation assessments and interventions for patients with COVID-19. The methodological quality, reporting quality and heterogeneity of recommendations were displayed in tables.

Patient and public involvement statement

Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this study.

Results

Search results

We identified 1016 records through database search and 57 from websites. 188 publications were duplicates, 854 were irrelevant records and 31 eligible CPGs and expert consensus statements3060 were eventually included. The flow chart of the selection process is shown in figure 1.

Figure 1 Flow chart of the selection process. CPG, clinical practice guideline.

Characteristics of the included guidelines

The characteristics of each guideline are provided in online supplemental appendix 3. The 31 guidelines were published from December 2019 to August 2024. Of the 31 guidelines, 25 (81%) were guidelines of rehabilitation and 6 (19%) were guidelines of diagnosis and treatment which involved recommendations of rehabilitation. 31 (100%) guidelines focused on modern rehabilitation, among which three (10%) guidelines recommended integrative rehabilitation.

Rehabilitation assessment

14 guidelines provided information on rehabilitation assessments which is divided into two main categories: clinical examination (ie, vital signs, medical history, physical examination, etc) and function assessment (including respiratory function assessment, motor function assessment, ADL assessment, psychological function assessment, limb pain assessment and participation function assessment). The details of rehabilitation assessments are summarised in table 1.

Table 1 Recommended rehabilitation assessment for patients with COVID-19

Recommended rehabilitation assessment categories	Specific rehabilitation assessments	Source of guidelines/ consensuses	
Clinical examination	Vital signs, medical history, physical examination, imaging examination, laboratory examination, nutrition screening and complication assessment	32 36 38 47 49 53 54 59 60	
Function assessment	Respiratory function assessment: (1) pulmonary function assessment: forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), FEV1/FVC, a ratio between FVC and diffusing capacity of carbon monoxide, maximum ventilation volume, deep breath volume, total lung volume, 6 min walking test (6 MWT), time up and go test;Respiratory muscle assessment: maximum inspiratory muscle strength index (MIP), maximum expiratory pressure (MEP), MIP/MEP;

Assessment of Dyspnoea: Borg Scale, modified British Medical Research Council Dyspnoea Scale (mMRC).

	3435 38 47 49 50 53 54 57 60	
Motor function assessment: (1) range of motion evaluation;Muscle force assessment: manual muscle test, isokinetic muscle testing, 30-s chair standing test, 30-s arm buckling test;

Balanced function evaluation: Berg Balance Scale, one-leg upright balance test, functional extension test;

Aerobic exercise ability: 6MWT, cardiopulmonary exercise testing, exercise intensity scale;

Physical activity assessment: International Physical Activity Questionnaire, Physical Activity Scale for the Elderly;

Assessment of freehand flexibility: rotary stability test, grab back test, seat extension test.

	34 3638 47 49 50 53 54 57	
ADL assessment: Barthel Index, Activity of Daily Living Scale (ADL).	34 36 38 50 58 60	
Psychological function assessment: (1) Self-rating Depression Scale (SDS), Baker Self-rating Depression Scale;Self-rating Anxiety Scale (SAS), Zung’s Anxiety/Depression Scale, Extensive Anxiety Scale;

Pittsburgh Sleep Quality Index (PSQI).

	3235 36 38 49 54 58 60	
Limb pain assessment: (1) Visual Analogue Scale; (2) Verbal Rating Scales	34 47 49 53 59	
Participation function assessment: (1) WHO Disability Assessment Schedule 2.0,The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36),

The WHO quality of life (WHOQOL).

	36 50 53 60	

Rehabilitation interventions

The details of the recommendations for interventions are presented in online supplemental appendix 4. At the early stage of COVID-19, the most common recommended intervention was exercise therapy (25.8%) (eg, aerobic training, hip bridge training and medical gymnastics), followed by respiratory function training (12.9%) (deep inhalation technique, breathing and expectoration skills training and chest physiotherapy, etc) and position management (9.7%).

At the development stage, the top three recommendations were exercise therapy (35.5%) (eg, stepping, medical gymnastics and joint activity training), airway cleaning (25.8%) (keeping the airway unobstructed, thoracic dilatation and sputum clearance, etc) and respiratory training (25.8%) (eg, respiratory control, active circulatory breathing technique, inspiratory and expiratory muscle training).

At the critical stage, the rehabilitation recommendations included exercise therapy (25.8%) (regular bed turnover and activities, bed/chair transfer, active/passive exercise training, muscle relaxation and stretching training, etc), respiratory function training (19.4%) (abdominal breathing training, lip-shrinking breath training, relaxing breath training, deep inhalation training and bed breathing training, etc) and position management (16.1%) (eg, position conversion training, regular roll over and maintain correct posture).

At the recovery stage, the rehabilitation interventions involving exercise therapy (58.1%) (eg, aerobic exercise, strength training and balance training), respiratory function training (54.8%) (respiratory muscle traction technology, respiratory muscle strength training and breath pattern training, etc) and psychological rehabilitation (35.5%) were strongly recommended.

TCM rehabilitation interventions such as Taichi, Baduanjin, acupuncture and Chinese medicine herbs were recommended in the whole period of COVID-19.

Quality assessment

The ICC between the two reviewers in the assessment of AGREE II was 0.81 (95% CI 0.60–0.91), which indicated very good strength of agreement.

Methodological quality

17 guidelines were rated as generally low quality, with a wide score range (35%–56%). 10 guidelines were considered as moderate quality (range 46%–62%) and four were high quality (range 69%–79%). The AGREE II domain scores for each guideline are shown in online supplemental appendix 5. The average score for domain 1 (scope and purpose) across all included guidelines was 78% (range 64%–97%). All eligible guidelines had mean scores of 41% (22%–81%) in domain 2 (stakeholder involvement). The average scores for domain 3 (rigour of development) were 40% (10%–89%) and 75% (36%–97%) for domain 4 (clarity of presentation). Regarding applicability (domain 5), 31 guidelines had mean scores of 30% (0%–85%). The mean scores for domain 6 (editorial Independence) were 45% (range 0%–88%).

Reporting quality

The reporting quality of CPGs and expert consensus statements was heterogeneous with a wide reporting rate range (10%–100%) according to the RIGHT statement (online supplemental appendix 6). The items with the lowest reporting rate were 14b with a reporting rate of 10%, followed by 14a, 19b, 16, 18b, 8b and 12 with a reporting rate of 16%, 19%, 26%, 26%, 29% and 29%, respectively. The most adequately reported items in the RIGHT statement were items 1b, 1c, 3, 6, 7a, 10a and 13a, which were reported in all included guidelines.

Heterogeneity of the recommendations

With regard to rehabilitation assessments, guidelines34 53 were selected as the reference guidelines, because of their high quality and inclusion of the most detailed recommendations. The main contents of heterogeneity for the recommendations are presented in online supplemental appendix 7. The other included guidelines were consistent with the reference guidelines (80%–100%).

Referring to rehabilitation interventions, the guideline30 issued by Chinese Association of Chest Physician COVID-19 Task Force almost contained all recommendations and was taken as the reference. The main contents of heterogeneity for the recommendations are displayed in online supplemental appendix 8. Most recommendations of rehabilitation interventions were consistent with the reference guidelines (80%–100%). Minor disagreements (60%–80%) existed in one guideline,38 in which, respiratory muscle training was not recommended routinely, except for respiratory muscle weakness.

Discussion

Based on comprehensive search, a total of 31 CPGs and expert consensus statements were included. According to all the eligible guidelines, rehabilitation assessments and interventions were recommended to be consistently implemented throughout the whole course of COVID-19. Exercise therapy and respiratory training were the most common interventions across the four stages of COVID-19. In addition, TCM interventions were recommended for patients with COVID-19. In terms of methodological quality, 17 included guidelines were rated as low methodological quality, 10 had moderate quality and four were high quality based on AGREE II. With regard to reporting quality, the reporting rate of 22 items in the RIGHT checklist ranged from 10% to 100%. Referring to heterogeneity, the included guidelines were consistent with the reference guidelines (80%–100%), and one guideline38 existed minor (60%–80%) disagreements in respiratory muscle training relative to the reference guideline.

According to the summary of recommendations from all included guidelines, the rehabilitation assessments and interventions should be implemented throughout the four stages of COVID-19 (online supplemental appendix 4). Moreover, rehabilitation interventions varied from different stages of the COVID-19. In the early stage, patients with COVID-19 suffered from physical disorders such as fever, fatigue and cough, accompanied by fear and anxiety.6 The recommended rehabilitation interventions focused on improving physical disorders and relieving unhealthy emotional disorders. Ahmed et al found that early pulmonary rehabilitation was safe and feasible for patients with COVID-19, and pulmonary rehabilitation could improve dyspnoea, exercise capacity, lung functions and fatigue.61 Early rehabilitation could prevent and improve functional impairment, shorten the duration of symptoms, reduce complications and minimise disability to the greatest extent possible.62 During the development stage of COVID-19, patients’ sitting and lying time increased obviously, which resulted in muscle weakness, poor sputum discharge, high risk of deep vein thrombosis and poor psychological problems such as anxiety and depression.63 The goal of rehabilitation was to maintain the physical condition, relieve psychological problems and prevent complications. The results of a meta-analysis demonstrated rehabilitation had the potential to improve health outcomes in patients with COVID-19, including dyspnoea, physical function, quality of life and depressive symptoms.64 Clinical study observed that respiratory rehabilitation could improve forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), FEV1/FVC%, diffusion capacity of the lung for carbon monoxide (DLCO)%, the scores of 6 min walking test and 36-item Short Form Health Survey.21 At the critical stage, rehabilitation interventions were very crucial. Moreover, vital signs monitoring and safety evaluation throughout the training should be conducted. Rehabilitation doctors and therapists should strengthen interdisciplinary communication and jointly formulate and implement rehabilitation interventions with clinicians.65 After rehabilitation interventions, patients with COVID-19 had increased mobility and activity of daily living (ADL), reduced oxygen requirements and enabled follow-up rehabilitation.66 Li et al reported that the majority of the patients in the critical stage had near-normal respiratory and functional outcomes, and no adverse events were observed after rehabilitation interventions (ie, positioning management, airway clearance techniques, oscillatory positive end-expiratory pressure, inspiratory muscle training and mobility exercises).67 In addition, 61% and 31% of these patients had low peak expiratory flow rate and maximal inspiratory pressure, respectively, while 46% had low mobility index, which suggested that long-term rehabilitation was required for these patients.67 At the recovery stage, rehabilitation focused on relieving anxiety and depression, restoring the ability of daily living and improving the quality of life to the greatest extent.68 Resistance training, endurance sessions, inspiratory muscle training and psychological rehabilitation could significantly improve muscle strength, dyspnoea, fatigue and depression scales.69 The results of the meta-analysis demonstrated that rehabilitation interventions (such as breathing training and aerobic exercises) were associated with improvements in functional exercise capacity, dyspnoea and quality of life in patients with post-COVID-19 condition.70 Li et al71 found that muscle relaxation training decreased the total scores of Patient Health Questionnaire-9 (PHQ-9), Generalized anxiety disorder-7 (GAD-7) and Pittsburgh Sleep Quality Index patients with COVID-19. After breathing and ADL training, the modified British Medical Research Council, Borg Scale, SDS and Self-rating Anxiety Scale scores decreased, and Barthel Index scores increased in patients with COVID-19.72

Traditional Chinese exercises (such as Tai Chi, Liuzijue and Yijinjing) were also recommended in the guidelines. Tang et al discovered that after 4 weeks of Liuzijue exercise, respiratory muscle strength and function improved, besides, exercise capacity increased, dyspnoea, depression, anxiety alleviated and quality of life improved.68 Zha et al reported that after 1 month of Baduanjin exercise, the prevalence of dry cough, productive cough, difficulty in expectoration and dyspnoea in patients with COVID-19 decreased from 41.7%, 43.3%, 35.0% and 50.0% to 11.7%, 11.7%, 8.3% and 15%, respectively.73 Acupuncture and Chinese herbal medicine as complementary therapies played important roles in the treatment of COVID-19. Yin et al reported acupuncture improved respiratory function, oxygen saturation and heart rate, and Chinese herbs accelerated the absorption of infected lung lesions; acupuncture combine with Chinese herbs decreased neutrophil/lymphocyte, monocyte/lymphocyte ratios and C reactive protein.74 The aforementioned evidence suggested that patients with COVID-19 were beneficial from rehabilitation of TCM.

The methodological quality varied from included guidelines. Among all the guidelines, the highest scores in the domains of AGREE II were ‘scope and purpose’ and ‘clarity of presentation’. Due to the fact that CPGs and expert consensus statements under-reported the additional materials of guidelines (eg, a summary document and a quick reference guide), potential promoters, obstacles, cost and resource input to implement its recommendations resulted in the lowest scores for ‘applicability’ in AGREE II. Additional materials are useful to help target users respond quickly to clinical problems. Insufficient reporting of cost and resource implications may be detrimental to the dissemination and implementation of the guidelines. In addition, system retrieval methods, recommendation formation methods, external reviews and guideline updates were reported insufficiently, leading to low scores in rigour of development. The detailed process of recommendation formation facilitates the target users to clearly and accurately determine the clinical application scenarios of the guidelines. External review helps to improve the reliability and objectivity of guidelines. Timely updating of guidelines helps to better adapt to the constantly changing clinical environment. Developers should consider the AGREE II standards when developing and publishing CPGs and expert consensus statements, especially in fields with low score of rigour of development (domain 3) and applicability (domain 5).

The RIGHT checklist helps guideline makers to report guidelines transparently and standardly. The reporting quality of included CPGs and expert consensus statements was low in the aspects of cost and resource implications, values and preferences of the target populations, conflicts of interest, recommendations strength and evidence quality. Understanding patients’ values and preferences helps clinicians provide the most favourable recommendations for patients and increases patient adherence. Non-transparency in conflicts of interest may cause reporting bias to some extent. Moreover, the strength of recommendations and quality of evidence are beneficial for users to judge the validity and safety of recommendations. Guideline makers are encouraged to strictly follow the RIGHT checklist and detail the guidelines’ key information, so as to report guidelines with high quality.

However, there are several limitations that should be acknowledged: (1) we only included the English version of the guidelines, which might have language bias to some extent. (2) The methodological and reporting quality of most included guidelines were regarded as low quality. The AGREE II standard and RIGHT checklist are recommended for guideline makers to develop guidelines. (3) The strength of recommendations were not evaluated in most of the included guidelines. Grades of Recommendation, Assessment, Development and Evaluation should be employed to assess the certainty of the evidence in the future.

Conclusion

Rehabilitation assessments and interventions should be carried out and run through the whole process of COVID-19, and the recommendations of rehabilitation interventions varied from different stages of the COVID-19. However, the methodological quality and reporting quality of most included guidelines were quite low. Developers should formulate and publish CPGs and expert consensus statements strictly in accordance with the AGREE II standard and RIGHT checklist.

supplementary material

10.1136/bmjopen-2024-086301 online supplemental file 1

Data availability statement

Data are available upon reasonable request.

Review Process File
10 09 2024

Funding: This work was supported by the Department of Science and Technology of Sichuan Province (grant number 2019YFS0019). The funder has no role in developing this study.

Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2024-086301).

Provenance and peer review: Not commissioned; externally peer reviewed.

Patient consent for publication: Not applicable.

Ethics approval: Not applicable.

Data availability free text: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Patient and public involvement: Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
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