From MARS to MAGIC: The remarkable journey through time and space of the Grading of Recommendations Assessment,Development and Evaluation initiative

For over 30 years, “evidence‐based” clinical guidelines remained entrenched in an oversimplified, design‐based, framework for rating the strength of evidence supporting clinical recommendations. The approach frequently equated the rating of evidence with that of the recommendations themselves. “Grading Recommendations Assessment, Development and Evaluation (GRADE)” has emerged as a proposed antidote to obsolete guideline methodology. GRADE sponsors and collaborators are in the process of attempting to amplify and extend the framework to encompass implementation and adaptation of guidelines, above and beyond the evaluation and rating of clinical research. Alternative schemes and models for such extensions are beginning to appear. This commentary reviews the strengths and weaknesses of GRADE with reference to other recent critiques. It considers the GRADE Working Group's “evidence‐to‐decision” extension of the evidence rating framework, together with proposed alternatives. It identifies pitfalls of the GRADE system's cooptation of relational processes necessary to the interpretation and uptake of recommendations that properly belong to end‐users. It also identifies dangers inherent in blurring important boundaries between clinical and policy applications of guidelines. Finally, it addresses criticisms regarding the lack of a theoretical framework supporting the different facets of the GRADE approach and proposes a social constructivist orientation to clinical guideline development and use. Recommendations are offered to potential guideline developers and users regarding how to draw upon the strengths of the GRADE framework without succumbing to its pitfalls.     

新型冠状病毒感染患者营养支持治疗专家建议(2023)

规范化营养支持治疗可有效改善新型冠状病毒感染患者的营养状况、免疫功能和临床结局,加速机体康复并降低复发风险,提高生活质量,在新型冠状病毒感染患者的治疗与康复中发挥着重要作用。《新型冠状病毒感染诊疗方案(试行第十版)》中也明确提出,应将营养支持治疗纳入新型冠状病毒感染患者治疗与康复的全过程。为此,北京市临床营养治疗质量控制和改进中心组织相关专家,在结合最新临床营养指南、研究证据及临床实践经验的基础上,制订了《新型冠状病毒感染患者营养支持治疗专家建议(2023)》。本建议提出,应建立并遵循包括营养筛查、营养诊断、营养支持治疗和临床监测在内的规范化营养管理路径与策略,并结合新型冠状病毒感染患者的临床特点,实施个体化营养管理,旨在为临床医生和临床营养医师等专业人员开展规范化营养支持治疗提供借鉴。     

Evidence for single-limb exercises on exercise capacity,quality of life,and dyspnea in patients with chronic obstructive pulmonary disease or chronic heart failure

Abstract

Background: Although single-limb exercise (SLE) has been used for patients with chronic obstructive pulmonary disease (COPD) and for patients with chronic heart failure (CHF), the evidence for SLE has not been evaluated systematically and remains unclear.

Objectives: Determine the evidence for the effect of SLE compared to any comparator on outcome measurements for exercise capacity, quality of life (QoL) or dyspnea in patients with COPD or CHF.

Methods: PubMed, PEDro, and CENTRAL databases were searched from inception until 31 May 2011. Searches started 1 April 2011. English language randomized controlled trials (RCTs) were included. Extraction of data was performed by two review authors. Data and evidence for SLE were summarized in accordance with grading of recommendations assessment, development and evaluation (GRADE) guidelines. Authors of included studies were contacted for missing data.

Results: Six RCTs (two COPD and four CHF) were included. Low to very low-quality evidence indicates that SLE significantly improved exercise capacity, but not dyspnea, in patients with COPD, and significantly improved exercise capacity outcomes compared to a control in patients with CHF. However, when SLE was compared to non-SLE regimes in patients with CHF, positive effects were found irrespective of training regime regarding exercise capacity and QoL.

Conclusions: SLE appears to be effective in both conditions especially regarding exercise capacity, and might be included in exercise programs in patients with COPD or CHF. However, the evidence is low to very low according to GRADE and more clinical studies of high quality are required.     

基于GRADE康复临床实践指南证据质量与推荐强度研究

目的 分析康复临床实践指南的GRADE结果。方法 在PubMed、EMBASE、中国知网(CNKI)、中国生物医学文献数据库(CBM)和万方等数据库以及指南相关网站检索康复医学临床指南,检索时限均为建库至2020年1月11日。由2名研究员独立筛选采用GRADE系统的指南,并对GRADE分级结果进行提取分析。结果 共纳入康复临床实践指南83篇,其中46篇(55.4%)应用分级系统,采用GRADE分级系统的指南仅4篇(4.8%),包含44条推荐意见,其中39条(88.6%)具有明确的证据质量。在推荐意见所引用证据中,低质量证据最多(34.1%);在推荐意见中,弱推荐较多(56.8%)。强推荐支持证据的质量高于弱推荐(χ² = 8.218, P < 0.05)。 结论 康复临床实践指南对GRADE分级系统的应用仍待提高。建议指南制订者进一步掌握指南和GRADE方法学,更有效地改善康复临床实践指南的可靠性和应用性。     

Management of bleeding following major trauma: an updated European guideline

Introduction

Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient, which when implemented may improve patient outcomes.

Methods

The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document presents an updated version of the guideline published by the group in 2007. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.

Results

Key changes encompassed in this version of the guideline include new recommendations on coagulation support and monitoring and the appropriate use of local haemostatic measures, tourniquets, calcium and desmopressin in the bleeding trauma patient. The remaining recommendations have been reevaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies.

Conclusions

This guideline provides an evidence-based multidisciplinary approach to the management of critically injured bleeding trauma patients.     

Common Community-acquired Bacterial Skin and Soft-tissue Infections in Children: an Intersociety Consensus on Impetigo,Abscess, and Cellulitis Treatment

Purpose

The main objective of this article was to offer practical suggestions, given the existing evidence, for identifying and managing bacterial impetigo, abscess, and cellulitis in ambulatory and hospital settings.

One-Third of Systematic Reviews in Rehabilitation Applied the Grading of Recommendations Assessment,Development, and Evaluation (GRADE) System to Evaluate Certainty of Evidence: A Meta-Research Study

ObjectiveTo determine how many systematic reviews (SRs) of the literature in rehabilitation assess the certainty of evidence (CoE) and how many apply the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to do this.Data SourcesFor this meta-research study, we searched PubMed and Cochrane Database of Systematic Reviews databases for SRs on rehabilitation published in 2020.Study Selection and Data ExtractionTwo reviewers independently selected the SRs and extracted the data. Reporting characteristics and appropriate use of the GRADE system were assessed.Data SynthesisThe search retrieved 827 records: 29% (239/827) SRs evaluated CoE, 68% (163/239) of which applied the GRADE system. GRADE was used by SRs of randomized controlled trials (RCTs, 88%; 144/163), non-randomized intervention studies (NRIS, 2%; 3/163), and both RCT and NRIS (10%; 16/163). In the latter case, a separate GRADE assessment according to the study design was not provided in 75% (12/16). The reasons for GRADE judgment were reported in 82% (134/163) of SRs.ConclusionsOne-third of SRs in rehabilitation assessed CoE with the GRADE system. GRADE assessment was presented transparently by most SRs. Journal editors and funders should encourage the uptake of the GRADE system when considering SRs in rehabilitation for publication. The authors should pre-define GRADE assessment in a registered and/or published protocol.     

通过改进挽留政策提高农村和边远地区卫生人力的可及性:WHO2010全球政策建议解读

农村和边远地区卫生人力资源不足是世界各国普遍关注的卫生问题之一,严重影响卫生公平的实现.对此,WHO提出全球政策建议——通过改进挽留政策提高农村和边远地区卫生人力的可及性.本文重点从循证医学方法学和指南制定角度,对该政策指南制定的关键步骤进行解读,主要包括背景及问题的提出、证据的检索与遴选、证据质量分级与推荐方案形成,从而进一步探讨卫生决策过程中如何正确认识、获得、评价与应用当前可得的研究证据,以及如何基于证据,利用GRADE系统做出科学可行的推荐,强调证据及GRADE系统在循证卫生决策中的重要作用.     

Exercise for Depressive Symptoms in Parkinson Disease: A Systematic Review and Meta-analysis of Randomized Controlled Trials

ObjectiveTo evaluate the efficacy of physical exercise in improving depressive symptoms in Parkinson disease (PD).Data Source and Study SelectionWe conducted a systematic review of randomized controlled trials (RCTs) following a prespecified protocol guidance (PROSPERO CRD42021243142). Two independent authors searched for studies in MEDLINE, Cochrane Register of Controlled Trials, Physiotherapy Evidence Database, Embase, PsycINFO, and Sports Discus from database inception to June 2022.Data ExtractionTwo independent authors extracted the data and evaluated the risk of bias using the revised Cochrane risk of bias tool. We performed random-effects meta-analyses and rated the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.Data SynthesisA total of 36 RCTs met the inclusion criteria, 14 of which were pooled in the quantitative synthesis. Depression symptomatology significantly decreased in the exercise group compared with usual care (standardized mean difference [SMD], ?0.49; 95% confidence interval [CI], ?0.74 to ?0.24; very low quality of evidence; 14 RCTs; 961 participants). Physical exercise also improved patients’ quality of life (SMD, ?0.51; 95% CI, ?0.81 to ?0.21; 7 RCTs; 485 participants). As for acceptability, we did not find any difference between exercise and usual care (relative risk, 1.01; 95% CI, 0.97 to 1.05; 12 RCTs; 1048 participants). We judged all the studies except 2 to be at high risk of bias.ConclusionsResults from our systematic review identify physical activity as a viable option to reduce depressive symptoms in PD. Future clinical practice guidelines should consider physical exercise in their recommendations for depression symptomatology reduction in people with PD.     

Economic evaluations for intensive care unit randomised clinical trials in Australia and New Zealand: Practical recommendations for researchers

ObjectivesEconomic evaluations of intensive care unit (ICU) interventions have specific considerations, including how to cost ICU stays and accurately measure quality of life in survivors. The aim of this article was to develop best practice recommendations for economic evaluations alongside future ICU randomised controlled trials (RCTs).Review methodsWe collated our experience based on expert consensus across several recent economic evaluations to provide best-practice, practical recommendations for researchers conducting economic evaluations alongside RCTs in the ICU. Recommendations were structured according to the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Consolidated Health Economic Evaluation Reporting Standards (CHEERS) Task Force Report.ResultsWe discuss recommendations across the components of economic evaluations, including: types of economic evaluation, the population and sample size, study perspective, comparators, time horizon, choice of health outcomes, measurement of effectiveness, measurement and valuation of quality of life, estimating resources and costs, analytical methods, and the increment cost-effectiveness ratio. We also provide future directions for research with regard to developing more robust economic evaluations for the ICU.ConclusionEconomic evaluations should be built alongside ICU RCTs and should be designed a priori using appropriate follow-up and data collection to capture patient-relevant outcomes. Further work is needed to improve the quality of data available for linkage in Australia as well as developing costing methods for the ICU and appropriate quality of life measurements.     

2019年期刊公开发表的中国临床实践指南文献调查与评价——证据质量和推荐强度

目的调查2019年期刊公开发表的中国临床实践指南证据质量和/或推荐强度分级现状,以期为指南制订者合理应用证据质量和推荐强度分级方法提供参考。方法系统检索并筛选2019年期刊公开发表的中国临床实践指南,纳入对推荐意见进行证据质量和/或推荐强度分级的指南。提取证据质量和推荐强度的分级方法、分级描述和表述内容等信息。结果 2019年期刊公开发表的中国临床实践指南共226篇,其中106篇(46.9%)(中文87篇,英文19篇)纳入本研究。采用的分级方法共18种,其中推荐意见分级评价、制订与评估(Grading of Recommendations Assessment, Development and Evaluation, GRADE)分级系统应用最多(35.8%,38/106);采用的分级描述共6种,证据质量分级描述多采用字母(39.6%,42/106),推荐强度分级描述多采用文字(34.9%,37/106)。采用文字描述推荐强度的指南中,最常使用的词语是"可以"。38篇指南采用GRADE分级,仅15篇按照GRADE工作组要求规范呈现分级标准及内容,共包含250条分级明确的推荐意见,60....     

2019年期刊公开发表的中国临床实践指南文献调查与评价——证据质量和推荐强度

目的调查2019年期刊公开发表的中国临床实践指南证据质量和/或推荐强度分级现状,以期为指南制订者合理应用证据质量和推荐强度分级方法提供参考。方法系统检索并筛选2019年期刊公开发表的中国临床实践指南,纳入对推荐意见进行证据质量和/或推荐强度分级的指南。提取证据质量和推荐强度的分级方法、分级描述和表述内容等信息。结果 2019年期刊公开发表的中国临床实践指南共226篇,其中106篇(46.9%)(中文87篇,英文19篇)纳入本研究。采用的分级方法共18种,其中推荐意见分级评价、制订与评估(Grading of Recommendations Assessment, Development and Evaluation, GRADE)分级系统应用最多(35.8%,38/106);采用的分级描述共6种,证据质量分级描述多采用字母(39.6%,42/106),推荐强度分级描述多采用文字(34.9%,37/106)。采用文字描述推荐强度的指南中,最常使用的词语是"可以"。38篇指南采用GRADE分级,仅15篇按照GRADE工作组要求规范呈现分级标准及内容,共包含250条分级明确的推荐意见,60.4%(151/250)为强推荐,44.8%(112/250)的推荐意见引用低或极低质量证据,38.4%(96/250)的推荐意见采用系统评价作为证据支持。结论 2019年期刊公开发表的中国指南分级系统使用率较低,且分级方法使用仍不完整、不统一、不规范。GRADE分级系统使用率低,仅极少数指南按照GRADE工作组要求规范呈现分级标准及内容。推荐使用GRADE分级系统,促进指南推荐意见的科学、透明与合理制订。     

Management of bleeding following major trauma: a European guideline

Introduction

Evidence-based recommendations can be made with respect to many aspects of the acute management of the bleeding trauma patient, which when implemented may lead to improved patient outcomes.

Methods

The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing guidelines for the management of bleeding following severe injury. Recommendations were formulated using a nominal group process and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) hierarchy of evidence and were based on a systematic review of published literature.

Results

Key recommendations include the following: The time elapsed between injury and operation should be minimised for patients in need of urgent surgical bleeding control, and patients presenting with haemorrhagic shock and an identified source of bleeding should undergo immediate surgical bleeding control unless initial resuscitation measures are successful. A damage control surgical approach is essential in the severely injured patient. Pelvic ring disruptions should be closed and stabilised, followed by appropriate angiographic embolisation or surgical bleeding control, including packing. Patients presenting with haemorrhagic shock and an unidentified source of bleeding should undergo immediate further assessment as appropriate using focused sonography, computed tomography, serum lactate, and/or base deficit measurements. This guideline also reviews appropriate physiological targets and suggested use and dosing of blood products, pharmacological agents, and coagulation factor replacement in the bleeding trauma patient.

Conclusion

A multidisciplinary approach to the management of the bleeding trauma patient will help create circumstances in which optimal care can be provided. By their very nature, these guidelines reflect the current state-of-the-art and will need to be updated and revised as important new evidence becomes available.     

The Development of Evidence-based Prehospital Guidelines Using a GRADE-based Methodology

Abstract

Background. The burgeoning literature in prehospital care creates an opportunity to improve care through evidence-based guidelines (EBGs). Previously, an established process for the creation of such guidelines and adoption and implementation at the local level was lacking. This has led to great variability in the content of prehospital protocols in different jurisdictions across the globe. Recently the Federal Interagency Committee on Emergency Medical Services (FICEMS) and the National EMS Advisory Council (NEMSAC) approved a National Prehospital Evidence-based Guideline Model Process for the development, implementation, and evaluation of EBGs. The Model Process recommends the use of established guideline development tools such as Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Objective. To describe the process of development of three prehospital EBGs using the National Prehospital EBG Model Process (EBG Model Process) and the GRADE EBG development tool. Methods. We conducted three unique iterations of the EBG Model Process utilizing the GRADE EBG development tool. The process involved 6 distinct and essential steps, including 1) assembling the expert panel and providing GRADE training; 2) defining the evidence-based guideline (EBG) content area and establishing the specific clinical questions to address in patient, intervention, comparison, and outcome (PICO) format; 3) prioritizing outcomes to facilitate systematic literature searches; 4) creating GRADE tables, or evidence profiles, for each PICO question; 5) vetting and endorsing GRADE evidence tables and drafting recommendations; and 6) synthesizing recommendations into an EMS protocol and visual algorithm. Feedback and suggestions for improvement were solicited from participants and relevant stakeholders in the process. Results. We successfully used the process to create three separate prehospital evidence-based guidelines, formatted into decision tree algorithms with levels of evidence and graded recommendations assigned to each decision point. However, the process revealed itself to be resource intensive, and most of the suggestions for improvement would require even more resource utilization. Conclusions. The National Prehospital EBG Model Process can be used to create credible, transparent, and usable prehospital evidence-based guidelines. We suggest that a centralized or regionalized approach be used to create and maintain a full set of prehospital EBGs as a means of optimizing resource use.     

Standardization of nutritional support: are protocols useful?

This paper reviews the benefits that a structured format such as a protocol can bring to the delivery of nutritional support. The four main areas of influence are: (1) patient selection, in which indications for feeding and evaluation of the risk/benefit ratio are discussed; (2) timing of nutritional support, in which guidelines for initiating feeding are proposed; (3) delivery of nutrition, in which protocols to limit complications and optimize delivery are reviewed; and (4) feed content, in which guidelines for appropriate nutrients and formulation for special considerations are identified. The importance of an evidence base is stressed and some of the evidence supporting specific recommendations is reviewed.     

Going from evidence to recommendations: Can GRADE get us there?

The evidence based medicine movement has championed the need for objective and transparent methods of clinical guideline development. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was developed for that purpose. Central to this framework is criteria for assessing the quality of evidence from clinical studies and the impact that body of evidence should have on our confidence in the clinical effectiveness of a therapy under examination. Grades of Recommendation, Assessment, Development, and Evaluation has been adopted by a number of professional medical societies and organizations as a means for orienting the development of clinical guidelines. As a result, the method of GRADE has implications on how health care is delivered and patient outcomes. In this paper, we reveal several issues with the underlying logic of GRADE that warrant further discussion. First, the definitions of the “grades of evidence” provided by GRADE, while explicit, are functionally vague. Second, the “criteria for assigning grade of evidence” is seemingly arbitrary and arguably logically incoherent. Finally, the GRADE method is unclear on how to integrate evidence grades with other important factors, such as patient preferences, and trade‐offs between costs, benefits, and harms when proposing a clinical practice recommendation. Much of the GRADE method requires judgement on the part of the user, making it unclear as to how the framework reduces bias in recommendations or makes them more transparent—both goals of the programme. It is our view that the issues presented in this paper undermine GRADE's justificatory scheme, thereby limiting the usefulness of GRADE as a tool for developing clinical recommendations.     

中国全膝关节置换术围手术期疼痛管理指南(2022)

全膝关节置换术(total knee arthroplasty, TKA)是目前治疗终末期膝关节疾病的主要方法。TKA术后常伴有中度至重度的疼痛,严重影响患者术后康复、患者满意度和总体疗效。多模式镇痛被认为是缓解TKA术后疼痛的理想方案。目前尚无TKA围手术期疼痛管理指南。经中华医学会骨科学分会关节外科学组、北京医学会骨科专业委员会关节外科学组批准及专家讨论,采用推荐意见的分级评估、制定及评价方法及国际实践指南报告规范,遴选出最为关注的20个临床问题,通过证据检索、证据质量评价及确立推荐意见和强度,采用德尔菲法进行4轮函询,最终形成20条推荐意见。本指南的制定旨在提高TKA围手术期疼痛管理的规范化和标准化。     

Beyond the RCT – understanding the relationship between interventions,individuals and outcome – the example of neurological rehabilitation

Background.?Rehabilitation is highly complex, involving multiple processes, outcomes and stakeholders. The way we deliver our services and work with our clients and their families should be informed by research approaches that produce the wide range of knowledge needed. This article aims to explore the degree to which the dominant approach to ‘evidence’ (the randomised clinical trial or RCT) meets those needs and discuss alternate/additional ways of gaining evidence.

Methods.?A critical review of the literature allowing exploration of problems encountered in rehabilitation RCTs and alterative approaches.

Findings.?We discuss some problematic issues related to using RCTs in rehabilitation research (for example the large number of people excluded from trials, and the small numbers of people with some neurological conditions making RCTs non-viable). Alternative approaches are discussed including clinical practice improvement studies (sometimes called practice-based evidence or PBE), which provide data on patients treated in routine practice; qualitative research, which can provide an understanding of the users of health care services to ensure they are meeting their needs; and metasynthesis, which can be used to summarise several qualitative studies to enhance our understanding of the principles underlying service delivery. Finally, we explore how clinicians and commissioners often use evidence generated by forms of research other than the RCT.

Conclusion.?The best answers about how to enhance rehabilitation outcomes are likely to come from a combination and integration of the most appropriate methods. In conclusion, we urge for more joined up thinking, for learning from different fields so that we can develop more effective and appropriate health care and rehabilitation.     

Nutritional assessment and counseling for prevention and treatment of cardiovascular disease

Physicians face several barriers to counseling their patients about nutrition, including conflicting evidence of the benefit of counseling, limited training and understanding of the topic, and imperfect and varied guidelines to follow. Because cardiovascular disease remains the leading cause of death in industrialized nations, family physicians should provide more than pharmacologic interventions. They must identify the patient's dietary habits and attitudes and provide appropriate counseling. Tools are available to help, and a seven-step approach to nutritional therapy for the dyslipidemic patient may be useful. These steps include recommending increased intake of plant proteins; increased intake of omega-3 fatty acids; modification of the types of oils used in food preparation; decreased intake of saturated and trans-fatty acids; increased intake of whole grains and dietary fiber (especially soluble fiber) and decreased intake of refined grains; modification of alcohol intake, if needed; and regular exercise. Recommendations should be accompanied by patient information handouts presenting acceptable substitutions for currently identified detrimental food choices.     

Effectiveness of Photobiomodulation and Oral Cryotherapy on Oral Mucositis Among Patients Undergoing Chemotherapy Conditioning Prior to Hematological Stem Cell Transplantation

ObjectivesThis review evaluated the best available evidence concerning the effectiveness of photobiomodulation compared to oral cryotherapy in oral-mucositis prevention among patients with hematological stem cell transplantation (HSCT) receiving chemo-conditioning.Data SourcesAn extensive search for published and unpublished studies was conducted in 11 electronic databases and reference lists. Only randomized controlled trials (RCTs) were included. Two reviewers independently screened relevant studies for eligibility, extracted data using a standardized data collection form, and appraised data using the Cochrane Risk of Bias Tool and Grading Recommendations, Assessment, Development and Evaluation (GRADE). Meta-analyses using a random-effect model was performed using Review Manager software. Subgroup analyses were conducted to examine the differential effect of interventions across subgroups and to explore potential sources of heterogeneity. Meta-analyses included 18 RCTs (involving 1,018 patients). Both photobiomodulation and cryotherapy were effective in reducing oral-mucositis severity, severe oral-mucositis incidence, duration, and pain with small to large effect sizes. No significant differences were detected between photobiomodulation and cryotherapy across all outcomes. Subgroup analyses showed significant differences for chemo-conditioning regimens. The overall Grading Recommendations, Assessment, Development and Evaluation quality of evidence was low.ConclusionBoth photobiomodulation and cryotherapy were effective nonpharmacological oral-mucositis prophylaxis and analgesia, with no significant difference in effectiveness. Chemo-conditioning regimens may influence their effectiveness. Future RCTs may directly compare the effectiveness of photobiomodulation and cryotherapy on the HSCT patients. Rigorous cost-effectiveness studies are also required.Implications for Nursing PracticePhotobiomodulation and cryotherapy can be offered to HSCT patients in clinical settings. A clinical guideline of both interventions can be also developed.