# Standardised operating procedures for recommendations in the field of physical and rehabilitation medicine

Christelle Nguyen, Maxence Compagnat, Jonathan Lévy, Isabelle Bonan, François Constant Boyer, Mickaël Dinomais, François Genêt, François Rannou, Patricia Ribinik, Dominic Pérennou, et al.

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Christelle Nguyen, Maxence Compagnat, Jonathan Lévy, Isabelle Bonan, François Constant Boyer, et al. Standardised operating procedures for recommendations in the field of physical and rehabilitation medicine. Annals of Physical and Rehabilitation Medicine, 2025, 68 (3), pp.101951. 10.1016/j.rehab.2025.101951. hal-05006604

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Original article

# Standardised operating procedures for recommendations in the field of physical and rehabilitation medicine

<figure><img src="image_2.png" /></figure>

Christelle Nguyen<sup>a,b,c,*</sup>, Maxence Compagnat<sup>d,e</sup>, Jonathan Lévy<sup>f,g</sup>, Isabelle Bonan<sup>h,i,j</sup>, François Constant Boyer<sup>k,l</sup>, Mickaël Dinomais<sup>m</sup>, François Genêt<sup>f,g</sup>, François Rannou<sup>a,b,c</sup>, Patricia Ribinik<sup>n</sup>, Dominic Pérennou<sup>o,p</sup>, Arnaud Dupeyron<sup>q</sup>

## ARTICLE INFO

### Article History:

Received 29 January 2025

Accepted 29 January 2025

Available online xxx

### Keywords:

Recommendations

Practical guidelines

Clinical guidelines

Physical and rehabilitation medicine

## ABSTRACT

**Background:** There is an outstanding increased demand for recommendations in the rehabilitation field. Over 600 recommendation articles have been published in the last decade, primarily by groups of authors based on unclear criteria and only a few by learned societies based on standardized methods.

**Objectives:** In 2007, the French Society of Physical and Rehabilitation Medicine (SOFMER) published a methodology to establish recommendations in physical and rehabilitation medicine (PRM). This framework, which served to publish 22 sets of management recommendations, must be reworked to meet new international methods for elaborating recommendations. Therefore, our objectives were: 1) to elaborate an updated methodology to enhance the dissemination and implementation of SOFMER-endorsed recommendations, and 2) to standardize and report in sufficient detail the successive steps from the elaboration of these recommendations to the evaluation of their impact and provide supporting tools to guide developers.

**Methods:** At the SOFMER's request, a steering committee assembled, consisting of 7 PRM senior physicians with experience in elaborating, disseminating, implementing and/or evaluating recommendations in the field of PRM. They conducted a non-systematic literature review to identify methodologies and standardized operating procedures previously published by scientific societies in France and overseas. Available information regarding strategies for elaboration, dissemination, implementation and evaluation of the recommendations, scientific valorization and business models was retrieved. Participants in previous recommendations were also interviewed regardless of their field.

**Abbreviations:** Acp, american college of physicians; Agree, appraisal of guidelines for research & evaluation; Ard, annals of rheumatic diseases; prem, physical and rehabilitation medicine; Bmj, British medical journal; Esprm, european society of physical and rehabilitation medicine; Eular, european league against rheumatism; Grade, grading of recommendations, assessment, development, and evaluations; ISPRM, international society of physical and rehabilitation medicine; NICE, national institute for health and

care excellence; PRM, physical and rehabilitation medicine; SOFMER, Société Française de Médecine Physique et de Réadaptation [French Society of Physical Medicine and Rehabilitation]

* Corresponding author.

E-mail address: christelle.nguyen2@aphp.fr (C. Nguyen).

<footnote><sup>a</sup> Université Paris Cité, Faculté de Santé, UFR de Médecine, 75006 Paris, France</footnote>

<footnote><sup>b</sup> AP-HP. Centre-Université Paris Cité, Service de Rééducation et de Réadaptation de l'Appareil Locomoteur et des Pathologies du Rachis, Hôpital Cochin, 75014 Paris, France</footnote>

<footnote><sup>c</sup> INSERM UMR-S 1124, Toxicité Environnementale, Cibles Thérapeutiques, Signalisation Cellulaire et Biomarqueurs (T3S), Campus Saint-Germain-des-Prés, 75006 Paris, France</footnote>

<footnote><sup>d</sup> HAVAE UR 20217 (Handicap, Aging, Autonomy, Environment), IFRH, University of Limoges, 87000 Limoges, France</footnote>

<footnote><sup>e</sup> Department of Physical Medicine and Rehabilitation, Department of Physical Medicine and Rehabilitation in the University Hospital Center of Limoges, 87000 Limoges, France</footnote>

<footnote><sup>f</sup> Department of Physical Medicine and Rehabilitation, Raymond Poincaré Teaching Hospital, APHP Université Paris Saclay, 92380 Garches, France</footnote>

<footnote><sup>g</sup> University of Versailles Saint-Quentin-en-Yvelines (Paris Saclay), 78180 Montigny-le-Bretonneux, France</footnote>

<footnote><sup>h</sup> CHU Rennes, Hôpital Pontchaillou, Service MPR adulte, 35000 Rennes, France</footnote>

<footnote><sup>i</sup> Univ Rennes, Inria, CNRS, Inserm, Irisa UMR 6074, EMPENN-ERL, U1228, 35000 Rennes, France</footnote>

<footnote><sup>j</sup> Inserm, CIC 1414, 35000 Rennes, France</footnote>

<footnote><sup>k</sup> Department of Physical and Rehabilitation Medicine, Hôpital Sébastopol 51100 Reims, France</footnote>

<footnote><sup>l</sup> Faculty of Medicine, Reims Champagne-Ardenne University, EA3797, VieFra, 51100 Reims, France</footnote>

<footnote><sup>m</sup> Department of Physical Medicine and Rehabilitation, University hospital of Angers (CHU) and Faculté de Santé, 49000 Angers, France</footnote>

<footnote><sup>n</sup> Service de Médecine Physique et de Réadaptation, CH de Gonesse, 95500 Gonesse, France</footnote>

<footnote><sup>o</sup> Univ. Grenoble Alpes, UMR CNRS 5105 Neuropsychology and NeuroCognition, CHU Grenoble Alpes, Dept of NeuroRehabilitation South Hospital, 38000 Grenoble, France</footnote>

<footnote><sup>p</sup> Service de Médecine Physique et de Réadaptation, CHU Nimes, Univ Montpellier, 30000 Nimes, France</footnote>

<footnote><sup>q</sup> EuroMov Digital Health in Motion, University of Montpellier, IMT Mines Ales, Montpellier, France</footnote>
**Results:** We identified 4 common key steps: preparation, elaboration, valorization and evaluation, usually scheduled according to an 18- to 24-month timetable. We divided these 4 steps into 9 sub-steps, each of which was standardized and described in detail. The steering committee also elaborated a specific editorial process for publishing recommendations.

**Conclusions:** This novel SOFMER methodology was designed to draw up high-level recommendations for the field of PRM and, more generally, for rehabilitation practices, facilitating their implementation. Standardization of operating procedures should provide guidance to authors to achieve replicable and high-quality recommendations.

© 2025 The Authors. Published by Elsevier Masson SAS. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

## Introduction

Recommendations in health are important productions that aim to inform diagnosis and care of people. Recommendations rely mostly on the highest available level of evidence, ranging from the results of systematic reviews and meta-analyses to experts' opinions. Recommendations in specific fields of medicine increasingly involve scientific consortiums and/or societies because these latter can conduct relevant critical reviews of the evidence, produce experts' opinions when needed and disseminate these recommendations to the targeted populations and/or care providers, who are the most likely to implement them [1]. However, the methods used to elaborate and disseminate recommendations are heterogeneous, not always standardized, and not fully reported [2]. Several scientific societies have established publicly available standardized operating procedures to report more transparently their processes to elaborate recommendations. The field of physical and rehabilitation medicine (PRM) requires specific skills from recommendation developers because interventions and diagnostic methods are multifactorial, composite and complex, rely on disease-specific and functional assessment, and therapeutic strategies combine pharmacological and non-pharmacological approaches. There has been a sharp increase in the number of publications dealing with recommendations (or guidelines) in the rehabilitation field, with about 70–80 articles per year in the last few years (Fig. 1). These recommendations are often proposed by groups of authors, based on unclear criteria and sometimes multiplying recommendations on different questions using inappropriate methodologies. Few are proposed by learned societies that mission experts of a specific subject to work within a pre-established methodological framework, standardized and transparent, as proposed by the French Society of PRM (SOFMER) as soon as 2007. Briefly, the SOFMER method was based on literature search, multidisciplinary expert opinion and application to primary care. Innovations included editorial independence and patient involvement [3].

From 2007 to 2023, it served to publish 22 sets of management recommendations in the field of PRM. However, this methodology is now reaching obsolescence and is no longer operating with regard to the recent framework proposed by the Appraisal of Guidelines for Research & Evaluation instrument Next Steps Consortium, which aims to provide a methodological strategy for the elaboration of recommendations to developers and researchers and to reduce the risk of low dissemination and low implementation of the recommendations [1,2,4].

The general objective of the present work was to standardise operational procedures for the elaboration of recommendations in the field of PRM that can be used by any developer. Specific objectives were: 1) to update the SOFMER methodology to enhance dissemination and implementation of SOFMER-endorsed recommendations, and 2) to report in sufficient detail the successive steps from the elaboration to the evaluation of the recommendations and provide supporting tools (e.g., manuals, templates), to guide developers.

## Methods

**Constitution of the steering committee.** On January 2023, the selection of members of the steering committee was carried out by the executive committee of the SOFMER, which holds international leadership in the field of PRM and is the owner of the scientific journal Annals of PRM, which consistently ranks as the first generalist journal in the rehabilitation category of the Journal Citation Reports (Clarivate Analytics). Criteria for selecting members of the steering committee were as follows: PRM senior physicians with experience in elaborating, disseminating, implementing and/or evaluating recommendations in the field of PRM, members of SOFMER, scientific, clinical and high level of publication experience, and no any potential conflict of interest in contributing to this work. In February 2023, the 7 members of the steering committee first met to define the project's specific objectives and work schedule.

<figure><img src="image_3.png" /><figcaption>**Fig. 1.** Recent and significant increase in the number of recommendation articles within the rehabilitation field. Source Web of Science (Core Collection, Clarivate Analytics), with the search performed on 24 October 2024 from the inception, detecting the query terms "rehabilitation and recommendation" or "rehabilitation and guidelines" in the title.</figcaption></figure>
**Benchmark of methodologies and standardized operating procedures for elaborating recommendations.** In May 2023, to identify methodologies and standardized operating procedures previously published by scientific societies in France and overseas, 2 members of the steering committee (MC, JL) conducted a non-systematic literature review on major referenced databases using the keywords: ("guideline*" OR "recommendation*") AND ("method*" OR "procedure*") AND ("physical and rehabilitation medicine"). They extended the search to grey literature and usual search engines to retrieve procedures and internal methodologies specific to each group of experts or scientific societies. Inclusion criteria for the narrative review were a published methodology or a methodology disseminated by a scientific society. They screened the results of the literature search to identify the most relevant publications in terms of methodology. This evaluation was based on the methodology used for elaborating recommendations, following the 6 domains of the Appraisal of Guidelines for Research & Evaluation (AGREE) grid: scope and purpose, stakeholders' involvement, rigor of development, clarity of presentation, applicability and editorial independence. They retrieved information regarding strategies for elaboration, dissemination, implementation and evaluation of the recommendations, scientific valorisation, and business models when available. They also collected information and feedback from participants in earlier recommendations. Results of the benchmark for the methodologies and standardized operating procedures for elaborating recommendations were synthesised and discussed among the steering committee during 2 remote meetings in June and October 2023 to standardise methodology and operational procedures for the elaboration of recommendations in the field of PRM.

**Benchmark of editorial strategies for publishing recommendations.** In October 2023, in order to identify editorial strategies endorsed by institutions or scientific societies to publish recommendations, 2 members of the steering committee (CN, DP) who have experience as editors of top-ranked journals (ie, Annals of PRM, PLOS Medicine) reviewed the process of publishing clinical guidelines and/or guidance statements from 2 selected general medicine journals in Europe (ie, British Medical Journal [BMJ]) and in the USA (Annals of Internal Medicine) and 1 speciality journal in Europe (ie, Annals of Rheumatic Diseases [ARD]). These journals were selected for 3 reasons: 1) they publish clinical guidelines and/or guidance statements on a regular basis, 2) their publication of clinical guidelines and/or guidance statements are elaborated and endorsed by institutions or scientific societies (ie, National Institute for Health and Care Excellence [NICE], American College of Physicians [ACP], European League Against Rheumatism [EULAR]), and 3) they have endorsed and published a specific strategy for publication and dissemination of recommendations. Results of the benchmark for editorial strategies to publish recommendations were synthesised and discussed among the steering committee during 1 remote meeting in October 2023 to standardise the editorial strategy for SOFMER-endorsed recommendations.

Elaboration of standardized operating procedures. Based on the previously published SOFMER methodology and the results of the benchmark, 2 members of the steering committee (CN, AD) produced a first draft of the standardized operating procedures. The different sections of the manuscript and the successive steps of the standardized operating procedures were discussed among the steering committee to ensure relevance and consistency before being validated. Each section of the manuscript was reworked and enriched by one or 2 members of the steering committee if needed. Specific attention was brought to ensure the consistency and the replicability of the procedures.

**Internal and external validations of standardized operating procedures.** The first and last authors produced a prefinal version of the standardized operating procedures that was reviewed by all the committee members and amended if needed for final internal validation. The version of the standardized operating procedures produced

by the steering committee was sent out for critical reviewing to selected members of the National Society of PRM who did not participate in the steering committee: the past President, the President, the President elect, and the President of the scientific committee.

## Results

**Methodologies and standardized operating procedures for elaborating recommendations.** The literature review highlighted shared characteristics of standardized operating procedures for elaborating, disseminating, implementing and evaluating recommendations across scientific societies and specialities. Overall, we found 4 common key steps in previously published methodologies: preparation, elaboration, valorisation and evaluation of recommendations. These 4 steps can be divided into 9 sub-steps that are shared by most of the published standardized operating procedures [5-8]:

### Step 1: Preparation

1. Definition of the recommendation theme: the first step should define the recommendation theme and specific questions that need to be answered by the working group or expert panel. The choice of topic is determined by the scientific society or institution upon request from the society members, a national authority (eg, Haute Autorité de Santé) or a society representative.

2. Constitution of a task force to draft the recommendations: potential members of the task force are selected by the scientific society or institution from a pool of recognised experts in the field studied. Typically, this expert panel is multidisciplinary, possibly includes international experts, is not limited to physicians and usually should include patients. Each member must disclose any potential financial or intellectual conflicts of interest.

### Step 2: Elaboration

3. Literature review: the review is conducted using medical databases (Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Meeting Abstracts, and Scopus). The search includes peer-reviewed articles in any language and conference abstracts. Panel members extract relevant information using standardized data extraction forms and various technological solutions (specific software or survey software). Disagreements are resolved through discussion or by a third-panel member if needed. Methodologists often assist task force members during this stage.

4. Classification of evidence for risk of bias: this step is commonly seen in recommendations and involves using recognised and validated scales from the literature (eg, Cochrane Risk of Bias Assessment Tool, Quality Assessment of Diagnostic Accuracy Studies).

5. Classification of recommendation evidence level: this step is consistent across all recommendations. The most used scale is GRADE (Grading of Recommendations, Assessment, Development, and Evaluations). However, some recommendations introduce other specific criteria based on the topic or speciality, such as the United States Preventative Services Task Force Criteria Modified for Interventional Spine Procedures.

6. Review and approval by an expert panel and/or proofreading group: a minority of recommendations mention validation by a broader panel of experts. Some scientific societies use a Delphi process for validation using various methods (in-person, electronic, and number of voting rounds). Additional questions may be asked during voting to provide extra indicators like applicability, principles of care, benefits relative to harms, importance of outcomes, patient preference variation, intervention feasibility and availability, and cost considerations. Indeed, evaluating the relevance, quality of evidence and formulation of recommendations
can be done using a Delphi method. The Delphi method is a structured research tool for obtaining expert consensus using interactive and anonymous questionnaires [9]. Experts can be chosen by the scientific committee on the recommendation of its members. The choice can also be made by consulting the professional societies of the experts sought. To guarantee the relevance of the analysis, the broadest possible panel of experts is required to bring a range of disciplinary viewpoints. PRM experts from the private sector or from public or private hospitals can, therefore, be called upon. Experts will be informed of the Delphi method. There is no consensus on the number of experts required for a Delphi, but 10 to 15 experts seem acceptable [10]. The number of experts contacted to obtain the panel should be specified. The number of rounds of questionnaires with interactive feedback should be defined before the start (2 or 3 is usually sufficient). Consensus is reached when more than 70-80% of the experts rate the item at least 7 out of 9 on a 9-point Likert scale (item retained) or 1 to 4 (item rejected). When an achieved item is rated between 40 and 60%, it is retained for the next round [11]. The Delphi method has been successfully used in the elaboration of recommendations in the field of PRM [12,13]. The first round consists of selecting the most relevant items, which will be retained in the final recommendations. A free text field is associated with each rating to collect comments or suggestions for wording. The second round concerns the respondents from the first round. It begins with the results of the first round, with the items retained and those still requiring a rating that has not reached the agreement threshold. This second round can also be used to add new items if necessary. Once again, a free text field allows the panel to make comments or suggestions for wording. A third round can be proposed to finalise the wording based on the suggestions and obtain agreement on all the reformulated items.

7. Final validation: the draft validation is typically done by the scientific committee of the scientific society, and other recognised scientific entities relevant to the topic.

### Step 3: Valorisation

8. Dissemination: for many scientific societies, recommendations are published in the society's affiliated journal in different formats (ie, a summary of recommendations and a concise argumentation). They are consistently shared on society websites allowing all readers an opportunity to provide feedback on the document.

### Step 4: Evaluation

9. Assessment of the impact of the recommendations: research on the impact of recommendations on clinical practice and their ability to improve relevant outcomes is encouraged.

**Editorial strategies for publishing recommendations.** Most scientific societies participate in the development of recommendations, but not all are published in peer-reviewed journals, which may decrease their visibility and implementation. Our review of editorial strategies for publishing recommendations focused on 3 high-impact journals (ie, BMJ, Annals of Internal Medicine and ARD) that regularly publish guidelines produced by the NICE, ACP and EULAR.

**NICE recommendations**

NICE recommendations are published in the BMJ on behalf of the Guideline Committee as practice guidelines. They include a summary article of NICE guidance and a visual abstract. Approximately 6 recommendation articles are published yearly.

**ACP recommendations**

ACP recommendations are published in the Annals of Internal Medicine on behalf of Clinical Guidelines Committee of the ACP as clinical guidelines. They include a full article and synoptic and visual abstracts. The same senior author, with expertise in health policy and population health, coordinates all clinical guidelines. Approximately 6 recommendation articles are published yearly.

**EULAR recommendations**

EULAR-endorsed recommendations are published in the ARD and are regularly updated by groups of authors. Full standardized operating procedures have been published in 2007 and updated in 2014. A complete description of the editorial strategy for publishing the guidelines is included in the "dissemination of the recommendations" section. Briefly, the minimum dissemination required is the submission of an abstract to the EULAR annual congress and the submission of a manuscript to the ARD, the EULAR journal, for consideration of publication. Early discussion with the ARD editor of the upcoming publication and the best publication strategy is underlined as a key point of the procedure.

**Results of the elaboration and internal validation of standardized operating procedures (Fig. 2)**

<figure><img src="image_4.png" /><figcaption>**Fig. 2.** Flowchart of the successive steps and sub-steps during the development of recommendations.</figcaption></figure>
## Wording and categories

Interestingly, in its 2014 updated version of standardized operating procedures, the EULAR raised attention to the wording. It is reminded that the first standardized operating procedures published in 2007 used the word 'guidelines'. However, as correctly pointed out by the authors, the word 'guidelines' may be perceived as too restrictive and might lead to legal implications if they are not followed. For the 2014 updated version of the standardized operating procedures, the EULAR introduced 2 different options for the wording: 'recommendations' and 'points to consider'. The word 'recommendations' may be used for projects that can be viewed as providing advice and, if applied, as a measure of good quality. Usually, this is used for a project when there is sufficient evidence from the literature so that the recommendations can be, at least partly, data-driven. The wording 'points to consider' is preferred for those projects where the advice cannot be substantiated by data or for clinical areas where the term 'recommendation' is simply avoided. Further, the EULAR suggested that the standardized operating procedures should be applied to 5 categories of recommendations: 1) recommendations for conducting clinical studies, 2) recommendations for management and/or monitoring in clinical practice, 3) recommendations for diagnostic approaches and/or imaging, 4) recommendations for standardisation of procedures, and 5) recommendations for implementation.

### Step 1 (months 1 to 3): preparation

A steering committee (≤5 persons), including the project convenor and a person with experience in methodology, will be appointed by the SOFMER executive, scientific and recommendation committees to define the theme and draw up the questions of interest (≤15) following the PICO principle. A member of the recommendation committee, who participated in the development of the present standardized operating procedures, will guide the steering committee from the preparation through the successive steps of elaboration and ensure they comply with the procedures. The steering committee will submit a proposal using a specific template (Appendix A) to the SOFMER committees for evaluation and approval. The request for developing SOFMER-endorsed recommendations should usually be addressed according to the following criteria: 1) no available guidelines on this topic, 2) existing national or international guidelines on this topic that should be adapted to the French Healthcare System setting, 3) existing national or international guidelines on this topic that should be updated due to recent therapeutic (or diagnostic) innovations/modification in the definition of the underlying medical condition/proposed public health policies. When the proposal is approved by the SOFMER committees, the convenor will appoint a task force (≤20 persons) that should involve senior physicians specialised in PRM with expertise related to the topic and one or more patients, and possibly international experts. Appointment of other specialities through their representative scientific societies and stakeholders may be considered (if relevant) and encouraged at this stage rather than at later stages. At this stage, the steering committee is encouraged to anticipate authorship (eg, first author, usually the person who drafted the recommendations, and last author, usually the person who supervised the elaboration of the recommendations) and the order of scientific societies, if more than one is involved. A librarian can be appointed by the SOFMER to support the literature review. Reflections should also be conducted at this stage to appoint an independent panel of experts and patients to take part in the Delphi survey (~ 20). The project convenor will ensure that the AGREE II instrument (Appendix B) is used in the project's planning and will be invited to report the progress of the project every 6 months to the SOFMER recommendation committee and once a year to the SOFMER executive and scientific committees.

### Step 2 (months 4 to 12): elaboration

* Meeting 1 (1 day): the task force appointed by the steering committee will have a first face-to-face (or remote) meeting to refine the questions of interest prespecified by the convenor, following the PICO principle. The research questions in their refined version will serve to elaborate the literature review and research equations, with the librarian's support, if needed.

* Systematic literature review: a systematic literature review will be requested for each question and entrusted to a pair comprising a senior expert and a fellow from the task force. For each literature review, a specific protocol will be prespecified using a dedicated template (Appendix C). Public registration of the review is strongly recommended at this stage (eg, PROSPERO). Researchers from the task force conducting the literature reviews can be supported by a librarian and can refer to the steering committee. For each question, a list of keywords/terms will be drawn up to identify relevant publications in the various databases. The list of articles thus identified will be completed using bibliographic references. The bibliographic search will cover a period determined by the latest update of national or international recommendations or will be defined by the steering committee if there are no recommendations on the subject. The bibliographic search will be restricted to publications in French and English, and any other language that can be translated if necessary or for which several members of the task force have sufficient proficiency. Only complete articles will be eligible for analysis. These articles may be clinical trials, reviews, meta-analyses or compendia of professional practice. The first phase of the bibliographic search can be carried out by librarians appointed by the SOFMER. Relevant articles will be selected by the pairs, and conflict resolution will be done by a third party. Literature review software can be used by all those involved (eg, Covidence, Ryyan). The pair will first select the articles based on their title and abstract. The shortlisted articles will then be subjected to a full analysis (article and supplements where applicable) with a view to a final selection. Articles presenting the results of randomised trials, systematic reviews with meta-analysis, or prospective cohort studies will be considered a priority. Studies of inferior methodological quality (eg, non-randomised, small number of subjects, imprecise interventions), as assessed by dedicated tools (eg, JADAD, Cochrane Risk of Bias tool), will be excluded. The data collected will be validated by the pair. If they disagree, a third party is called in to settle the matter. The evaluation of the methodological quality of the included studies will be carried out by the pair, with conflict resolution by a third party using the selected software. A bias assessment grid will also be produced.

* Meeting 2 (1 day): the task force will have a second face-to-face (or remote) meeting to formulate the recommendations. Pairs will draft a recommendation for each question addressed. They will present the drafted recommendations to the task force and a proposal for categories of evidence and strength of recommendation (face-to-face or remote) (Appendix D) in the first plenary meeting session. Drafted recommendations will be discussed and amended by subgroups of the task force, then finalised and validated by the entire task force in a second plenary session on the same day. A maximum of 15 recommendations will be proposed and can include overarching principles. The word 'recommendation' will be avoided. Relevant topics that could not be addressed in the recommendations may be included in a 'Research Agenda' for further research.

* Delphi survey. The steering committee will conduct a 3-round online Delphi survey (including members of the task force and an independent panel of experts and patients who did not participate in the task force) to optimise the recommendations and to determine the degree of agreement for each recommendation. The first
round aims at eliminating irrelevant recommendations. The second round aims to validate the recommendations and improving the wording. In the third round, all the selected recommendations will be finalised, and the degree of agreement will be calculated.

### Step 3 (months 13 to 18): valorisation

Several strategies will be implemented. The primary level of valorisation will correspond to an international dissemination conveyed by a publication in the scientific journal of the SOFMER, the Annals of PRM. The journal does not publish enough recommendations to sustain a specific section, so recommendations go into the most appropriate among the 3 sections of the contents: interventions, physiopathology of impairment (understanding disability and metrology), and clinimetrics. The article title will have to indicate the framework of the recommendations (i.e. 'recommendations' or 'points to consider', the year of production and the name of the learned societies involved). All articles will be reviewed by independent members of the SOFMER executive, scientific and/or recommendation committees before submission to ensure their relevance and integrity. The journal will also publish high-quality recommendations made by other joint-learned societies and encourage collaborative works performed jointly by several learned societies concerned with the same topic, viewed under the prism of specific questions involving complementary fields. The journal will do its best to ensure a rapid publication of high-quality recommendations elaborated on the basis of the SOFMER methodology after a home review. These articles will be immediately accessible for free in open access. The journal will prioritise the full-paper format for all recommendation articles expected to strongly impact the field due to their novelty, high level of evidence, and reporting and writing quality. However, it may occur to favour a letter to the editor format to report points to consider with a low level of evidence or experts' opinion. We do not exclude the possibility of combining a full paper and a letter for outstanding works leading to comprehensive and innovative recommendations which will have a great impact on the field. The journal will remain flexible in how it publishes the recommendations elaborated by learned societies on the basis of pre-established methods and will do its best to contribute to its international dissemination. In case recommendations are elaborated by another learned society, the publication of a concise report of the recommendations in the journal of the joint society may be considered. Presentations at international congresses will also contribute to the global dissemination of these SOFMER recommendations, mainly through the International (ISPRM) and European (ESPRM) societies of PRM as well as through any congresses of other international learned societies concerned. Once published, the current article will be sent to editors in chiefs of several PRM and rehabilitation journals for information and editorial proposals. The project convenor will ensure that the AGREE instrument (Appendix B) is used in the reporting of the recommendation preparation and elaboration and the writing of the manuscript. On a national level, the recommendations will be disseminated at the main PRM and non-PRM conferences. The recommendations will also be presented at regional study days. A final stage of dissemination will be offered at local continuing education meetings through local university teachers in each town. Short texts of the recommendations will also be published on the websites and social media of PRM scientific and training societies, other social media, and in the form of webinars, podcasts or journal articles. In case of joint recommendations, SOFMER-endorsed recommendations could also be published as joint reports with national scientific authorities (eg, Haute Autorité de Santé, Institut National de la Santé et de la Recherche Médicale)

### Step 4 (> 18 months): evaluation

Once the recommendations have been published, the steering committee can determine a strategy to evaluate their acceptance and

possible impact on the practice. In general, the shortcomings in care practice or inadequacies in care pathways that led to the recommendations need to be changed. It may involve a change in the behaviour of the professional, the patient or even a change in the care system. Measuring the impact of implementing recommendations is not a measure of the effectiveness or efficiency of care. Rather, it is a measure of compliance with practices. Usually, PRM recommendations involve multimodal care that can be applied in a single block, and this change in care can be studied by measuring, for example, whether all the recommended care is applied during the implementation process (process evaluation), with possible feedback to the health professional (formative evaluation), and broader evaluations of the use of the recommendations after the implementation phase (summative evaluations) [14]. These measures may be quantitative, in the form of structured surveys (organisation of care, professional behaviour, patients' opinions about the change, etc.), or qualitative, through semi-directive interviews with patients and professionals, either individually or in focus groups, or direct evaluation of clinical processes. Other measures of impact may also be considered, such as scientific metrics for the recommendation article, measures of citations in professional and social networks, and the number of papers presented at conferences or other events of interest related to the subject. These impact measurements can, therefore, begin as soon as the recommendations are published and then be spread over 3 years on an annual or biannual basis.

## Conclusion

The updated SOFMER methodology aims to establish high-quality recommendations in the field of Physical and Rehabilitation Medicine while improving their implementation. By standardising operating procedures, the methodology provides clear guidance to authors and ensures that recommendations are consistent, replicable and of high-quality. This approach aims to promote consistency and improve the overall effectiveness of rehabilitation practice in different healthcare settings.

## Data availability

No data was used for the research described in the article.

## Declaration of competing interest

None.

## Supplementary materials

Supplementary material associated with this article can be found in the online version at doi:10.1016/j.rehab.2025.101951.

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