Critical Appraisal of Clinical Practice Guidelines for the Care of Patients with Multiple Sclerosis

Critical Appraisal of Clinical Practice Guidelines for the Care of Patients with Multiple Sclerosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Critical Appraisal of Clinical Practice Guidelines for the Care of Patients with Multiple Sclerosis Somayeh Azimpour, Nasrollah Alimohammadi, Fereshteh Ashtari, Fatemeh Nazari This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8317543/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Evidence-based clinical practice guidelines (CPGs) are key instruments for enhancing care quality, standardizing health services, and improving clinical decision-making. Several international guidelines have been developed managing multiple sclerosis (MS), differing in comprehensiveness, consideration of care dimensions, methodological quality, and overall structure. This research aimed to critically appraise existing CPGs on MS care and identify the most appropriate options for adaptation within health systems in low- and middle-income countries. Methods: This guideline appraisal research was conducted during 2024–2025. A systematic search was performed in databases and clinical guideline repositories to identify relevant CPGs. Selected guidelines were evaluated by a panel of MS care specialists using the AGREE II instrument across six domains: scope and purpose, stakeholder involvement, Rigor of development, clarity of presentation, applicability, and editorial independence as well as two overall assessment criteria. Results: Of 28 identified guidelines, eight met the inclusion criteria and were appraised , while 20 were excluded due to issues with relevance, methodological quality, credibility, or lack of full-text accessibility. The appraisal revealed variability in the quality across the six domains, with significant differences in overall scores. Conclusion: The findings indicate that the existing MS care CPGs exhibit heterogeneity in structural and content quality. Based on AGREE II scores, two guidelines—including those from Malaysia and NICE—showed the highest quality and are recommended as foundation for adaptation within health systems in low- and middle-income countries. Developing a locally adapted guideline based on these results can improve nursing care quality, promote evidence-based decision-making, strengthen multidisciplinary coordination, and improve patient outcomes. Clinical Practice Guideline Multiple Sclerosis Nursing Care Critical Appraisal AGREE II Supportive Care Instruction The gap between the generation of scientific knowledge and its application in clinical practice has always been a major challenge for health systems. This discrepancy can lead to reduced effectiveness of therapeutic and care interventions, increased heterogeneity in service delivery methods, and the occurrence of clinical errors( 1 ). In response to this issue, clinical practice guidelines have been introduced as key instruments to facilitate the translation of knowledge into practice and to standardize care decisions( 2 ). Clinical practice guidelines are documents that include scientific and practical recommendations to assist patients, healthcare Specialists, and policymakers in making the best care decisions( 3 ). These documents are developed through a systematic review of the best available evidence, evaluation of the advantages and disadvantages of various care options, and consideration of professional expertise, as well as patients’ values and preferences( 4 ). In recent years, the increasing complexity of patients’ needs, the expansion of multidisciplinary care, and the variability in healthcare providers’ approaches have led to heterogeneity in the quality and continuity of care( 5 ). The lack of coordination among care team members and an overreliance on individual judgment have highlighted the necessity for a structured framework to guide clinical decision-making( 6 ). In response to these challenges, structured clinical guidelines have been developed to enhance interprofessional coordination, reduce performance variability, ensure patient safety, and improve the quality of care( 7 ). These guidelines, grounded in holistic care principles, seek to address all dimensions of patient health—physical, psychological, social, and spiritual—in clinical and care decision-making processes, especially in chronic and complex diseases such as multiple sclerosis, which are inherently multidimensional( 8 ). However, their effectiveness depends on the quality of their design, methodological transparency, and implementation in real-world settings( 7 ). In recent years, the field of clinical guidelines development has undergone significant advancements, including the development of standardized frameworks for designing and applying appraisal instruments to measure the Rigor, consistency, and transparency of these documents( 9 ). Clinical practice guidelines, by providing practical recommendations based on the best evidence, contribute to improving the quality of patient care, empowering healthcare personnel, enhancing professional autonomy, reducing complications and mortality, increasing consistency in clinical decision-making, and achieving cost-effectiveness( 7 , 10 ). Additionally, these guidelines enable nurses and other healthcare providers to deliver safe, coordinated, and evidence-based care through up-to-date and understandable recommendations( 11 ). Adherence to clinical guidelines helps to decrease disparities in patient care across different settings and emphasizes active patient participation, aligning decisions with their preferences and needs( 12 ). Despite this, clinical practice guidelines vary significantly in quality, raising concerns about inconsistencies in methodological Rigor and the validity of their recommendations. To ensure the utilization of high-quality guidelines, a systematic appraisal of these documents' quality is essential( 13 ). In response to this need, an international group of researchers developed the Appraisal of Guidelines for Research and Evaluation(AGREE)instrument in 2003( 14 ), which was later updated as AGREE II( 15 ). Recognized as the most reputable global framework for evaluating the quality of clinical guidelines( 16 ), this instrument provides objective information regarding the methodological Rigor and transparency of each guideline( 17 ). Several clinical guidelines have been developed internationally for the management and care of patients with multiple sclerosis; however, systematic reviews have indicated that these guidelines vary significantly in terms of methodological quality, clarity of development, comprehensiveness of recommendations, and applicability. This heterogeneity can lead to differences in care practices, varying interpretations of evidence, and challenges in implementing standardized care( 18 ). Considering the high prevalence of MS both globally and in low- and middle-income countries ( 19 , 20 ), the present research aimed to critically appraise the existing clinical practice guidelines related to the care of MS patients and to identify the most appropriate option for Adaptation to the healthcare system of low- and middle-income countries. Methods Design This research is a clinical practice guidelines Critical appraisal, utilizing the AGREE II instrument to measure the methodological quality and transparency of guidelines for the care of patients with multiple sclerosis. The research is part of a doctoral nursing thesis titled "Adaptation of Clinical Care Guidelines for Multiple Sclerosis Patients," conducted in Iran during the period 2024 to 2025. Search Strategy A structured and targeted search was conducted across reputable international sources to identify clinical practice guidelines related to the care of patients with multiple sclerosis. This process involved reviewing guidelines developed by organizations such as the National Institute for Health and Care Excellence (NICE), the National Guidance Centre (NGC), the Scottish Intercollegiate Guidelines Network (SIGN), the National Health Service (NHS), the New Zealand Guidelines Group, the Institute for Healthcare Improvement (IHI, USA), and the Clinical Practice Guidelines website. To supplement the data and ensure comprehensiveness of the search, scientific databases including Medline, Embase, Cochrane Library, CINAHL, PubMed, Ovid, Springer, and Elsevier Science were also systematically searched. The search utilized a combination of keywords such as "Multiple Sclerosis," "Practice Guideline," "Adaptation," "Nursing Care," and "Holistic Nursing" (see Table 1 ). Guidelines were included in the research if they met the following criteria: relevant to the research topic, written in English, published between 2010 and 2025, developed by reputable scientific or professional organizations, and availability of the full-text version. Table 1 search strategy (“Multiple sclerosis” OR “Demyelinating Autoimmune Diseases” OR “inflammatory demyelination” OR “ cerebral demyelinating diseases ’’) AND (“Practice guideline” OR “Clinical practice guideline” OR “Protocol” OR “Guideline” OR “Best Practice” OR “Critical Pathway” OR “Clinical Path” OR “ Care Plan” OR “Recommendation” OR “Care Standard” OR “Standards of Care”) AND ("Nursing Care” OR “Management” OR “ Holistic Nursing”) Appraisers Following a systematic search, a total of 28 clinical practice guidelines related to the care of patients with multiple sclerosis were identified. In the initial stage, these guidelines were subjected to preliminary appraisal by the research committee members. The screening criteria included the credibility of the developing organization, comprehensiveness of content, observable primary quality, adequate coverage of care aspects, and accessibility of the full text. Based on the appraisals and consensus among the members, 8 guidelines were deemed eligible to proceed to the final appraisal stage using the AGREE II instrument. Subsequently, the full-text versions of the 8 selected guidelines, along with the AGREE II instruction manual and scoring form, were provided to 10 healthcare professionals specializing in MS care at Kashani Hospital (Isfahan MS Center) and Isfahan University of Medical Sciences(Table 2 ). The inclusion criteria for appraisers consisted of a willingness to participate in the research and a minimum of one year of clinical experience in the treatment and care of MS patients. Table 2 Demographic characteristics of participants in the appraisal and critique of clinical practice guidelines No Occupation Education Gender Work Experience (years) 1 Nursing Faculty Member PhD in Nursing Male 30 2 Nursing Faculty Member PhD in Nursing Female 29 3 Nursing Faculty Member PhD in Nursing Female 15 4 Medical Faculty Member (Neurologist) Specialty in Neurology Female 20 5 Neurologist Specialty in Neurology Male 15 6 Nutritionist Specialty in Neurology Female 20 7 Head Nurse PhD in Nutrition Female 30 8 Nurse BSc in Nursing Male 14 9 Physiotherapy Faculty Member PhD in Nursing Male 25 10 Psychology PhD in Physiotherapy Male 15 The AGREE II appraisal instrument consists of 23 key items organized into six domains and two overall assessment criteria. These six domains include Scope and Purpose (Items 3 − 1), Stakeholder Involvement (Items 6 − 4), Rigor of Development (Items 14 − 7), Clarity of Presentation (Items 17 − 15), Applicability (Items 21 − 18), and Editorial Independence (Items 23 − 22). Two overall assessment criteria include judgment regarding the overall quality of the guideline and the recommendation or non-recommendation for its implementation in clinical practice. Each item is scored on a 7-point Likert scale, ranging from 1 (strongly disagree) to 7 (strongly agree). A score of 1 indicates an absence of information or very poor reporting, while a score of 7 reflects full compliance with the criteria and transparent reporting. Intermediate scores (2 to 6) are used when some criteria are partially met. The validity and reliability of this instrument have been confirmed in numerous international studies( 21 , 22 ). Data Analysis After the completion of the AGREE II forms by the appraisers (Table 3 ), the data were collected and analyzed by the research team. The raw scores of each item across the six domains of the instrument were standardized according to the official AGREE II Instructions. Subsequently, the mean scores for each domain were calculated and used to appraise the overall quality of each guideline( 23 ). In the next step, based on the mean domain scores and the appraisers’ overall judgment, the guidelines were classified into three categories: recommended (scores of 50% or higher in all domains), recommended with modifications (scores of 50% or higher in the overall appraisal), and not recommended (scores below 50% in all domains and in the overall appraisal)( 21 ). Finally, the guidelines with the highest scores and the greatest alignment with the care needs of MS patients were selected for the subsequent Adaptation phase. Table 3 Selected clinical practice guidelines for multiple sclerosis care No Title of Clinical Practice Guideline Year Developing Organization Scope of Coverage 1 Clinical Practice Guidelines: Management of multiple sclerosis 2015 Malaysian Society of Neurosciences Medical, nursing, psychological, infection prevention and control, and rehabilitation aspects 2 NICE Guideline: Multiple sclerosis in adults: management 2022 National Institute for Health and Care Excellence (NICE) United Kingdom (England) Medical, nursing, psychosocial, nutritional, rehabilitation, and educational aspects 3 Multiple sclerosis: Best practices in Nursing Care, Disease Management, Comprehensive Care, pharmacologic Management, Nursing Research 2022 International Organization of Multiple Sclerosis Nurses(United States of American) Nursing care, disease management, psychological support, patient education, and pharmacological care from a nursing perspective 4 Guideline for the diagnosis and management of multiple sclerosis 2013 A Southern African perspective Multidisciplinary care, pharmacological management, and rehabilitation 5 CMSC practical Guidelines for the selection of Disease-modifying Therapies in Multiple Sclerosis 2019 The consortium of multiple sclerosis centers(united states of American) Medical diagnosis, treatment monitoring, pharmacology, and patient education 6 Practice Guideline: Disease-modifying therapies for adults with multiple sclerosis 2018 American Academy of Neurology (AAN) Medical management, pharmacology, monitoring, and drug safety 7 Clinical Practice Guideline Series Nursing Management of the Patient with Multiple Sclerosis 2011 American Association of Neuroscience Nurses (AANN), the Association of Rehabilitation Nurses (ARN), and the International Organization of Multiple Sclerosis Nurses (IOMSN) Nursing management, rehabilitation, and psychological care 8 A Practical Guide to Rehabilitation in Multiple sclerosis 2015 The consortium of multiple sclerosis centers(united states of American) Nursing care, symptom management, psychological support, patient education, and long-term care Ethics Statement and Consent This research was conducted in full accordance with the ethical principles outlined in the Declaration of Helsinki ( https://www.wma.net/policies-post/wma-declaration-of-helsinki/)(24) . Ethical approval was obtained from the Research Ethics Committee of Isfahan University of Medical Sciences, Iran, with approval code IR.MUI.MED.REC.1403.259. Before initiation of the research, the objectives, methods, and data utilization procedures were clearly explained to all participants, and written informed consent was obtained from each appraiser. Confidentiality of participants’ information and the appraised guidelines were maintained, and participants’ right to withdraw voluntarily at any stage of the research without any consequences was assured. Results In this study, eight clinical practice guidelines related to the care of patients with multiple sclerosis were appraised using the AGREE II instrument by ten specialists (Table 3 ). Scores were assigned across six main domains and as well as the overall appraisal for each guideline (Table 4 ). The results were descriptively analyzed and reported from the lowest to the highest quality levels. The findings indicated that most guidelines received the highest scores in the domains of scope and purpose and clarity of presentation, while applicability and editorial independence received comparatively lower scores. Three guidelines achieved scores above 50% across all domains and were classified as "recommended" in the overall appraisal. Data analysis revealed notable differences in the development processes and reporting clarity among the appraised guidelines. Some documents featured structured frameworks, systematic evidence reviews, and effective stakeholder participation, whereas others provided limited details about the development process or evidence appraisal methods. Overall, all appraised guidelines were developed by reputable international scientific and professional organizations. The results of this appraisal solely reflect a structural and methodological comparison of these guidelines, aimed at identifying the most appropriate options for adaptation within health systems in low- and middle-income countries. The findings obtained from this research can serve as a foundation for the subsequent stages of selection, adaptation, and finalization of clinical care guidelines for patients with multiple sclerosis. Table 4 Standardized AGREE II Scores for the Evaluation of Clinical Practice Guidelines on the Care of Patients with Multiple Sclerosis No Guideline Title Scope and Purpose Stakeholder Involvement Rigor of Development Clarity of Presentation Applicability Editorial Independence overall accessment Level of Classification 1 NICE Guideline: Multiple Sclerosis in Adults – Management 85/55 80/55 73/33 83/33 63/75 81/66 76/66 Recommended 2 Clinical Practice Guidelines: Management of Multiple Sclerosis 95 79/44 85/83 86/11 68/33 65 71/66 Recommended 3 Multiple Sclerosis: Best Practices in Nursing Care, Disease Management, Comprehensive Care, Pharmacologic Management, Nursing Research 63/88 68/33 49/58 73/33 48/75 60/83 66/66 Recommended with modifications 4 Clinical Practice Guideline Series: Nursing Management of the Patient with Multiple Sclerosis 71/11 70 48/12 65 32/91 15 56/66 Recommended with modifications 5 A Practical Guide to Rehabilitation in Multiple Sclerosis 63/88 72/77 19/37 61/11 14/16 49/16 46/66 Not recommended 6 Practice Guideline: Disease-Modifying Therapies for Adults with Multiple Sclerosis 85/55 70 59/37 49/44 35 54/16 28/33 Not recommended 7 CMSC Practical Guidelines for the Selection of Disease-Modifying Therapies in Multiple Sclerosis 63/33 51/66 33/95 47/22 32/08 44/16 18/33 Not recommended 8 Guideline for the Diagnosis and Management of Multiple Sclerosis 67/22 56/11 33/12 50/55 30/41 16/39 16/66 Not recommended 1. Guideline for the Diagnosis and Management of Multiple Sclerosis This clinical guideline was developed in 2013 by the South African Neurology Association( 25 ). The primary objective of this guideline was to provide a practical framework tailored to the needs and circumstances of resource-limited countries for the diagnosis and treatment of multiple sclerosis. According to the AGREE II appraisal, the overall assessment score was 16.66%, with domain scores as follows: scope and purpose 67.22%, stakeholder involvement 56.11%, Rigor of development 33.12%, clarity of presentation 50.55%, applicability 30.41%, and editorial independence 39.16%. The Strengths of this guideline include clear articulation of objectives, target population, and resource limitations; simplification of the diagnostic process; provision of clinical decision-making algorithms suitable for limited resources; and consideration of the specific needs of patients in developing countries. 2.The CMSC Practical Guidelines for the Selection of Disease-Modifying Therapies in Multiple Sclerosis This clinical guideline was developed and published in 2019 by the Consortium of Multiple Sclerosis Centers (CMSC) ( 26 ). Its objective is to provide practical, evidence-based recommendations for the selection, monitoring, and modification of disease-modifying therapies (DMTs) in patients with multiple sclerosis. According to the AGREE II appraisal, the overall assessment score was 18.33%, with domain scores as follows: Scope and Purpose 63.33%, stakeholder involvement 51.66%, Rigor of development 33.95% , clarity of presentation 47.22%, applicability 32.08%, and editorial independence 44.16%. The strengths of this guideline include a simple and practical structure for clinical decision-making, clear definition of objectives, a strong focus on individualized and patient-centered therapeutic decisions, and a step-by-step approach to the selection and modification of treatment. Moreover, it places particular emphasis on treatment safety, monitoring of therapeutic effectiveness, and the integration of patient preferences into clinical care. 3. Practice Guideline: Disease-modifying therapies for adults with multiple sclerosis This clinical practice guideline was developed by the American Academy of Neurology in 2018( 27 ). Its primary objective is to provide evidence-based recommendations for the selection, initiation, monitoring, and modification of disease-modifying therapies (DMTs) in adult patients with multiple sclerosis. In the appraisal conducted using the AGREE II instrument, according to the AGREE II appraisal, the overall assessment score was 28.33%, with domain scores as follows: scope and purpose 85.55%, stakeholder involvement 70%, Rigor of development 59.37%, clarity of presentation 49.44%, applicability 35%, and editorial independence 54.16%. Strengths of this guideline include the clear definition of the target population, explicit statement of objectives, involvement of multidisciplinary expert groups in the development process, clarity and logical structure in presenting recommendations, precise delineation of treatment selection criteria based on disease severity, and consideration of safety, adverse effects, and drug interactions. However, it appears to have been developed primarily for healthcare systems in developed countries and relies heavily on broad access to new pharmaceutical therapies. 4. A Practical Guide to Rehabilitation in Multiple Sclerosis This clinical guideline was developed by the Consortium of Multiple Sclerosis Centers (CMSC) in the United States, in collaboration with The France Foundation, in 2015( 28 ). According to the AGREE II appraisal, the overall assessment score was 46.66%, with domain scores as follows: Scope and Purpose 63.88%, Stakeholder Involvement 72.77%, Rigor of Development 19.37%, Clarity of Presentation 61.11%, Applicability14.16%, and Editorial Independence 49.16%. This guideline was developed to assist rehabilitation specialists in the comprehensive management of patients with multiple sclerosis, with the primary focus on restoring functional independence, enhancing quality of life, and promoting patient participation in daily activities. Its strengths include a clear structure, emphasis on interdisciplinary care, and a holistic approach to physical, psychological, social, and cognitive rehabilitation of patients. The development process involved active participation from various healthcare specialists, including physiotherapists, occupational therapists, nurses, and neurologists. However, it appears that this guideline is tailored for use by multidisciplinary teams in developed countries with advanced rehabilitation infrastructure. 5. Clinical Practice Guideline Series: Nursing Management of the Patient with Multiple Sclerosis The Clinical Practice Guideline was developed in 2011 by the American Association of Neuroscience Nurses (AANN), the Association of Rehabilitation Nurses (ARN), and the International Organization of Multiple Sclerosis Nurses (IOMSN)( 29 ). According to the AGREE II appraisal, the overall assessment score was 56.66%, with domain scores as follows: scope and purpose 71.11%, stakeholder involvement 70%, Rigor of development 48.12%, clarity of presentation 65%, applicability 32.91%, and editorial independence15%. Among the key strengths of this guideline are the active participation of specialized nurses in the development process, clarity of objectives and target population, and comprehensive attention to various aspects of nursing care, including patient education, care across different stages of the disease, and promotion of patients’ quality of life. However, certain areas require improvement, including the need to update the content to reflect recent advances in MS treatment and care, as well as the expansion of interprofessional collaboration throughout the development process. 6. Multiple sclerosis: Best practices in Nursing Care, Disease Management, Comprehensive Care, pharmacologic Management, Nursing Research This clinical guideline was developed in 2022 by the International Organization of Nurses in Multiple Sclerosis (IOMSN)( 30 ). According to the AGREE II appraisal, the overall assessment score was 66.66%, with domain scores as follows: scope and objectives 63.88%, stakeholder involvement 68.33%, Rigor of development 49.58%, clarity of presentation 73.33%, applicability 48.75%, and editorial independence 60.83%. This guideline focuses specifically on the nursing role in providing comprehensive care for patients with multiple sclerosis. Its primary objective is to enhance the quality of care through standardization of nursing processes and education. Strengths of this guideline include a clear structure of recommendations, active participation of nursing professionals in the development process,, and a multidimensional approach to patient care encompassing physical, psychological, and social aspects, emphasis nurse empowerment, family education, and promotion of interprofessional collaboration within the care team. The guideline is well-organized, up-to-date, and provides practical instructions to various clinical setting. 7. Clinical Practice Guidelines: Management of Multiple Sclerosis This clinical practice guideline was developed in 2015 by the Ministry of Health Malaysia in collaboration with a committee of specialists in neurology, nursing, rehabilitation, and pharmacy( 31 ). According to the AGREE II appraisal, the overall assessment score was 71.66%, with domain scores as follows: Scope and Purpose 95%, Stakeholder Involvement 79.44%, Rigor of Development 85.88%, Clarity of Presentation 86.11%, Applicability 68.33%, and Editorial Independence 65%. Notable features of this guideline include its comprehensive content, transparency in recommendation development, use of systematic evidence reviews, clear description of study selection processes, balanced analysis of benefits and harms of pharmacological and non-pharmacological interventions, and the inclusion of clinical decision-making pathways. By emphasizing multidisciplinary collaboration and addressing the physical, psychological, social, and cognitive dimensions of patient care, the guideline adopts a holistic approach to the management of multiple sclerosis. Given its high scientific quality, rigorous methodology, and alignment with the needs of the low- and middle-income countries healthcare system, this guideline was identified as one of the three primary sources identified for the adaptation of care for patients with multiple sclerosis. 8. NICE Guideline: Multiple sclerosis in adults: management This clinical practice guideline was developed and published by the National Institute for Health and Care Excellence (NICE) United Kingdom in 2022 ( 32 ). According to the AGREE II appraisal, the overall assessment score was 76.66%, with domain scores as follows: Scope and Purpose 85.55%, Stakeholder Involvement 80.55%, Rigor of Development 73.33%, Clarity of Presentation 83.33%, Applicability 63.75%, and Editorial Independence 81.66%. Notable features of this guideline include comprehensive content, rigorous documentation of development stages, active participation of multidisciplinary professionals —including neurologists, nurses, physiotherapists, psychologists, and patient representatives— throughout the development process, clear definition of the target population and objectives, a systematic evidence review, quality appraisal of studies, and a coherent structure in developing recommendations. The guideline demonstrates transparency in presenting recommendations, citing references, and supporting evidence for each statement, and outlining potential barriers to implementation. Additionally, the guideline discusses pharmacological and non-pharmacological treatments, while addressing psychological, social, and lifestyle aspects of patient care, thereby adopting a holistic and patient-centered approach to the management of multiple sclerosis. Given its high methodological quality, organized structure, and alignment with the principles of comprehensive care, the NICE guideline was identified as one of the primary sources identified for adaptation within the low- and middle-income countries healthcare system. Discussion This study aimed to systematically appraise the quality of existing clinical practice guidelines related to the care of patients with multiple sclerosis using the AGREE II instrument. However, given the inherent limitations of purely quantitative assessments and the importance of considering clinical and contextual factors, the judgments of the appraisal team members were also incorporated as a complementary component to the quantitative analysis. The integration of the instrument scores with expert opinions enabled a more comprehensive and realistic appraisal in selecting appropriate guidelines for adaptation. As noted by Hoffmann et al. (2017), although AGREE II is recognized as the most validated and widely adopted instrument for appraising the quality of clinical guidelines, there remains no universally accepted method for interpreting scores and making final decisions—thus, professional judgment continues to play a pivotal role in this process( 14 ). Among the reviewed guidelines, the “Multiple Sclerosis in Adults: Management” developed by the National Institute for Health and Care Excellence (NICE, 2022) was identified as one of the most comprehensive structured resources. In the AGREE II appraisal, this document achieved high scores in the domains of Scope and Purpose, Stakeholder Involvement, Rigor of Development, and Clarity of Presentation, reflecting its scientific coherence and appropriate updating. However, the Applicability domain received a relatively lower score, primarily due to limited provision of implementation instruments, monitoring indicators, and insufficient attention to systemic barriers and cost considerations. Moreover, although psychological and social dimensions of care were addressed, spiritual aspects are not discussed as an independent component. Similarly, Marck et al. (2025) highlighted the implementation challenges of this guideline in clinical settings, and emphasizing the need to achieve a balance between scientific quality and practical feasibility( 33 ). In continuation of the findings, the “Management of Multiple Sclerosis” guideline developed by the Ministry of Health Malaysia (2015) was appraised and as a regional document, demonstrated satisfactory performance in the domains of Scope and Purpose, Rigor of Development, and Clarity of Presentation. However, it showed weaker performance in the areas of Applicability and Editorial Independence, primarily due to limited implementation instruments, insufficient monitoring indicators, and inadequate consideration of cost-related factors. Furthermore, the lack of updates to this guideline and the predominant focus on physical aspects—with limited attention to spiritual and psychosocial components—were notable points of concern in the appraisal. These findings are consistent with those reported in a recent study published in Multiple Sclerosis and Related Disorders (MSARD, 2024), in which the authors, focusing on resource-limited settings, noted that although many MS guidelines possess sound scientific structures, they still require adaptation and contextualization to improve feasibility, monitoring mechanisms, and cultural and systemic relevance( 34 ). Among the guidelines evaluated in this study, the “Clinical Practice Guideline Series: Nursing Management of the Patient with Multiple Sclerosis”, developed by the American Nursing Association, represents one of the earliest structured efforts in nursing. In the present assessment, it achieved moderate scores across most AGREE II domains. The domains of Scope and Purpose and Stakeholder Involvement demonstrated relatively better performance; however, weaknesses were identified in Rigor of Development and Applicability, largely due to the lack of a clearly described development process and the absence of related implementation instruments. The participation of professional organizations in the development process contributed to the overall coherence of the document. Nevertheless, the lack of updates since 2011 and the absence of a reported systematic search methodology were identified as key structural limitations. These findings align with the systematic review conducted by Ng et al. (2021), which examined international MS management guidelines—including this nursing guideline—and emphasized the need to strengthen psychosocial and spiritual care interventions within such documents( 18 ). In this study, the guideline “Multiple Sclerosis: Best Practices in Nursing Care”, published by the International Organization of Multiple Sclerosis Nurses (IOMSN) in 2022, provides a comprehensive framework for nursing care. This document demonstrates a well-organized structure with a clear focus on patient empowerment, interprofessional collaboration, and a well-defined nursing role. However, according to the AGREE II appraisal, certain domains, such as Applicability and Rigor of Development, received lower scores, primarily due to the lack of monitoring indicators, implementation instruments, and limited attention to spiritual interventions. Although this guideline is regularly updated, its most recent version has not yet been operationally appraised in many resource-limited health systems. This finding highlights that even well-structured guidelines require further contextual adaptation to align with specific clinical and cultural settings. These results are consistent with the findings of Fontaine et al. (2024), who, in their systematic review on the implementation strategies of nursing guidelines, reported that even structured documents require enhancement in monitoring indicators, implementation tools, and cultural adaptability, particularly in resource-constrained environments( 35 ). Finally, based on the structural appraisal conducted using the AGREE II instrument, the guidelines that achieved scores above 50% in all domains and overall assessment were classified as recommended sources, while those that met this threshold only in the overall assessment were considered complementary references, subject to modification. Accordingly, experts selected the NICE (2022) and Ministry of Health Malaysia (2015 ) guidelines as the primary sources, and the Best Practices and Nursing Management guidelines as supplementary references for the adaptation process of MS care. This selection was made with the aim of utilizing credible, evidence-based documents that are adaptable to the clinical and cultural needs of low- and middle-income countries, marking an important starting point for developing coherent, multidimensional, and contextually appropriate clinical practice guidelines aligned with national healthcare capacities. Limitations and strengths Of the limitations of this study, the focus on English-language guidelines and the limited access to detailed information regarding the development processes of some guidelines may have affected the precision of the assessments. In contrast, the use of a combined appraisal approach, incorporating both the AGREE II instrument and the expert judgment of interdisciplinary appraisers, was among the major strengths of this study. This integration enabled a more comprehensive and realistic analysis of the quality and contextual adaptability of the guidelines. Moreover, the emphasis on adaptation of guidelines within health systems of low- and middle-income countries and the utilization of reputable international sources further strengthened the rigor and relevance of the research. Conclusion The systematic appraisal of clinical practice guidelines for the care of patients with multiple sclerosis using the AGREE II instrument revealed structural and content differences among the existing documents. Although all the appraised guidelines were developed by reputable international organizations, their attention to various quality aspects—such as methodological transparency, stakeholder participation, and applicability in clinical settings—varied considerably. Among the appraised guidelines, the NICE (2022) and Ministry of Health Malaysia (2015) guidelines achieved the highest scores across most AGREE II domains. Due to their rigorous methodological structure, clarity in recommendations, multidisciplinary involvement, and relative attention to the physical, psychological, and social dimensions of patient care, these two were identified as the primary frameworks for adaptation within health systems in low- and middle-income countries. They are therefore recommended as suitable bases for Adaptation and use in resource-limited healthcare settings. These findings indicate that combining standardized appraisal instruments such as AGREE II with expert judgment can enhance the selection of clinical guidelines that are both realistic and contextually appropriate. The adaptation of these guidelines—while taking into account cultural context, health system structure, and holistic care principles — can provide a foundation for developing more effective national clinical guidelines and improving the quality of care for patients with MS. Furthermore, careful attention to all essential dimensions — relevance, clarity, usefulness, comprehensiveness, and practicality — in developing clinical practice guidelines can facilitate achieving their core objectives, including enhancing care quality, reducing variability in clinical decision-making, and improving patient outcomes. Abbreviations MS multiple sclerosis CPGs clinical practice guidelines AGREE Appraisal of Guidelines for Research and Evaluation Declarations Clinical trial number not applicable. Competing Interests The authors declare no competing interests. Funding This study was financially supported by Isfahan University of Medical Sciences under grant number 3403443. Author Contribution Somayeh Azimpour: Conceptualization and design of the study, conducting the systematic search and data collection, performing data analysis, and drafting the initial version of the manuscript.Nasrollah Alimohammadi:* Supervision of the study design, guidance in methodological framework, participation in data interpretation, critical scientific and editorial revision of the manuscript, and overall project supervision.Fereshteh Ashtari: Scientific oversight of the research process, providing methodological consultation, and final critical revision of the manuscript for important intellectual content.Fatemeh Nazari: Assistance in data extraction and analysis, contribution to interpretation of findings, and revision of manuscript drafts. Acknowledgement The authors extend their sincere gratitude to Isfahan University of Medical Sciences for its support in conducting this research. Data Availability All data are available from the corresponding author upon reasonable request.Before beginning the research, the objectives, methods, and procedures for data use were clearly explained to all participants, and informed written consent was obtained from each evaluator for participation and publication of the results. To maintain confidentiality, information related to participants' age was anonymized. References Walker LA, Gardner C, Freedman MS, MacLean H, Rush C, Bowman M. to-practice gaps in multiple sclerosis care for patients with subjective cognitive, mental health, and psychosocial concerns in a Canadian center. Int J MS Care. 2019;21(6):243–8. https://doi.ir/ 10.7224/1537-2073.2017-090 . Farouk M, Smit Sibinga CT, Abdella YE. The Effect of Standards and Guidelines in Clinical Practice. Clinical Use of Blood: A Different Approach. Springer; 2024. pp. 175–84. Breneol S, Curran JA, Marten R, Minocha K, Johnson C, Wong H, et al. Strategies to adapt and implement health system guidelines and recommendations: a scoping review. Health Res Policy Syst. 2022;20(1):64. https://doi.ir/ 10.1186/s12961-022-00865-8 . Jun J, Kovner CT, Stimpfel AW. Barriers and facilitators of nurses’ use of clinical practice guidelines: an integrative review. Int J Nurs Stud. 2016;60:54–68. https://doi.ir/ 10.1016/j.ijnurstu.2016.03.006 . Khatri R, Endalamaw A, Erku D, Wolka E, Nigatu F, Zewdie A, et al. Continuity and care coordination of primary health care: a scoping review. BMC Health Serv Res. 2023;23(1):750. https://doi.ir/ 10.1186/s12913-023-09718-8 . Dillon EC, Martinez MC, Li M, Mann-Grewal AK, Luft HS, Liang S-Y, et al. It is not the fault of the health care team-it is the way the system works: a mixed-methods quality improvement study of patients with advanced cancer and family members reveals challenges navigating a fragmented healthcare system and the administrative and financial burdens of care. BMC Health Serv Res. 2024;24(1):1378. https://doi.ir/ 10.1186/s12913-024-11744-z . Dixon DL, Harris IM, Aljadeed R, Anderson KC, Aycock A, Beavers C, et al. Overview of clinical practice guideline development, application to pharmacy practice, and roles for pharmacists. J Am Coll Clin Pharm. 2023;6(1):73–84. https://doi.ir/ 10.1002/jac5.1743 . Giovannoni G, Ford HL, Schmierer K, Middleton R, Stennett AM, Pomeroy I, et al. MS care: integrating advanced therapies and holistic management. Front Neurol. 2024;14:1286122. https://doi.ir/ 10.3389/fneur.2023.1286122 . Neumann I, Santesso N, Akl EA, Rind DM, Vandvik PO, Alonso-Coello P, et al. A guide for health professionals to interpret and use recommendations in guidelines developed with the GRADE approach. J Clin Epidemiol. 2016;72:45–55. https://doi.ir/ 10.1016/j.jclinepi.2015.11.017 . Panteli D, Legido-Quigley H, Reichebner C, Ollenschläger G, Schäfer C, Busse R. Clinical practice guidelines as a quality strategy. Improving Healthc Qual Europe. 2019:233. Soler B, Raats J, Abasiyanik Z, Lamers I, Makshakov G, Feys P. Systematic evaluation of the guidelines for rehabilitation in multiple sclerosis patients: an overview according to ICF functioning domains. Int J Rehabil Res. 2021;44(4):289–97. https://doi.ir/ 10.1097/MRR.0000000000000501 . Pereca J, N’Dow J, Omar MI. The Importance of Clinical Practice Guidelines. Primer on Urology: Springer; 2025. pp. 3–13. Florez ID, Brouwers MC, Kerkvliet K, Spithoff K, Alonso-Coello P, Burgers J, et al. Assessment of the quality of recommendations from 161 clinical practice guidelines using the Appraisal of Guidelines for Research and Evaluation–Recommendations Excellence (AGREE-REX) instrument shows there is room for improvement. Implement Sci. 2020;15(1):79. https://doi.ir/ 10.1186/s13012-020-01036-5 . Hoffmann-Eßer W, Siering U, Neugebauer EA, Brockhaus AC, Lampert U, Eikermann M. Guideline appraisal with AGREE II: systematic review of the current evidence on how users handle the 2 overall assessments. PLoS ONE. 2017;12(3):e0174831. https://doi.ir/ 10.1371/journal.pone.0174831 . Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839–42. https://doi.ir/ 10.1503/cmaj.090449 . Wang B, Luo X, Zhang J, Shi Q, Lai H, Liu H, et al. Evaluating the Quality of Guidelines Using the AGREE II Tool by a Large Language Model vs Human Appraisers. JAMA Netw Open. 2025;8(5):e2512621–e. https://doi.ir/ 10.1001/jamanetworkopen.2025.12621 . Rizvi F, Rizvi A, Chorath K, Suresh NV, Ng J, Harris J, et al. AGREE II Evaluation of Clinical Practice Guidelines on Generalized Cancer Pain Management. Pain Manage Nurs. 2025;26(2):163–70. 10.1016/j.pmn.2024.09.006 . https://doi.ir/ . Ng JY, Kishimoto V. Multiple sclerosis clinical practice guidelines provide few complementary and alternative medicine recommendations: a systematic review. Complement Ther Med. 2021;56:102595. https://doi.ir/ 10.1016/j.ctim.2020.102595 . Portaccio E, Magyari M, Havrdova EK, Ruet A, Brochet B, Scalfari A et al. Multiple sclerosis: emerging epidemiological trends and redefining the clinical course. Lancet Reg Health–Europe. 2024;44. https://doi.ir/ 10.1016/j.lanepe.2024.100977 Moghtaderi A, Shahidi-Pourakbari M, Izadi S, Khosravi A, Hashemzehi Z. Ongoing increase in incidence and prevalence of multiple sclerosis in south-eastern Iran: a three decade study. Multiple Scler Relat Disorders. 2023;71:104557. https://doi.ir/ 10.1016/j.msard.2023.104557 . Bagheri I, Yousefi H, Bahrami M, Shafie D. Adaptation of interdisciplinary clinical practice guidelines to palliative care for patients with heart failure in iran: application of adapte method. Iran J Nurs Midwifery Res. 2023;28(1):92–8. https://doi.ir/ 10.4103/ijnmr.ijnmr_152_22 . Rosetti L, Elliott S, Lee AH, McCracken LA, Hocaloski S, Hodge K, et al. The availability and quality of breastfeeding guidelines for women with spinal cord injury: a narrative review. Spinal Cord. 2022;60(9):837–42. 10.1038/s41393-022-00805-x . https://doi.ir/ . Ou J-Y, Liu J-J, Xu J, Li J-Y, Liu Y, Liu Y-Z, et al. Quality appraisal of clinical practice guidelines for motor neuron diseases or related disorders using the AGREE II instrument. Front Neurol. 2023;14:1180218. https://doi.ir/ 10.3389/fneur.2023.1180218 . General Assembly WMA, Finland H. WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Participants June 1964 [Available from: Association SAN. Guideline for the diagnosis and management of multiple sclerosis. 2013. https://doi.ir/ 10.7196/SAMJ.7124 Centers CMS. Practice Guideline: Disease-modifying therapies for adults with multiple sclerosis 2019. Available from: Neurology AAo. Practice Guideline: Disease-modifying therapies for adults with multiple sclerosis. 2018. https://doi.ir/ 10.1212/WNL.0000000000005347 CMSC CoMSC. A Practical Guide To Rehabilitation In Multiple sclerosis 2015. Available from: AANN G. Nursing Management of the Patient with Multiple Sclerosis 2011. Available from: IOMSN G. Best Practices in Nursing Care, Disease Management, Comprehensive Care, Pharmacologic Management, Nursing Research 2022. Available from: Malaysian G. Management of Multiple sclerosis: Malaysia Health Technology Assessment Section (MaHTAS) Medical Development Division, Ministry of Health Malaysia; 2015. Available from: NICE G. Multiple sclerosis in adults: management 2022. Available from: Marck CH, Weld-Blundell IV, Klaic M, Motl RW, Learmonth YC. The actionability of physical activity guidelines for multiple sclerosis care: a systematic review and AACTT framework analysis. Arch Phys Med Rehabil. 2025;106(4):590–606. https://doi.ir/ 10.1016/j.apmr.2024.09.020 . Yamout B, Al-Jumah M, Sahraian M, Almalik Y, Al Khaburi J, Shalaby N, et al. Consensus recommendations for diagnosis and treatment of Multiple Sclerosis: 2023 revision of the MENACTRIMS guidelines. Multiple Scler Relat Disorders. 2024;83:105435. https://doi.ir/ 10.1016/j.msard.2024.105435 . Fontaine G, Vinette B, Weight C, Maheu-Cadotte M-A, Lavallée A, Deschênes M-F, et al. Effects of implementation strategies on nursing practice and patient outcomes: a comprehensive systematic review and meta-analysis. Implement Sci. 2024;19(1):68. https://doi.ir/ 10.1186/s13012-024-01398-0 . Footnotes Achieving a standardized score of 50% or higher in all domains (all six domains) is classified as “Strongly Recommended.” Achieving a standardized score of 50% or higher only in the overall assessment is classified as “Recommended with modifications.” Failure to achieve a standardized score of 50% or higher in either all domains or the overall assessment is classified as “Not Recommended.” Achieving a standardized score of 50% or higher in all domains (all six domains) is classified as “Strongly Recommended.” Achieving a standardized score of 50% or higher only in the overall assessment is classified as “Recommended with modifications.” Failure to achieve a standardized score of 50% or higher in either all domains or the overall assessment is classified as “Not Recommended.” Additional Declarations No competing interests reported. Supplementary Files StandardizedAGREEIIScoresfortheEvaluationofClinicalPracticeGuidelines...docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 19 Jan, 2026 Reviewers agreed at journal 13 Jan, 2026 Reviewers invited by journal 13 Jan, 2026 Editor assigned by journal 13 Jan, 2026 Editor invited by journal 18 Dec, 2025 Submission checks completed at journal 18 Dec, 2025 First submitted to journal 18 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8317543","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":574003591,"identity":"5527132c-f08c-4090-b55e-3b6b26d2a890","order_by":0,"name":"Somayeh Azimpour","email":"","orcid":"","institution":"PhD student in Nursing, Student Research Committee, School of Nursing and Midwifery, Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Somayeh","middleName":"","lastName":"Azimpour","suffix":""},{"id":574003592,"identity":"660c22a1-8548-41ca-889d-881b84156a6f","order_by":1,"name":"Nasrollah Alimohammadi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYDACdsYGBiACAYMDH8A0hMuDUwszkpaDM4jTAlfDYMCMWxkS4G9mbt3wcYddtG774Y2HbXdsY9CdkdzA8KOGQca8AbsWicOMbTdnnknO3XYmreBw7pnbDGY3EhsYe44x8MgcwGENUMtt3jbm3G0HcgwO57ZBtDDwNjDwSODQIQ/RUp+77fwbg8OWUC2Mf/FoMYBoOZy77UYOmA3WwozPFkOwX9qOA7U8KzjY23abx+zMw4bDMsckcGqRO97+7MbHtmqgw5I3f/jZdlvO7Hj6w4dvamzscWnBAOCoOQAMSmI1jIJRMApGwSjAAgCmPWOR8r9YUgAAAABJRU5ErkJggg==","orcid":"","institution":"Professor, Nursing and Midwifery Care Research Center, Department of Critical Care Nursing, School of Nursing and Midwifery, Isfahan University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Nasrollah","middleName":"","lastName":"Alimohammadi","suffix":""},{"id":574003593,"identity":"f4df890b-e30d-49d7-bfc9-d3de615d6eb8","order_by":2,"name":"Fereshteh Ashtari","email":"","orcid":"","institution":"Professor of Neurology, Department of Neurology, Isfahan Neurosciences Research Center, Isfahan University of Medical Science","correspondingAuthor":false,"prefix":"","firstName":"Fereshteh","middleName":"","lastName":"Ashtari","suffix":""},{"id":574003594,"identity":"0ab74206-60da-4c53-92d9-0a03078d1455","order_by":3,"name":"Fatemeh Nazari","email":"","orcid":"","institution":"Assistant Professor, Nursing and Midwifery Care Research Center, Department of Adult Health Nursing, School of Nursing and Midwifery, Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Fatemeh","middleName":"","lastName":"Nazari","suffix":""}],"badges":[],"createdAt":"2025-12-09 12:23:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8317543/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8317543/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100448155,"identity":"d276df89-2fda-4a30-81d2-ff59262efe9f","added_by":"auto","created_at":"2026-01-16 19:13:10","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":68371,"visible":true,"origin":"","legend":"","description":"","filename":"ArticleCriticalappraisal.docx","url":"https://assets-eu.researchsquare.com/files/rs-8317543/v1/70aa092bb1b5e459e452fbb7.docx"},{"id":100547334,"identity":"5af2fa20-2d56-4ee5-9f7e-1a4a26ea4e29","added_by":"auto","created_at":"2026-01-19 08:15:18","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":24722,"visible":true,"origin":"","legend":"","description":"","filename":"table.docx","url":"https://assets-eu.researchsquare.com/files/rs-8317543/v1/fbe3983fce321e5036a94111.docx"},{"id":100547545,"identity":"e0698fed-0360-4587-aa34-178d2e664304","added_by":"auto","created_at":"2026-01-19 08:15:57","extension":"json","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7251,"visible":true,"origin":"","legend":"","description":"","filename":"d9bd37e22559447ea5a61051ef036536.json","url":"https://assets-eu.researchsquare.com/files/rs-8317543/v1/739666d4f57c785af678a3cf.json"},{"id":100547639,"identity":"aed68172-83c8-437a-90d7-c8a6ac2465d0","added_by":"auto","created_at":"2026-01-19 08:16:09","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":160210,"visible":true,"origin":"","legend":"","description":"","filename":"StandardizedAGREEIIScoresfortheEvaluationofClinicalPracticeGuidelines...docx","url":"https://assets-eu.researchsquare.com/files/rs-8317543/v1/d7aeac78dc627de441b5aa89.docx"},{"id":100547855,"identity":"1b801294-bf4a-446b-8b64-f2f0a2857655","added_by":"auto","created_at":"2026-01-19 08:16:46","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":142210,"visible":true,"origin":"","legend":"","description":"","filename":"d9bd37e22559447ea5a61051ef0365361enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8317543/v1/d516859974f04e559e73d803.xml"},{"id":100547216,"identity":"b742a369-2c58-4302-8c26-30b6f7c02d39","added_by":"auto","created_at":"2026-01-19 08:14:54","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":140029,"visible":true,"origin":"","legend":"","description":"","filename":"d9bd37e22559447ea5a61051ef0365361structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8317543/v1/0a3ecdfd54370cc89c783193.xml"},{"id":100547153,"identity":"a2d8b90f-5676-4c87-865b-cc164e1ababb","added_by":"auto","created_at":"2026-01-19 08:14:41","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":152215,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8317543/v1/2cf0d9e41eee3e648265d6eb.html"},{"id":100554113,"identity":"b2428e9e-72a9-4af5-8930-a2face33d945","added_by":"auto","created_at":"2026-01-19 08:38:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1040893,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8317543/v1/44dd8aed-6fd3-41f1-b6c5-96e88a77596b.pdf"},{"id":100547842,"identity":"9f351218-7748-4191-a5a9-67f287420242","added_by":"auto","created_at":"2026-01-19 08:16:42","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":160210,"visible":true,"origin":"","legend":"","description":"","filename":"StandardizedAGREEIIScoresfortheEvaluationofClinicalPracticeGuidelines...docx","url":"https://assets-eu.researchsquare.com/files/rs-8317543/v1/55bb9b6b726fe97f00b6a3da.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Critical Appraisal of Clinical Practice Guidelines for the Care of Patients with Multiple Sclerosis","fulltext":[{"header":"Instruction","content":"\u003cp\u003eThe gap between the generation of scientific knowledge and its application in clinical practice has always been a major challenge for health systems. This discrepancy can lead to reduced effectiveness of therapeutic and care interventions, increased heterogeneity in service delivery methods, and the occurrence of clinical errors(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In response to this issue, clinical practice guidelines have been introduced as key instruments to facilitate the translation of knowledge into practice and to standardize care decisions(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Clinical practice guidelines are documents that include scientific and practical recommendations to assist patients, healthcare Specialists, and policymakers in making the best care decisions(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). These documents are developed through a systematic review of the best available evidence, evaluation of the advantages and disadvantages of various care options, and consideration of professional expertise, as well as patients\u0026rsquo; values and preferences(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In recent years, the increasing complexity of patients\u0026rsquo; needs, the expansion of multidisciplinary care, and the variability in healthcare providers\u0026rsquo; approaches have led to heterogeneity in the quality and continuity of care(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The lack of coordination among care team members and an overreliance on individual judgment have highlighted the necessity for a structured framework to guide clinical decision-making(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In response to these challenges, structured clinical guidelines have been developed to enhance interprofessional coordination, reduce performance variability, ensure patient safety, and improve the quality of care(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). These guidelines, grounded in holistic care principles, seek to address all dimensions of patient health\u0026mdash;physical, psychological, social, and spiritual\u0026mdash;in clinical and care decision-making processes, especially in chronic and complex diseases such as multiple sclerosis, which are inherently multidimensional(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, their effectiveness depends on the quality of their design, methodological transparency, and implementation in real-world settings(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In recent years, the field of clinical guidelines development has undergone significant advancements, including the development of standardized frameworks for designing and applying appraisal instruments to measure the Rigor, consistency, and transparency of these documents(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eClinical practice guidelines, by providing practical recommendations based on the best evidence, contribute to improving the quality of patient care, empowering healthcare personnel, enhancing professional autonomy, reducing complications and mortality, increasing consistency in clinical decision-making, and achieving cost-effectiveness(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Additionally, these guidelines enable nurses and other healthcare providers to deliver safe, coordinated, and evidence-based care through up-to-date and understandable recommendations(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Adherence to clinical guidelines helps to decrease disparities in patient care across different settings and emphasizes active patient participation, aligning decisions with their preferences and needs(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite this, clinical practice guidelines vary significantly in quality, raising concerns about inconsistencies in methodological Rigor and the validity of their recommendations. To ensure the utilization of high-quality guidelines, a systematic appraisal of these documents' quality is essential(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In response to this need, an international group of researchers developed the Appraisal of Guidelines for Research and Evaluation(AGREE)instrument in 2003(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), which was later updated as AGREE II(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Recognized as the most reputable global framework for evaluating the quality of clinical guidelines(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), this instrument provides objective information regarding the methodological Rigor and transparency of each guideline(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral clinical guidelines have been developed internationally for the management and care of patients with multiple sclerosis; however, systematic reviews have indicated that these guidelines vary significantly in terms of methodological quality, clarity of development, comprehensiveness of recommendations, and applicability. This heterogeneity can lead to differences in care practices, varying interpretations of evidence, and challenges in implementing standardized care(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Considering the high prevalence of MS both globally and in low- and middle-income countries (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), the present research aimed to critically appraise the existing clinical practice guidelines related to the care of MS patients and to identify the most appropriate option for Adaptation to the healthcare system of low- and middle-income countries.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eThis research is a clinical practice guidelines Critical appraisal, utilizing the AGREE II instrument to measure the methodological quality and transparency of guidelines for the care of patients with multiple sclerosis. The research is part of a doctoral nursing thesis titled \"Adaptation of Clinical Care Guidelines for Multiple Sclerosis Patients,\" conducted in Iran during the period 2024 to 2025.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSearch Strategy\u003c/h3\u003e\n\u003cp\u003eA structured and targeted search was conducted across reputable international sources to identify clinical practice guidelines related to the care of patients with multiple sclerosis. This process involved reviewing guidelines developed by organizations such as the National Institute for Health and Care Excellence (NICE), the National Guidance Centre (NGC), the Scottish Intercollegiate Guidelines Network (SIGN), the National Health Service (NHS), the New Zealand Guidelines Group, the Institute for Healthcare Improvement (IHI, USA), and the Clinical Practice Guidelines website. To supplement the data and ensure comprehensiveness of the search, scientific databases including Medline, Embase, Cochrane Library, CINAHL, PubMed, Ovid, Springer, and Elsevier Science were also systematically searched. The search utilized a combination of keywords such as \"Multiple Sclerosis,\" \"Practice Guideline,\" \"Adaptation,\" \"Nursing Care,\" and \"Holistic Nursing\" (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Guidelines were included in the research if they met the following criteria: relevant to the research topic, written in English, published between 2010 and 2025, developed by reputable scientific or professional organizations, and availability of the full-text version.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003esearch strategy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(\u0026ldquo;Multiple sclerosis\u0026rdquo; OR \u0026ldquo;Demyelinating Autoimmune Diseases\u0026rdquo; OR \u0026ldquo;inflammatory demyelination\u0026rdquo; OR \u0026ldquo;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ecerebral demyelinating diseases\u003c/span\u003e\u0026rsquo;\u0026rsquo;)\u003c/p\u003e \u003cp\u003eAND\u003c/p\u003e \u003cp\u003e(\u0026ldquo;Practice guideline\u0026rdquo; OR \u0026ldquo;Clinical practice guideline\u0026rdquo; OR \u0026ldquo;Protocol\u0026rdquo; OR \u0026ldquo;Guideline\u0026rdquo; OR \u0026ldquo;Best Practice\u0026rdquo; OR \u0026ldquo;Critical Pathway\u0026rdquo; OR \u0026ldquo;Clinical Path\u0026rdquo; OR \u0026ldquo; Care Plan\u0026rdquo; OR \u0026ldquo;Recommendation\u0026rdquo; OR \u0026ldquo;Care Standard\u0026rdquo; OR \u0026ldquo;Standards of Care\u0026rdquo;)\u003c/p\u003e \u003cp\u003eAND\u003c/p\u003e \u003cp\u003e(\"Nursing Care\u0026rdquo; OR \u0026ldquo;Management\u0026rdquo; OR \u0026ldquo; Holistic Nursing\u0026rdquo;)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eAppraisers\u003c/h3\u003e\n\u003cp\u003eFollowing a systematic search, a total of 28 clinical practice guidelines related to the care of patients with multiple sclerosis were identified. In the initial stage, these guidelines were subjected to preliminary appraisal by the research committee members. The screening criteria included the credibility of the developing organization, comprehensiveness of content, observable primary quality, adequate coverage of care aspects, and accessibility of the full text. Based on the appraisals and consensus among the members, 8 guidelines were deemed eligible to proceed to the final appraisal stage using the AGREE II instrument. Subsequently, the full-text versions of the 8 selected guidelines, along with the AGREE II instruction manual and scoring form, were provided to 10 healthcare professionals specializing in MS care at Kashani Hospital (Isfahan MS Center) and Isfahan University of Medical Sciences(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The inclusion criteria for appraisers consisted of a willingness to participate in the research and a minimum of one year of clinical experience in the treatment and care of MS patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of participants in the appraisal and critique of clinical practice guidelines\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWork Experience (years)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNursing Faculty Member\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhD in Nursing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNursing Faculty Member\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhD in Nursing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNursing Faculty Member\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhD in Nursing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedical Faculty Member (Neurologist)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpecialty in Neurology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeurologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpecialty in Neurology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNutritionist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpecialty in Neurology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHead Nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhD in Nutrition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBSc in Nursing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysiotherapy Faculty Member\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhD in Nursing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePsychology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhD in Physiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eThe AGREE II appraisal instrument\u003c/h3\u003e\n\u003cp\u003econsists of 23 key items organized into six domains and two overall assessment criteria. These six domains include Scope and Purpose (Items 3\u0026thinsp;\u0026minus;\u0026thinsp;1), Stakeholder Involvement (Items 6\u0026thinsp;\u0026minus;\u0026thinsp;4), Rigor of Development (Items 14\u0026thinsp;\u0026minus;\u0026thinsp;7), Clarity of Presentation (Items 17\u0026thinsp;\u0026minus;\u0026thinsp;15), Applicability (Items 21\u0026thinsp;\u0026minus;\u0026thinsp;18), and Editorial Independence (Items 23\u0026thinsp;\u0026minus;\u0026thinsp;22). Two overall assessment criteria include judgment regarding the overall quality of the guideline and the recommendation or non-recommendation for its implementation in clinical practice. Each item is scored on a 7-point Likert scale, ranging from 1 (strongly disagree) to 7 (strongly agree). A score of 1 indicates an absence of information or very poor reporting, while a score of 7 reflects full compliance with the criteria and transparent reporting. Intermediate scores (2 to 6) are used when some criteria are partially met. The validity and reliability of this instrument have been confirmed in numerous international studies(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eAfter the completion of the AGREE II forms by the appraisers (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), the data were collected and analyzed by the research team. The raw scores of each item across the six domains of the instrument were standardized according to the official AGREE II Instructions. Subsequently, the mean scores for each domain were calculated and used to appraise the overall quality of each guideline(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In the next step, based on the mean domain scores and the appraisers\u0026rsquo; overall judgment, the guidelines were classified into three categories: recommended (scores of 50% or higher in all domains), recommended with modifications (scores of 50% or higher in the overall appraisal), and not recommended (scores below 50% in all domains and in the overall appraisal)(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Finally, the guidelines with the highest scores and the greatest alignment with the care needs of MS patients were selected for the subsequent Adaptation phase.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSelected clinical practice guidelines for multiple sclerosis care\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTitle of Clinical Practice Guideline\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDeveloping Organization\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eScope of Coverage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical Practice Guidelines: Management of multiple sclerosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMalaysian Society of Neurosciences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedical, nursing, psychological, infection prevention and control, and rehabilitation aspects\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNICE Guideline: Multiple sclerosis in adults: management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNational Institute for Health and Care Excellence (NICE) United Kingdom (England)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedical, nursing, psychosocial, nutritional, rehabilitation, and educational aspects\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultiple sclerosis: Best practices in Nursing Care, Disease Management, Comprehensive Care, pharmacologic Management, Nursing Research\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInternational Organization of Multiple Sclerosis Nurses(United States of American)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNursing care, disease management, psychological support, patient education, and pharmacological care from a nursing perspective\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGuideline for the diagnosis and management of multiple sclerosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA Southern African perspective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMultidisciplinary care, pharmacological management, and rehabilitation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCMSC practical Guidelines for the selection of Disease-modifying Therapies in Multiple Sclerosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe consortium of multiple sclerosis centers(united states of American)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedical diagnosis, treatment monitoring, pharmacology, and patient education\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePractice Guideline: Disease-modifying therapies for adults with multiple sclerosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAmerican Academy of Neurology (AAN)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedical management, pharmacology, monitoring, and drug safety\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical Practice Guideline Series Nursing Management of the Patient with Multiple Sclerosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAmerican Association of Neuroscience Nurses (AANN), the Association of Rehabilitation Nurses (ARN), and the International Organization of Multiple Sclerosis Nurses (IOMSN)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNursing management, rehabilitation, and psychological care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA Practical Guide to\u003c/p\u003e \u003cp\u003eRehabilitation in Multiple sclerosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe consortium of multiple sclerosis centers(united states of American)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNursing care, symptom management, psychological support, patient education, and long-term care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthics Statement and Consent\u003c/h2\u003e \u003cp\u003eThis research was conducted in full accordance with the ethical principles outlined in the Declaration of Helsinki (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.wma.net/policies-post/wma-declaration-of-helsinki/)(24)\u003c/span\u003e\u003cspan address=\"https://www.wma.net/policies-post/wma-declaration-of-helsinki/)(24)\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Ethical approval was obtained from the Research Ethics Committee of Isfahan University of Medical Sciences, Iran, with approval code IR.MUI.MED.REC.1403.259. Before initiation of the research, the objectives, methods, and data utilization procedures were clearly explained to all participants, and written informed consent was obtained from each appraiser. Confidentiality of participants\u0026rsquo; information and the appraised guidelines were maintained, and participants\u0026rsquo; right to withdraw voluntarily at any stage of the research without any consequences was assured.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn this study, eight clinical practice guidelines related to the care of patients with multiple sclerosis were appraised using the AGREE II instrument by ten specialists (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Scores were assigned across six main domains and as well as the overall appraisal for each guideline (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The results were descriptively analyzed and reported from the lowest to the highest quality levels. The findings indicated that most guidelines received the highest scores in the domains of scope and purpose and clarity of presentation, while applicability and editorial independence received comparatively lower scores. Three guidelines achieved scores above 50% across all domains and were classified as \"recommended\" in the overall appraisal. Data analysis revealed notable differences in the development processes and reporting clarity among the appraised guidelines. Some documents featured structured frameworks, systematic evidence reviews, and effective stakeholder participation, whereas others provided limited details about the development process or evidence appraisal methods. Overall, all appraised guidelines were developed by reputable international scientific and professional organizations. The results of this appraisal solely reflect a structural and methodological comparison of these guidelines, aimed at identifying the most appropriate options for adaptation within health systems in low- and middle-income countries. The findings obtained from this research can serve as a foundation for the subsequent stages of selection, adaptation, and finalization of clinical care guidelines for patients with multiple sclerosis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStandardized AGREE II Scores for the Evaluation of Clinical Practice Guidelines on the Care of Patients with Multiple Sclerosis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGuideline Title\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eScope and Purpose\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStakeholder Involvement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRigor of Development\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eClarity of Presentation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eApplicability\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEditorial Independence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eoverall accessment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eLevel of Classification\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNICE Guideline: Multiple Sclerosis in Adults \u0026ndash; Management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85/55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80/55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e73/33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e83/33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e63/75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e81/66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e76/66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRecommended\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical Practice Guidelines: Management of Multiple Sclerosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79/44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e85/83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e86/11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e68/33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e71/66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRecommended\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultiple Sclerosis: Best Practices in Nursing Care, Disease Management, Comprehensive Care, Pharmacologic Management, Nursing Research\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63/88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68/33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49/58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e73/33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e48/75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e60/83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e66/66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRecommended with modifications\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical Practice Guideline Series: Nursing Management of the Patient with Multiple Sclerosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71/11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48/12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e32/91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e56/66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRecommended with modifications\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA Practical Guide to Rehabilitation in Multiple Sclerosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63/88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72/77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19/37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e61/11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14/16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e49/16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e46/66\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003eNot recommended\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePractice Guideline: Disease-Modifying Therapies for Adults with Multiple Sclerosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85/55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59/37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e49/44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e54/16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e28/33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNot recommended\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCMSC Practical Guidelines for the Selection of Disease-Modifying Therapies in Multiple Sclerosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63/33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51/66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33/95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e47/22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e32/08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e44/16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e18/33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNot recommended\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGuideline for the Diagnosis and Management of Multiple Sclerosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67/22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56/11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33/12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50/55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30/41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e16/39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e16/66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNot recommended\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e1. Guideline for the Diagnosis and Management of Multiple Sclerosis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis clinical guideline was developed in 2013 by the South African Neurology Association(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The primary objective of this guideline was to provide a practical framework tailored to the needs and circumstances of resource-limited countries for the diagnosis and treatment of multiple sclerosis. According to the AGREE II appraisal, the overall assessment score was 16.66%, with domain scores as follows: scope and purpose 67.22%, stakeholder involvement 56.11%, Rigor of development 33.12%, clarity of presentation 50.55%, applicability 30.41%, and editorial independence 39.16%. The Strengths of this guideline include clear articulation of objectives, target population, and resource limitations; simplification of the diagnostic process; provision of clinical decision-making algorithms suitable for limited resources; and consideration of the specific needs of patients in developing countries.\u003c/p\u003e \u003cp\u003e \u003cb\u003e2.The CMSC Practical Guidelines for the Selection of Disease-Modifying Therapies in Multiple Sclerosis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis clinical guideline was developed and published in 2019 by the Consortium of Multiple Sclerosis Centers (CMSC) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Its objective is to provide practical, evidence-based recommendations for the selection, monitoring, and modification of disease-modifying therapies (DMTs) in patients with multiple sclerosis. According to the AGREE II appraisal, the overall assessment score was 18.33%, with domain scores as follows: Scope and Purpose 63.33%, stakeholder involvement 51.66%, Rigor of development \u003cem\u003e33.95%\u003c/em\u003e, clarity of presentation 47.22%, applicability 32.08%, and editorial independence 44.16%. The strengths of this guideline include a simple and practical structure for clinical decision-making, clear definition of objectives, a strong focus on individualized and patient-centered therapeutic decisions, and a step-by-step approach to the selection and modification of treatment. Moreover, it places particular emphasis on treatment safety, monitoring of therapeutic effectiveness, and the integration of patient preferences into clinical care.\u003c/p\u003e \u003cp\u003e \u003cb\u003e3. Practice Guideline: Disease-modifying therapies for adults with multiple sclerosis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis clinical practice guideline was developed by the American Academy of Neurology in 2018(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Its primary objective is to provide evidence-based recommendations for the selection, initiation, monitoring, and modification of disease-modifying therapies (DMTs) in adult patients with multiple sclerosis. In the appraisal conducted using the AGREE II instrument, according to the AGREE II appraisal, the overall assessment score was 28.33%, with domain scores as follows: scope and purpose 85.55%, stakeholder involvement 70%, Rigor of development 59.37%, clarity of presentation 49.44%, applicability 35%, and editorial independence 54.16%. Strengths of this guideline include the clear definition of the target population, explicit statement of objectives, involvement of multidisciplinary expert groups in the development process, clarity and logical structure in presenting recommendations, precise delineation of treatment selection criteria based on disease severity, and consideration of safety, adverse effects, and drug interactions. However, it appears to have been developed primarily for healthcare systems in developed countries and relies heavily on broad access to new pharmaceutical therapies.\u003c/p\u003e \u003cp\u003e \u003cb\u003e4. A Practical Guide to Rehabilitation in Multiple Sclerosis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis clinical guideline was developed by the Consortium of Multiple Sclerosis Centers (CMSC) in the United States, in collaboration with The France Foundation, in 2015(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). According to the AGREE II appraisal, the overall assessment score was 46.66%, with domain scores as follows: Scope and Purpose 63.88%, Stakeholder Involvement 72.77%, Rigor of Development 19.37%, Clarity of Presentation 61.11%, Applicability14.16%, and Editorial Independence 49.16%. This guideline was developed to assist rehabilitation specialists in the comprehensive management of patients with multiple sclerosis, with the primary focus on restoring functional independence, enhancing quality of life, and promoting patient participation in daily activities. Its strengths include a clear structure, emphasis on interdisciplinary care, and a holistic approach to physical, psychological, social, and cognitive rehabilitation of patients. The development process involved active participation from various healthcare specialists, including physiotherapists, occupational therapists, nurses, and neurologists. However, it appears that this guideline is tailored for use by multidisciplinary teams in developed countries with advanced rehabilitation infrastructure.\u003c/p\u003e \u003cp\u003e \u003cb\u003e5. Clinical Practice Guideline Series: Nursing Management of the Patient with Multiple Sclerosis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe Clinical Practice Guideline was developed in 2011 by the American Association of Neuroscience Nurses (AANN), the Association of Rehabilitation Nurses (ARN), and the International Organization of Multiple Sclerosis Nurses (IOMSN)(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). According to the AGREE II appraisal, the overall assessment score was 56.66%, with domain scores as follows: scope and purpose 71.11%, stakeholder involvement 70%, Rigor of development 48.12%, clarity of presentation 65%, applicability 32.91%, and editorial independence15%. Among the key strengths of this guideline are the active participation of specialized nurses in the development process, clarity of objectives and target population, and comprehensive attention to various aspects of nursing care, including patient education, care across different stages of the disease, and promotion of patients\u0026rsquo; quality of life. However, certain areas require improvement, including the need to update the content to reflect recent advances in MS treatment and care, as well as the expansion of interprofessional collaboration throughout the development process.\u003c/p\u003e \u003cp\u003e \u003cb\u003e6. Multiple sclerosis: Best practices in Nursing Care, Disease Management, Comprehensive Care, pharmacologic Management, Nursing Research\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis clinical guideline was developed in 2022 by the International Organization of Nurses in Multiple Sclerosis (IOMSN)(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). According to the AGREE II appraisal, the overall assessment score was 66.66%, with domain scores as follows: scope and objectives 63.88%, stakeholder involvement 68.33%, Rigor of development 49.58%, clarity of presentation 73.33%, applicability 48.75%, and editorial independence 60.83%. This guideline focuses specifically on the nursing role in providing comprehensive care for patients with multiple sclerosis. Its primary objective is to enhance the quality of care through standardization of nursing processes and education. Strengths of this guideline include a clear structure of recommendations, active participation of nursing professionals in the development process,, and a multidimensional approach to patient care encompassing physical, psychological, and social aspects, emphasis nurse empowerment, family education, and promotion of interprofessional collaboration within the care team. The guideline is well-organized, up-to-date, and provides practical instructions to various clinical setting.\u003c/p\u003e \u003cp\u003e \u003cb\u003e7. Clinical Practice Guidelines: Management of Multiple Sclerosis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis clinical practice guideline was developed in 2015 by the Ministry of Health Malaysia in collaboration with a committee of specialists in neurology, nursing, rehabilitation, and pharmacy(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). According to the AGREE II appraisal, the overall assessment score was 71.66%, with domain scores as follows: Scope and Purpose 95%, Stakeholder Involvement 79.44%, Rigor of Development 85.88%, Clarity of Presentation 86.11%, Applicability 68.33%, and Editorial Independence 65%. Notable features of this guideline include its comprehensive content, transparency in recommendation development, use of systematic evidence reviews, clear description of study selection processes, balanced analysis of benefits and harms of pharmacological and non-pharmacological interventions, and the inclusion of clinical decision-making pathways. By emphasizing multidisciplinary collaboration and addressing the physical, psychological, social, and cognitive dimensions of patient care, the guideline adopts a holistic approach to the management of multiple sclerosis. Given its high scientific quality, rigorous methodology, and alignment with the needs of the low- and middle-income countries healthcare system, this guideline was identified as one of the three primary sources identified for the adaptation of care for patients with multiple sclerosis.\u003c/p\u003e \u003cp\u003e \u003cb\u003e8. NICE Guideline: Multiple sclerosis in adults: management\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis clinical practice guideline was developed and published by the National Institute for Health and Care Excellence (NICE) United Kingdom in 2022 (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). According to the AGREE II appraisal, the overall assessment score was 76.66%, with domain scores as follows: Scope and Purpose 85.55%, Stakeholder Involvement 80.55%, Rigor of Development 73.33%, Clarity of Presentation 83.33%, Applicability 63.75%, \u003cem\u003eand\u003c/em\u003e Editorial Independence 81.66%. Notable features of this guideline include comprehensive content, rigorous documentation of development stages, active participation of multidisciplinary professionals \u0026mdash;including neurologists, nurses, physiotherapists, psychologists, and patient representatives\u0026mdash; throughout the development process, clear definition of the target population and objectives, a systematic evidence review, quality appraisal of studies, and a coherent structure in developing recommendations. The guideline demonstrates transparency in presenting recommendations, citing references, and supporting evidence for each statement, and outlining potential barriers to implementation. Additionally, the guideline discusses pharmacological and non-pharmacological treatments, while addressing psychological, social, and lifestyle aspects of patient care, thereby adopting a holistic and patient-centered approach to the management of multiple sclerosis. Given its high methodological quality, organized structure, and alignment with the principles of comprehensive care, the NICE guideline was identified as one of the primary sources identified for adaptation within the low- and middle-income countries healthcare system.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to systematically appraise the quality of existing clinical practice guidelines related to the care of patients with multiple sclerosis using the AGREE II instrument. However, given the inherent limitations of purely quantitative assessments and the importance of considering clinical and contextual factors, the judgments of the appraisal team members were also incorporated as a complementary component to the quantitative analysis. The integration of the instrument scores with expert opinions enabled a more comprehensive and realistic appraisal in selecting appropriate guidelines for adaptation. As noted by Hoffmann et al. (2017), although AGREE II is recognized as the most validated and widely adopted instrument for appraising the quality of clinical guidelines, there remains no universally accepted method for interpreting scores and making final decisions\u0026mdash;thus, professional judgment continues to play a pivotal role in this process(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong the reviewed guidelines, the \u0026ldquo;Multiple Sclerosis in Adults: Management\u0026rdquo; developed by the National Institute for Health and Care Excellence (NICE, 2022) was identified as one of the most comprehensive structured resources. In the AGREE II appraisal, this document achieved high scores in the domains of Scope and Purpose, Stakeholder Involvement, Rigor of Development, and Clarity of Presentation, reflecting its scientific coherence and appropriate updating. However, the Applicability domain received a relatively lower score, primarily due to limited provision of implementation instruments, monitoring indicators, and insufficient attention to systemic barriers and cost considerations. Moreover, although psychological and social dimensions of care were addressed, spiritual aspects are not discussed as an independent component. Similarly, Marck et al. (2025) highlighted the implementation challenges of this guideline in clinical settings, and emphasizing the need to achieve a balance between scientific quality and practical feasibility(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn continuation of the findings, the \u0026ldquo;Management of Multiple Sclerosis\u0026rdquo; guideline developed by the Ministry of Health Malaysia (2015) was appraised and as a regional document, demonstrated satisfactory performance in the domains of Scope and Purpose, Rigor of Development, and Clarity of Presentation. However, it showed weaker performance in the areas of Applicability and Editorial Independence, primarily due to limited implementation instruments, insufficient monitoring indicators, and inadequate consideration of cost-related factors. Furthermore, the lack of updates to this guideline and the predominant focus on physical aspects\u0026mdash;with limited attention to spiritual and psychosocial components\u0026mdash;were notable points of concern in the appraisal. These findings are consistent with those reported in a recent study published in Multiple Sclerosis and Related Disorders (MSARD, 2024), in which the authors, focusing on resource-limited settings, noted that although many MS guidelines possess sound scientific structures, they still require adaptation and contextualization to improve feasibility, monitoring mechanisms, and cultural and systemic relevance(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong the guidelines evaluated in this study, the \u0026ldquo;Clinical Practice Guideline Series: Nursing Management of the Patient with Multiple Sclerosis\u0026rdquo;, developed by the American Nursing Association, represents one of the earliest structured efforts in nursing. In the present assessment, it achieved moderate scores across most AGREE II domains. The domains of Scope and Purpose and Stakeholder Involvement demonstrated relatively better performance; however, weaknesses were identified in Rigor of Development and Applicability, largely due to the lack of a clearly described development process and the absence of related implementation instruments. The participation of professional organizations in the development process contributed to the overall coherence of the document. Nevertheless, the lack of updates since 2011 and the absence of a reported systematic search methodology were identified as key structural limitations. These findings align with the systematic review conducted by Ng et al. (2021), which examined international MS management guidelines\u0026mdash;including this nursing guideline\u0026mdash;and emphasized the need to strengthen psychosocial and spiritual care interventions within such documents(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, the guideline \u0026ldquo;Multiple Sclerosis: Best Practices in Nursing Care\u0026rdquo;, published by the International Organization of Multiple Sclerosis Nurses (IOMSN) in 2022, provides a comprehensive framework for nursing care. This document demonstrates a well-organized structure with a clear focus on patient empowerment, interprofessional collaboration, and a well-defined nursing role. However, according to the AGREE II appraisal, certain domains, such as Applicability and Rigor of Development, received lower scores, primarily due to the lack of monitoring indicators, implementation instruments, and limited attention to spiritual interventions. Although this guideline is regularly updated, its most recent version has not yet been operationally appraised in many resource-limited health systems. This finding highlights that even well-structured guidelines require further contextual adaptation to align with specific clinical and cultural settings. These results are consistent with the findings of Fontaine et al. (2024), who, in their systematic review on the implementation strategies of nursing guidelines, reported that even structured documents require enhancement in monitoring indicators, implementation tools, and cultural adaptability, particularly in resource-constrained environments(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFinally, based on the structural appraisal conducted using the AGREE II instrument, the guidelines that achieved scores above 50% in all domains and overall assessment were classified as recommended sources, while those that met this threshold only in the overall assessment were considered complementary references, subject to modification. Accordingly, experts selected the NICE (2022) and Ministry of Health Malaysia (2015\u003cb\u003e)\u003c/b\u003e guidelines as the primary sources, and the Best Practices and Nursing Management guidelines as supplementary references for the adaptation process of MS care. This selection was made with the aim of utilizing credible, evidence-based documents that are adaptable to the clinical and cultural needs of low- and middle-income countries, marking an important starting point for developing coherent, multidimensional, and contextually appropriate clinical practice guidelines aligned with national healthcare capacities.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and strengths\u003c/h2\u003e \u003cp\u003eOf the limitations of this study, the focus on English-language guidelines and the limited access to detailed information regarding the development processes of some guidelines may have affected the precision of the assessments. In contrast, the use of a combined appraisal approach, incorporating both the AGREE II instrument and the expert judgment of interdisciplinary appraisers, was among the major strengths of this study. This integration enabled a more comprehensive and realistic analysis of the quality and contextual adaptability of the guidelines. Moreover, the emphasis on adaptation of guidelines within health systems of low- and middle-income countries and the utilization of reputable international sources further strengthened the rigor and relevance of the research.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe systematic appraisal of clinical practice guidelines for the care of patients with multiple sclerosis using the AGREE II instrument revealed structural and content differences among the existing documents. Although all the appraised guidelines were developed by reputable international organizations, their attention to various quality aspects\u0026mdash;such as methodological transparency, stakeholder participation, and applicability in clinical settings\u0026mdash;varied considerably. Among the appraised guidelines, the NICE (2022) and Ministry of Health Malaysia (2015) guidelines achieved the highest scores across most AGREE II domains. Due to their rigorous methodological structure, clarity in recommendations, multidisciplinary involvement, and relative attention to the physical, psychological, and social dimensions of patient care, these two were identified as the primary frameworks for adaptation within health systems in low- and middle-income countries. They are therefore recommended as suitable bases for Adaptation and use in resource-limited healthcare settings. These findings indicate that combining standardized appraisal instruments such as AGREE II with expert judgment can enhance the selection of clinical guidelines that are both realistic and contextually appropriate. The adaptation of these guidelines\u0026mdash;while taking into account cultural context, health system structure, and holistic care principles\u003cb\u003e\u0026mdash;\u003c/b\u003ecan provide a foundation for developing more effective national clinical guidelines and improving the quality of care for patients with MS. Furthermore, careful attention to all essential dimensions\u003cb\u003e\u0026mdash;\u003c/b\u003erelevance, clarity, usefulness, comprehensiveness, and practicality\u003cb\u003e\u0026mdash;\u003c/b\u003ein developing clinical practice guidelines can facilitate achieving their core objectives, including enhancing care quality, reducing variability in clinical decision-making, and improving patient outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emultiple sclerosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCPGs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eclinical practice guidelines\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAGREE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAppraisal of Guidelines for Research and Evaluation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eClinical trial number\u003c/h2\u003e \u003cp\u003enot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting Interests\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study was financially supported by Isfahan University of Medical Sciences under grant number 3403443.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSomayeh Azimpour: Conceptualization and design of the study, conducting the systematic search and data collection, performing data analysis, and drafting the initial version of the manuscript.Nasrollah Alimohammadi:* Supervision of the study design, guidance in methodological framework, participation in data interpretation, critical scientific and editorial revision of the manuscript, and overall project supervision.Fereshteh Ashtari: Scientific oversight of the research process, providing methodological consultation, and final critical revision of the manuscript for important intellectual content.Fatemeh Nazari: Assistance in data extraction and analysis, contribution to interpretation of findings, and revision of manuscript drafts.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors extend their sincere gratitude to Isfahan University of Medical Sciences for its support in conducting this research.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data are available from the corresponding author upon reasonable request.Before beginning the research, the objectives, methods, and procedures for data use were clearly explained to all participants, and informed written consent was obtained from each evaluator for participation and publication of the results. To maintain confidentiality, information related to participants' age was anonymized.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWalker LA, Gardner C, Freedman MS, MacLean H, Rush C, Bowman M. to-practice gaps in multiple sclerosis care for patients with subjective cognitive, mental health, and psychosocial concerns in a Canadian center. Int J MS Care. 2019;21(6):243\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.7224/1537-2073.2017-090\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.7224/1537-2073.2017-090\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarouk M, Smit Sibinga CT, Abdella YE. The Effect of Standards and Guidelines in Clinical Practice. Clinical Use of Blood: A Different Approach. Springer; 2024. pp. 175\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBreneol S, Curran JA, Marten R, Minocha K, Johnson C, Wong H, et al. Strategies to adapt and implement health system guidelines and recommendations: a scoping review. Health Res Policy Syst. 2022;20(1):64. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.1186/s12961-022-00865-8\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.1186/s12961-022-00865-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJun J, Kovner CT, Stimpfel AW. Barriers and facilitators of nurses\u0026rsquo; use of clinical practice guidelines: an integrative review. Int J Nurs Stud. 2016;60:54\u0026ndash;68. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.1016/j.ijnurstu.2016.03.006\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.1016/j.ijnurstu.2016.03.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhatri R, Endalamaw A, Erku D, Wolka E, Nigatu F, Zewdie A, et al. Continuity and care coordination of primary health care: a scoping review. BMC Health Serv Res. 2023;23(1):750. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.1186/s12913-023-09718-8\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.1186/s12913-023-09718-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDillon EC, Martinez MC, Li M, Mann-Grewal AK, Luft HS, Liang S-Y, et al. It is not the fault of the health care team-it is the way the system works: a mixed-methods quality improvement study of patients with advanced cancer and family members reveals challenges navigating a fragmented healthcare system and the administrative and financial burdens of care. BMC Health Serv Res. 2024;24(1):1378. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.1186/s12913-024-11744-z\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.1186/s12913-024-11744-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDixon DL, Harris IM, Aljadeed R, Anderson KC, Aycock A, Beavers C, et al. Overview of clinical practice guideline development, application to pharmacy practice, and roles for pharmacists. J Am Coll Clin Pharm. 2023;6(1):73\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.1002/jac5.1743\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.1002/jac5.1743\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiovannoni G, Ford HL, Schmierer K, Middleton R, Stennett AM, Pomeroy I, et al. MS care: integrating advanced therapies and holistic management. Front Neurol. 2024;14:1286122. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.3389/fneur.2023.1286122\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.3389/fneur.2023.1286122\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeumann I, Santesso N, Akl EA, Rind DM, Vandvik PO, Alonso-Coello P, et al. A guide for health professionals to interpret and use recommendations in guidelines developed with the GRADE approach. J Clin Epidemiol. 2016;72:45\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.1016/j.jclinepi.2015.11.017\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.1016/j.jclinepi.2015.11.017\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePanteli D, Legido-Quigley H, Reichebner C, Ollenschl\u0026auml;ger G, Sch\u0026auml;fer C, Busse R. Clinical practice guidelines as a quality strategy. Improving Healthc Qual Europe. 2019:233.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoler B, Raats J, Abasiyanik Z, Lamers I, Makshakov G, Feys P. Systematic evaluation of the guidelines for rehabilitation in multiple sclerosis patients: an overview according to ICF functioning domains. Int J Rehabil Res. 2021;44(4):289\u0026ndash;97. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.1097/MRR.0000000000000501\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.1097/MRR.0000000000000501\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePereca J, N\u0026rsquo;Dow J, Omar MI. The Importance of Clinical Practice Guidelines. Primer on Urology: Springer; 2025. pp. 3\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlorez ID, Brouwers MC, Kerkvliet K, Spithoff K, Alonso-Coello P, Burgers J, et al. Assessment of the quality of recommendations from 161 clinical practice guidelines using the Appraisal of Guidelines for Research and Evaluation\u0026ndash;Recommendations Excellence (AGREE-REX) instrument shows there is room for improvement. Implement Sci. 2020;15(1):79. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.1186/s13012-020-01036-5\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.1186/s13012-020-01036-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoffmann-E\u0026szlig;er W, Siering U, Neugebauer EA, Brockhaus AC, Lampert U, Eikermann M. Guideline appraisal with AGREE II: systematic review of the current evidence on how users handle the 2 overall assessments. PLoS ONE. 2017;12(3):e0174831. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.1371/journal.pone.0174831\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.1371/journal.pone.0174831\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.1503/cmaj.090449\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.1503/cmaj.090449\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang B, Luo X, Zhang J, Shi Q, Lai H, Liu H, et al. Evaluating the Quality of Guidelines Using the AGREE II Tool by a Large Language Model vs Human Appraisers. JAMA Netw Open. 2025;8(5):e2512621\u0026ndash;e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.1001/jamanetworkopen.2025.12621\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.1001/jamanetworkopen.2025.12621\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRizvi F, Rizvi A, Chorath K, Suresh NV, Ng J, Harris J, et al. AGREE II Evaluation of Clinical Practice Guidelines on Generalized Cancer Pain Management. Pain Manage Nurs. 2025;26(2):163\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.pmn.2024.09.006\u003c/span\u003e\u003cspan address=\"10.1016/j.pmn.2024.09.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/\u003c/span\u003e\u003cspan address=\"https://doi.ir/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNg JY, Kishimoto V. Multiple sclerosis clinical practice guidelines provide few complementary and alternative medicine recommendations: a systematic review. Complement Ther Med. 2021;56:102595. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.1016/j.ctim.2020.102595\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.1016/j.ctim.2020.102595\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePortaccio E, Magyari M, Havrdova EK, Ruet A, Brochet B, Scalfari A et al. Multiple sclerosis: emerging epidemiological trends and redefining the clinical course. Lancet Reg Health\u0026ndash;Europe. 2024;44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.1016/j.lanepe.2024.100977\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.1016/j.lanepe.2024.100977\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoghtaderi A, Shahidi-Pourakbari M, Izadi S, Khosravi A, Hashemzehi Z. Ongoing increase in incidence and prevalence of multiple sclerosis in south-eastern Iran: a three decade study. Multiple Scler Relat Disorders. 2023;71:104557. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.1016/j.msard.2023.104557\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.1016/j.msard.2023.104557\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBagheri I, Yousefi H, Bahrami M, Shafie D. Adaptation of interdisciplinary clinical practice guidelines to palliative care for patients with heart failure in iran: application of adapte method. Iran J Nurs Midwifery Res. 2023;28(1):92\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.4103/ijnmr.ijnmr_152_22\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.4103/ijnmr.ijnmr_152_22\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRosetti L, Elliott S, Lee AH, McCracken LA, Hocaloski S, Hodge K, et al. The availability and quality of breastfeeding guidelines for women with spinal cord injury: a narrative review. Spinal Cord. 2022;60(9):837\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41393-022-00805-x\u003c/span\u003e\u003cspan address=\"10.1038/s41393-022-00805-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/\u003c/span\u003e\u003cspan address=\"https://doi.ir/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOu J-Y, Liu J-J, Xu J, Li J-Y, Liu Y, Liu Y-Z, et al. Quality appraisal of clinical practice guidelines for motor neuron diseases or related disorders using the AGREE II instrument. Front Neurol. 2023;14:1180218. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.3389/fneur.2023.1180218\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.3389/fneur.2023.1180218\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeneral Assembly WMA, Finland H. WMA Declaration of Helsinki \u0026ndash; Ethical Principles for Medical Research Involving Human Participants June 1964 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.wma.net/policies-post/wma-declaration-of-helsinki/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAssociation SAN. Guideline for the diagnosis and management of multiple sclerosis. 2013. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.7196/SAMJ.7124\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.7196/SAMJ.7124\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCenters CMS. Practice Guideline: Disease-modifying therapies for adults with multiple sclerosis 2019. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.mscare.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeurology AAo. Practice Guideline: Disease-modifying therapies for adults with multiple sclerosis. 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/\u003c/span\u003e\u003cspan address=\"https://doi.ir/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1212/WNL.0000000000005347\u003c/span\u003e\u003cspan address=\"10.1212/WNL.0000000000005347\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCMSC CoMSC. A Practical Guide To Rehabilitation In Multiple sclerosis 2015. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.cmeaims.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAANN G. Nursing Management of the Patient with Multiple Sclerosis 2011. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.rehabnurse.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIOMSN G. Best Practices in Nursing Care, Disease Management, Comprehensive Care, Pharmacologic Management, Nursing Research 2022. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.iomsn.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalaysian G. Management of Multiple sclerosis: Malaysia Health Technology Assessment Section (MaHTAS) Medical Development Division, Ministry of Health Malaysia; 2015. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.academed.org.my\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNICE G. Multiple sclerosis in adults: management 2022. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.nice.org.uk/guidance/ng220\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarck CH, Weld-Blundell IV, Klaic M, Motl RW, Learmonth YC. The actionability of physical activity guidelines for multiple sclerosis care: a systematic review and AACTT framework analysis. Arch Phys Med Rehabil. 2025;106(4):590\u0026ndash;606. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.1016/j.apmr.2024.09.020\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.1016/j.apmr.2024.09.020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamout B, Al-Jumah M, Sahraian M, Almalik Y, Al Khaburi J, Shalaby N, et al. Consensus recommendations for diagnosis and treatment of Multiple Sclerosis: 2023 revision of the MENACTRIMS guidelines. Multiple Scler Relat Disorders. 2024;83:105435. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.1016/j.msard.2024.105435\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.1016/j.msard.2024.105435\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFontaine G, Vinette B, Weight C, Maheu-Cadotte M-A, Lavall\u0026eacute;e A, Desch\u0026ecirc;nes M-F, et al. Effects of implementation strategies on nursing practice and patient outcomes: a comprehensive systematic review and meta-analysis. Implement Sci. 2024;19(1):68. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.ir/ 10.1186/s13012-024-01398-0\u003c/span\u003e\u003cspan address=\"https://doi.ir/ 10.1186/s13012-024-01398-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Achieving a standardized score of 50% or higher in all domains (all six domains) is classified as \u0026ldquo;Strongly Recommended.\u0026rdquo;\u003c/span\u003e\u003cdiv id=\"Par35\" class=\"Para\"\u003eAchieving a standardized score of 50% or higher only in the overall assessment is classified as \u0026ldquo;Recommended with modifications.\u0026rdquo;\u003c/div\u003e\u003cdiv id=\"Par36\" class=\"Para\"\u003eFailure to achieve a standardized score of 50% or higher in either all domains or the overall assessment is classified as \u0026ldquo;Not Recommended.\u0026rdquo;\u003c/div\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Achieving a standardized score of 50% or higher in all domains (all six domains) is classified as \u0026ldquo;Strongly Recommended.\u0026rdquo;\u003c/span\u003e\u003cdiv id=\"Par80\" class=\"Para\"\u003eAchieving a standardized score of 50% or higher only in the overall assessment is classified as \u0026ldquo;Recommended with modifications.\u0026rdquo;\u003c/div\u003e\u003cdiv id=\"Par81\" class=\"Para\"\u003eFailure to achieve a standardized score of 50% or higher in either all domains or the overall assessment is classified as \u0026ldquo;Not Recommended.\u0026rdquo;\u003c/div\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Clinical Practice Guideline, Multiple Sclerosis, Nursing Care, Critical Appraisal, AGREE II, Supportive Care","lastPublishedDoi":"10.21203/rs.3.rs-8317543/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8317543/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Evidence-based clinical practice guidelines (CPGs) are key instruments for enhancing care quality, standardizing health services, and improving clinical decision-making. Several international guidelines have been developed managing multiple sclerosis (MS), differing in comprehensiveness, consideration of care dimensions, methodological quality, and overall structure. This research aimed to critically appraise existing CPGs on MS care and identify the most appropriate options for adaptation within health systems in low- and middle-income countries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This guideline appraisal research was conducted during 2024–2025. A systematic search was performed in databases and clinical guideline repositories to identify relevant CPGs. Selected guidelines were evaluated by a panel of MS care specialists using the AGREE II instrument across six domains: scope and purpose, stakeholder involvement, Rigor of development, clarity of presentation, applicability, and editorial independence as well as two overall assessment criteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: Of 28 identified guidelines, eight met the inclusion criteria and were appraised\u003c/strong\u003e, while 20 were excluded due to issues with relevance, methodological quality, credibility, or lack of full-text accessibility. The appraisal revealed variability in the quality across the six domains, with significant differences in overall scores.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The findings indicate that the existing MS care CPGs exhibit heterogeneity in structural and content quality. Based on AGREE II scores, two guidelines—including those from Malaysia and NICE—showed the highest quality and are recommended as foundation for adaptation within health systems in low- and middle-income countries. \u0026nbsp;Developing a locally adapted guideline based on these results can improve nursing care quality, promote evidence-based decision-making, strengthen multidisciplinary coordination, and improve patient outcomes.\u003c/p\u003e","manuscriptTitle":"Critical Appraisal of Clinical Practice Guidelines for the Care of Patients with Multiple Sclerosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 19:13:04","doi":"10.21203/rs.3.rs-8317543/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"207947641111168695510614645162778222134","date":"2026-01-19T14:18:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"19352275102233576980451579557812882180","date":"2026-01-13T10:33:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-13T10:21:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-13T05:14:43+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-19T03:46:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-18T16:47:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-12-18T15:47:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d85ae3c9-5ee3-4ae8-bb4f-6b8608fbfb59","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-16T19:13:04+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 19:13:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8317543","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8317543","identity":"rs-8317543","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}