Physical Activity as a Habit in Long-Term Care: A Multidisciplinary Guideline

Round 1

Reviewer 1 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

REVIEW REPORT

1. Summary of the manuscript and key contributions The manuscript presents the development of the Dutch multidisciplinary guideline “Physical activity as a habit in long-term care,” which aims to integrate physical activity as a structural component in long-term care settings.

The paper describes: The process of developing the guideline through a multidisciplinary working group, The identification and prioritization of structural challenges in the integration of physical activity, The formulation of critical questions that guide the recommendations, The incorporation of literature reviews, focus groups, and stakeholder engagement, Practical recommendations organized around six key questions, and The identification of knowledge gaps that should guide future research.

 

The main contributions of the manuscript are: Providing a structured framework for integrating physical activity into long-term care, Translating scientific evidence into applicable recommendations, Including multiple levels of the system (organization, professionals, technology, users, and informal caregivers), and Identifying future research priorities.

The manuscript is relevant to healthcare, especially because of its translational and systemic approach.

2. Detailed evaluation of methodology, analysis, and conclusions. Given that this is a communication focused on the development of a guideline, the evaluation should consider quality standards in the development of clinical guidelines and consensus documents.

2.1. Methodology for developing the guideline

The process described includes: Multidisciplinary working group, Needs assessment, Prioritization of challenges, Formulation of critical questions, Literature review, and Consultation with focus groups and sounding boards.

Strengths: Participatory approach, Inclusion of stakeholders, and Explicit identification of knowledge gaps.

Areas for improvement:

1. Greater methodological transparency: It is not clearly specified whether any international guideline development framework (e.g., AGREE II or GRADE) was followed. The literature review method (systematic, scoping, narrative?) is not described. The criteria for inclusion/exclusion of studies are not detailed. How the quality of the evidence was assessed is not described.
2. Consensus process: It would be desirable to specify whether a formal method (Delphi, nominal group technique) was used and to indicate the number of participants, their professional profile, and the selection criteria.
3. Management of conflicts of interest: How potential conflicts were managed should be made explicit, especially in a guideline document.

In an international journal, even in Communication format, it is important to reinforce the methodological robustness of the process.

2.2. Content of the recommendations

The six critical questions are well structured and cover macro and micro levels: Justification of physical activity, Institutional organization, Integration into daily life, Types of activities, Technology, and Motivation of users and caregivers.

Strengths: Ecological and systemic approach, consideration of informal caregivers, and inclusion of technology as a facilitator.

However: It is not always clear which recommendations are strongly supported by empirical evidence and which are derived mainly from expert consensus. It would be useful to classify recommendations according to level of evidence or strength of recommendation.

2.3. Scientific rationale

The manuscript adequately explains the importance of physical activity in physical and mental health. However: The introduction could be strengthened with recent systematic reviews documenting the impact of physical activity on vulnerable populations. Given that older adults, people with intellectual disabilities, and nursing home residents are included, it would be relevant to incorporate specific evidence on populations with complex needs.

In this regard, consideration could be given to integrating literature such as: Influence of Physical Activity in Children and Adolescents with Cerebral Palsy: A Systematic Review, which exemplifies how physical activity can be structured in populations with disabilities, and Prosocial Behaviour in Sports and Physical Activity: A Systematic Review, which can enrich the social and relational dimension of physical activity, especially in residential settings where social connection is key. These references could strengthen the discussion by placing the guide within a broader biopsychosocial framework.

 

2.4. Discussion and knowledge gaps

The identification of knowledge gaps is one of the strengths of the manuscript. However: It would be advisable to prioritize these gaps (which are critical? which are emerging?), A brief structured research agenda could be included, and It would be advisable to discuss the international transferability of the guide beyond the Dutch context.

2.5. Conclusions

The conclusions are consistent with the content presented. However: They could be clarified by emphasizing that these are recommendations based on available evidence combined with expert consensus, and it would be advisable to explicitly highlight the limitations of the development process.

3. Constructive comments for authors

Main strengths: Highly relevant public health topic, multidisciplinary approach, clear practical guidance, inclusion of stakeholders, and explicit identification of knowledge gaps.

Areas for improvement

1. Methodological rigor: Specify the methodological framework used to develop the guideline, describe the literature review process in greater detail, indicate the level of evidence and strength of recommendations, and detail the consensus procedure.
2. Transparency: Include information on conflicts of interest and describe the exact composition of the working group.
3. Theoretical basis: Expand the scientific basis with recent systematic reviews and reinforce the social and psychosocial dimension of physical activity.
4. Transferability: Discuss applicability outside the Dutch healthcare system and consider implications for international policies.
5. Overall assessment: The manuscript is a valuable and relevant contribution in Communication format. The topic is relevant and the structure is clear. However, to strengthen its scientific impact and international credibility, it is recommended to improve methodological transparency and reinforce the basis in systematic evidence.

Recommendation

The manuscript is publishable after methodological improvements and expansion of the scientific basis, especially with regard to the transparency of the guide development process and the level of evidence for the recommendations.

Author Response

Thank you for the opportunity to revise our manuscript. We are very grateful to the reviewers for taking the time to provide us with these valuable and constructive comments on our manuscript. We believe our manuscript has improved because of these comments and the revisions we made. We provide our responses to the comments below in a point-by-point fashion. The changes we made to the manuscript are highlighted in the new version of the manuscript.

Reviewer 1

1. Summary of the manuscript and key contributions The manuscript presents the development of the Dutch multidisciplinary guideline “Physical activity as a habit in long-term care,” which aims to integrate physical activity as a structural component in long-term care settings. The paper describes: The process of developing the guideline through a multidisciplinary working group, The identification and prioritization of structural challenges in the integration of physical activity, The formulation of critical questions that guide the recommendations, The incorporation of literature reviews, focus groups, and stakeholder engagement, Practical recommendations organized around six key questions, and The identification of knowledge gaps that should guide future research.
   The main contributions of the manuscript are: Providing a structured framework for integrating physical activity into long-term care, Translating scientific evidence into applicable recommendations, Including multiple levels of the system (organization, professionals, technology, users, and informal caregivers), and Identifying future research priorities. The manuscript is relevant to healthcare, especially because of its translational and systemic approach.
   Thank you for these kind words, and taking the time to review our manuscript. Your comments helped us to improve our manuscript greatly. We provide our responses to the comments below in a point-by-point fashion. The changes we made to the manuscript are highlighted in the new version of the manuscript.
   
   2. Detailed evaluation of methodology, analysis, and conclusions. Given that this is a communication focused on the development of a guideline, the evaluation should consider quality standards in the development of clinical guidelines and consensus documents.
   2.1. Methodology for developing the guideline
   The process described includes: Multidisciplinary working group, Needs assessment, Prioritization of challenges, Formulation of critical questions, Literature review, and Consultation with focus groups and sounding boards.
   Strengths: Participatory approach, Inclusion of stakeholders, and Explicit identification of knowledge gaps.
   Areas for improvement:
   - Greater methodological transparency: It is not clearly specified whether any international guideline development framework (e.g., AGREE II or GRADE) was followed. The literature review method (systematic, scoping, narrative?) is not described. The criteria for inclusion/exclusion of studies are not detailed. How the quality of the evidence was assessed is not described.
   Thank you for these comments. In section 2.2 we describe the guideline development framework used: ‘The guideline was developed according to methodology of SKILZ, the Dutch institute for developing guidelines in long-term care, which is in accordance with established standards for high-quality guideline development. The process was informed by the AQUA Framework (2021) [24], the HARING tools (2013) [25], and the AGREE II instrument (2010) [26]’

Systematic literature reviews were performed following a predefined protocol, based on the PICO framework (see section 2.2.2). Due to substantial heterogeneity of the included studies we were not able to perfom a meta-analysis, so evidence was synthesised. We have further clarified this in section 2.2.2: ‘Due to substantial heterogeneity across studies in terms of populations, interventions, outcomes, and study designs, no meta‑analysis was performed. Instead, evidence was synthesised in evidence tables, and where possible, the certainty of evidence was assessed using the GRADE methodology [28] (supplementary file B).’

The inclusion and exclusion criteria are described in detail in supplementary file A. We now more clearly refer to this supplementary file in section 2.2.2: ‘The search strategy and detailed inclusion and exclusion criteria are provided in supplementary file A.’

Risk of bias of included studies was assessed using appropriate tools, such as the AMSTAR-2 checklist [27] and risk-of-bias tables and where possible, the certainty of evidence assessed using the GRADE methodology, described in section 2.2.2. Riks of bias scores are presented in detail in supplementary file B.

- Consensus process: It would be desirable to specify whether a formal method (Delphi, nominal group technique) was used and to indicate the number of participants, their professional profile, and the selection criteria.
Thank you for this comment. We now clarify that no formal consensus method (e.g., Delphi or nominal group technique) was applied. Instead, the guideline followed the SKILZ methodological framework, in which consensus is achieved through structured, iterative discussion within the multidisciplinary working group. All 13 members, whose profiles are described in section 2.2, participated in this process. We have now further specified this in section 2.2.3: ‘This process followed the SKILZ guideline development methodology and did not involve a formal consensus technique. All 13 members of the multidisciplinary working group participated in this structured deliberation, drawing on their diverse professional backgrounds to ensure that the recommendations reflected clinical relevance, patient preferences, feasibility, ethical considerations, safety, and cost‑effectiveness.’

- Management of conflicts of interest: How potential conflicts were managed should be made explicit, especially in a guideline document.
Thank you for this helpfull suggestions. All working group members submitted declarations of their roles, ancillary activities, funding, and potential conflicts of interest prior to participation. These were assessed by SKILZ to determine whether any conflicts precluded membership. We have added a short statement to section 2.2 to clarify this process: ‘All working group members declared their functions, ancillary positions, funding sources, and potential conflicts of interest prior to participation. These declarations were reviewed by SKILZ to assess eligibility and are publicly available in the published guideline documents.’

In an international journal, even in Communication format, it is important to reinforce the methodological robustness of the process.
Thank you, we have addressed your comments accordingly.

2.2. Content of the recommendations
The six critical questions are well structured and cover macro and micro levels: Justification of physical activity, Institutional organization, Integration into daily life, Types of activities, Technology, and Motivation of users and caregivers.
Strengths: Ecological and systemic approach, consideration of informal caregivers, and inclusion of technology as a facilitator.
However: It is not always clear which recommendations are strongly supported by empirical evidence and which are derived mainly from expert consensus. It would be useful to classify recommendations according to level of evidence or strength of recommendation.
We cannot specify the strength/level of evidence of the recommendations because the recommendations were made based on a triangulation of multiple information sources (scientific evidence, input from the focus and sounding board groups, relevant contextual factors, and the experience and expertise of the working group). The process of formulating the recommendations is described in our method section 2.2.3: ‘To triangulate these information sources, each working group member received the systematic review results as well as the outputs from the focus groups and sounding board groups. Members completed a questionnaire to synthesise these inputs with their professional experience and expertise and to draft initial recommendations. Consensus on the final recommendations was then achieved through structured deliberation during the working group meetings.’

2.3. Scientific rationale
The manuscript adequately explains the importance of physical activity in physical and mental health. However: The introduction could be strengthened with recent systematic reviews documenting the impact of physical activity on vulnerable populations. Given that older adults, people with intellectual disabilities, and nursing home residents are included, it would be relevant to incorporate specific evidence on populations with complex needs. In this regard, consideration could be given to integrating literature such as: Influence of Physical Activity in Children and Adolescents with Cerebral Palsy: A Systematic Review, which exemplifies how physical activity can be structured in populations with disabilities, and Prosocial Behaviour in Sports and Physical Activity: A Systematic Review, which can enrich the social and relational dimension of physical activity, especially in residential settings where social connection is key. These references could strengthen the discussion by placing the guide within a broader biopsychosocial framework.
Thank you for this helpful comment. While we agree that integrating evidence from systematic reviews on vulnerable populations strengthens the scientific rationale, the two reviews suggested by the reviewer focus on children and adolescents. Because our guideline addresses adults and older adults living in long‑term care, these reviews were not considered directly relevant. The introduction already includes population‑specific evidence, such as the recent systematic review and network meta‑analysis by Valenzuela et al. (2023) on physical exercise in older adults in residential care [21]. We have now added a brief sentence highlighting how this adult‑focused evidence supports the need for a tailored guideline in long‑term care: ‘This urgency is further underscored by recent evidence demonstrating that physical exercise can meaningfully improve function among older adults living in residential long‑term care settings’

2.4. Discussion and knowledge gaps
The identification of knowledge gaps is one of the strengths of the manuscript. However: It would be advisable to prioritize these gaps (which are critical? which are emerging?), A brief structured research agenda could be included, and It would be advisable to discuss the international transferability of the guide beyond the Dutch context.
Thank you for this constructive suggestion. In response, we have strengthened the Discussion section by prioritising the identified knowledge gaps and distinguishing short‑term from long‑term research and practice needs. We also added a concise, structured research agenda highlighting key areas for future work: ‘To guide future work, a distinction can be made between short‑term and long‑term priorities. In the short term, research should focus on understanding which strategies effectively support clients to become and remain more physically active over time, and how technology can facilitate activity in long‑term care. Further, the effects of increased physical activity in daily life on the physical, mental and social well-being of clients in long-term care should be studied. Long‑term priorities include evaluating the long-term impact of increased physical activity of clients on reducing the required care and associated healthcare costs (cost-effectiveness), and workforce outcomes such as workload, job satisfaction and absenteeism. For policymakers, a suggested research agenda includes investing in implementation studies, stimulating cross‑sector collaboration, supporting technological innovation, and funding long‑term evaluation studies that can inform structural policy adjustments.’

Furthermore, we expanded our discussion of international transferability, noting that differences in organisational structures, policy environments, and available resources require careful contextual adaptation of the guideline outside the Dutch context: ‘However, its applicability outside the Netherlands will depend on local regulatory structures, staffing models, funding mechanisms and cultural norms, and therefore should be adapted rather than adopted wholesale.’  and ‘The guidelines principles, such as the socio‑ecological approach and the focus on daily‑life activity, are informative for other countries. However, international applicability requires careful contextual adaptation.’

2.5. Conclusions
The conclusions are consistent with the content presented. However: They could be clarified by emphasizing that these are recommendations based on available evidence combined with expert consensus, and it would be advisable to explicitly highlight the limitations of the development process.
We have revised the Conclusion to more clearly state that the recommendations are based on available evidence combined with expert consensus, acknowledging this limitation in the development process: ‘The development process integrated multiple sources of evidence (systematic reviews, stakeholder input, and expert consensus) and used a structured consensus methodology, focusing on system‑level integration. The resulting recommendations therefore reflect the best available evidence combined with professional judgement where evidence was limited.’

3. Constructive comments for authors
Main strengths: Highly relevant public health topic, multidisciplinary approach, clear practical guidance, inclusion of stakeholders, and explicit identification of knowledge gaps.
Areas for improvement
1. Methodological rigor: Specify the methodological framework used to develop the guideline, describe the literature review process in greater detail, indicate the level of evidence and strength of recommendations, and detail the consensus procedure.
2. Transparency: Include information on conflicts of interest and describe the exact composition of the working group.
3. Theoretical basis: Expand the scientific basis with recent systematic reviews and reinforce the social and psychosocial dimension of physical activity.
4. Transferability: Discuss applicability outside the Dutch healthcare system and consider implications for international policies.
Thank you for this clear summary of the main strengths and areas for improvement. We have addressed each of these points in detail in our responses to the individual comments. In brief, we clarified the methodological framework and expanded the description of the literature review and consensus procedures; added explicit information on conflicts of interest and working‑group composition; strengthened the scientific and psychosocial rationale drawing on evidence relevant to adults in long‑term care; and expanded our discussion of international transferability and contextual adaptation. We believe these revisions have strengthened the overall transparency, methodological clarity, and international relevance of the manuscript.
4. Overall assessment: The manuscript is a valuable and relevant contribution in Communication format. The topic is relevant and the structure is clear. However, to strengthen its scientific impact and international credibility, it is recommended to improve methodological transparency and reinforce the basis in systematic evidence.
Thank you, we have revised our manuscript based on your comments.

Recommendation
The manuscript is publishable after methodological improvements and expansion of the scientific basis, especially with regard to the transparency of the guide development process and the level of evidence for the recommendations.
Thank you for this constructive overall assessment. We believe these revisions improve both the rigor and the transparency of the manuscript, and we appreciate the reviewer’s guidance in enhancing its quality.

Reviewer 2 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

Dear Authors,

The manuscript describes the development process of a multidisciplinary guideline aimed at embedding physical activity as a habitual practice in long-term care (LTC). Overall, the structure aligns with the standard format for guideline-development communication papers. However, several sections require greater clarity, enhanced methodological transparency, and a more explicit presentation of evidence levels and recommendation strength.

ABSTRACT

The objective could be clarified and strengthened as follows:

This study aimed to systematically develop and synthesise a multidisciplinary, evidence-informed national guideline for integrating physical activity into routine long-term care practice.

In the Methods section of the abstract, the systematic methodology should be described more specifically and supported with numerical details. The link between evidence synthesis and the formulation of recommendations should be articulated more clearly.

The conclusion of the abstract is currently rather general. The manuscript’s unique contribution should be more explicitly highlighted.

INTRODUCTION

The introduction is strong in terms of literature coverage. However, the study objective should be presented in a clear, measurable, and structured sentence.

It should also be clarified whether the manuscript is:

• a methodological paper,
• a summary of the guideline,
• or an implementation framework.

This distinction is important for reader expectations and journal positioning.

A comparative gap analysis with existing guidelines (e.g., WHO, ACSM, or other long-term care physical activity guidelines) would strengthen the rationale. The statement that “such a guideline does not exist” should be supported by a more systematic evaluation of the literature.

Although guideline development studies do not necessarily include formal hypotheses, the manuscript should at least clearly define the problem and outline the conceptual solution framework guiding the development process.

METHODS

The overall methodological framework appears appropriate; however, transparency needs to be improved. Currently, the reader cannot adequately assess the quality of the systematic review component.

The following elements should be clarified:

• Inclusion and exclusion criteria.
• The specific levels of long-term care covered (primary, secondary, tertiary LTC).
• Details of the systematic review methodology:
• Which databases were searched?
• What was the time frame?
• How many studies were included?
• Was inter-rater reliability assessed?
• Was a meta-analysis conducted, or was a narrative synthesis used?
• GRADE results are not presented in the main text.
• The strength of recommendations is not specified.
• The levels of evidence supporting each recommendation are not reported.
• A summarized study flow diagram could have been presented in the main manuscript.

Without these elements, the transparency and reproducibility of the guideline development process remain limited.

 

RESULTS

It is unclear whether the survey instrument was developed based on existing literature. Was it pilot tested? How was content validity ensured? These aspects require clarification.

The prioritization process should be described in greater detail. For example:

• Participants identified their “top three priorities,” but the analytical approach used to process these responses is not explained.
• Was a weighted scoring system applied?
• Were simple frequencies used?
• What criteria were used in the consensus process?

Percentage distributions are presented; however, no comparative analyses across different care types (e.g., nursing homes vs. intellectual disability care) are reported. The rationale for not conducting subgroup analyses should be explained.

For the modules, the manuscript states that systematic literature reviews were conducted, GRADE was used, and risk-of-bias assessments were performed. However, the Results section should additionally report:

• The number of studies included per module.
• The overall strength of evidence per module.
• Whether recommendations were classified as strong or weak.

Each module should include a concise evidence summary along with the corresponding GRADE evaluation.

DISCUSSION

The Discussion section would benefit from revision in the following ways:

• The claimed contribution should be made more concrete and specific.
• International generalizability should be discussed more cautiously.
• An explicit implementation framework perspective could be integrated.
• The strength of evidence and study limitations should be more openly and critically discussed.

Additionally, it would be helpful to distinguish between short-term and long-term research and practice priorities. A suggested research agenda for policymakers could further enhance the manuscript’s practical relevance.

CONCLUSION

General expressions such as “an important step” should be made more concrete.

The guideline’s unique contribution should be more clearly articulated:

• How does it differ from existing guidelines?
• What methodological innovations does it offer?

The manuscript uses the term “evidence-informed,” yet the levels of evidence supporting the recommendations are not clearly presented in the main text. Therefore, this claim currently lacks sufficient methodological substantiation.

International generalizability should be expressed more cautiously, considering that:

• The implementation context is specific to the Dutch healthcare system.
• The guideline’s feasibility and effectiveness have not yet been tested.
• The need for contextual adaptation in other healthcare systems should be more explicitly acknowledged.

While the Conclusion mentions implementation, monitoring, and future research needs, it would benefit from brief guidance on the following points:

• How will monitoring be conducted?
• Is there an impact evaluation plan?
• Have performance indicators been defined?

Author Response

Reviewer 2

Dear Authors,
The manuscript describes the development process of a multidisciplinary guideline aimed at embedding physical activity as a habitual practice in long-term care (LTC). Overall, the structure aligns with the standard format for guideline-development communication papers. However, several sections require greater clarity, enhanced methodological transparency, and a more explicit presentation of evidence levels and recommendation strength.
Thank you for these kind words, and your valuable comments on our manuscript. Your comments helped us to improve our manuscript greatly. We provide our responses to the comments below in a point-by-point fashion. The changes we made to the manuscript are highlighted in the new version of the manuscript.

ABSTRACT
The objective could be clarified and strengthened as follows:
This study aimed to systematically develop and synthesise a multidisciplinary, evidence-informed national guideline for integrating physical activity into routine long-term care practice.
We revised our aim accordingly in both our abstract and introduction: ‘This paper presents a comprehensive overview of the systematic development and synthesis of a national, multidisciplinary guideline for integrating physical activity into routine long‑term care practice.’

In the Methods section of the abstract, the systematic methodology should be described more specifically and supported with numerical details. The link between evidence synthesis and the formulation of recommendations should be articulated more clearly.
Thank you for this valuable suggestion. We have revised the Methods section of the abstract to provide greater methodological specificity and to clarify the link between evidence synthesis and recommendation development, while also trying to stay close to the recommended word count: ‘A multidisciplinary working group (n=13) developed the guideline. A national online questionnaire (April-May 2023), disseminated through 20 organisations, identified and prioritised key challenges for implementing physical activity in long-term care. Next, critical questions were formulated and answered by systematic literature reviews, complemented with input from a focus group and sounding board groups, including all stakeholders. Recommendations were drafted and finalised through structured consensus procedures, integrating scientific evidence, stakeholder perspectives, contextual considerations, and professional expertise.’

The conclusion of the abstract is currently rather general. The manuscript’s unique contribution should be more explicitly highlighted.
Thank you for this comment. We have revised the conclusion of the abstract to more clearly highlight the unique contribution of our manuscript, while also trying to stay close to the recommended word count (now 271 words of the recommended 250 words): ‘It offers practical and evidence-informed recommendations for incorporating physical activity in routine long-term care practices, specifically addressing the unique challenges encountered in long-term care settings.’

INTRODUCTION
The introduction is strong in terms of literature coverage. However, the study objective should be presented in a clear, measurable, and structured sentence. It should also be clarified whether the manuscript is:

• a methodological paper,
• a summary of the guideline,
• or an implementation framework.

This distinction is important for reader expectations and journal positioning.
Thank you for this valuable comment. We have revised the study objective to make it clearer, more structured, and more specific. In addition, we clarified that this manuscript provides an overview of the guideline development process and a synthesis of the main components of the resulting national guideline, rather than a full methodological report or a complete reproduction of the guideline: ‘This paper presents a comprehensive overview of the systematic development and synthesis of a national, multidisciplinary guideline for integrating physical activity into routine  long‑term care practice. In doing so, we provide a high‑level description of the development process and a concise synthesis of the guideline’s core components, without presenting the full underlying systematic reviews or the complete guideline in detail.’

A comparative gap analysis with existing guidelines (e.g., WHO, ACSM, or other long-term care physical activity guidelines) would strengthen the rationale. The statement that “such a guideline does not exist” should be supported by a more systematic evaluation of the literature.
Thank you for this helpful comment. We have expanded the introduction by adding a brief description of existing guidelines (WHO, ACSM). We clarified why these existing guidelines do not sufficiently address the organisational, environmental, and policy‑level complexities of long‑term care settings. We also revised the statement that such a guideline does not exist to reflect a better evaluation of the existing guidelines and why they are not sufficient: ‘Existing international guidelines provide important general recommendations for promoting physical activity, such as the WHO guidelines on physical activity and sedentary behaviour [23] and the American College of Sports Medicine’s Expert Consensus Statement Prescribing Exercise and Designing Physical Activity Programs for People with Disabilities [15]. However, these primarily focus on physical activity prescriptions or pro-grammatic advice, and do not provide a comprehensive, setting wide framework for embedding physical activity into daily care routines within long term care [14]. A guideline addressing all socio ecological levels, and designed for routine use in long term care practice, is still lacking.’

Although guideline development studies do not necessarily include formal hypotheses, the manuscript should at least clearly define the problem and outline the conceptual solution framework guiding the development process.
In line with the previous comment, we have added a clearer definition of the problem and a description of the conceptual framework guiding the development of the guideline, based on the socio‑ecological model. This addition clarifies the underlying rationale and structure of the development process: ‘Existing international guidelines provide important general recommendations for promoting physical activity, such as the WHO guidelines on physical activity and sedentary behaviour [23] and the American College of Sports Medicine’s Expert Consensus Statement Prescribing Exercise and Designing Physical Activity Programs for People with Disabilities [15]. However, these primarily focus on physical activity prescriptions or pro-grammatic advice, and do not provide a comprehensive, setting wide framework for embedding physical activity into daily care routines within long term care [14]. A guideline addressing all socio ecological levels, and designed for routine use in long term care practice, is still lacking.’

METHODS
The overall methodological framework appears appropriate; however, transparency needs to be improved. Currently, the reader cannot adequately assess the quality of the systematic review component. The following elements should be clarified:

• Inclusion and exclusion criteria: The inclusion and exclusion criteria are described in supplementary file A. We now more clearly refer to this supplementary file in section 2.2.2: ‘The search strategy and detailed inclusion and exclusion criteria are provided in supplementary file A.’
• The specific levels of long-term care covered (primary, secondary, tertiary LTC): We have clarified this in our method section 2.1: ‘The guideline is a single unified framework, targeted to individuals receiving primary, secondary or tertiary long-term care, due to a (combination of) psychogeriatric conditions, intellectual disabilities, gerontopsychiatric disorders, physical disabilities, and/or somatic conditions.’
• Details of the systematic review methodology:
• Which databases were searched? We have added this to section 2.2.2 and stated this more clearly in our supplementary file A: ‘Literature searches were performed in the databases CINAHL, Cochrane, Embase, PsycInfo and Pubmed on 19 December 2023, covering articles published from January 2014 onwards. The search strategy and detailed inclusion and exclusion criteria are provided in supplementary file A.’
• What was the time frame? The search was performed on 19 December 2023, and we searched for articles published from 1 January 2014 onwards. We have added this to section 2.2.2.
• How many studies were included? In total 25 studies were included, this is described in the flow diagram in figure 1, supplementary file B. We also added the number of included studies to results section.
• Was inter-rater reliability assessed? Inter‑rater reliability was not formally quantified. All screening and selection steps were performed by one reviewer. A second reviewer independently screened and selected a random sample of 10% of the records. Any discrepancies were discussed until consensus was reached. We have clarified this in section 2.2.2 Critical questions: ‘All screening and selection steps were performed by one reviewer. A second reviewer independently screened and selected a random sample of 10% of the records.’
• Was a meta-analysis conducted, or was a narrative synthesis used? A meta‑analysis was not conducted because the included studies were highly heterogeneous in terms of populations, interventions, outcomes, and study designs. Therefore, a narrative synthesis was used to summarise the evidence. We have clarified this in the section 2.2.2: ‘Due to substantial heterogeneity across studies in terms of populations, interventions, outcomes, and study designs, no meta-analysis was performed. Instead, evidence was synthesised in evidence tables, and where possible, the certainty of evidence was assessed using the GRADE methodology [28] (supplementary file B).’
• GRADE results are not presented in the main text. We chose not to integrate to many details on the systematic reviews into the main text, as doing so would reduce the paper’s readability due to the substantial volume of additional material. Moreover, the aim of our paper is not to present the underlying systematic reviews in full, but to provide an overview of the guideline development process summarise the guideline. Focusing on these elements allows us to present a concise and coherent paper that captures the most essential aspects of the guideline. We report the search strategy, inclusion/exclusion criteria, PRISMA flowcharts (Figure 1), tables with the included studies (Table 1-3) for each systematic review presenting the study aims, study and participant characteristics, interventions/comparisons, outcomes, conclusions, and the risk of bias scores.  
• The strength of recommendations is not specified. & The levels of evidence supporting each recommendation are not reported: We cannot specify the strength/level of evidence of the recommendations because the recommendations were made based on a triangulation of multiple information sources (scientific evidence, input from the focus and sounding board groups, relevant contextual factors, and the experience and expertise of the working group). The process of formulating the recommendations is described in our method section 2.2.3: ‘To triangulate these information sources, each working group member received the systematic review results as well as the outputs from the focus groups and sounding board groups. Members completed a questionnaire to synthesise these inputs with their professional experience and expertise and to draft initial recommendations. Consensus on the final recommendations was then achieved through structured deliberation during the working group meetings.’
• A summarized study flow diagram could have been presented in the main manuscript. We have chosen to include the study flow diagram and other detailed elements of the systematic reviews in the supplementary file in order to maintain the readability and conciseness of the main manuscript. We refer to the supplementary files in the manuscript.

Without these elements, the transparency and reproducibility of the guideline development process remain limited. Thank you for your valuable comments, we have addressed them separately above.

RESULTS
It is unclear whether the survey instrument was developed based on existing literature. Was it pilot tested? How was content validity ensured? These aspects require clarification.
The questionnaire was developed based on the desk research in which relevant existing national and international guidelines, policy documents, and research related to the topic of physical activity in long-term care were identified, accompanied by interviews with two experts. Based on this desk research a list of challenges was presented in the questionnaire. Additionally, respondents were asked to report any additional challenges encountered and indicate the top three challenges they believed should be prioritised in the guideline, this is described in section 2.2.1. Although the questionnaire was not formally validated, its structure has been applied in the development of multiple other guidelines and has demonstrated its utility in providing the input required to identify and prioritise the challenges that should be addressed in the guideline. We have added this clarification to the manuscript in section 2.2.1: ‘The questionnaire presented a list of challenges identified through the desk research, asking respondents to indicate whether they experienced these challenges. Additionally, respondents were asked to report any additional challenges encountered and indicate the top three challenges they believed should be prioritised in the guideline. Although the questionnaire was not formally validated, its structure has been applied in the development of multiple other guidelines by SKILZ and has demonstrated its utility in providing the input required to identify and prioritise the challenges that should be addressed in the guideline.’

The prioritization process should be described in greater detail. For example:

• Participants identified their “top three priorities,” but the analytical approach used to process these responses is not explained.
• Was a weighted scoring system applied?
• Were simple frequencies used?
• What criteria were used in the consensus process?

Thank you for this comment. We have added more detail to the Methods section 2.2.1. The top‑three priorities from the questionnaire were analysed using simple frequency counts. These frequencies were then used as input for a structured consensus discussion within the working group, during which members considered relevance, feasibility, and expected impact in long‑term care practice. No weighted scoring system was applied. This process has now been described more explicitly: ‘Respondents indicated the challenges they encountered and their top three priorities, which were analysed using simple frequency counts to determine how often each challenge was selected. These frequencies were used as input for a structured consensus discussion within the multidisciplinary working group, resulting in the key challenges to be addressed in the guideline. During this discussion, members considered the frequency data alongside the perceived relevance, feasibility, and expected impact of each challenge in long term care practice. No weighted scoring system or statistical prioritisation method was applied. Instead, prioritisation was based on deliberative consensus, in accordance with SKILZ guideline development methodology.’

Percentage distributions are presented; however, no comparative analyses across different care types (e.g., nursing homes vs. intellectual disability care) are reported. The rationale for not conducting subgroup analyses should be explained.
The guideline was specifically aimed to be a single unified framework for the long-term care setting, we did not aim to differentiate recommendations tailored to specific subpopulations. Recommendations are (mostly) made for the entire setting. Within the working group, we explicitly discussed whether separating subgroups would be necessary or desirable. However, we repeatedly concluded that the care settings and organisational contexts are sufficiently similar to allow for one overarching approach to integrating physical activity. We have specified in the manuscript that we use a single unified framework (section 2.1): ‘The guideline is a single unified framework, targeted to individuals receiving long-term care, due to a (combination of) psychogeriatric conditions, intellectual disabilities, gerontopsychiatric disorders, physical disabilities, and/or somatic conditions.’

For the modules, the manuscript states that systematic literature reviews were conducted, GRADE was used, and risk-of-bias assessments were performed. However, the Results section should additionally report:

• The number of studies included per module: We have added the number of studies included per module to table 2.
• The overall strength of evidence per module & Whether recommendations were classified as strong or weak: We cannot specify the strength/level of evidence of the recommendations because the recommendations were made based on a triangulation of multiple information sources (scientific evidence, input from the focus and sounding board groups, relevant contextual factors, and the experience and expertise of the working group). The process of formulating the recommendations is described in our method section 2.2.3: ‘To triangulate these information sources, each working group member received the systematic review results as well as the outputs from the focus groups and sounding board groups. Members completed a questionnaire to synthesise these inputs with their professional experience and expertise and to draft initial recommendations. Consensus on the final recommendations was then achieved through structured deliberation during the working group meetings.’

Each module should include a concise evidence summary along with the corresponding GRADE evaluation.
We chose not to integrate to many details on the systematic reviews into the main text, as doing so would reduce the paper’s readability due to the substantial volume of additional material. Moreover, the aim of our paper is not to present the underlying systematic reviews in full, but to provide an overview of the guideline development process summarise the guideline. Focusing on these elements allows us to present a concise and coherent paper that captures the most essential aspects of the guideline. We report the search strategy, inclusion/exclusion criteria, PRISMA flowcharts (Figure 1), tables with the included studies (Table 1-3) for each systematic review presenting the study aims, study and participant characteristics, interventions/comparisons, outcomes, conclusions, and the risk of bias scores. 

DISCUSSION
The Discussion section would benefit from revision in the following ways:
Thank you for these helpful suggestions. We have adjusted the Discussion to more concretely articulate the specific contribution of the guideline accordingly:

• The claimed contribution should be made more concrete and specific: We clarified the specific contribution of the guideline by more explicitly describing its added value as a multidisciplinary and system‑oriented framework tailored to long‑term care: ‘The guideline ‘Physical activity as a habit in long-term care guideline contributes specifically by providing a multidisciplinary and system oriented framework that translates both scientific evidence and stakeholder experience into actionable, context specific recommendations for long term care. It bridges the gap between general physical activity guidance and the practical realities of long-term care.’
• International generalizability should be discussed more cautiously. We further nuanced our statements regarding international relevance by acknowledging the need for contextual adaptation: ‘However, its applicability outside the Netherlands will depend on local regulatory structures, staffing models, funding mechanisms and cultural norms, and therefore should be adapted rather than adopted wholesale.’
• An explicit implementation framework perspective could be integrated. We incorporated an explicit reference to implementation frameworks (e.g., CFIR) to position our implementation considerations within a broader theoretical context: ‘These implementation considerations align with recognised implementation frameworks, such as the Consolidated Framework for Implementation Research (CFIR), which emphasises multilevel determinants, including individuals, inner setting, outer setting, and processes, that directly map onto the socio ecological levels addressed in this guideline.’
• The strength of evidence and study limitations should be more openly and critically discussed. We strengthened the critical reflection on the evidence base by commenting on the varying certainty of evidence across recommendations and the implications of existing research gaps. These additions have been integrated in the discussion: ‘However, its applicability outside the Netherlands will depend on local regulatory structures, staffing models, funding mechanisms and cultural norms, and therefore should be adapted rather than adopted wholesale.’ and ‘Furthermore, the evidence base for certain recommendations is limited, and therefore some rely more on expert consensus, due to gaps in research on long-term effects and cost-effectiveness.’

 

Additionally, it would be helpful to distinguish between short-term and long-term research and practice priorities. A suggested research agenda for policymakers could further enhance the manuscript’s practical relevance.
Thank you for this comment. We have expanded the Discussion section by distinguishing between short‑term and long‑term research priorities, and we have added a brief suggested research agenda for policymakers to enhance the practical relevance of the manuscript: ‘To guide future work, a distinction can be made between short term and long term priorities. In the short term, research should focus on understanding which strategies effectively support clients to become and remain more physically active over time, and how technology can facilitate activity in long term care. Further, the effects of increased physical activity in daily life on the physical, mental and social well-being of clients in long-term care should be studied. Long term priorities include evaluating the long-term impact of increased physical activity of clients on reducing the required care and associated healthcare costs (cost-effectiveness), and workforce outcomes such as workload, job satisfaction and absenteeism. For policymakers, a suggested research agenda includes investing in implementation studies, stimulating cross sector collaboration, supporting technological innovation, and funding long term evaluation studies that can inform structural policy adjustments.’

CONCLUSION
General expressions such as “an important step” should be made more concrete. The guideline’s unique contribution should be more clearly articulated:

• How does it differ from existing guidelines?
• What methodological innovations does it offer?

The manuscript uses the term “evidence-informed,” yet the levels of evidence supporting the recommendations are not clearly presented in the main text. Therefore, this claim currently lacks sufficient methodological substantiation.
International generalizability should be expressed more cautiously, considering that:

• The implementation context is specific to the Dutch healthcare system.
• The guideline’s feasibility and effectiveness have not yet been tested.
• The need for contextual adaptation in other healthcare systems should be more explicitly acknowledged.

Thank you for these helpful comments. We deliberately use the term “evidence‑informed” instead of “evidence‑based,” as the strength or level of evidence for each recommendation cannot be specified. The recommendations are grounded in a triangulation of information sources, scientific evidence, input from focus and sounding board groups, relevant contextual factors, and the expertise of the working group, which aligns with the concept of evidence‑informed guideline development. We have strengthened the Conclusion according to the reviewers’ comments by specifying the unique contribution of the guideline, including its system‑oriented, multidisciplinary focus and the integration of multiple evidence sources through a structured consensus process. We have also revised statements about international relevance to more clearly acknowledge the need for contextual adaptation and the fact that feasibility and effectiveness have not yet been tested. These changes improve the precision and practical applicability of the Conclusion: ‘Concluding, this guideline represents a unique contribution by providing a multidisciplinary and system‑oriented framework specifically tailored to long‑term care settings, supporting the embedding of physical activity as a fundamental component of long-term care. By addressing key challenges and involving all relevant stakeholders in its development, it offers practical and evidence-informed recommendations for incorporating physical activity in routine long-term care practices. The development process integrated multiple sources of evidence (systematic reviews, stakeholder input, and expert consensus) and used a structured consensus methodology, focusing on system level integration. While the guideline is rooted in the Dutch context, its multidisciplinary approach and alignment with international evidence make it a valuable reference for other countries seeking to enhance physical activity in long-term care settings. The guidelines principles, such as the socio‑ecological approach and the focus on daily‑life activity, are informative for other countries. However, international applicability requires careful contextual adaptation. To fully realise its potential, continued efforts are needed to support implementation, monitor outcomes, and address the identified knowledge gaps through targeted research. Only then can physical activity truly become a sustainable habit in long-term care, benefiting clients, professionals, and healthcare systems alike.’

While the Conclusion mentions implementation, monitoring, and future research needs, it would benefit from brief guidance on the following points:

• How will monitoring be conducted?
• Is there an impact evaluation plan?
• Have performance indicators been defined?

We have a paragraph in the discussion with the practical implications for the different stakeholders to make the implications more accessible and actionable for the stakeholders. It is however beyond our scope to include a complete implementation, monitoring and evaluation plan.

Round 2

Reviewer 2 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

Dear Authors,

First of all, I would like to thank you for carefully addressing the comments raised in the previous review and for undertaking thorough and thoughtful revisions. With these improvements, the manuscript has been significantly strengthened both scientifically and in terms of its practical relevance.

In particular, the increased methodological transparency in the Methods section, the clarification of the online survey process, and the more explicit description of the prioritization procedure have substantially enhanced the credibility of the work. The Introduction now more clearly defines the gap in the literature and better articulates how the guideline differs from existing long-term care and physical activity recommendations, thereby reinforcing the originality and added value of the study.

The inclusion of a Limitations section and the more structured presentation of practical implications for different stakeholder groups have further improved the manuscript’s applicability and real-world relevance. In this respect, the study provides an important and original contribution to the integration of physical activity into routine long-term care practice.

Overall, I believe that the revisions have addressed the previous concerns to a large extent and that the manuscript has reached a level suitable for publication. I am confident that this work will make a meaningful contribution to the field.

I wish you continued success in your work.

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors, 

The following comments and suggestions are offered with the belief that they will meaningfully strengthen your manuscript. The study addresses an important need in long-term care, and I consider that the revisions proposed below will enhance both the scientific rigor and practical applicability of the study.

Introduction

It would strengthen the manuscript if the authors add a short but compelling introductory paragraph to capture readers’ attention more effectively. Although the structural organization of the Introduction is generally appropriate, the section lacks sufficient scientific depth and a stronger emphasis on the originality of the work. This needs to be improved.

The Introduction should explicitly address the following key questions:

Why are existing LTC guidelines insufficient?

Which interventions have failed, and why?

What specific gaps exist in the current literature?

From the reader’s perspective, the manuscript conveys that “there is a problem and this is a guideline,” but it does not convincingly clarify why this guideline is unique or what specific gap it fills.

Within the socio-ecological model, the linkage between individual, professional, organizational, and policy levels should be articulated more explicitly—ideally in one or two sentences to show how these levels intersect in LTC settings.

The purpose statement is overly descriptive and should be rewritten in a more directive and focused manner. A possible alternative phrasing is:

“This paper describes the systematic development of a national multidisciplinary guideline aimed at embedding physical activity as a habitual component of daily care in long-term care settings.”

Methods

The manuscript should clarify whether the guideline provides a single unified framework or includes differentiated recommendations tailored to specific LTC subpopulations.

For the online survey, important methodological details are missing, including:

How many individuals received the questionnaire?

How many responded?

Which professional groups participated?

How was the questionnaire validated and structured?

In the Critical Questions section, the rationale for not conducting systematic reviews for some topics is not clearly explained. The authors should justify why certain questions relied on expert opinion rather than systematic evidence, and clarify the types of evidence used.

Results

The Results section is logically aligned with the processes described in the Methods.

However, the following questions remain unanswered:

How were thresholds defined to priorities challenges as key challenges?

Although the recommendations are practical and well-formulated, the lack of an explicit link between the level of evidence and the strength of the recommendations may limit their interpretability for end-users.

Overall, the Results section provides a clear and practice-oriented summary of the guideline’s outputs. Still, transparency would be improved through more explicit reporting of prioritization criteria and clearer connections between recommendations and evidence certainty or expert consensus.

Discussion

The Discussion contextualizes the guideline effectively but would benefit from: a clearer explanation of the guideline’s added value compared with existing LTC or PA guidelines, an explicit Limitations section, and a more critical reflection on implementation challenges and generalizability.

A Limitations subsection is essential and should be included.

It is recommended that the authors add a short but structured subsection titled ‘Practical Implications’ at the end of the Discussion. This section should explicitly describe how different stakeholder groups (care staff, managers, family members, decision makers) can operationalize the recommendations and what the guideline implies for policymakers. Such a subsection would facilitate translating the guideline into real-world practice and significantly enhance both the purpose and practical utility of the manuscript.

Although these implications can be inferred from the manuscript as a whole, presenting them clearly and in a structured format would make the practical applications more understandable, accessible, and actionable for diverse stakeholders.

Reviewer 2 Report

Comments and Suggestions for Authors

I appreciate the invitation to evaluate the manuscript Physical activity as a habit in long-term care: A multidisciplinary guideline.

In my opinion, the paper presents a very relevant and well-motivated multidisciplinary guideline, with stakeholder involvement and the use of methodological frameworks (AGREE II, GRADE, AMSTAR-2). However, in order to meet the methodological rigor and transparency requirements demanded by Healthcare (MDPI), it is necessary to expand the methodological documentation, clarify the evidence-recommendation relationship, present the results of systematic reviews in an accessible manner, and strengthen the implementation/monitoring section. Below is a detailed analysis.

Clear summary of the manuscript and its key contributions

The manuscript describes the development process of the Dutch guideline “Physical activity as a habit in long-term care.”

Key contributions: Identification of challenges (needs assessment; n = 206) in integrating physical activity into long-term care settings; Formulation of critical questions and guideline modules (organization, activities, technology, motivation, informal caregivers, etc.); Conducting systematic reviews for five modules (according to PICO protocols) and assessing the certainty of evidence using GRADE; synthesis into practical recommendations; participation of focus groups and validation tables by professional associations and stakeholders; the guideline is authorized by professional associations and published in national format (in Dutch).

The manuscript has several key strengths: High clinical and social relevance. The guideline addresses a clearly priority issue in health policy and care for dependent populations; Multidisciplinary and participatory approach. It involves professionals, managers, client representatives, and family members—which promotes acceptance and feasibility; Use of recognized methods and standards. The stated use of AGREE II, GRADE, and AMSTAR-2 tools supports the methodological framework; Combination of evidence and experience (evidence + practice). The guideline does not rely solely on the literature but incorporates expert judgments and feasibility/ethical considerations; Supplementary documentation. The existence of comprehensive reviews and supplementary material (PRISMA/study table) is positive and promotes transparency, although its main presentation could be improved (see weaknesses).

Despite this, there are some weaknesses and critical aspects (methodology, writing, and organization).

Transparency and methodological reporting (PRIORITY)

-Lack of sufficient methodological details in the body of the text. It is indicated that systematic reviews were conducted using PICO protocols and risk of bias assessment, but key information is missing from the manuscript: search strategy (databases, dates, terms), inclusion/exclusion criteria, number of studies identified per review, quantitative summary (where applicable), and synthesis of findings. The reader of the article cannot assess its robustness without this data (although it appears in supplements in Dutch).

Requirement: include at least one operational summary (PRISMA flow + summary table per review) in the English manuscript or make the supplement available in English.

-Risk of bias and GRADE results not presented in text. Indicate the certainty rating for key results and how that certainty influenced the strength of the recommendations.

-Prioritization process not described in detail. Explicit criteria for how challenges were prioritized are missing (e.g., scales, thresholds, nominal consensus). Explain the consensus method (Delphi? Nominal panel? Simple consensus?) and how discrepancies were resolved.

-Evidence → recommendation relationship insufficiently explicit. For each recommendation, the evidence (level), justification, and strength of the recommendation (strong/conditional) should be stated. Currently, evidence and experience appear to be mixed without clear traceability.

1. Survey results (needs assessment)

-Brief description of the survey: although n = 206 and distribution by field/profession are reported, the questionnaire (items), response rate, sampling procedure, and non-response analysis are not presented. It is essential to know: dissemination method, period, rates, and possible selection biases.

-Superficial analysis of heterogeneity: there is no analysis by subgroups (type of center, profession, region), which would limit the applicability of specific recommendations.

1. Evidence review and synthesis

-Synthesize key findings: the recommendation sections are well written, but the manuscript does not synthesize the empirical findings in an accessible way (e.g., effectiveness of interventions, magnitude of effect, target population, limitations of studies).

-Absence of meta-analysis or quantitative synthesis (if applicable): if some reviews allowed for meta-analysis, its absence or reasoning (due to heterogeneity) should be detailed.

1. Implementation, monitoring, and evaluation

-Weak implementation plan: the guide requires operational guidance for implementation (pilot plans, roles, resources, process and outcome indicators).

Requirement: include a section with: adoption/outcome indicators (e.g., increases in minutes of activity, functional scales), audit frequency, responsible parties, and resource estimates.

-Cost-effectiveness and feasibility: the guide mentions cost-effectiveness considerations, but does not present evidence or a framework for economic evaluation; it would be useful to at least provide guidance on economic research priorities.

1. Credibility and generalizability

-National context: the authors assert international relevance, but should qualify generalizability and list which elements are context-dependent (funding, organizational structure, regulation).

-Accessibility of supporting evidence: the complete materials are in Dutch on the national website; it is recommended that an English version or executive summaries be provided for the international community.

1. Writing and organization

-The manuscript is generally clear, but the organization could be improved: results → present PRISMA/summary by module; recommendations → link to evidence; discussion → explicitly summarize methodological limitations.

4. Specific evaluation of methodology (clarity, rigor, consistency with objectives)

-Clarity: moderate. The methodological steps are mentioned (identification of challenges, formulation of critical questions, systematic reviews, GRADE, focus groups), but operational details that would allow for reproducibility are lacking.

-Rigor: good in intention (use of AMSTAR-2, GRADE, AGREE II), but execution and reporting require expansion to demonstrate rigor in practice (see Weaknesses A–C).

-Consistency with objectives: high. The chosen approach responds to the objectives: identifying barriers and proposing recommendations. However, the evidence-substantiation of each recommendation needs better traceability to affirm that the guideline is scientifically based and not just expert-based.

5. Are the conclusions supported by sufficient data?

Partially. The conclusions regarding the need for the guide and the practical recommendations are plausible and consistent with the combination of literature review + stakeholder contributions. However:

-To support claims about the effectiveness of specific actions, clearer summaries of the evidence (effects, magnitude, quality) are needed.

-To affirm international generalizability, the statement should be moderated and an explanation provided of which aspects require adaptation.

-Consequently, the guide serves as a framework but, as presented, does not provide sufficient methodological transparency for the independent reader to fully verify that each recommendation is supported by high-quality evidence.

6. Specific recommendations (action by action)

Methodological content (essential)

1. Include in the manuscript (not just in Dutch supplements): summarized PRISMA flowcharts for each review, tables of included studies (characteristics, population, intervention, outcomes), GRADE summary (evidence profile) with justification for each statement.
2. Describe the search strategy (databases consulted, periods, key terms) or attach the strategy in an English supplement.
3. Explain the prioritization and consensus process (specific method, number of rounds, consensus criteria).
4. Report risk of bias results (AMSTAR-2/ROB2 or other) and how they influenced the strength of the recommendations.
5. Determine and state the strength of each recommendation (e.g., strong/conditional) and its basis (quality of evidence, balance of benefits/harms, feasibility).

Results and analysis

6. Add subgroup analysis of the survey by type of center and by profession to identify specific needs.
7. If applicable, present meta-analysis or justify why it was not performed (heterogeneity, different outcomes).
8. Specify implementation and monitoring indicators: primary metrics (minutes/day of activity, proportion complying with recommendation), process metrics (number of professionals trained), and those responsible.

Writing and structure

9. Reorganize Results: clearly separate Needs assessment / Results of reviews / Consensus process / Recommendations.
10. Include a table entitled “Recommendation – Level of evidence – Implementation comments” for each recommendation (very useful for readers and implementers).

Generalization and accessibility

11. Qualify statements about international applicability and provide clear guidance on how to adapt the guide to other contexts.
12. Publish executive summaries of the reviews in English for the international community.
13. Additional expert comments (high-level improvements)

-Connect recommendations with a logic model that shows causally how the recommended actions lead to intermediate outcomes (e.g., increased activity → increased functional capacity → reduced dependency → reduced caregiver burden). This aids implementation and evaluation.

-Prepare practical complementary resources (algorithms, implementation checklist, training guides) that facilitate dissemination and adoption in centers. Include an appendix with templates.

-Consider a 2–3-year evaluation plan (implementation and effectiveness study) and suggest primary/secondary indicators for future research.

-Accessibility statement: if the guideline already has online materials (in Dutch), incorporate plans for translation and international versions to broaden impact and citability.

Suggested editorial decision

Major revision. The manuscript is a valuable and potentially publishable contribution to Healthcare, but requires the methodological corrections and additions described above to ensure transparency, reproducibility, and international utility.