Healthy movement behaviours of Canadian children and youth have been found to be suboptimal; this is associated with declines in physical fitness, increases in obesity, and elevated chronic disease risk. Physical literacy is an evolving construct representing foundational domains upon which physically active lifestyles are based. Many sectors and organizations in Canada are embracing physical literacy in their programs, practices, policies, and research; however, the use of inconsistent definitions and conceptualizations of physical literacy had been identified by stakeholders as hindering promotion and advancement efforts.With leadership from ParticipACTION, organizations from the physical activity, public health, sport, physical education, and recreation sectors collaborated to create a physical literacy consensus definition and position statement for use by all Canadian organizations and individuals. The process involved an environmental scan, survey of related evidence, stakeholder consultations, and creation of a Steering Committee. From this background work a consensus statement was drafted, shared with stakeholders, revised, and ratified.Canada’s Physical Literacy Consensus Statement was launched in June 2015 at the International Physical Literacy Conference in Vancouver, British Columbia. To further promote the Consensus Statement, the Sport for Life Society developed and simultaneously released the “Vancouver Declaration”, which contained additional guidance on physical literacy. Both the Consensus Statement and the Declaration endorsed the International Physical Literacy Association’s definition of physical literacy, namely “the motivation, confidence, physical competence, knowledge and understanding to value and take responsibility for engagement in physical activities for life”.Sector partners hope that the Consensus Statement, with its standardized definition, brings greater harmony, synergy, and consistency to physical literacy efforts in Canada and internationally. Going forward, the impact of this initiative on the sector, and the more distal goal of increasing habitual physical activity levels, should be assessed.The online version of this article (10.1186/s12889-018-5903-x) contains supplementary material, which is available to authorized users. There are global concerns over the current lifestyle behaviours and future health of children and youth –8, with Objectively measured physical activity data show that only 9% of Canadian children and youth aged 5–17 years are getting enough physical activity to meet the guidelines of at least 60 min of MVPA daily .In terms of sedentary behaviour, Canadian 5- to 17-year olds spent an average of 8 h and 27 min – nearly two-thirds (or 64%) of their waking hours each day – being sedentary. Those aged 12–17 years were more sedentary than those aged 5–11 years  while children aged 3–4 years were the least sedentary, at 7 h and 28 min of waking time  are meetCurrent habitual movement behaviours of Canadian children and youth warrant concern given the important physical, psycho-social, and academic benefits that are accrued through healthy daily movement , 20, 21.https://www.physical-literacy.org.uk/) (IPLA) and a global movement embracing the construct of physical literacy.Given the seminal role physical activity plays in promoting health, it is important to recognize the important contributors to helping Canadians of all ages, backgrounds, circumstances, and abilities become and remain physically active. One important contributor to lifelong physical activity is physical literacy, a relatively new construct first proposed by Whitehead in 1993 . WhiteheOver the past generation, physical literacy has progressively gained momentum as a core construct of physical education, sport, physical activity, recreation, and public health, and it has recently been shown to be positively related to guideline adherence for physical activity and sedentary behaviour  as well sportforlife.ca & physicalliteracy.ca), Physical Literacy for Life , Physical & Health Education Canada , and the Ontario Society of Physical Activity Promoters in Public Health . These actions have prompted the development of multiple programs and resources in Canada, and provided an opportunity to establish new partnerships across sectors ; however, this same enthusiasm also created professional friction among organizations as they each established their own leadership role in the area of physical literacy. Exacerbating this tension, and a potential barrier to desired progress, was the multitude of definitions and conceptualizations of physical literacy, and consequent confusion [passportforlife.ca); Physical Literacy Assessment for Youth (PLAY tools) by S4L ; Canadian Assessment of Physical Literacy  by the Healthy Active Living and Obesity Research Group (HALO) at the Children’s Hospital of Eastern Ontario Research Institute; and The Fundamental Movement Skills Assessment Tool by the 60 Minute Kids Club (https://60minkidsclub.org/about/teachers/).Many sectors in Canada, including sport, recreation, physical activity, education, and public health, have embraced physical literacy and are making it a core priority of their business. Notable among these are the formal adoption of physical literacy by the Sport for Life Society , the physical (effective interaction in different contexts) and the cognitive (knowledge and understanding)” .Three organizations providing leadership in the Canadian physical literacy movement – S4L, PHE Canada, and HALO – all had different definitions of physical literacy even though all specified that physical literacy comprised four essential elements: motivation and confidence; physical competence; knowledge and understanding; and engagement in physical activities for life. Despite having common elements, multiple competing definitions were problematic for some local, provincial/territorial, and national organizations that were creating programs, resources, and campaigns. The development and implementation of different evaluation tools to measure physical literacy among children and youth, as described above, also contributed to the challenges.In 2014, an opportunity to create a common definition emerged through two different but parallel processes. First, inspired by a series of conversations with Dr. Charles Corbin and Dr. Margaret Whitehead, researchers at HALO determined the need for a systematic review of research, a forum for debate, and a process to reach consensus on key issues in physical literacy, including terminology, measurement, and a conceptual model. A comprehensive approach was envisioned whereby researchers in the field could develop a series of background papers to directly address divergent views and existing controversies, and to support discussion. It was also agreed that a consensus meeting was required to connect leading researchers and key experts to review the findings from the background papers and participate in a facilitated discussion, all of which would lead to the development of a consensus statement or position paper that could then be launched at a strategic time.https://www.participaction.com) received a multi-year investment from the Royal Bank of Canada (RBC) and the Public Health Agency of Canada (PHAC) to develop the RBC Learn to Play Project, a multipronged effort to enhance physical literacy in children and youth with a goal of encouraging more kids to get outside and play [Concurrently, ParticipACTION , and to present and discuss the outcomes of this harmonization initiative. It was recognized that physical literacy is a journey that continues across the lifespan; however, given the interest and scope of services of the participating organizations involved in the harmonization project, priority was given to physical literacy in the context of promoting healthy and holistic child development. This manuscript serves as a comprehensive and transparent account of the processes and outcomes of developing Canada’s Physical Literacy Consensus Statement, which aspired to provide a mechanism and impetus to clarify terminology, reduce confusion, increase alignment, and enhance synergy of effort among sector partners.The purpose of this paper is to describe the processes employed to develop and release Canada’s Physical Literacy Consensus Statement.A comprehensive, multi-stakeholder approach was used to pursue a common understanding and harmonization of physical literacy definitions and initiatives in Canada. The primary objective was to achieve a broadly supported definition of, and consensus statement for, physical literacy that would serve as a foundational document for the multiple sectors and stakeholders engaged in Canada’s physical literacy movement. This project occurred between 2014 and 2015  and identify the needs of the physical activity, sport, and recreation sectors related to physical literacy. To that end, they conducted an online survey  and a series of in-person consultations in the Fall of 2014 in order to:a promotional postcard that was disseminated via delegate bags and display booths at Physical Literacy Summits taking place just prior to or during the survey period;emails from ParticipACTION to their extensive partner network to distribute the survey to each of their partners’ networks;www.participaction.com/en-ca/programs/participaction-teen-challenge) coordinators to distribute to their networks;emails from ParticipACTION to Teen Challenge , Ontario, Manitoba, New Brunswick, and the Northwest Territories. Participants were invited based on recommendations from local and provincial/territorial organizations or were attendees at a related Physical Literacy Summit. Consultations occurring at conferences had a designated time allocation, and an open invitation to delegates was issued. Five of the consultations were led by ParticipACTION staff with the assistance of S4L consultants and/or the local or provincial organizer. One (Alberta) was led by a provincial partner organization (Ever Active Schools). Feedback was captured on flip charts and/or electronically. Three of the conversations were audiotaped .Concurrent to the survey and consultations, ParticipACTION met with researchers and a representative from S4L. It was agreed that a Steering Committee was essential to guide and inform the formulation of a common definition and Consensus Statement. The organizations and/or sectors well-known for their leadership in physical literacy were invited to participate, and accepted. The Steering Committee comprised representatives from HALO (research sector), S4L (sport sector), PHE Canada (education sector), the Canadian Parks and Recreation Association (CPRA) (recreation sector), OSPAPPH , and the IPLA. It should be noted the two IPLA representatives contributed in-depth expertise in physical literacy with the intent to achieve a Canadian consensus statement with global input, rather than influencing/creating a global consensus statement. The Committee was chaired by ParticipACTION.The Steering Committee met for the first time in January 2015 to learn the background of the initiative and to discuss the role of the Committee and its members. Key roles of Committee members included participating in Steering Committee meetings; developing the Consensus Statement and related document; participating in the development, implementation, and analysis of the Stakeholder Survey; planning the activation session at the International Physical Literacy Conference in June 2015; and disseminating the Consensus Statement throughout their respective networks. In February 2015, the Steering Committee conducted a half-day, face-to-face meeting in Ottawa, Canada, with the two IPLA members joining via conference call. All other meetings and communication were completed by email and conference calls.Given the complex history of physical literacy development in Canada, the high expectations related to this process, and the skepticism of its success, building an influential Steering Committee to guide and inform the common definition / Consensus Statement development process was a pivotal part of the process. Membership was kept relatively small to facilitate a timely and efficient process, yet represented all of the key sectors currently engaged in physical literacy work. A list of Steering Committee members is provided in Table The proposed Consensus Statement development process was envisioned as involving the creation of a series of five to seven papers that would be prepared by leading physical literacy experts. The papers were planned to focus on historical background, constructs, controversies, and the different aspects of physical literacy, to inform delegates who would be invited to attend a Consensus Workshop to develop the final Consensus Statement.https://www.physical-literacy.org.uk/) It was unanimously decided that the project would take a new approach to build consensus on a definition of physical literacy in Canada. In preference to the proposed series of papers and a Consensus Workshop informing the development of a consensus statement, the Steering Committee decided to put forward the IPLA’s definition and write an accompanying consensus statement. This document would then be distributed for broad sector feedback in the form of a survey. That process would be followed by a Canadian endorsement of the definition and Consensus Statement at the International Physical Literacy Conference, taking place in June 2015 in Vancouver, Canada. Also proposed were activation sessions with practitioners from various sectors to determine the types of tools and resources that would be useful in communicating and understanding physical literacy within each sector.Having agreed upon the topics for the papers, a conversation ensued that was premised on the proposal that the IPLA definition of physical literacy could provide the foundation of the Consensus Statement. Developed through an analysis of the evidence and a consensus process, the IPLA definition read as follows: “Physical literacy can be described as the motivation, confidence, physical competence, knowledge and understanding to value and take responsibility for engagement in physical activities for life.”  was used to collect input from stakeholders. Respondents were asked to provide feedback on the clarity of the Consensus Statement, as well as their level of agreement, perceived importance, and support for the Consensus Statement. Two additional questions appeared in the French survey, requesting feedback on the translation of the term “physical literacy”. A final question was included in the French and English surveys that allowed respondents to self-identify and choose to “endorse” the Consensus Statement. The stakeholder survey is provided in Additional file The survey results were provided to Steering Committee members, in both raw data and summary formats, for the purpose of making modifications to the Consensus Statement. The Steering Committee then met to review the results, and to make decisions and recommendations about what changes should be made and how they should be incorporated. ParticipACTION staff coordinated finalization of the Consensus Statement document with ongoing direction and involvement of Steering Committee members. The Consensus Statement document was finalized, translated into French, designed, and printed for paper and electronic distribution.https://www.participaction.com) to or to endorse it at the/or to endorse it at the International Physical Literacy Conference for those attending. The Declaration was also printed on a large banner to be displayed and signed by delegates during the conference.To further promote the Consensus Statement, the S4L team led the development of the “Vancouver Declaration”. This featured the common definition of physical literacy, all aspects of the Consensus Statement , evidence-based facts supporting the need for attention on physical literacy, and a final declaration. This document was also translated into French, designed, and printed for electronic and paper distribution. The Vancouver Declaration was distributed to sector partners with a request to visit the ParticipACTION website . This theme was characterized by a lack of value given to physical literacy and, therefore, a lack of willingness or buy-in to change current programming/initiatives. Cross-sector collaboration was seen as a challenge by five respondents (8%), with a lack of coordination, duplication, and an inability to connect all the stakeholders through an effective delivery model given as examples. In fact, a large majority of survey respondents agreed  that having a common definition of physical literacy would help them in their day-to-day work. Five respondents (8%) maintained that physical literacy programs were not accessible to people because of financial, transportation, or language barriers.When asked about the issues and challenges in advancing physical literacy in their sector, respondents indicated a number of barriers. A total of 21 respondents indicated that www.physicalliteracy.ca/play-tools/), 42% used the Canadian Assessment of Physical Literacy , 21% used PHE Canada’s Passport for Life (www.phecanada.ca/resources/passport-for-life), and 21% indicated they used an “Other” tool. The majority of respondents (66%) somewhat or strongly agreed that further research about assessment methods was needed.Survey respondents reported the physical literacy initiatives they were involved in developing/delivering/promoting, and which resources/tools they were using. Respondents were involved in delivering programs and integrating physical literacy into existing programs and practices, providing and supporting leadership training, assessment, developing partnerships, creating resources, research and evaluation, and advocacy. There was a very wide range of tools and resources in use (> 30 examples given); these tools and resources originated from the sport, education, recreation, physical activity, health, research, not-for-profit, and child development sectors, both within Canada and internationally. Similar diversity was observed with respect to physical literacy assessment methods: of the 41% who indicated they used an assessment method, 47% used the PLAY tools . Respondents felt that physical literacy information could be improved, including its importance to specific sectors and “how to implement physical literacy” in various settings. They suggested a hub of information about best practices would be beneficial, and called for more information about the affective aspect, such as the motivation component of physical literacy. Five respondents (7%) suggested that additional research and evaluation were needed to assess whether current implementation models result in lifelong participation, and how assessment tools help to predict active healthy behaviour.Collaboration and coordination in the physical literacy field . They suggested that collaboration and coordination in the sector could be improved by building a community; using a bottom-up approach; sharing resources and information among sectors; working together; and developing a common implementation ideology.It was also noted by 8 respondents (12%) that both the general public and practitioners could benefit from education regarding physical literacy and the importance of a multi-sport approach.Resources were emphasized as gaps by 7 respondents (10%), who said that resources could be made more relevant and simple for those working at the grass-roots level. They reported that current resources are expensive and cumbersome to use; resources should be easily applied to a day-to-day practice; lesson plans would be helpful; and more resources are needed in French.Finally, a noted gap was the need for a universal assessment tool for physical literacy that would be targeted to all age groups .Respondents identified a number of gaps related to physical literacy resources/tools/information, including:A total of six in-person consultations were conducted. Sectors represented included education, health, government, sport, recreation, and physical activity. There were between 15 and 30 participants in each consultation.Participants were asked if/how having a common definition and/or understanding of physical literacy would help them in their day-to-day work, and whether or not having common key messages would be helpful in the communication of their physical literacy–based programs and initiatives. The responses indicated strong support for having common key messages and a common understanding of physical literacy, somewhat supporting the need for a common definition. Participants felt a common definition might be of more importance to researchers versus practitioners, but recognized its value in applying for funding and conducting assessments. Table Those who did not feel a common definition was required reasoned that a common definition had either already been developed or was currently being developed, or that it would not be helpful. There were also concerns that developing a common definition could be fraught with challenges, including getting people together to do the work, the commitment to existing systems and definitions, and the risk of confusion from changing current definitions. It was also felt that the public’s and parents’ understanding of physical literacy would not be informed or changed by a new definition and all it entails. Other participants suggested an audit be done of what each organization was doing currently, while some felt that advancing a common definition would not matter because the organizations that employed differing definitions were communicating only with people who were working within their respective fields.Similar to the Environmental Scan Survey, stakeholder consultation participants were asked to name the organizations they believed should be engaged in building a consensus around physical literacy terminology and a common definition. Responses appear in Table The stakeholder consultations were also designed to gather information about the work already taking place in each sector. Representatives were asked to share information about the programs, initiatives, tools, and resources they were working on or knew about. The findings reinforced the Environmental Scan Survey results, indicating that many and wide-ranging resources were being developed, used, and disseminated. These included projects, programs, training and learning opportunities, program adaptations, marketing and research, and evaluation initiatives in a variety of sectors and through new and existing partnerships. Post-secondary training , dedicated government staff positions, and funding for physical literacy initiatives were cited.Assessment methods for evaluating physical literacy programs and initiatives that were mentioned in the stakeholder consultation meetings included S4L PLAY tools, PHE Canada – Passport for Life, CAPL, NCCP Fundamental Movement Skills (training program), Mount Royal University Physical Literacy Observation Tool , Quest 2 Tool (High Five), gross motor skill assessment tools, and parent feedback, as well as registration, participation, and retention rates. Some of the points raised in the discussion of assessment instruments included: assessments needed to be simpler for younger populations; there was a need for clarity regarding which tool to use; each tool served a different purpose, assessed at different levels and provided different methods of feedback; users needed to know why they were doing the assessment and what the goal of the assessment was; assessment tools needed to be varied as the most appropriate tool depended on what was being taught and who the target population was; assessment should be standardized; and it was important to use the same tool for pre- and post-assessment. Suggestions for future research included: the long-term impact of physical literacy programming; developing tools for a younger-aged population; addressing physical literacy in adults; development of simple tools; clarifying what it means to be physically literate; more study on the emotional side of physical literacy; causal rather than correlational research; determining what the measure of success was for various population groups; community-level assessments to show how the community was doing in terms of physical literacy; use of physical literacy evidence to inform practice and policy; and evaluating how assessment data are being used.Participants in the consultation sessions also discussed challenges to advancing physical literacy across sectors. The most notable challenges identified were the lack of awareness of the construct of physical literacy ; communicating the message about physical literacy using a branding strategy targeted specifically to the audience of interest; lack of coordination across sectors invested in physical literacy; competing priorities; and lack of best practices available for organizations to take action. Table The specific needs articulated by respondents mirrored the challenges they reported facing in advancing physical literacy work, and were similar to the needs gathered through the Environmental Scan Survey. The major issues are listed in Table Responses to questions about issues and challenges to implementing physical literacy programs and projects were similar to what had been discussed regarding broad challenges to advancing physical literacy and needs to advance physical literacy work, as presented above. The major themes included resources, programming challenges, understanding physical literacy, an emphasis on sport and athletics, definition/branding/marketing issues, and relative value compared to competing priorities.Relationship-building was the most mentioned way of working together in the sector. In some cases, participants developed formal partnership agreements, while others worked with organizations that were interested in collaborating. Participants identified a number of partners from different sectors with whom they are working including non-government, government, health, and education organizations. Collaboration took place by developing joint use agreements; partnering on grant applications; forming community coalitions; having common agendas; advancing grassroots collaborations; attending or hosting multi-sector events; and jointly developing policy. Challenges of working with partners included the optics of working with a for-profit organization, particularly when a corporate sponsor was involved, and the need for government support of physical literacy. Developing further partnerships with non-traditional groups  was suggested.During the 2.5 weeks the online stakeholder survey was open, 2243 respondents landed on the front page. Responses varied by question , with lower completion rates on questions in the middle to end of the survey. Respondents were from every province and territory, with the majority living in Ontario (35%), Alberta (16%), British Columbia (14%), Manitoba (8%), and Québec (7%). International respondents (4%) were from other parts of North America , South America (Brazil), Europe , Asia , and Oceania . The majority of respondents represented the education (30%), sport (20%), recreation (11%), and physical activity/fitness (10%) sectors.Canada’s Physical Literacy Consensus Statement , the proportion of respondents who strongly agreed or somewhat agreed that the sections were clearly stated ranged from 89 to 96%. The proportion who strongly agreed or somewhat agreed with the content of the message in these sections ranged from 87 to 96%  of participants’ comments agreed with the Consensus Statement and proposed definition, praised the consensus process, or felt that this initiative was important and were supportive.16% (n = 112) of participants’ comments indicated that the definition required modification, including suggested revisions such as: remove the word “responsibility” since it seldom applies to children ; include wording relevant to children with disabilities; highlight accessibility issues; provide age-specific goals; provide examples of activities for different stages of development; include the environments in which physical activity occurs .23% (n = 155) believed that the Consensus Statement was too complex, and that simplifying/rewording it would make it easier to understand for the entire population.32% (n = 110) of participants provided miscellaneous comments.23%  indicated they would like to be contacted for final review so they could decide whether to be listed as a supporter. The Consensus Statement was sent out electronically and distributed via social media through the different networks of the Steering Committee members. As well, printed copies were provided to all International Physical Literacy Conference 2015 delegates and sent to subsequent conferences upon request. Copies of the Consensus Statement were distributed and incorporated into presentations by members .Canada’s Physical Literacy Consensus Statement took place in Vancouver, Canada, at the 2015 International Physical Literacy Conference. At the opening ceremonies, an introduction to the Consensus Statement  was presented; the President of ParticipACTION and the Chief Executive Officer of S4L signed the Vancouver Declaration banner; and delegates were encouraged to sign the banner during their time at the conference. Over the 3 days of the conference, delegates were invited to visit the Consensus Statement activation area (display) hosted by Steering Committee members; 400 delegates signed the banner, and 140 registered their endorsement on computers at the activation area. Throughout the 3 days, input from all delegates was sought regarding the types of resources, key messages, and other initiatives they would like to access to support their work related to physical literacy. They shared their comments on large poster boards at the activation area and at a consultation that was part of the conference program. The conference concluded with Dr. Margaret Whitehead, President of the IPLA, signing the Vancouver Declaration banner.The official launch of Physical literacy is made up of component parts that are not new, but as an over-arching construct it has inspired both great enthusiasm and debate since it began to garner attention through the teachings of Whitehead . PhysicaThe emergence of the physical literacy movement prompted widespread and rapid growth in the areas of program and resource development. In an effort to define physical literacy in a way that reflected, supported, and promoted the mandate of each sector, a variety of definitions emerged that were relevant to specific sectors. While similarities existed, the different definitions led to confusion within and across sectors.As evidenced by the findings from the two different surveys  and the consultations, support for a common definition and common elements of the construct of physical literacy was identified as a foundation to enhance coordination and communication across the country in a way that would support practitioners and inform the general public, especially parents . The need for a common definition was identified across survey questions and consultations, and was reinforced in Steering Committee discussions. The issue of having a common definition that was relevant to all practitioners was raised in both the surveys and during the consultations. Therefore, there was an obligation to ensure that all practitioners could see how the definition of physical literacy, its elements, and its principles influence their work.Working toward a more collaborative approach to enhancing physical literacy was a common theme and involved having access to more opportunities to communicate; to share information, resources and tools; to coordinate initiatives; and to learn from each other. Respondents also suggested the notion of a central hub, which could be a forum to share best practices, success stories, and training tools. Key to the success of such initiatives was a common understanding of the construct of physical literacy.An issue that was both explicitly stated and subtly referenced in the surveys, consultations, and Steering Committee meetings was the issue of “in-fighting” or the notion of having different “camps” in Canada when it came to physical literacy resources, training, and evaluation. Ultimately, better alignment among the diverse sectors and organizations was the desired outcome, which many indicated would be facilitated by the Consensus Statement.A great deal of information was collected about the needs and gaps that each sector sees as needing to be filled in order to enhance physical literacy levels in Canada. Survey participants, when asked what support they needed, requested resources that gave information on “how to implement physical literacy”. The environmental scan and stakeholder consultations demonstrated the need to raise awareness of the importance of physical literacy in general, and to tailor messages and provide information to specific sectors about how to support and enhance the development of physical literacy. It is the responsibility of sectoral leaders to take these requests and determine how to support their respective sectors. An encouraging start is having a common definition and understanding of physical literacy. It will now require a concerted effort, from all organizations and sectors involved, to begin to share the Consensus Statement with stakeholders and to ensure that the Statement is the foundation upon which their programs and resources are developed moving forward.More than 200 organizations and individuals endorsed the Consensus Statement on ParticipACTION’s website.https://www.participaction.com/en-ca/thought-leadership/physical-literacy).S4L and the Coaching Association of Canada facilitated the development of the National Physical Literacy Alliance (NPLA), consisting of more than 40 national/provincial organizations (from grass roots to podium) that are committed to ensuring all Canadians are healthy and active. This alliance seeks to ensure that all Canadians are competent, confident, and motivated to remain physically active for their entire lives. One of the key areas of work of the NPLA is communications, and a sub-committee was formed (led by ParticipACTION) to support the development of communication tools targeted to the broad physical activity sector to communicate the elements of the Consensus Statement in a consistent and coordinated way. RBC Learn to Play and PHAC supported the NPLA’s development, and ParticipACTION and the sub-committee members disseminated the tools through their networks, at conferences, and through their communication channels. The following link houses all the physical literacy resources including the Consensus Statement, an infographic, a key messages document based on the Consensus Statement, and a social media kit  used in the translation of the Consensus Statement ultimately was NOT accepted. After much dialogue the following was accepted “Canada’s Physical Literacy Consensus Statement, physical literacy is defined as the motivation, confidence, physical competence, knowledge and understanding to value and take responsibility for engagement in physical activities for life. Sector partners hope that the Consensus Statement will bring greater harmony, synergy, and consistency to physical literacy efforts both in Canada and internationally.In Additional file 1:Environmental Scan Survey. (DOCX 19 kb)Additional file 2:Stakeholder Survey. (DOCX 137 kb)Additional file 3:Detailed results from the Stakeholder Survey. (DOCX 50 kb)


To produce a best evidence synthesis of the clinical effects of topical glyceryl trinitrate (GTN) in the treatment of tendinopathies.A systematic review of published randomised controlled trials (RCTs) of the use of GTN in patients with tendinopathy.MEDLINE, Embase, Scopus and CINAHL from database inception to January 2018.et al.We examined RCTs comparing the effects of topical GTN with either placebo or other treatments on tendinopathy. Overall quality of each eligible study was determined based on a combined assessment of internal validity, external validity and precision. The level of evidence for each assessed parameter was rated based on the system by van Tulder A total of 10 eligible RCTs were identified including patients with tendinopathy of the rotator cuff (n=4), wrist extensors (n=3), Achilles (n=2) and patellar (n=1) tendons. For all tendinopathies, improvements in pain were significant when comparing GTN versus placebo in the short term . Significant improvements in midterm outcomes for treatment with GTN versus placebo included the following: patient satisfaction (strong evidence); chances of being asymptomatic with activities of daily living (strong evidence); range of movement (moderate evidence); strength (moderate evidence); pain  and local tenderness (poor evidence). Patients treated with topical GTN reported a higher incidence of headaches than those who received placebo (moderate evidence).Treatment of tendinopathies with topical GTN for up to 6 months appears to be superior to placebo and may therefore be a useful adjunct to the treating healthcare professions. Overuse tendon injuries namely tendinopathies pose a significant clinical problem, particularly in musculoskeletal and sports-related medicine,et al,As the basic science of tendinopathy has evolved, so have the treatment options for these conditions. First-line treatment comprising several modalities ranging from relative rest and progressive loading to invasive pharmacological interventions continues to be the mainstay of treatment.Nitric oxide (NO) is a free radical produced by a family of enzymes, the nitric oxide synthases (NOSs). Its involvement in tendon injury has been clearly demonstrated in the laboratory in several rodent studies, where all three NOS isoforms  were found to be upregulated both in acute and chronic tendon injuries,et alet alet alThe limited existing evidence on the effectiveness of topical GTN on tendinopathy has reported conflicting results.The aim of this systematic review is to present the best available evidence on the effectiveness of topical GTN on tendinopathy and its side effects with a view to guiding future guidelines. After presentation of the findings of studies comparing topical GTN with placebo or alternative treatments, assessment of their quality and determination of the strength of available evidence, our specific objectives were to conclude on the effects of topical GTN in generic outcomes for each type of tendinopathy and all tendinopathies both in the short-term and midterm phases.The present systematic review has been conducted and authored according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)Included studies were RCTs comparing at least one treatment group receiving topical GTN with a control group receiving either placebo or an alternative treatment. Studies with participants undergoing concurrent additional therapies were included only if both arms of the study received this additional treatment at the same frequency and intensity. Participants had to be over 18 years with a clinical diagnosis of tendinopathy with or without radiological signs. Duration of symptoms/signs was not a criterion, neither was length of treatment with, dosage and type of topical GTN used. Language criteria were not applied.A thorough literature search was conducted by two of the authors (DC and DB) independently via MEDLINE, Embase and Scopus in January 2018, with the following Boolean operators: ‘(GTN OR glyceryl trinitrate OR nitroglycerin) AND ’. Medical Subject Headinngs (MeSH)terms were not used to minimise the risk of missing relevant articles. Review articles were used to identify eligible articles that were missed at the initial search. Additionally, reference list screening and citation tracking in Google Scholar was performed for each relevant article.From an initial total of 106 articles that were independently identified by two reviewers (DC and DB), after exclusion of duplicate and non-eligible articles, title and abstract screening and addition of missed studies identified by review articles, reference list screening and citation tracking, 10 studies were found to fulfil the inclusion and exclusion criteria. A thorough quality assessment of the studies was conducted: all internal validity (freedom from bias), external validity  and precision (reproducibility/freedom from random error) were assessed separately by two of the authors independently (DC and DB), and a third independent opinion (MM and CC) was sought where disagreements existed. Quality scales and resulting scores were not used as these usually combine aspects of study methodology with aspects of reporting; therefore, they are thought to be inappropriate for assessment of study quality.Overall, studies were characterised as of ‘good’, ‘moderate’ or ‘poor’ quality based on a combined assessment of their internal validity, external validity and precision, which was again conducted by two of the authors independently (DC and DB) and the opinion of a third author (MM) was provided where the two judgements differed. The criteria used for overall quality assessment were as follows: ‘Good’ quality studies had ‘high’ risk of bias in <2 of the seven internal validity categories, external validity and precision; ‘Moderate’ quality studies had ‘high’ risk bias in 2 of the seven internal validity categories, external validity and precision; ‘Poor’ quality studies had ‘high’ risk of bias in >2 of the seven internal validity categories, external validity and precision.et alEach of the eligible articles was initially read by the first author to gain familiarity, and subsequently each article was reread, and their key characteristics and findings were extracted and inserted in tables to facilitate analysis and presentation. For the presentation of results, outcomes were divided into short term and midterm, where follow-up findings at 2–8 weeks and 12–24 weeks were reported, respectively. Results for acute (symptoms less than 6 weeks) and chronic (symptoms more than 3 months) tendinopathy are also presented separately. For the classification of strength of evidence for each outcome reported, the rating system formulated by van Tulder The quality assessment tools used are shown in All 10 studies were randomised. Three of the studiesTwo of the 10 studies were not double-blinded (‘high’ risk); one of them compared topical GTN with local corticosteroid injectionBlinding of outcome measures was thought to be sufficient in seven studies (‘low’ risk) where the authors specifically state that the outcome assessors/examiners were blinded and/or did not participate in the assessment.et al,Reasons for dropouts/withdrawals of participants were adequately reported in all studies (‘low’ risk). Rate of follow-up completion was stated in all but three studies, wherein it was assumed to be 100% as suggested by their results tables.et alReporting of results was appropriate and adequate in all but one study; Berrazueta Inclusion and exclusion criteria were thought to be adequate for all but one study, which only used as an inclusion criterion age more than 18 years and did not describe how the diagnosis of tendinopathy  was made.et al,et al,General, non-specific populations were used in all studies but one, which included wheelchair user patients with complete motor paraplegia only.et alStatistical power calculation prior to recruitment was performed in all but three studies,et alet alTwo published studies investigated the effects of topical GTN on acute rotator cuff tendinopathy. Berrazueta Overall, for acute rotator cuff tendinopathy only data on short-term outcomes are available from two studies of poor overall quality. Compared with placebo, topical GTN appears to be superior with respect to pain, ROM, hours of sleep and satisfaction (level 3 evidence). Compared with local corticosteroid injections, GTN appears to be less effective in improving pain (level 3 evidence).et al,Two studies investigated the effects of topical GTN on chronic rotator cuff tendinopathy. In the study by Paoloni et alIn a subsequent study in wheelchair user patients with chronic rotator cuff tendinopathy, Giner-Pascual Overall for chronic rotator cuff tendinopathy short-term outcomes from one study of good overall quality, showed the only significant difference between topical GTN and placebo was a greater subscapularis force in patients using GTN (level 3 evidence). Midterm outcomes were assessed by two studies, one of goodet alThe study by Steunebrink In summary, no significant differences in short-term or midterm outcomes were identified in patients receiving topical GTN versus those receiving placebo patches by one study of moderate overall quality (level 3 evidence).et al,Two RCTs assessed the effects of topical GTN on chronic Achilles tendinopathy. In the study by Kane et al,In the other RCT of chronic Achilles tendinopathy by Paoloni Overall, for chronic Achilles tendinopathy short-term outcomes comparing the use of topical GTN with placebo were reported by one study of good overall quality and no significant differences were detected in any of the outcomes (level 3 evidence). Midterm outcomes were reported by two studies: one of goodet alThree RCTs investigated the effects of topical GTN therapy on chronic lateral elbow tendinopathy (‘tennis elbow’). Paoloni Six years later, the same groupet al,In a recent study by Ozden Overall for chronic lateral elbow tendinopathy, a total of three studies  compared short-term outcomes of topical GTN therapy versus placebo; significant differences favouring topical GTN include less pain  and less pain with activity (level 2 evidence). Two studies  also described midterm outcomes; patients who received topical GTN had significantly less pain (level 3 evidence) and local tenderness (level 3 evidence) as well as greater force (level 3 evidence), satisfaction (level 2 evidence) and chances of being asymptomatic with ADLs (level 3 evidence) compared with those treated with placebo patches.A summary of the results of the included studies on different patient-related outcomes is shown in The results of this systematic review provide good evidence for the effectiveness of topical GTN for the treatment of tendinopathies compared with placebo in the short and intermediate term (<6 months). Treatment with topical GTN for 12–24 weeks was associated with increased ROM in chronic rotator cuff disease (moderate strength evidence), and for all chronic tendinopathies topical GTN had positive effects on satisfaction (strong evidence), chances of being asymptomatic with ADLs (strong evidence), unspecified pain (moderate strength evidence), ROM (moderate strength evidence) and tendon force (moderate strength evidence). Pain at rest was unaffected by treatment with topical GTN for the same period for all chronic tendinopathies (strong evidence); however, it should be remembered that tendons are rarely painful at rest but typically when loaded, and thus this finding may not be clinically relevant. Overall effects of topical GTN on pain at night, pain with activity and local tenderness may also be beneficial; however, this is only based on poor strength evidence. Effects of treatment for shorter periods (<8 weeks) seem to be less pronounced. Equally, conclusions on the effects of topical GTN on acute tendinopathies could not be drawn due to the lack of high-quality evidence; however, there may be benefits in pain, ROM and sleep in patients with acute rotator cuff disease based on a single study with high risk of bias (poor strength evidence). Finally, with regard to side effects, topical GTN seems to be associated with a higher incidence of headaches (moderate strength evidence) while its effect on rashes seemed to be non-significant; however, this was only based on evidence of poor strength.et alet alLong-term effects of topical GTN in tendinopathy have only been assessed by two prospective studies, which were not included in the present review as they did not fulfil the eligibility criteriaet al,The findings of previously published reviews assessing the effects of topical GTN on tendinopathy are partly in agreement with our results. A systematic review and meta-analysis of seven RCTs on all types of tendinopathyi-NOS, e-NOS and b-NOS mRNAs were overexpressed in the supraspinatus tendon of rats subjected to treadmill running for 14 daysFinally, it is important given our incomplete understanding of the mechanisms underpinning tendon pathophysiology to consider the mechanism of action of GTN in the setting of tendon disease. Following injury to a tendon, NO is produced by all three isoforms of NOSDespite the rigour of our review with respect to identifying all the available evidence and the quality assessment of the included studies, we do recognise its limitations. First, due to the small number of eligible studies, our results on most outcomes had a poor level of evidence, especially for specific types of tendinopathies. Additionally, the different dosages of topical GTN and outcome measures used resulted in lack of homogeneity, which made the conduction of a meta-analysis impossible. Finally, the effects of the concurrent physiotherapy (eccentric and stretching exercises) that most participants received might have affected the results, even though, where used, both treatment arms were instructed to perform the same exercises at the same frequency and intensity, the actual frequency, intensity and correct performance of the exercises were not assessed.The results of this review provide good evidence for the effectiveness of GTN in the short and intermediate term treatment of tendinopathies (<6 months). GTN treatment is thus a good example that translational tendinopathy (laboratory bench to patient) can provide pharmacological adjuncts to aid the practising healthcare professional in addition to loading regimes. Importantly, other than headaches and occasionally rashes, topical GTN is a safe and practical treatment modality with very low costs both for the patient and the healthcare system. Therefore, the use of topical GTN should be considered for all chronic tendinopathies as an adjunct to loading programmes that fail to produce satisfactory resolution of symptoms. However, physicians should alert patients that large, well-designed RCTs and prospective cohort studies are warranted to provide convincing evidence on the effects of topical GTN in both acute and chronic tendinopathy, especially its long-term outcomes.Twenty years since concept of glyceryl trinitrate (GTN) therapy in tendinopathy with still no clear guidance/evidence of efficacy.New findingsTen eligible randomised controlled trials in all tendinopathies reveal improved midterm (up to 6 months) improvements in pain, strength and patient satisfaction.Main adverse event is headaches in up to one in five patients.Topical GTN is useful for all chronic tendinopathies as an adjunct to loading programmes that fail to produce satisfactory resolution of symptoms.


Equitable access to essential psychotropic medicines at primary level is fundamental to universal health coverage for mental health. It relies upon rational selection, affordable pricing, financial protection and consistent supply systems. Which medicines are selected as essential impacts patient care and the economic sustainability of the health system. Rational selection uses the best available evidence for efficacy, safety and acceptability, and requires the assurance of affordability, obtainability and appropriate usage of the medicines. The process should be reliable, transparent and consultative.The aim of this study is to describe the process of rational selection of essential psychotropic medicines at primary health care (PHC) level, using SSRIs as an example.Population, intervention, comparison and outcome (PICO) questions were developed for a rapid review of SSRIs for depression and anxiety. PubMed, Trip Database and Cochrane Library were searched for evidence, which was critically appraised (graded as per SORT criteria) and synthesised. Good governance principles were maintained using a consensus decision-making process within the constraints of the PHC Expert Review Committee’s terms of reference, confidentiality and conflict of interest policies. Evidence-based medicine principles were used, considering social values of equity, acceptability, comparative cost and relative budget impact analysis.The PubMed search for meta-analyses yielded 588 articles, of which 13 met inclusion criteria. An additional 4 meta-analyses were retrieved from the Cochrane Library and 4 from additional reference lists. A second search specifying an HIV population retrieved 43 articles, of which 3 were included. The evidence for efficacy and harm of 24 papers was critically appraised by the committee. Conflicts of interest were declared, and there was appropriate recusal from the final decision-making, which took place in July 2018.Rapid reviews using an evidence-based medicine framework contributed to the selection of SSRIs for the PHC essential medicine list. This approach is intensive in terms of resources and capacity, requiring adaptation to the South African setting. Important limitations include time pressure and the use of a single reviewer, with possible incomplete database searches and reviewer bias. Nevertheless, the process allows for thorough, consistent and transparent decision-making, and improved capacity is recommended.


Patients with multiple myeloma (MM) are often treated with chemotherapy, radiation, and, if indicated, autologous stem cell transplant. In addition to side effects of the treatment, patients with MM often have bone pain, pathological fractures, spinal cord compressions, fatigue, and muscle weakness, which negatively impact functional performance and quality of life. Currently, there are no related guidelines for safe and effective physiotherapy (PT) management. Accordingly, the aim of the present study is to develop guidelines for effective physiotherapy management of patients with MM by systematically reviewing and evaluating the available evidence followed by a consensus process to specifically describe the research questions as detailed below.Physiotherapy management guidelines for patients with multiple myeloma will be developed based on the results of a systematic search of the following databases: US National Library of Medicine Database (PubMed), Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Elton B. Stephens Co. (EBSCO), Web of Science, Database of Abstracts of Reviews of Effects (DARE), Cochrane Database of Systematic Review, and Physiotherapy Evidence Database (PEDro). All articles will be screened for inclusion and exclusion criteria. Relevant potential articles will be identified and systematically reviewed for final phase of inclusion. Two independent reviewers will systematically review and analyze the quality of identified articles using standardized assessment tools. Scientific conclusions will be drawn and recommendations will be made based on a critical appraisal process. The guideline development will also be based on the team’s judgment about the overall quality of the studies and a consensus process.Draft guidelines will be developed in the form of action statements based on the strength of evidence and grades of recommendations. The draft guidelines will be reviewed internally by two independent reviewers using AGREE II and externally by a methodological expert from Evidence-Based Care – Cancer Care Ontario and will be sent to the Canadian Physiotherapy Association (CPA) for feedback from physiotherapists.CRD42017064056PROSPERO The online version of this article (10.1186/s13643-018-0785-7) contains supplementary material, which is available to authorized users. Multiple myeloma (MM) is a malignancy of plasma cells that normally reside in bone marrow, producing immunoglobulins (antibodies). In MM, the uncontrolled growth of these cells result in increased osteoclastic activity with the destruction of bone matrix leading to hypercalcemia and an increased risk of fracture . AccordiPatients with MM are generally treated with chemotherapy, radiation and potentially autologous stem cell transplant, and/or radiation. High-dose chemotherapy is a systemic therapy that uses high doses of cytotoxic drugs to destroy myeloma cells. In addition to destroying myeloma cells, the cytotoxic drugs also destroy hematopoietic stem cells leading to neutropenia and thrombocytopenia . This puRadiation therapy is often prescribed for management of bone pain and osteolytic lesions, preventing paralysis in patients with spinal cord compression. Radiation therapies induce apoptosis and reduce the tumor size . This rePatients considered as candidates for high-dose chemotherapy and autologous transplantation are admitted to hospital for a 2- to 3-week period. During the in-patient stay, number of factors may significantly affect the physical performance and functional status of hospitalized patients with MM including, prolonged periods of bed rest with muscle inactivity, older age, effects of cancer treatments including fatigue. Careful attention to pain management, safe mobilization by providing exercises that are safe and preventing functional decline (deconditioning), improving strength and physical performance are significant in improving quality of life and also help in preventing complications.Physiotherapy (PT) is a part of cancer rehabilitation and is often recommended for patients with MM; however, there are no specific guidelines for safe and effective PT management. Evidence-based guidelines also known as clinical guidelines are systematically developed statements that guide health care practitioners and patients in making decisions on the selection of appropriate health care services/treatments –14. GuidThe aim of the present study is to develop guidelines for effective physiotherapy management of patients with MM by systematically reviewing and evaluating the available evidence followed by an expert review process to specifically describe the research questions as detailed below.The following steps recommended by the American Physical Therapy Association (APTA)  will be The APTA recommends draft guideline review by content experts and stakeholders  published by Centre for Reviews and Dissemination, University of York, in order to reduce duplication of effort and publication bias , 20. ThiThe studies that are of interest for this current investigation are those that focus on physical therapy intervention in patients with MM who had been actively receiving cancer treatment and in follow-up care. However, a preliminary literature search suggested that few randomized controlled trials addressing this topic were available. Therefore, the guideline development team has decided to include systematic reviews, meta-analyses, interventional and observational studies, and case series, which collectively might be informative and helpful in developing the guidelines. In addition, a gray literature search will be conducted to ensure that any potential informative articles are not missed. Only articles published in the English language from the earliest to Aug 2017 will be included.Articles with human participants diagnosed with MM of any age, regardless of gender, tumor stage, and type of cancer treatment will be included.Articles examining the effects of exposure or the effects of physical therapy interventions including physical activity, exercise, and other modalities will be included. Articles with comparison groups with standard interventions or no intervention will be included.Articles reporting on the following primary outcomes of interest will be included: (1) pain, (2) safety, (3) laboratory values, (4) length of stay, (5) range of motion, (6) muscle strength, (7) balance, (8) gait, (9) endurance, (10) fatigue, (11) physical performance, (12) functional performance, and (13) aerobic capacity. The secondary outcomes of interest are (1) quality of life and (2) anxiety/depression.A detailed literature search will be conducted on the US National Library of Medicine Database (PubMed), Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), EBSCO, Web of science, Database of Abstracts of Reviews of Effects (DARE), Cochrane Database of Systematic Review, and Physiotherapy Evidence Database (PEDro). All relevant literature from the abovementioned databases will be retrieved for each research question. Table Steps recommended by Pai et al.  will be Two independent reviewers will extract the data from all the articles that are included in the final selection phase using a standardized data extraction form. The standardized data extraction form will be customized from the data extraction and assessment template proposed by “The Cochrane Public Health Group” . Data exEach article will be critically appraised using standardized critical appraisal tools including the PEDro scale, the Methodological Index for Non-Randomized Studies (MINORS), the Critical Appraisal Skills Programme (CASP) checklists , the MeaScientific conclusions will be drawn and recommendations will be made based on the critical appraisals, the guideline development team’s  judgment about the overall quality of the studies and consensus from the expert group.The levels of evidence for each article will be determined based on the recommendations of Kaplan and colleagues  and critThe Grading of Recommendations, Assessment, Development and Evaluation (GRADE) will be used to determine the strength of evidence . See Tabmust will be used if the evidence supports a strong recommendation (grade A) and harm might occur if the action is not followed. The term should will be used if the evidence supports a strong (grade A) or moderate (grade B) recommendation. The terms may or could will be used if the evidence is weak (grade C).The following terms will be used in describing levels of obligation as recommended by the APTA Who, When (under what specific conditions), Must, Should, or May (the level of obligation), Do what (precise action), and to Whom. Action statements will be supplemented by action statement profiles listing aggregate decisions made by the guideline development team and consensus process. The action statement profiles will include the following headings: aggregate evidence quality, level of confidence in evidence, benefits, risks, harm, costs, benefit-harm assessment, value judgments, intentional vagueness, role of patient preferences, exceptions, policy level, and differences of opinion [Recommendations will be made in the form of action statements. Brief, precise, quality-driven action-oriented statements will be created using a BRIDGE-Wiz software as recommended by the APTA. The action statements will be described in terms of  opinion , 34.Five physiotherapists across Canada experienced with the care of patients with MM will independently review the contents of the guidelines and provide feedback. Aggregate level of evidence will be assigned after the group reaches consensus on the evidence supporting each key action statement. The guidelines will be revised till 80% consensus is achieved on each of the statements and profiles. Action statements that do not reach 80% consensus after three rounds of consensus process will be removed from the guideline document.Three independent reviewers will evaluate the guideline using AGREE II. It is a reliable and valid instrument used to assess the quality of clinical practice guidelines. AGREE II consists of 23 items clustered under 6 domains  developed to assess the quality of the guidelines. Each item in the questionnaire is evaluated on a 7-point scale where score 1 refers to strong disagreement and score 7 refers to strong agreement.The guideline will undergo two external reviews. The guideline will be sent to CPA for feedback from physiotherapists. The guideline will also be reviewed by a methodological expert from Evidence-Based Care - Cancer Care Ontario. The draft guideline will be posted on the Health Sciences North (HSN) website for public comment.This study will employ validated methodologies such as PICO guidelines, systematic reviews, and consensus process. This study will also use standardized quality assessment tools for specific research designs. The literature search and data extraction processes will be done by independent reviewers thereby enhancing the validity of the study. Additionally, the review panel will consist of experts in patients with MM. Moreover, the formulated guidelines will also be evaluated using the AGREE II instrument, which adds to the validity of this study.The following study limitations are noted. We acknowledge that this study might have significant result publication bias, meaning that this study might review articles showing significant results (effects) on earlier described research question, which tells nothing about possible ineffective interventions, as non-significant results are less likely to be published; however, this is beyond the control of any researcher. This study may be subjected to selection bias by not including relevant articles published in languages other than English. Reporting bias will be minimized by having two independent reviews and by having a third independent reviewer intervene when there are disagreements at each stage of data identification, data extraction, and critical appraisal.The outcomes of the study are expected to benefit practitioners because it will provide clear evidence-based guidelines regarding best practices to administer physiotherapy treatment to patients with MM. The recommendations made from this study will be based on rigorous and validated methods that will assist in minimizing potential harms and improve the quality of care. The patients will benefit from receiving the best possible treatment that is tailored to their unique set of health concerns. Rather than using a “one-size fits all” approach to PT treatment, the study will focus specifically on patients that have MM and will seek to determine what specific PT treatment options are best suited for this population. The benefits could be measured qualitatively by requesting input from practitioners regarding the guidelines (clarity and ease of implementation). The benefits to the patients could be assessed in a follow-up study comparing standard PT care compared to the MM-tailored PT intervention program. The findings of this study will also provide a comprehensive platform for future research directions by identifying gaps in the literature.Additional file 1:PRISMA-P checklist. (DOCX 26 kb)