Strength of Recommendations
Strength Strength Visual Definition
Strong
★★★★
A high level of certainty of moderate-to-
substantial benefit, harm, or cost, or a
moderate level of certainty for substantial
benefit, harm, or cost (based on a
preponderance of Level 1 or 2 evidence with
at least one Level 1 study).
Moderate
★★★★
A high level of certainty of slight-to-moderate
benefit, harm, or cost, or a moderate level
of certainty for a moderate level of benefit,
harm, or cost (based on a preponderance
of Level 2 evidence, or a single high-quality
RCT).
Weak
★★★★
A moderate level of certainty of slight benefit,
harm, or cost, or a low level of certainty for
moderate-to-substantial benefit, harm, or
cost (based on Level 2 thru 5 evidence).
Theoretical/
foundational
★★★★
A preponderance of evidence from animal or
cadaver studies, from conceptual/theoretical
models/principles, or from basic science/
bench research; or published expert opinion
in peer-reviewed journals that supports the
recommendation.
Best Practice
★★★★
Recommended practice based on current
clinical practice norms; exceptional
situations in which validating studies have
not or cannot be performed yet there is a
clear benefit, harm, or cost; or expert opinion.