OBJECTIVE: The Philadelphia Panel recently formulated evidence-based guidelines for selected rehabilitation interventions in the management of low back, knee, neck, and shoulder pain.
STUDY DESIGN: The guidelines were developed with the use of a 5-step process: define the intervention, collect evidence, synthesize results, make recommendations based on the research, and grade the strength of the recommendations.
POPULATION: Outpatient adults with low back, knee, neck, or shoulder pain without vertebral disk involvement, scoliosis, cancer, or pulmonary, neurologic, cardiac, dermatologic, or psychiatric conditions were included in the review.
OUTCOMES MEASURED: To prepare the data, systematic reviews were performed for low back, knee, neck, and shoulder pain. Therapeutic exercise, massage, transcutaneous electrical nerve stimulation, thermotherapy, ultrasound, electrical stimulation, and combinations of these therapies were included in the literature search. Studies were identified and analyzed based on study type, clinical significance, and statistical significance.
CONCLUSIONS: The Philadelphia Panel guidelines recommend continued normal activity for acute, uncomplicated low back pain and therapeutic exercise for chronic, subacute, and postsurgical low back pain; transcutaneous electrical nerve stimulation and exercise for knee osteoarthritis; proprioceptive and therapeutic exercise for chronic neck pain; and the use of therapeutic ultrasound in the treatment of calcific tendonitis of the shoulder.
- The Philadelphia Panel recommends continued normal activities for acute, uncomplicated low back pain and therapeutic exercise for chronic, subacute, and postsurgical low back pain.
- The Philadelphia Panel also recommends transcutaneous electrical nerve stimulation and exercise for knee osteoarthritis.
- For chronic neck pain, the Philadelphia Panel recommends proprioceptive and therapeutic exercise.
- The Philadelphia Panel found evidence to support the use of therapeutic ultrasound in the treatment of calcific tendonitis of the shoulder.
- The main difficulty in determining the effectiveness of rehabilitation interventions is the lack of well-designed, prospective, randomized, controlled trials.
The Philadelphia Panel evidence-based clinical guidelines on musculoskeletal rehabilitation interventions were published as 5 separate articles in the October 2001 issue of Physical Therapy, the journal of the American Physical Therapy Association.1-5 Originally convened on December 17, 1999, the panel included member representatives from the American Physical Therapy Association (Andrew A. Guccione, PT, PhD), the American College of Rheumatology (Scott M. Hasson, PT, PhD), the American Academy of Orthopedic Surgeons (John Albright, MD), the American Academy of Neurology (Bruce Dobkin, MD), the American College of Physicians (Richard Allman, MD, and Alicia Conill, MD), the Cochrane Back Group (Paul Shekelle, PhD), the American Society of Physical Medicine and Rehabilitation (Randolph Russo, MD, and Richard Paul Bonfiglio, MD), and the American Academy of Family Physicians (Jeffrey L. Susman, MD). The purpose of the group was to create evidence-based practice guidelines that identify the clinical benefit of rehabilitation interventions for low back, knee, neck, and shoulder problems. The guidelines did not address medical or pharmacologic management of these conditions. Although the guidelines primarily benefit the rehabilitation specialist (physical therapists, occupational therapists, and sports therapists), family practitioners and other primary care physicians are responsible for managing these conditions and their treatments. By knowing which rehabilitation interventions have proven clinical benefit, physicians can better coordinate a patient’s care and make evidence-based decisions when ordering physical therapy. In this report, we summarize and disseminate these guidelines for specific rehabilitation modalities in the management of common conditions that cause back pain, knee pain, neck pain, or shoulder pain.
The Philadelphia Panel is not a novel evaluation of evidence-based rehabilitation interventions. Previous assessments of therapies have been published by Disorders; the Agency for Health Care Policy and Research (guidelines for low back problems); the British Medical Journal; Clinical Evidence; and the American College of Rheumatology (guidelines for knee osteoarthritis). However, those guidelines had significant limitations or have become outdated. The Philadelphia Panel set out to provide a structured and rigorous set of evidence-based clinical guidelines for the conservative (nonsurgical) management of conditions associated with low back, knee, neck, or shoulder pain.
Professional organizations of clinicians who routinely care for patients with back, knee, neck, and shoulder pain nominated members to create the Philadelphia Panel. Panelists were nominated based on their clinical expertise and previous experience developing evidence-based guidelines. Members of the panel included an orthopedic surgeon, a rheumatologist, an internist, a physiatrist, a neurologist, a family physician, a doctorate-level researcher from the Cochrane Back Group, and 2 physical therapists. The panel chair formed a research staff to identify and screen articles and construct evidence tables for pertinent references.
Development of guidelines
To provide evidence-based practice guidelines for each condition, a 5-step process was established: defining the intervention, collecting the evidence, synthesizing the results, making recommendations based on the research, and grading the strength of the recommendations. To prepare the data, systematic reviews were performed for the conditions of interest and specific interventions. Rehabilitation interventions frequently used in the care of low back, knee, neck, and shoulder pain were identified, and the patient population was defined. Therapeutic exercise, massage, transcutaneous electrical nerve stimulation (TENS), thermotherapy, ultrasound, electrical stimulation, and combinations of these therapies were included in the literature search. Evidence from randomized controlled trials and observational studies such as controlled clinical trials, cohort studies, and case-control studies was identified and analyzed. Studies were included if they had evaluated outcome measures such as pain, function, strength, range of motion, return to work, patient satisfaction, activities of daily living, or quality of life. Data from studies that included outpatient adults with vertebral disk disease, scoliosis, cancer, or pulmonary, neurologic, cardiac, dermatologic, or psychiatric conditions were excluded.