The data from pertinent articles were synthesized, and the relative clinical benefit between treatment and control groups was calculated for each condition for each intervention. The panel deemed a 15% or greater improvement between treatment and control groups to be clinically important. Relevant studies were then graded according to the type and clinical importance of the presented data. The grading scheme is summarized in Table 1. Once the panel compiled the intervention recommendations for each condition, external review by practitioners ensured the relevance of the recommendations. Interventions with a grade of A or B were to be included in the guidelines. No grade B recommendations were made. Grade C interventions could be neither included nor excluded in the final guidelines due to lack of demonstrated clinical benefit.
TABLE 1
Details of the Philadelphia Panel Classification System*
| Grade | Clinical importance | Study design type |
|---|---|---|
| A | 15% | RCT (single or meta-analysis) |
| B | 15% | CCT or observational study (single or meta-analysis) |
| C | 15% | RCT or CCT or observational (single or meta-analysis) |
| ID | NA | Insufficient or no data |
| *Adapted from the Philadelphia Panel Members and Ottawa Methods Group.5 | ||
| CCT, controlled clinical trial; NA, not applicable; RCT, randomized, controlled trial. | ||
Recommendations for low back pain
Low back pain results in significant socioeconomic repercussions due to the restriction of occupational activities and functional ability in the activities of daily living. Treatment goals in the care of patients with low back pain include relief from pain, reduction of muscle spasm, improvement in range of motion and strength, correction of postural problems, and improvement of functional status at work and in daily life. The care of patients with low back pain can be a very frustrating process for physicians or therapists. Use of treatment modalities with proven effectiveness can provide structure and credibility to the recovery process. The Philadelphia Panel’s recommendations are summarized in Table 2.
The panel found grade A evidence for improvement in the ability to return to work with continuation of normal activity vs enforced bedrest for acute low back pain (<4 weeks). Interestingly, no clinically important benefit was shown for the continuation of normal activity for the improvement, of pain (5% decrease) or function (10% improvement). It is important to note that the recommendations for low back pain are based on studies that excluded patients with disk involvement; therefore, the effects of continuing normal activity in patients with acute back pain and disk involvement were not assessed. The Philadelphia Panel chose not to evaluate data from studies with vertebral disk involvement in their patient population.
With regard to acute low back pain, data from randomized controlled trials demonstrated no clinically important benefit (<15% from control) of stretching or strengthening exercises, mechanical traction, or TENS. Likewise, a study of therapeutic ultrasound showed no demonstrable clinical benefit. There was poor evidence to include or exclude these modalities alone as an intervention for acute low back pain. No study with an acceptable research design was identified for thermotherapy, electrical stimulation, therapeutic massage, or electromyographic biofeedback as interventions for low back pain.
For subacute low back pain (4–12 weeks), data from randomized controlled trials showed a clinically significant improvement in pain, function, and global assessment from therapeutic exercise. Mechanical traction for subacute low back pain was given a grade C rating for patient global improvement and return to work. Consequently, there is poor evidence to include or exclude mechanical traction alone for low back pain.
The assessment of chronic low back pain (>12 weeks) identified 1 grade A guideline. Therapeutic exercise, including stretching, strengthening, and mobility exercises, resulted in clinically significant improvement in pain and function but had no clinical benefit in facilitating return to work. Mechanical traction, TENS, electromyographic biofeedback, and therapeutic ultrasound showed no clinical benefit. No studies assessed efficacy of thermotherapy, massage, or electrical stimulation.
Back pain due to prior back surgery was considered separately from other conditions. A grade A guideline was given to therapeutic exercise for pain due to prior back surgery.
Combinations of rehabilitation interventions for acute and chronic low back pain produced insufficient data to make a recommendation. Although most patients who are referred to physical therapy undergo combination therapy, the panel could not formalize a guideline for combination therapy.
TABLE 2
Summary grid of low back pain guidelines*
| Therapy | Acute | Subacute | Chronic | Postsurgery |
|---|---|---|---|---|
| Exercise | C | A | A | A |
| Continue normal activities | A | ID | ID | ID |
| Traction | C | C | C | ID |
| Ultrasound | C | ID | C | ID |
| TENS | C | ID | C | ID |
| EMG biofeedback | ID | ID | C | ID |
| Massage | ID | ID | ID | ID |
| Thermotherapy | ID | ID | ID | ID |
| Electrical stimulation | ID | ID | ID | ID |
| Combined rehabilitation modalities | ID | ID | ID | ID |
| *Adapted from the Philadelphia Panel Members and Ottawa Methods Group.4 | ||||
| A, benefit demonstrated; C, no benefit demonstrated; EMG, electromyographic; ID, insufficient or no data; TENS, transcutaneous electrical nerve stimulation. | ||||
Recommendations for knee pain
Chronic knee pain is one of the more common complaints presented to primary care physicians. Acute and chronic pain can be related to acute injury, osteoarthritis, overuse injuries, or knee surgery. Due to the frequency of knee pain and its tendency to improve with time, there is a need to provide clinicians with the ability to make informed decisions regarding treatment options. The panel’s recommendations are summarized in Table 3.