Managing musculoskeletal complaints with rehabilitation therapy: Summary of the Philadelphia Panel evidence-based clinical practice guidelines on musculoskeletal rehabilitation interventions

The Philadelphia Panel identified two interventions that demonstrated grade A data for the treatment of osteoarthritis. Therapeutic exercise and TENS showed clinically important benefit for pain and patient global assessment in osteoarthritis. Thermotherapy, ultrasound, and electrical stimulation demonstrated no clinically important benefit for knee osteoarthritis. In summary, there is poor evidence to include or exclude thermotherapy, ultrasound, or electrical stimulation in the treatment of knee osteoarthritis.

With regard to knee tendonitis, the only intervention with significant data was deep transverse friction massage, which showed no clinical benefit. Patellofemoral pain also had 1 grade C intervention recommendation for the use of ultrasound. Further, preoperative exercise, thermotherapy, and TENS showed no clinical benefit for the management of postsurgical knee pain.

The remaining interventions for osteoarthritis of the knee, patellofemoral pain, tendonitis of the knee, and postsurgical pain showed insufficient evidence for the Philadelphia Panel to make guideline recommendations. The major implication of this analysis is that there is poor evidence to support the use of several widely accepted interventions in the treatment of knee pain.

TABLE 3
Summary grid of knee pain guidelines*

Recommendations for neck pain

Acute neck pain is often associated with injury or accident, whereas chronic neck pain is related to repetitive injury. Neck pain is commonly managed with analgesics and rest, but referrals to rehabilitation are increasing. The Philadelphia Panel sought to improve the appropriate use of rehabilitation interventions for neck pain by providing evidence-based guidelines. A summary of the Panel’s recommendations can be found in Table 4.

Only 8 trials met all selection criteria for the management of neck pain. Of these trials, only proprioceptive and therapeutic exercise for chronic neck pain showed clinical benefit for pain and function. The remaining studies showed no clinical benefit or insufficient data. Mechanical traction showed no clinically important benefit in the treatment of acute or chronic neck pain. No further studies that met selection criteria were found with regard to rehabilitation interventions for neck pain. Clearly there are insufficient data in the medical literature with regard to neck pain.

TABLE 4
Summary grid of neck pain guidelines*

Recommendations for shoulder pain

Rehabilitation specialists offer several conservative interventions for the management of shoulder pain. There are few published guidelines for the management of shoulder pain. Results of the analysis are shown in Table 5. As in the analysis of neck pain, the Philadelphia Panel was able to develop a single recommendation with clinical benefit. Clinically important benefit was shown for ultrasound for calcific tendonitis. There was no evidence of clinically important benefit for the use of ultrasound for capsulitis, bursitis, or tendonitis.

TABLE 5
Summary grid of shoulder pain guidelines*

Discussion

By using a rigorous methodology, the Philadelphia Panel has created evidence-based clinical practice guidelines for low back, knee, neck, and shoulder pain rehabilitation based on the current medical literature. Despite the thorough techniques used to create the guidelines, there are methodologic limitations, as with all such reviews. The panel identified many problems with the current body of evidence in the medical literature. The main difficulty with the current literature is the lack of standardization of outcome measurements used in different studies. Future studies need to develop standards of measurement that are valid, reliable, and sensitive to changes in outcome. Further, current studies have used broad inclusion criteria and enrolled patients with diverse etiologies for their pain. Problems with selection and description of patients, definitions of conditions, and standardizations of treatments and outcome measures need to be solved to properly demonstrate benefit from a rehabilitation intervention and remove misclassification bias.

Another limitation is the inherent difficulty of studying rehabilitation interventions. The effectiveness of physical rehabilitation interventions is affected by psychosocial, physical, and occupational factors. These factors can be minimized by fully randomizing large patient groups, thus minimizing selection bias. Another difficulty with developing high-quality randomized controlled trials in the area of rehabilitation is the blinding of patients or caregivers to interventions.