Philadelphia panel evidence-based clinical practice guidelines on selectedrehabilitation interventions: Overview and methodology

Introduction. A structured and rigorous methodology was developed for the f ormulation of evidence-based clinical practice guidelines (EBCPGs), then wa s used to develop EBCPGs for selected rehabilitation interventions for the management of low back, neck, knee, and shoulder pain. Methods. Evidence fr om randomized controlled trials (RCTs) and observational studies was identi fied and synthesized using methods defined by the Cochrane Collaboration th at minimize bias by using a systematic approach to literature search, study selection, data extraction, and data synthesis. Meta-analyses were conduct ed where possible. The strength of evidence was graded as level I for RCTs or level II for nonrandomized studies. Developing Recommendations. An exper t panel was formed by inviting stakeholder professional organizations to no minate a representative. This panel developed a set of criteria for grading the strength of both the p evidence and the recommendation. The panel deci ded that evidence of clinically important benefit (defined as 15% greater r elative to a control based on panel expertise and empiric results) in patie nt-important outcomes was required for a recommendation. Statistical signif icance was also required but was insufficient alone. Patient-important outc omes were decided by consensus as being pain, function, patient global asse ssment, quality of life, and return to work, providing that these outcomes, were assessed with a scale for which measurement reliability and validity have been established. Validating the Recommendations. A feedback survey qu estionnaire was sent to 324 practitioners from 6 professional organizations . The response rate was 51 %. Results. Eight positive recommendations of cl inical benefit were developed. These recommendations were mainly in agreeme nt with previous EBCPGs, although some were not covered by other EBCPGs. Th ere was wide agreement with these recommendations from practitioners (great er than 75% agreement). For several interventions and indications (eg, ther motherapy, therapeutic ultrasound, massage electrical stimulation, mechanic al traction), there was a lack of evidence regarding efficacy. Conclusions. This methodology of developing EBCPGs provides a structured approach to as sessing the literature and developing EBCPGs that incorporates clinicians' feedback and is widely acceptable to practicing clinicians. Further well-de signed RCTs are warranted regarding the use of several interventions where evidence was insufficient to make recommendations.