Philadelphia panel evidence-based clinical practice guidelines on selectedrehabilitation interventions for low back pain

Introduction. A structured and rigorous methodology was developed for the - based clinical practice guidelines (EBCPGs), then formulation of evidence w as used to develop EBCPGs for selected rehabilitation interventions for the management of low back pain. Methods. Evidence from randomized controlled trials (RCTs) and observational studies was identified and synthesized usin g methods defined by the Cochrane Collaboration that minimize bias by using a systematic approach to literature search, study selection, data extracti on, and data synthesis. Meta-analysis was conducted where possible. The str ength of evidence was graded as level I for RCTs or level II for nonrandomi zed studies. Developing Recommendations. An expert panel was formed by invi ting stakeholder professional organizations to nominate a representative. T his panel developed a set of criteria for grading the strength of both the evidence and the recommendation. The panel decided that evidence of clinica lly important benefit (defined as 15% greater relative to a control based o n panel expertise and empiric results) in patient-important outcomes was re quired for a recommendation. Statistical significance was also required, bu t was insufficient alone. Patient-important outcomes were decided by consen sus as being pain, function, patient global assessment, quality of life, an d return to work, providing that these outcomes were assessed with a scale for which measurement reliability and validity have been established. Valid ating the Recommendations. A feedback survey questionnaire was sent to 324 practitioners from 6 professional organizations. The response rate was 51%. Results. Four positive recommendations of clinical benefit were developed. Therapeutic exercises were found to be beneficial for chronic, subacute, a nd postsurgery low back pain. Continuation of normal activities was the onl y intervention with beneficial effects for acute low back pain. These recom mendations were mainly in agreement with previous EBCPGs, although some wer e not covered by other EBCPGs. There was wide agreement with these recommen dations from practitioners (greater than 85%). For several interventions an d indications (eg, thermotherapy, therapeutic ultrasound, massage, electric al stimulation), there was a lack of evidence regarding efficacy. Conclusio ns. This methodology of developing EBCPGs provides a structured approach to assessing the literature and developing guidelines that incorporates clini cians' feedback and is widely acceptable to practicing clinicians. Further well-designed RCTs are warranted regarding the use of several interventions for patients with low back pain where evidence was insufficient to make re commendations.