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

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 shoulder pain. Methods. Evidence from randomized controlled t rials (RCTs) and observational studies was identified and synthesized using methods defined by the Cochrane Collaboration that minimize bias by using a systematic approach to literature search, study selection, data extractio n, and data synthesis. Meta-analysis was conducted where possible. The stre ngth of evidence was graded as level I for RCTs or level II for nonrandomiz ed studies. Developing Recommendations. An expert panel was formed by invit ing stakeholder professional organizations to nominate a representative. Th is panel developed a set of criteria for grading the strength of both the e vidence and the recommendation. The panel decided that evidence of clinical ly important benefit (defined as 15% greater relative to a control based on panel expertise and empiric results) in patient-important outcomes was req uired for a recommendation. Statistical significance was also required but was insufficient alone. Patient-important outcomes were decided by consensu s as being pain, function, patient global assessment, quality of life, and return to work, providing that these outcomes were assessed with a scale fo r which measurement reliability and validity have been established. Validat ing the Recommendations. A feedback survey questionnaire was sent to 324 pr actitioners from 6 professional organizations. The response rate was 51%. R esults. Only 1 positive recommendation of clinical benefit was developed. U ltrasound provided clinically important pain relief relative to a control f or patients with calcific tendinitis in the short term (less than 2 months) . There was good agreement with this recommendation from practitioners (75% ). For several interventions and indications (eg, thermotherapy, therapeuti c exercise, massage, electrical stimulation, mechanical traction), there wa s a lack of evidence regarding efficacy. Conclusions. This methodology of d eveloping EBCPGs provides a structured approach to assessing the literature and developing EBCPGs that incorporates clinicians' feedback and is widely acceptable to practicing clinicians. Further well-designed RCTs are warran ted regarding the use of several interventions for patients with shoulder p ain where evidence was insufficient to make recommendations.