Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Low Back Pain Han, Yueh-Chin Phys Ther. 2001;81:1641-1674.

Philadelphia Panel Evidence-Based Clinical Practice Guidelines on

Selected Rehabilitation Interventions for Low Back Pain

Han, Yueh-Chin

Phys Ther. 2001;81:1641-1674

Introduction

60-90% of the adult population is at risk of developing LBP at some point in their lifetime. 30% develop chronic LBP

Impact on functional ability, restricting occupational activities with marked socioeconomic repercussions.

Different practitioners treat people with LBP

Purpose– to describe the evidence-based clinical practice guidelines (EBCPGs) developed by panel about rehabilitation interventions for LBP. Target users: PT, physiatrists, orthopedic surgeons, rheumat

ologists, family physcians, and neurologists

Methods--1

Literature search: Randomized control trials (RCTs), nonrandomized control clinic

al trials (CCTs), or case control or cohort studies

Non-specific LBP: pain between the gluteal fold and he uppermost lumbar vertebrae, including postsurgery back pain

Interventions: massage, thermal therapy (hot or cold packs), ES, EMG biofeedback, TENS, therapeutic ultrasound, therapeutic exercises, and combinations.

Outcomes: functional status, pain, ability to work, clobal improvement, satisfaction and quality of life

Language: English-, French-, and Spanish-

Methods--2 Databases :

Electronic databases of MEDLINE,EMBASE,Current Contents, CINAHL,and Cochrane Controlled Trials Register up to July 1, 2000

The registries of the Cochrane Field of Rehabilitation and Related Therapies and the Cochrane Musculoskeletal Group and the Physiotherapy Evidence Database (PEDro)

2 independent reviewers:titles and abstracts (prior checklist)

2 independent reviewers:full articles Predetermined extraction forms Population characteristics, interventions. Trial design, allocation co

ncealment, and outcomes Methodological quality: 5-point validated scale– 2 points each for ra

ndomization and double-blinding and 1 points for description and withdrawals

Methods--3

Data analyzed time : 1 month, 6months, and 12 months post-therapy The closest time

3 categories of LBP Acute (< 4 weeks duration) Subacute (4-12 weeks duration) Chronic ( > 12 weeks duration) Excluded: mixed acute and chronic disease durations Subacute and chronicchronic

Statistical Analysis--1

Data analyzed using Reviews Manager (RevMan) computer program, version 4.1 for Windows

Continuous data: weight mean differences between the treatment and control groups Standardized mean differences for different scales

Dichotomous data: relative risks Heterogeneity: chi-square

Significant: random-effects models Not significant: fixed-effects models

Recommendations

Clinical improvement: 15% relative to a control

Level of evidence (I or II) Strength of evidence (A, B, C) Survey questionnaire to 324

practitioners

Results

Results

Literature Search 4981 articles related o LBP 340 considered potentially relevant based on the selection criteria

checklist 41 met the selection criteria

324 practitioner feedback survey: from the American Academy of Family Physicians (AAFP), American Academy of Orthopaedic Surgeons (AAOS), American College of Physicians (ACP), American Physical Therapy Association (APTA), American College of Rheumatology Health Professionals (ARHP), Physiatric Association of Spine, Sports, and Occupational Rehabili

tation (PASSOR) 51% response rate, 47% completed the survey

Number of included trials

Acute LBP –Therapeutic Exercises

Level I(RCT), Grade C for pain, function and return to work 4 RCTs (N=1035) McKenzie, back extension, Kendall flexio

n, and Strengthening ex. 1-3 sessions per weeks for 4-8 weeks

Efficacy: Therapeutic exercise no better than contr

ol at 1 or 12 months Pooled estimates at 1 months were not cli

nical for pain, function, or return to work No different between types of exercise

Acute LBP –Therapeutic Exercises

Strength of evidence compared with other guidelines Consistent with the Québec Task Force on Spinal Disorders (QTF),

the Agency for Health Care Policy and Research (AHCPR)

Clinical recommendations compared with other guidelines Poor evidence to include or exclude stretching or strengthening ex

ercise alone as an intervention for acute LBP Agree with AHCPR and BMJ The BMJ: increase stress from therapeutic exercise may harmful In contrast, QTF: general exercise as an option to increase strengt

h, ROM, and endurance but not discriminate between different types of exercise

Acute LBP – Continuation of Normal Activities vs. Enforced Bed Rest

Level I, Grade A for return to work, grade C for pain ad function One RCT(N=186) of continuing normal activities(CNA) versus 2 days

of enforced bed rest(EBR) Efficacy:

CNA 49% fewer sick days after 3 weeks related to EBR CAN 10% better for functional status and 5% for pain After 3 months, 51% fewer sick days, 10% better function (Oswestry scal

e), and 5% less pain (10-cm VAS)

Strength of evidence compared with other guidelines Similar to AHCPR of functional activities on return to work (level I)

Clinical recommendations compared with other guidelines Grade A for return to work, grade C for pain and function Agree with AHCPR BMJ: no discussion to normal activities as an inervention QTF: not discriminate between normal activities and stretching and streng

thening

Acute LBP – Continuation of Normal Activities vs. Enforced Bed Rest

Practitioner agreement Response rate for this EBCPG: 46% Percentage of practitioners giving comments for EBCPG: 41% Agree with recommendation: 98% Think a majority of my colleagues would agree: 98% Will (or already) follow this recommendation: 98%

Practitioner comments: Guideline should differentiate acute herniated disk,which may ben

efit from bed rest. Amount of bed rest is important—more than 72 hours is unnecess

ary. Panel’s response:

Excluded disk involvement A Cochrane review: short(2 days) or long(7 days) bed rest: no dif.

Acute LBP – Mechanical Traction

Level I(RCT), grade C for pain and global assessment 3 RCTs (N=176) of intermittent mechanical traction vs. place

bo; 1 RCT (N=16) vertical traction vs. bed rest Efficacy:

No difference at 1 month for improve pain (relative risk=0.88, 95% CI=0.50-1.55) or pain (-3.4mm on 100-mm VAS, 95% CI= -21.2-14.5)

No evidence in pain for vertical traction or global improvement

Acute LBP – Mechanical Traction

Strength of evidence compared with other guidelines QTF, no scientific evidence AHCPR moderate scientific evidence of lack of benefit

Clinical recommendations compared with other guidelines Poor evidence to include or exclude mechanical traction alone as a

n intervention for acute LBP Agree with AHCPR and BMJ BMJ reported potential harms: (not validated in trails)

• Debilitation• Loss of muscle tone• Bone demineralization• thrombophlebitis

In contrast, QTF: mechanical traction as an option to increase ROM

Acute LBP – Therapeutic Ultrasound Level II(CCT), grade C for pain One nonrandomized controlled trial(N=73) of

ultrasound vs. placebo Efficacy

No difference for pain improvement ROM of flexion and extension was improved after 1 month

Acute LBP – Therapeutic Ultrasound

Strength of evidence compared with other guidelines QTF, no scientific evidence AHCPR: agrees with this EBCPG

Clinical recommendations compared with other guidelines Poor evidence to include or exclude therapeutic ultrasound alone a

s an intervention for acute LBP Agree with AHCPR and BMJ QTF: as an option to diminish muscle spasm and pain release Thermotherapy, Pulsed US?

Acute LBP – TENS

Level I(RCT), grade C for pain or function One RCT(N=58) compared TENS and placebo

15 minutes of high-frequency TENS followed by 15 minutes of acupuncture-like TENS

Efficacy: No dif. in VAS pain, functional status, strength, or ROM at 1 month

Acute LBP – TENS

Strength of evidence compared with other guidelines Similar to AHCPR: one used electroacupunture, not TENS QTF: no scientific evidence

Clinical recommendations compared with other guidelines Poor evidence to include or exclude TENS alone as an intervention

for acute LBP Agree with AHCPR and BMJ QTF: as a useful modality for pain relief

Acute LBP – Intervention for Insufficient Data

No evidence with acceptable research design, intervention, group comparisons, and outcomes were identified for thermotherapy, ES, massage, or EMG biofeedback Lack of evidence with both QTF and AHCPR QTF recommended thermotherapy, massage, and EMG biofeedba

ck as potential interventions for acute LBP

Combination intervention: poor definitions of intervention, population r nonstandard outcomes.

Subacute LBP –Therapeutic Exercises

Level I(RCT),Grade A for pain, function and global assessment 3 RCTs (N=405) McKenzie,Kendall, and strengthening ex. Twice per weeks for 4 weeks

Efficacy: Benefit on pain relief and global condition More pain relief relative to control: 10% for strengthening ex. along, 11

% for Kendall flexion, 50 % and 57 % for McKenzie ex. Functional status improvement relative to control: 11% for McKenzie e

x. 15% for strengthening ex. Global improvement: 17 % to 24 % for McKenzie ex, not statistical diff.


Strength of evidence compared with other guidelines Disagrees with QTF: no scientific evidence for general ex AHCPR: 3 trials– 1 chronic LBP, 1 with psychological intervention,

1 involving a back school

Clinical recommendations compared with other guidelines Good evidence to include extension,flexion,and strengthening ex. Not for patients with neurological or radicular pain Partial concordance with AHCPR: low-stress aerobic ex within the

first 4 weeks (acute LBP) BMJ: agreement with the EBCPG, but increase stress may harmfu

l QTF: general ex. As option to increase strength, ROM and endura

nce



Practitioner comments Selection of exercises depends on clinical presentation; if there are

neurological or sensory deficits,exercises could exacerbate the pain Type of exercise (eg, Kendall, McKenzie) depends on patient. A combined approach with education is needed.

Panel’s response Patients with neurological/ radicular pain Individualized approach, clinical opinion but little empiric evidence Educational on posture and biomechanics (1 has, not in 2)

Subacute LBP – Mechanical Traction

Level I(RCT), grade C for global assessment and return to work

2 RCTs (N=212) of static traction vs. placebo Efficacy:

No clinical improvement for global assessment at 1 month return to work at 12 months

Subacute LBP – Mechanical Traction

Strength of evidence compared with other guidelines QTF, no scientific evidence AHCPR moderate scientific evidence of no benefit


n intervention for subacute LBP Agree with AHCPR and BMJ BMJ reported potential harms: (not validated in trails)



Chronic LBP –Therapeutic Exercises

Level I(RCT), Grade A for pain, function, grade C for return to work 8 RCTs (N=1035) Flexion, extension, stretching, circuit training, strength ex. with pro

gressive increases in resistance Efficacy:

Pain relief relative to control (5 RCTs); 2 RCTs—no difference Functional status: improve in 3 RCTs (N=209) related to control wi

th stretching ex., with strengthening, stretching, and aerobics, and with strengthening ex.

No different in ROM, strength, or reurn o work 1 RCTs (n=56): no difference between flexion and extension ex. f

or pain or global assessment at 1 month posttherapy


Efficacy: At 6-12 months follow-up (2 RCTs) Pain relief: 60%, function improve: 0% (1 trial) Function improve: 30%(another trial)


Strength of evidence compared with other guidelines QTF: no scientific evidence for general exercise (only one of

trails )

Clinical recommendations compared with other guidelines Good evidence to include stretching or strengthening, and

mobility exercise as interventions for acute LBP Agree BMJ: strengthening exercise QTF: general exercise as an option to increase strength, ROM,

and endurance but could have adverse effects due to increased stress on the spine

Chronic LBP –Therapeutic Exercises Practitioner agreement

Response rate for this EBCPG: 48% Percentage of practitioners giving comments for EBCPG: 38% Agree with recommendation: 88% Think a majority of my colleagues would agree: 91% Will (or already) follow this recommendation: 81%

Practitioner comments Evidence for functional status is not convincing Be careful about lumping different types of exercise McKenzie exercises are insufficient for chronic LBP,useful only for acute LBP Abdominal muscle re-education for spondylolisthesis should be included. Neuromotor retraining should be included in this EBCPG

Panel’s response 15% function improvement related to control group Not lumped different exercises (separately in table 9 and table 10) Educational on posture and biomechanics (1 has, not in 2) McKenzie ex. For chronic LBP in only one trail Combined heat, massage and ultrasound, but not the control No controlled studies evaluating the effectiveness of neuromotor retraining

Chronic LBP – Mechanical Traction

Level I(RCT), grade C for pain, function, global assessment, and return to work

4 RCTs (N=176)2intermittent traction and 2 static vs. placebo;

Efficacy: No difference in pain, function, global assessment

Chronic LBP – Mechanical Traction

Strength of evidence compared with other guidelines QTF, no scientific evidence


n intervention for acute LBP Agree with BMJ,reported potential harms (not validated in trails)



Chronic LBP – Therapeutic Ultrasound Level II(CCT), grade C for pain One RCT (N=36) of ultrasound vs. placebo Efficacy

No difference for pain improvement No data reported for ROM, strength, quality of life, function, or

return to work

Chronic LBP – Therapeutic Ultrasound

Strength of evidence compared with other guidelines Fair scientific evidence (level II) in this EBCPG QTF: no scientific evidence

Clinical recommendations compared with other guidelines Poor evidence to include or exclude therapeutic ultrasound alone

as an intervention for chronic LBP Agree with BMJ QTF: as an option to diminish muscle spasm and pain release

Chronic LBP – TENS

Level I(RCT), grade C for pain or function 4 RCT(N=235) compared TENS and placebo

Application acupuncture-like and alternate between both low- and high-frequency TENS in one

High-frequency TENS (>10 Hz) in 2 trails Low-frequency TENS (4 Hz) in 1

Efficacy: No difference in the pooled estimate of pain at 1 month post-therapy No difference for function status, ROM, or strength at 1 month

Chronic LBP – TENS

Strength of evidence compared with other guidelines Disagrees with QTF: weak scientific evidence based on a CCT

(excluded due to compare with massage )


for chronic LBP Agree with BMJ QTF: as a useful modality for pain relief

Chronic LBP – EMG Biofeedback

Level I(RCT), grade C for pain or function 5 RCT(N=162) compared EMG biofeedback and placebo Efficacy:

No effect on pain relief, function, or ROM at 1 month post-therapy

Chronic LBP – EMG Biofeedback

Strength of evidence compared with other guidelines Good scientific evidence showed no clinical benefit on pain or

function with EMG Biofeedback QTF: no scientific evidence


for chronic LBP BMJ: conflicting evidence QTF: as a useful modality for reduce muscle spasm

Chronic LBP – Intervention for Insufficient Data

No evidence with acceptable research design, intervention, group comparisons, and outcomes were identified for thermotherapy, ES, or massage Lack of evidence with both QTF and BMJ Both QTF and BMJ recommend massage as an intervention for chr

onic LBP

Combination intervention: poor definitions of intervention, population r nonstandard outcomes.

Deep abdominal stabilization ex. For patients with chronic spondylolisthesis improved pain and function relative to general ex., heat, massage, and therapeutic ultrasound (no placebo comparison group)

Postsurgery BP–Therapeutic Exercises

Level I (RCT), grade A for pain and function 1 RCT(N=200), 3 groups (strengthening, McKenzie, control) Efficacy:

Clinical benefit on pain and function with 2 types of ex. vs. control Function status in table 11 Exercise groups improved more on ROM and strength at 2 month Extended the re-enter treatment time for LBP

Postsurgery BP–Therapeutic Exercises

Strength of evidence compared with other guidelines QTF: no scientific evidence for general exercise

Clinical recommendations compared with other guidelines Good evidence to include stretching or strengthening, extension ex

ercise as interventions for postsurgery LBP Agree BMJ /QTF: strengthening/ therapeutic exercise BMJ: increased stress on the spine is a potential risk of therapeutic

exercise

Postsurgery BP –Therapeutic Exercises


Practitioner comments High-technology equipment is not practical in a clinical situation (iso

tonic or isokinetic)

Panel’s response Either high-technology exercise or low-technology (traditional stren

gthening and McKenzie exercise) be used for postsurgery LBP

Discussion

Discussion -- 1

Complex issue: certain intervention such as crytherapy, ho pack application, and massage are used for pain relief or as a treatment preparation before the main intervention

Influenced by a number of risk factors: biological, psychosocial, and occupational health indicators

Largely in agreement with previous and relatively recent EBCPGs

Feedback from the practitioners: clinical ease of use

Exercise

Continuation of normal activities for acute LBP Extension, strength or flexion exercise

For subacute, chronic and postsurgery For acute: agreement, moderate effective, advice to stay active,

negative effects of immobilization and bed rest Task-oriented activities

Future studies Clarifying types of exercise, intensity Patient-specific classification of physical dysfunction, need, reat

ment goals, and outcomes

Mechanical Traction

Static, intermittent, or vertical traction in acute, subacute, and chronic LBP: no benefit

Agree with previous systematic reviews for acute and chronic LBP management

To the patients with neurological signs Current literature does not support the suggestion

Therapeutic Ultrasound

Lacking evidence for effectiveness

Agrees with the AHCPR and BMJ guidelines

QTF: for muscle spasm and pain relief (common practice)

The available 2 trails were both of low quality (0 out of 5)

Pulsed type may be more effective than continuous type in acute condition (non-thermal effect)

TENS

No consistent benefit was shown on clinical outcomes for acute, subacute, or chronic LBP

No diff. between acute and chronic condition, low- and high- quality studies, or conventional and acupuncture-like application, or duration of TENS session

Agree with AHCPR and BMJ

QTF: for pain relief

Vibratory stimulation has been as part of the TENS (not included)

Therapeutic Massage

Insufficient data to make recommendation

Agree with AHCPR

BMJ and QTF: for relief muscle spasm

Influenced by the type of maneuvers used, therapist’s experience, number and size of muscles involved, patient position, press exerted, rhythm and progression, the frequency and duration of the treatment sessions

Thermotherapy

Insufficient evidence to make recommendation

Agree with AHCPR and QTF guidelines in chronic LBP

QTF: for acute LBP

Ice or heat were used in conjunction with other inerventions

Significant effects of crytherapy on circulatory and temperature responses on muscle spasm and inflammation translate to clinical effects? (thick muscles)

Electrical Stimulation

Insufficient evidence to make recommendation

Agree with AHCPR

BMJ and QTF: not evaluate his modality

ES to increase functional activities with intact peripheral nervous system

EMG Biofeedback

No consistent clinical benefit for EMG biofeedback for either acute or chronic LBP

Concordance with other guidelines

May be important in the relief of muscle spasm in people with acute LBP

Combined rehabilitation Interventions

QTF and BMJ: specialist use intervention in combination at their own discretion to achieve treatment goals

Difficult studies in combination of treatment

Overall

The main difficulty in determining the effectiveness of rehabilitation intervention is lack of weel-designed prospective RCTs

An appropriate placebo, adequate randomization, homogeneous sample of patients, adequate sample size to detect clinical important differences with confidence

Conclusion

There is evidence to use of continued normal activities for acute nonspecific LBP Therapeuic exercise for chronic, subacute, and postsurgery LBP

Developing with a transdisciplinary team approach, using structured methodology, including practitioner feedback

Lack of evidence of thermotherapy, therapeuic massage, EMG biofeedback, mechanical traction, therapeutic ultrasound, TENS, ES, and combined intervention (include or exclude)

Thank You!!

Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Low Back Pain Han, Yueh-Chin Phys Ther. 2001;81:1641-1674.

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philadelphia panel evidence

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