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Special Issue |
Clinical Specialty Experts
(Orthopaedic Surgeon), American Academy of Orthopaedic Surgeons, USA
(Internist, Rheumatologist), American College of Physicians, USA
(Physiatrist)
(Internist), University of Pennsylvania, Philadelphia. USA
(Neurologist), American Academy of Neurology, USA
(Physical Therapist), American Physical Therapy Association, USA
(Physical Therapist), American College of Rheumatology, Association of Health Professionals, USA
(Physiatrist), American Academy of Physical Medicine and Rehabilitation, USA
(Internist), Cochrane Back Group, USA
(Family Practice), American Academy of Family Physicians, USA
Ottawa Methods Group
(Public Health, specialization in epidemiology); Career Scientist, Ministry of Ontario Health (Canada), and Assistant Professor, Physiotherapy Program, School of Rehabilitation Sciences, University of Ottawa, Ottawa, Ontario, Canada
(Epidemiology), Chair, Centre for Global Health, Institute of Population Health, Ottawa, Ontario, Canada
(Epidemiology and Biostatistics), Professor and Chairman, Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
(Kinesiology), Research Associate, Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
(Medical Sociology), Medical Research Council Scholar, Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
(Epidemiology), Research Associate, Department of Medicine, University of Ottawa and Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
Research Fellow, Ottawa Hospital, General Campus, Ottawa, Ontario, Canada
Director of the Medical Library, Ottawa Hospital, Ottawa, Ontario, Canada
Research Associate, Department of Medicine, Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
Program of Physiotherapy, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
Address all correspondence and requests for reprints to: Peter Tugwell, MD, MSc, Chair, Centre for Global Health, Institute of Population Health, 1 Stewart St, Rm 312, Ottawa, Ontario, Canada K1N 6N5 (ptugwell{at}uottawa.ca)
Introduction. A structured and rigorous methodology was developed for the formulation of evidence-based clinical practice guidelines (EBCPGs), then was used to develop EBCPGs for selected rehabilitation interventions for the management of knee pain. Methods. Evidence from randomized controlled trials (RCTs) and observational studies were identified and synthesized using methods defined by the Cochrane Collaboration that minimize bias by using a systematic approach to literature search, study selection, data extraction, and data synthesis. Meta-analysis was conducted where possible. The strength of evidence was graded as level I for RCTs or level II for nonrandomized studies. Developing Recommendations. An expert panel was formed by inviting stakeholder professional organizations to nominate a representative. This panel developed a set of criteria for grading the strength of both the evidence and the recommendation. The panel decided that evidence of clinically important benefit (defined as 15% greater relative to a control based on panel expertise and empiric results) in patient-important outcomes was required for a recommendation. Statistical significance was also required but was insufficient alone. Patient-important outcomes were decided by consensus as being pain, function, patient global assessment, 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 questionnaire was sent to 324 practitioners from 6 professional organizations. The response rate was 51%. Results. Two positive recommendations of clinical benefit were developed: (1) transcutaneous electrical nerve stimulation (TENS) and therapeutic exercises were beneficial for knee osteoarthritis, and (2) there was good agreement with these recommendations from practitioners (73% for TENS, 98% for exercises). For several interventions and indications (eg, thermotherapy, therapeutic ultrasound, massage, electrical stimulation), there was a lack of evidence regarding efficacy. Conclusions. This methodology of developing EBCPGs provides a structured approach to assessing the literature and developing EBCPGs that incorporates clinicians' feedback and is widely accetable to practicing clinicians. Further well-designed RCTs are warranted regarding the use of several interventions for patients with knee pain where evidence was insufficient to make recommendations.
Key Words: Clinical practice guidelines • Evidence-based practice • Knee • Meta-analysis • Physical therapy • Practitioner feedback survey • Rehabilitation • Systematic reviews
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