General

Guideline Title

Occupational therapy practice guidelines for adults with musculoskeletal conditions.

Bibliographic Source(s)

Snodgrass J, Amini D. Occupational therapy practice guidelines for adults with musculoskeletal conditions. Bethesda (MD): American Occupational Therapy Association, Inc. (AOTA); 2017. 77 p. [460 references]

Guideline Status

This is the current release of the guideline.

This guideline meets NGC’s 2013 (revised) inclusion criteria.

NEATS Assessment

Disclosure of Guideline Funding Source

Disclosure and Management of Financial Conflict of Interests

Guideline Development Group Composition: Multidisciplinary Group

Unknown

Guideline Development Group Composition: Methodologist Involvement

Guideline Development Group Composition: Patient and Public Perspectives

Use of a Systematic Review of Evidence: Search Strategy

Use of a Systematic Review of Evidence: Study Selection

Use of a Systematic Review of Evidence: Synthesis of Evidence

Evidence Foundations for and Rating Strength of Recommendations: Grading the Quality or Strength of Evidence

Evidence Foundations for and Rating Strength of Recommendations: Benefits and Harms of Recommendations

Evidence Foundations for and Rating Strength of Recommendations: Evidence Summary Supporting Recommendations

Evidence Foundations for and Rating Strength of Recommendations: Rating the Strength of Recommendations

Specific and Unambiguous Articulation of Recommendations

External Review

Updating

Recommendations

Major Recommendations

Note from the National Guideline Clearinghouse : In addition to the evidence-based recommendations below, the guideline includes extensive information on the evaluation process and intervention strategies for adults with cancer.

Definitions for the strength of recommendations ( A–D, I ) and levels of evidence ( I–V ) are provided at the end of the “Major Recommendations” field.

Recommendations for Occupational Therapy Interventions for People With Musculoskeletal Conditions

Shoulder

Fracture

Early therapy with controlled range of motion (ROM) and sling wear for comfort to improve tumor necrosis factor (TNF)α functional outcomes and pain reduction with nondisplaced fracture ( A )
Home exercise program (HEP) and sling over a supervised therapy exercise program for nondisplaced fractures ( I )

Adhesive Capsulitis

Exercise and mobilization techniques combined with steroid injections to improve function ( A )
Cryotherapy, laser therapy, and electrotherapy to reduce pain and improve function ( C )
Exercise beyond the pain threshold ( C )

Neck and Shoulder Pain

Resistive exercise to increase function and decrease pain ( B )
Magnets and biofeedback to reduce pain ( C )
Relaxation programs to reduce pain on a short-term basis ( I )

Nonspecified Shoulder Pain

Preparatory activities combined with resistive exercise to reduce pain and improve function ( A )
Ultrasound to reduce shoulder pain related to calcific tendinitis ( C )

Rotator Cuff Tear

Rehabilitation including progressive tendon forces to reduce pain and improve function after surgical repair ( A )
Progressive strengthening exercises, ROM, and joint mobilizations to improve strength and ROM in conservative management ( B )
Postsurgical rehabilitation programs that include continuous passive motion, supervised or unsupervised therapy, land- or aquatic-based therapy, and video-based or therapist-guided programs to reduce pain and improve function ( I )
Accelerated therapy progressions vs. slow progressions to improve long-term outcomes after surgical repair ( I )

Subacromial Impingement

Exercise after arthroscopic surgery to improve short- and long-term outcomes of pain reduction and improved function ( A )
Exercises combined with physical agent modalities (PAMs), neuromuscular reeducation, steroid injections, and/or mobilizations for conservative management and surgical management to reduce pain and improve functional outcome ( B )
Therapeutic and elastic taping for short-term pain reduction ( B )

Elbow

Lateral Epicondylitis

Resistive exercise to improve short- and long-term outcomes of function, grip strength, and pain ( A )
Manual techniques to improve short- and long-term outcomes of function, grip strength, and pain ( A )
Multimodal therapy interventions over cortisone injections to improve long-term outcomes of function, grip strength, and pain ( A )
Low-level laser therapy (LLLT) to improve grip strength and decrease pain ( A )
Eccentric exercises in a multimodal therapy program to reduce pain and improve function ( B )
Low-intensity ultrasound for long-term pain improvement ( B )
Wearing of a forearm orthosis on a short-term basis to reduce pain and increase grip strength ( B )
Noxious-level electrical stimulation to improve short-term outcomes ( C )
Mobilization techniques and elastic taping in addition to standard rehabilitation to improve outcomes ( I )

Fracture, Contracture, and Dislocation

ROM exercises either early or late after joint mobilization to improve ROM after elbow fracture ( A )
Functional treatment (pain-free active range of motion [AROM] exercises after reposition of an elbow dislocation) with varying levels of immobilization to improve motion, strength, and function after elbow dislocation ( A )
Short period (2 days) of immobilization followed by early ROM exercises to improve strength and function in people with nondisplaced radial head fracture ( B )
Static progressive and dynamic orthoses to improve long-term functional outcomes for people with elbow contracture ( B )

Subacute Elbow Injury

Core strengthening to decrease compensatory movements ( B )

Cubital Tunnel Syndrome

Rigid night orthosis and activity modification to improve strength and function and decrease pain ( I )

Musculoskeletal Conditions of Forearm, Wrist, and Hand

Bone, Joint, and General Hand Disorders

Distal Radius and Boxer’s Fracture

Exercise to reduce pain and improve upper-limb activity for people with upper-limb fracture (but not to improve wrist extension or strength) ( A )
In-person occupational therapy (OT) over surgeon-directed HEP to improve grip and pinch strength after internal fixation of distal radius fracture ( B )
Splinting and buddy strapping to improve functional outcomes after boxer’s fracture ( B )
Standard care and dynamic splinting to promote AROM and passive range of motion (PROM) and occupational performance after distal radius fracture ( B )
Early mobilization to improve maximal web space of the thumb (but not to improve activities of daily living [ADLs] and strength) at 12 weeks after distal radius fracture with external fixation ( B )
Contralateral strengthening to improve grip strength (but not hand functioning) in women older than age 50 with distal radius fracture ( B )
HEP to improve hand functioning after distal radius fracture treated by internal volar plate fixation ( I )
Manual edema management intervention to improve edema, ADL performance, pain, and AROM after distal radius fracture ( I )
Early ROM treatment to reduce number of therapy visits and improve rate of functional recovery after distal radius fracture treated with open reduction and internal fixation ( I )

Rheumatoid Arthritis (RA)

Thumb orthosis to reduce pain (but not functional outcomes) for people with boutonniere deformity of the thumb secondary to RA ( B )
Silver ring splint and prefabricated thermoplastic splints to improve dexterity for people with swan neck deformity secondary to RA ( B )
Strengthening and stretching vs. education to improve hand functioning for people with RA ( B )

Osteoarthritis (OA)

Radial nerve mobilization to improve pinch (but not pain sensitivity) for people with thumb carpometacarpal OA ( B )
Splinting to control pain ( I )
Which type of splinting design to best improve pain and hand function ( I )

Contracture

Joint mobilization techniques at the wrist to improve ROM after a distal radius fracture ( B )
Mirror therapy to improve AROM and self-reported disability after orthopedic hand injury ( B )
Dynamic splinting for contracture to improve active wrist ROM and occupational performance after distal radial fracture ( I )
Dynamic Capener splints to improve ROM ( I )

General Hand Dysfunction

Joint mobilization techniques at the wrist to reduce pain and improve ROM after distal radius fracture ( B )
Core strengthening activities to improve trunk strength and head, trunk, and total compensation after wrist or elbow injury ( B )
Custom-made leather wrist splint and commercially available fabric splint with a palmar metal bar to reduce pain and improve function in people with chronic wrist pain (satisfaction was higher for the custom-made splint) ( B )
Patient-oriented hand rehabilitation program in a multidisciplinary setting to improve pain and hand function ( C )

Peripheral Nerve Disorders

Combination of stretching and splinting vs. general stretching or splinting alone for people with carpal tunnel syndrome (CTS) ( B )
Ischemic compression on active vs. latent trigger points to reduce pain and improve function for people with CTS ( B )
Mobilization and exercise interventions to improve symptoms and function for people with CTS ( B )
Heat wraps to reduce pain and improve function for people with CTS ( C )
Magnetic field therapy to reduce pain for people with CTS ( C )
Phonophoresis (over iontophoresis) to improve motor latency, strengthen grip and pinch, and lower resting pain for people with mild to moderate CTS ( C )
Therapeutic ultrasound to reduce pain and paresthesia ( C )
Ergonomic keyboards to reduce pain for people with CTS ( C )
Sensory reeducation for short-term reduction of pain and improvement in function after ulnar nerve injury ( C )
Manual therapy and massage to reduce pain and paresthesias for people with CTS ( C )
Joint mobilization to reduce pain and improve function for people with CTS ( C )
Ergonomic keyboards to reduce symptoms and improve hand function for people with CTS ( I )
Nighttime splinting for overall improvement and reduction of symptoms for people with CTS ( I )
Mobilization to improve symptoms and function for people with CTS ( I )
Neural gliding to reduce pain and symptoms and improve function for people with CTS ( I )
Specific dosage of therapeutic ultrasound to reduce pain and improve function for people with CTS ( I )
LLLT to reduce pain for people with CTS ( I )

Tendon Disorders

Early active and dynamic splinting protocols to improve grip strength and overall results after extensor tendon surgery ( B )
Early active motion on a short-term basis to improve strength and ROM and promote earlier return to work after tendon transfer ( B )
Cast immobilization to reduce edema and increase active distal interphalangeal joint for people with mallet finger ( C )
Removable orthotic immobilization to reduce pain for people with mallet finger ( C )
Combination of Kleinert and Duran protocols over use of Kleinert or Duran protocols applied individually to improve active motion after flexor tendon injury ( I )
Splinting in addition to rehabilitation to improve outcomes for people with Dupuytren’s contracture ( I )
Therapy combined with corticosteroid injection to improve function and reduce pain for people with trigger finger ( I )
Splinting techniques (volar, dorsal, or custom) to produce better outcomes for people with mallet finger ( I )

Lower Extremity

Hip Fracture

Comprehensive care model including early mobilization and daily rehabilitation by OT and physical therapy (PT), interdisciplinary care, and home modifications to improve function, increase cost-effectiveness, and decrease postoperative falls ( B )
OT combined with PT to reduce pain and fatigue ( B )
Training in patient handling and ergonomics for caregivers to reduce caregiver emotional distress, anxiety, and depression ( B )
High-intensity OT services in acute and inpatient settings to improve function ( I )

Hip and Knee Replacement

OT-created and -delivered educational materials to decrease pain and disability, increase self-management, and decrease number of OT visits needed ( A )
Individually tailored preoperative self-care education, client education on adaptive equipment, and home modifications to reduce length of stay ( B )
Multidisciplinary and multimodal interventions to decrease length of stay and increase quality of life (QOL) ( B )
OT focusing on ADL performance, compensatory strategies for functional limitations, joint protection strategies, and use of adaptive equipment to reduce pain and depression ( C )

Amputation and Limb Loss

Participation in sports or physical activity to improve general physical conditioning, cardiopulmonary function, and QOL ( B )
Volunteer-led self-management program to reduce risk of depression, reduce functional limitations, and increase self-efficacy ( B )
Inpatient rehabilitation to improve mobility and emotional outcomes ( C )

Hip and Knee Osteoarthritis

Activity pacing to reduce stiffness and the effect of fatigue on activity ( B )
Fall prevention education combined with an aquatic program to improve balance and falls efficacy ( B )
Tailored HEP plus education to reduce pain, hip function, and mobility ( B )
Tailored HEP plus exercise to improve QOL and reduce disability ( I )
Self-management program to reduce pain and improve function ( I )

Spine

Psychosocial and Cognitive Interventions

Cognitive-behavioral therapy (CBT) to increase physical capacity (ergonometer, lifting, and subjective ratings) ( B )
Cognitive treatment of illness perceptions to improve patient-relevant activity ( B )
Behavioral–medical interventions to promote pain coping strategies and reduce depression ( B )
CBT to reduce pain and improve function for people with low back pain ( C )

Education

Back schools to treat and prevent back injury and reduce pain and disability ( A to B )
Education approaches including web-based daily reminders, information and advice on return-to-work strategies, job coaching, energy conservation, and joint protection to treat and prevent back injury, pain, and disability ( A to B )
Lumbar back supports to reduce incidence and prevalence of back pain ( C )
Addition of lumbar supports to a short course on healthy working methods to reduce number of days when low back pain occurs (but not work absenteeism) for workers with previous low back pain ( C )
Ergonomic interventions to prevent back pain and injury and reduce functional limitations ( I )

Ergonomics and Work Technique or Modification and Functional Restoration

Workplace intervention approach, function-centered treatment, and multimodal work hardening to improve return to work ( B )
Real-time occupational Internet-based interventions (e.g., postural and exercise intervention in a work context) to prevent progression to chronicity of subacute nonspecific low back pain among office workers ( C )
Ergonomic adjustments at computer workstations to improve work posture and reduce prevalence of low back pain ( C )
Graded activity or addition of a work-transition component to improve return to work ( I )

Multidisciplinary Approaches

Integrated care program to reduce disability for people with chronic low back pain ( B )
Multidisciplinary program consisting of CBT and exercise training to reduce disability, fear-avoidance beliefs, and pain and enhance QOL of people with chronic low back pain ( B )
Multidisciplinary rehabilitation program (3 weeks, inpatient) for people with ankylosing spondylitis ( B )
Combination of exercise, education, and pain management (including transcutaneous electrical nerve stimulation [TENS]) to reduce disability and pain for people with low back pain ( C )

Physical Agent Modalities

Continuous ultrasound and phonophoresis to provide greater improvements in pain, extensor muscle strength, and walking performance than exercise alone for people with chronic low back pain ( B )
Continuous low-level heat wrap therapy to prevent and treat the early phase of low back delayed-onset muscle soreness ( B )
Therapeutic exercises alone (including low-intensity cycling, lower extremity [LE] strengthening, and abdominal muscle strengthening and flexion exercises) to reduce pain and disability for people with lumbar spinal stenosis, with the addition of ultrasound to lower analgesic intake ( B )
Electrical stimulation to improve QOL, functional performance, and isometric strength for people with chronic low back pain ( B )
Electrotherapy with interferential electrical stimulation and high-intensity laser therapy for people with chronic low back pain ( C )
LLLT to reduce pain and disability for people with low back pain ( I )
TENS to reduce pain and improve function for people with low back pain ( I )

Physical Activity

Aerobic exercise (especially walking) to improve strength for people with low back pain ( B )
Stretching of lower extremities and trunk to reduce disability for people with chronic low back pain ( C )
Wii gaming console activities to reduce pain and disability for people with low back injury ( I )
Use of a treadmill with body weight support or cycling for conservative management of lumbar spinal stenosis ( I )
Supervised or unsupervised Nordic walking to increase activity levels of people with chronic low back pain ( I )

Return to Work

Workplace Interventions

Tailored work rehabilitation programs and on-site interventions to reduce absenteeism, increase productivity, and reduce health care cost of outpatient treatment programs for people with short-term work absence ( A )
Workplace design modifications to promote return to work, increase comfort, reduce days lost and pain intensity, and lower pain prevalence and injury rate for people remaining on the job ( A )
Patient handling training alone for health care workers to reduce injury and pain ( B )
Return-to-work interventions starting within 12 weeks of absenteeism and lasting no longer than 12 hours to promote return to work, prevent health-related job loss, and lower mean days of sick leave; interventions over 12 hours may be more effective in preventing job loss for people with short-term work absence ( B )

Psychological and Behavioral Interventions

Clinic-based interdisciplinary program (including psychological interventions and worksite visits) to increase ability to work fulltime for people with short-term work absence ( B )
Active case management with vocational counseling to reduce anxiety and stress and improve reported health status and work readiness for people with long-term work absence ( B )
CBT alone to reduce job loss prevalence, injury rate, pain, and sick leave for people remaining on the job ( B )

Daily Activity Interventions

Specific resistance training, physical exercise, and clinic-based therapy paired with reengagement in daily activities to reduce pain and promote return to work for people with short-term work absence ( A )

Chronic Pain

Self-management

Self-management programs to reduce pain and disability for chronic musculoskeletal conditions (MSCs), especially for people with arthritis ( B )
Self-management programs to reduce pain and disability for people with low back pain ( I )

Physical Activity

Resistance training to increase muscle strength, functional ability, and QOL for people with chronic or acute MSCs ( A )
Kettlebell training to reduce neck, shoulder, and low back pain and increase back extension strength for employees with a high prevalence of MSCs ( B )
Kettlebell training to improve trunk flexion, shoulder elevation strength, and aerobic fitness for people in occupations reporting a high level of musculoskeletal pain ( C )
Resistance training to increase muscle strength after anterior cruciate ligament reconstruction surgery ( C )
Eccentric strength training to increase muscle strength for people with chronic Achilles or patellar tendinopathy ( I )

Kinesiotaping

Kinesiotaping to increase strength, force sense error, and AROM for people with shoulder pain ( I )

Education

Education addressing the neurophysiology of pain to reduce pain ratings, improve function, and help clients develop strategies to cope with pain ( B )
Multicomponent educational intervention targeting self-management provided by a health care provider in a medical or community setting to reduce pain and depressive symptoms and increase global health, physical function, and self-efficacy ( B )

Multidisciplinary Interventions

Multidisciplinary pain management programs to reduce pain and improve function ( B )

Physical Agent Modalities

Short-term electrical stimulation in conjunction with botulinum toxin injections into myofascial trigger points to reduce pain in people with chronic myofascial pain syndromes of the neck and shoulder region ( C )
Use of TENS to reduce phantom pain after amputation ( I )
Therapeutic massage to reduce musculoskeletal pain ( I )

Psychosocial Interventions

Internet-delivered CBT to reduce pain ( A )
Full graded motor imagery program to reduce pain and increase function in patient-selected tasks ( A )
Mirror therapy to reduce chronic pain ( A )
Internet-delivered CBT intervention to decrease severity of depression, generalized anxiety, and disability and increase ability to cope with pain ( B )
Mind–body therapy to reduce pain and depression and increase health and function ( B )
Mindfulness-based interventions to decrease pain and depressive symptoms ( B )
Cognitive–behavioral component added to physical training for self-employed people with MSCs ( B )
Motivational interviewing to decrease pain intensity and improve physical function ( C )
Graded motor imagery plus medical management to reduce pain and improve function for people with chronic regional pain ( C )
Mirror therapy to reduce pain and improve upper-limb function for people with poststroke chronic regional pain syndrome ( C )
Motor imagery alone can increase pain after treatment for people with chronic pain ( I )

Brief Lifestyle Intervention

Lifestyle intervention to increase global health and physical function (but not to decrease depression) ( B )

Complex Regional Pain Syndrome

OT or PT interventions over passive attention and advice ( I )

Burns

Orthoses and Physical Activity

Aerobic conditioning in combination with standard therapy to improve aerobic capacity and muscle strength for people with severe burns ( A )
Exercise alone rather than splinting and exercise to improve ROM and QOL for people with axillary burns ( B )

Inpatient Rehabilitation

Intense rehabilitation to increase strength and reduce complications and contractures ( B )

Early Excision and Grafting

Early excision and grafting vs. later grafting to improve ROM, strength, and function and reduce length of hospital stay ( B )

QOL, Pain Management, and Scar Management Interventions

Timely hospital discharge and return to work to improve QOL for people with severe burns ( I )
Virtual reality techniques to decrease subjective scores on pain scales and anxiety ( A )
Silicone gel or silicone sheet for scar management ( B )
Combination of a pressure garment, silicone gel sheeting or spray, and lanolin cream massage to manage scars ( B )
Pressure garments alone to manage scars ( I )

Definitions

Levels of Evidence for Occupational Therapy Outcomes Research

Levels of Evidence	Definition
Level I	Systematic reviews, meta-analyses, and randomized, controlled trials
Level II	Two groups, nonrandomized studies (e.g., cohort, case control)
Level III	One group, nonrandomized (e.g., before-after, pretest and posttest)
Level IV	Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series)
Level V	Case reports and expert opinions, which include narrative literature reviews and consensus statements

Note: Adapted from “Evidence-based medicine: What it is and what it isn’t.” D. L. Sackett, W. M. Rosenberg, J. A. Muir Gray, R. B. Haynes, & W. S. Richardson, 1996, British Medical Journal, 312, pp. 71-72. Copyright © 1996 by the British Medical Association. Adapted with permission.

Strength of Recommendations

A –There is strong evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. Good evidence was found that the intervention improves important outcomes and concludes that benefits substantially outweigh harm.

B –There is moderate evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. There is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial.

C –There is weak evidence that the intervention can improve outcomes. It is recommended that the intervention be provided selectively on the basis of professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.

I –There is insufficient evidence to determine whether or not occupational therapy practitioners should be routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harm cannot be determined.

D –It is recommended that occupational therapy practitioners do not provide the intervention to eligible clients. At least fair evidence was found that the intervention is ineffective or that harm outweighs benefits.

Note : Criteria for level of evidence and recommendations (A, B, C, I, D) are based on standard language from the U.S. Preventive Services Task Force (2012). Suggested recommendations are based on the available evidence and content experts’ clinical expertise regarding the value of using it.

Clinical Algorithm(s)

None provided

Scope

Disease/Condition(s)

Musculoskeletal conditions affecting the body’s movement system such as fractures, burns, lacerations, inflammation, arthritis, and muscle tears or inflammation

Other Disease/Condition(s) Addressed

Diabetes
Pain
Cancer
Depression
Anxiety

Guideline Category

Counseling
Evaluation
Management
Rehabilitation
Treatment

Clinical Specialty

Family Practice
Nursing
Physical Medicine and Rehabilitation

Intended Users

Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Nurses
Occupational Therapists
Physical Therapists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Students

Guideline Objective(s)

To provide an overview of occupational therapy interventions for people with musculoskeletal conditions (MSCs) on the basis of existing evidence of the effects of various interventions
To help guide decisions on future research by highlighting areas in which promising interventions lack enough evidence of a clear benefit or in which available interventions fail to meet the specific needs of clients with various MSCs
To be useful to many involved in providing occupational therapy services to people with MSCs, including occupational therapy practitioners, educators, clients, families, caregivers, third-party payers, and policymakers

Target Population

Adults with musculoskeletal disorders of the upper extremity (shoulder, elbow, forearm, wrist, and hand)
Adults with musculoskeletal disorders of the lower extremity (pelvis, hip, leg, ankle, and foot)
Adults with musculoskeletal disorders of the spine (cervical, thoracic, and lumbar)

Interventions and Practices Considered

Interventions for shoulder conditions * Fracture * Adhesive capsulitis * Neck and shoulder pain * Nonspecified shoulder pain * Rotator cuff tear * Subacromial impingement
Interventions for elbow conditions * Lateral epicondylitis * Fracture, contracture, and dislocation * Subacute elbow injury * Cubital tunnel syndrome
Interventions for musculoskeletal conditions of forearm, wrist, and hand * Bone, joint, and general hand disorders * Peripheral nerve disorders * Tendon disorders
Interventions for lower extremity conditions * Hip fracture * Hip and knee replacement * Amputation and limb loss * Hip and knee osteoarthritis
Interventions for spine conditions
Interventions for return to work
Interventions for chronic pain
Interventions for burns

Major Outcomes Considered

Effectiveness of interventions as determined by:

Performance of activities of daily living and instrumental activities of daily living
Return to work
Participation in leisure and social activities
Symptom and complications management
Quality of life

Methodology

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

The following three focused questions, from the review of occupational therapy interventions for people with musculoskeletal disorders, framed the reviews:

What is the evidence for the effect of occupational therapy interventions for adults with musculoskeletal disorders of the upper extremity (shoulder, elbow, forearm, wrist, and hand)?
What is the evidence for the effect of occupational therapy interventions for adults with musculoskeletal disorders of the lower extremity (pelvis, hip, leg, ankle, and foot)?
What is the evidence for the effect of occupational therapy interventions for adults with musculoskeletal disorders of the spine (cervical, thoracic, and lumbar)?

Method

Search terms for the reviews were developed by the research methodologist to the American Occupational Therapy Association (AOTA) Evidence-Based Practice (EBP) Project and AOTA staff, in consultation with the review authors of each question, and by the advisory group. The search terms were developed not only to capture pertinent articles but also to make sure that the terms relevant to the specific thesaurus of each database were included. The original search strategy for the upper extremity (UE) and low back focused questions was used for the updated reviews. Additional search terms were added to ensure maximum coverage of those questions. A search strategy was created for the full reviews of spine and lower extremity (LE).

Table E.1 in the original guideline document lists the search terms related to the population (people with musculoskeletal conditions [MSCs]) and types of interventions included in each systematic review. A medical research librarian with experience in completing systematic review searches conducted all searches and confirmed and improved the search strategies. Databases and sites searched included MEDLINE, PsycINFO, CINAHL, Ergonomics Abstracts, and OTseeker. In addition, consolidated information sources, such as the Cochrane Database of Systematic Reviews, were included in the search. These databases include peer-reviewed summaries of journal articles and provide a system for clinicians and scientists to conduct systematic reviews of selected clinical questions and topics. Moreover, reference lists from articles included in the systematic reviews were examined for potential articles, and selected journals were hand searched to ensure that all appropriate articles were included.

Inclusion and exclusion criteria are critical to the systematic review process because they provide the structure for the quality, type, and years of publication of the literature that is incorporated into a review. The reviews of all three questions were limited to peer-reviewed scientific literature published in English. The intervention approaches examined were within the scope of practice of occupational therapy. The literature included in the reviews was published between January 2006 and June 2014 and included study participants with MSCs. As described earlier, full searches for spine and LE were completed for January 1995 to June 2014. The reviews excluded data from presentations, conference proceedings, non–peer-reviewed research literature, dissertations, and theses. Studies included in the reviews provide Level I, II, and III evidence.

A total of 21,623 citations and abstracts were included in the reviews. For the question on the upper extremity (UE), there were 5,139 references; for the lower extremity (LE) question, 10,533 references; and for the spine question, 5,951 references. The research methodologist completed the first step of eliminating references on the basis of citation and abstract. The systematic reviews were carried out either by individual review authors or as academic partnerships in which academic faculty worked as faculty pairs or with graduate students. Review teams completed the next step of eliminating references on the basis of citations and abstracts. The full-text versions of potential articles were retrieved, and the review teams determined final inclusion in the review on the basis of predetermined inclusion and exclusion criteria.

A total of 346 articles were included in the final review: 259 Level I, 24 Level II, and 9 Level III studies. In addition to the three focused questions, the search produced 54 articles on return to work, chronic pain, and burns. These articles were evaluated separately.

Number of Source Documents

A total of 346 articles were included in the final review: 259 Level I, 24 Level II, and 9 Level III studies.

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence for Occupational Therapy Outcomes Research

Levels of Evidence	Definition
Level I	Systematic reviews, meta-analyses, and randomized, controlled trials
Level II	Two groups, nonrandomized studies (e.g., cohort, case control)
Level III	One group, nonrandomized (e.g., before-after, pretest and posttest)
Level IV	Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series)
Level V	Case reports and expert opinions, which include narrative literature reviews and consensus statements

Note: Adapted from "Evidence-based medicine: What it is and what it isn't." D. L. Sackett, W. M. Rosenberg, J. A. Muir Gray, R. B. Haynes, & W. S. Richardson, 1996, British Medical Journal, 312, pp. 71-72. Copyright © 1996 by the British Medical Association. Adapted with permission.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

The teams working on each focused question reviewed the articles according to their quality (scientific rigor and lack of bias) and levels of evidence. Each article included in the review was then abstracted using an evidence table that provides a summary of the methods and findings of the article. American Occupational Therapy (AOTA) staff and the research methodologist reviewed the evidence tables to ensure quality control. All studies are summarized in full in the evidence tables in Appendix F in the original guideline document. The risk of bias of individual studies was assessed using the methods described by Higgins, Altman, and Sterne (2011). The method for assessing the risk of bias of systematic reviews was based on the measurement tool developed by Shea et al. (2007).

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

A major focus of the American Occupational Therapy Association’s (AOTA’s) Evidence-based Practice (EBP) Project is an ongoing program of systematic review of the multidisciplinary scientific literature, using focused questions and standardized procedures to identify occupational therapy–relevant evidence and discuss its implications for practice, education, and research. An evidence-based perspective is founded on the assumption that scientific evidence of the effectiveness of occupational therapy intervention can be judged to be more or less strong and valid according to a hierarchy of research designs, an assessment of the quality of the research, or both.

AOTA uses standards of evidence modeled on those developed in evidence-based medicine. This model standardizes and ranks the value of scientific evidence for biomedical practice. In this system, the highest level of evidence, Level I, includes systematic reviews of the literature, meta-analyses, and randomized controlled trials (RCTs). In RCTs, participants are randomly allocated to either an intervention or a control group, and the outcomes of both groups are compared. Other levels of evidence include Level II studies, in which assignment to a treatment or a control group is not randomized (cohort study); Level III studies, which do not have a control group; Level IV studies, which use a single-case experimental design, sometimes reported over several participants; and Level V studies, which are case reports and expert opinions that include narrative literature reviews and consensus statements.

The systematic reviews on musculoskeletal conditions (MSCs) summarized in this Practice Guideline were supported by AOTA as part of the EBP Project. AOTA is committed to supporting the role of occupational therapy in this important area of practice.

Previous reviews covering the upper extremity (UE) and low back were completed for January 1986 through December 2005 and updated for January 2006 to June 2014. In addition, full searches for cervical spine and lower extremity (LE) were completed for January 1995 through June 2014. These reviews are crucial because occupational therapy practitioners need access to the results of the latest and best available literature to support interventions within the scope of occupational therapy practice for people with musculoskeletal conditions.

The three research questions for the systematic review were reviewed by the review authors, an advisory group of experts in the field, AOTA staff, and the methodology consultant to the AOTA EBP Project.

Rating Scheme for the Strength of the Recommendations

Strength of Recommendations

Cost Analysis

The guideline developers reviewed published cost analyses.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

This Practice Guideline was reviewed by a group of content experts for people with musculoskeletal conditions (MSCs) that included practitioners, researchers, educators, consumer representatives and other health care providers, and policy experts.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the “Major Recommendations” field).

A total of 346 articles were included in the final review: 259 Level I, 24 Level II, and 9 Level III studies.

Number of Articles Included for Each Topic

Review	Evidence Level	Total in Each Review
I	II	III	IV	V
Shoulder	67	7	2	0	0	76
Elbow	20	3	1	0	0	24
Forearm, wrist, hand	51	5	3	0	0	59
Lower extremity	32	8	3	0	0	43
Spine	89	1	0	0	0	90
Return to work	13	0	0	0	0	13
Chronic pain	22	1	0	0	0	23
Burns	14	3	1	0	0	18
Total	308	28	10	0	0	346

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

This document may be used to assist:

Occupational therapists and occupational therapy assistants in providing evidence-based interventions to people with musculoskeletal conditions (MSCs)
Occupational therapists in the selection of appropriate assessments and outcome measures used to evaluate treatment outcomes and the effectiveness of interventions used with people experiencing MSCs
Occupational therapists and occupational therapy assistants in the selection of appropriate billing codes to ensure reimbursement for services
Occupational therapists in the selection of accurate diagnostic codes for people with MSCs
Occupational therapists and occupational therapy assistants in communicating about occupational therapy services to external audiences
Other health care practitioners, case managers, clients, families and caregivers, and health care facility managers in determining whether referral for occupational therapy services is appropriate
Third-party payers in determining the medical necessity for occupational therapy services
Legislators; third-party payers; federal, state, and local agencies; and administrators in understanding the professional education, training, and skills of occupational therapists and occupational therapy assistants
Program developers; administrators; legislators; federal, state, and local agencies; and third-party payers in understanding the scope of occupational therapy services
Employers in understanding the role of occupational therapy in recommending appropriate adaptations, modifications, and interventions within the workplace to prevent or reduce the impact of MSCs
Occupational therapy researchers in this practice area in determining outcome measures and defining current occupational therapy practice to compare the effectiveness of occupational therapy interventions
Policy and health care benefit analysts in understanding the appropriateness of occupational therapy services for people with MSCs
Policymakers, legislators, and organizations in understanding the contribution occupational therapy can make in health promotion, program development, workplace safety, and health care reform to support people with MSCs
Occupational therapy educators in designing appropriate curricula that incorporate the role of occupational therapy with people with MSCs.

Potential Harms

This Practice Guideline is based on findings from systematic reviews of interventions for people with musculoskeletal conditions (MSCs) that were produced for the American Occupational Therapy Association (AOTA). The studies that met the inclusion criteria for the systematic reviews did not explicitly report potential adverse events associated with the interventions evaluated in the studies. If harms were noted, they would have been explicitly reported in the summary of key findings and would have been taken into account in the determination of the recommendations. Before implementing any new intervention with a client, it is always prudent for occupational therapy practitioners to be aware of the potential benefits and harms of the intervention.

Occupational therapy practitioners should exercise clinical reasoning based on a sound evaluation of the client’s strengths and limitations and an understanding of the intervention to determine the potential benefits and harms of an intervention for an individual client. Finally, clinical reasoning is also required to translate the intervention protocols used in the reviewed studies into client-centered, clinically feasible interventions.

Qualifying Statements

This guideline does not discuss all possible methods of care, and although it does recommend some specific methods of care, the occupational therapist makes the ultimate judgment regarding the appropriateness of a given intervention in light of a specific person’s or group’s circumstances and needs and the evidence available to support the intervention.
This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold or distributed with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the services of a competent professional person should be sought.
It is the objective of the American Occupational Therapy Association to be a forum for free expression and interchange of ideas. The opinions expressed by the contributors to this work are their own and not necessarily those of the American Occupational Therapy Association.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Chart Documentation/Checklists/Forms
Resources
Staff Training/Competency Material

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Getting Better
Living with Illness

IOM Domain

Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)

Snodgrass J, Amini D. Occupational therapy practice guidelines for adults with musculoskeletal conditions. Bethesda (MD): American Occupational Therapy Association, Inc. (AOTA); 2017. 77 p. [460 references]

Adaptation

Not applicable: The guideline is not adapted from another source.

Date Released

2017

Guideline Developer(s)

American Occupational Therapy Association, Inc. - Professional Association

Source(s) of Funding

This guideline was commissioned, edited, and endorsed by the American Occupational Therapy Association (AOTA) without external funding being sought or obtained. The report was supported financially entirely by AOTA and was developed without any involvement of industry.

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Authors : Jeff Snodgrass, PhD, MPH, OTR, FAOTA, Chair, Department of Occupational Therapy, Professor of Healthcare Administration & Occupational Therapy, Milligan College, Milligan College, TN, Contributing Faculty, School of Health Sciences, Walden University, Minneapolis, MN; Debbie Amini, EdD, OTR/L, FAOTA, Director of Professional Development, American Occupational Therapy Association, Bethesda, MD

Series Editor : Deborah Lieberman, MHSA, OTR/L, FAOTA, Director, Evidence-Based Practice Project, Staff Liaison to the Commission on Practice, American Occupational Therapy Association, Bethesda, MD

Issue Editor : Elizabeth G. Hunter, PhD, OTR/L, Assistant Professor, Graduate Center for Gerontology, College of Public Health, University of Kentucky, Lexington

Financial Disclosures/Conflicts of Interest

The authors of this Practice Guideline have signed a Conflict of Interest statement indicating that they have no conflicts that would bear on this work.

Guideline Status

This is the current release of the guideline.

This guideline meets NGC’s 2013 (revised) inclusion criteria.

Guideline Availability

Electronic copies: Not available at this time.

Print copies: Available for purchase from The American Occupational Therapy Association (AOTA), Inc., 4720 Montgomery Lane, Bethesda, MD 20814, Phone: 1-877-404-AOTA (2682), TDD: 800-377-8555, Fax: 301-652-7711. This guideline can also be ordered online from the AOTA Web site.

Availability of Companion Documents

The following is available:

Occupational therapy practice framework: domain and process. 3rd ed. Bethesda (MD): American Occupational Therapy Association, Inc. (AOTA); 2014. Available to order from the American Occupational Therapy Association, Inc. (AOTA) Web site.

In addition, the following are available in the original guideline document:

Occupational therapy (OT) process for adults with musculoskeletal conditions (MSCs)
Case examples describing OT evaluations and interventions for clients with MSCs
Sample international classification of diseases (ICD)–10–CM codes for OT evaluations and interventions for adults with MSCs
Selected current procedural terminology (CPT) ® codes for MSCs

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on May 7, 2018. The information was verified by the guideline developer on June 5, 2018.

This NEATS assessment was completed by ECRI Institute on April 10, 2018. The information was verified by the guideline developer on June 5, 2018.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer’s copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria.

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.