SIMFER guidelines on physical modalities for chronic primary pain management.

The panel itself judged the overall certainty of the evidence to be low, ranging from moderate to very low, because of imprecise estimates, risk of bias including performance, detection and attrition bias, and inconsistency between studies. Several of the largest reported effects, for whole-body vibration, cryotherapy and NMES, come from single small or high-risk-of-bias studies, so those numbers could easily be wrong in either direction. No studies at all were found for primary bone marrow oedema syndromes, which was one of the three conditions the guideline set out to answer for. No cost-effectiveness studies were identified. Costs were estimated from Italian national reimbursement tariffs, and the searches for feasibility and equity studies returned nothing eligible. Data on patient values and preferences came from a single study, and none existed for people with CRPS. Documented adverse events were based on only a subset of studies that systematically reported them. The recommendation is conditional rather than strong, and it is written for the Italian healthcare system, so access and cost implications may not transfer elsewhere.

The authors state they received no external funding for the guideline. Two panel members declared interests: Matteo Franchi reported research support relating to reimbursement for attending conferences or educational activities, and Alessandro Picelli reported research funding from organisations with commercial interests related to the guideline topic. The panel states that members abstained from voting on the strength of recommendations where they had authored included studies or had received direct or indirect funding from companies connected to the intervention under evaluation, and the remaining authors declared no competing interests.

Do not take the recommendation as proof these therapies work. The panel itself rated the overall certainty of the evidence as low, and the eye-catching effect sizes for whole-body vibration, cryotherapy and NMES come from a few small or high-risk-of-bias studies. Treat them as add-ons to exercise, education and psychological support, not as replacements for them.