SIMFER guidelines on physical modalities for chronic primary pain management.

Chronic primary pain is a leading cause of disability worldwide and requires a multimodal management approach. Instrumental physical therapies are widely used in rehabilitation, although their effectiveness remains heterogeneous across conditions and modalities. The objective of this paper is to synthesize the evidence and recommendations from the 2026 Clinical Practice Guideline developed by the Italian Society of Physical and Rehabilitation Medicine (SIMFER) on the use of instrumental physical therapies in chronic primary pain (i.e., complex regional pain syndrome, fibromyalgia, and primary bone marrow edema syndromes). The guideline was developed following the GRADE methodology. Systematic searches of Medline, Embase, and Cochrane Library were performed to identify systematic reviews and randomized controlled trials. Evidence was appraised in terms of risk of bias, inconsistency, indirectness, imprecision, and publication bias. Recommendations were formulated using the Evidence-to-Decision framework. The panel issued a conditional recommendation in favor of adding instrumental physical therapies to conventional treatment in patients with fibromyalgia, complex regional pain syndrome, and primary bone marrow edema syndromes. Evidence suggests modest to large improvements in pain and disability for specific modalities such as TENS, low-level laser therapy, and electromagnetic field therapy. However, overall certainty of evidence ranged from moderate to very low due to methodological limitations and heterogeneity. Adverse events were generally mild and transient, and patient acceptability was high. Instrumental physical therapies may be considered as adjunctive interventions within a multimodal rehabilitation approach for chronic primary pain. Despite encouraging findings, the low certainty of evidence highlights the need for high-quality trials with standardized protocols and long-term follow-up to strengthen future recommendations.