March 27, 2013

DynaMed EBM Journal Volume 8, Issue 13

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Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: March 27, 2013

Expiration Date: March 27, 2014

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD - Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote EducationCompany and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: Enduring Material activity, DynaMed EBM Focus, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 7, 2012. Term of approval is for one year from this date with the option of yearly renewal. Each EBM Focus is worth .25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.

Program ID: 1210393D


Last week 343 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 222 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article of significant interest was selected by the DynaMed Editorial Team.

Initial Treatment with Physical Therapy for Meniscal Tear Associated with Functional Improvement Similar to Surgery and May Lower Surgery Rates in Patients with Knee Osteoarthritis
Reference: N Engl J Med 2013 Mar 18 early online, (level 2 [mid-level] evidence)

Meniscal tears are common in patients with osteoarthritis of the knee, and symptomatic tears are frequently treated with arthroscopic surgery. Existing data from randomized trials show arthroscopic debridement is not effective for treating knee osteoarthritis (N Engl J Med 2008 Sep 11;359(11):1097, N Engl J Med 2002 Jul 11;347(2):81), but these trials have not specifically addressed meniscal tears. A new trial compared initial physical therapy vs. initial arthroscopic surgery for symptomatic meniscal tears in this population.

A total of 351 patients with mild-to-moderate osteoarthritis and symptomatic meniscal tear were randomized to 1 of 2 treatments and followed for 1 year. The first group began treatment with a standardized physical therapy regimen but had the option for surgery at the discretion of patient and surgeon. The second group had immediate arthroscopic partial meniscectomy followed by the same standardized physical therapy. The physical therapy regimen for both groups included interventions to address inflammation, range of motion, muscle strength, aerobic conditioning, functional mobility, and balance. There were 1 or 2 weekly sessions plus home exercises for approximately 6 weeks depending on patient progress. All patients could have acetaminophen or NSAIDs as needed, and intraarticular glucocorticoid injections were permitted. The primary outcome was change in physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index scale (WOMAC score, 0-100 scale with higher scores indicating more severe symptoms). The mean WOMAC scores at baseline were 37.5 in physical therapy group and 37.1 in surgery group. A change in score of 8 points was considered clinically meaningful.

Patients who did not complete follow-up (6% at 6 months and 9% at 1 year) were excluded from the analyses. Both groups showed significant improvement in physical function by WOMAC score at 6 months (decrease in score 18.5 vs. 20.9) and 1 year (decrease in score 22.8 vs. 23.5). There were no significant differences in improvement between groups at either time point. 30% of the physical therapy group crossed over to surgical treatment in the first 6 months (surgery was performed in 94% of the surgery group). In the physical therapy group, 44% had clinically relevant improvement at 6 months without crossing over, compared to 67% in the surgery group (p < 0.001). There were no significant differences in adverse events or pain at 6 or 12 months.

Most of the patients in the physical therapy group who had surgery in the first 6 months had little functional improvement prior to crossover. However, their 1-year outcomes were similar to those of the immediate surgery group, suggesting that delaying surgery did not have a detrimental effect. It should be noted that the WOMAC questionnaire is a valid measure of physical function during basic activities of daily living, but it does not assess high-level function as may be required for work or sports. Nevertheless, these results suggest that physical therapy may be an appropriate first option for many patients with osteoarthritis and meniscal tears and that it may be possible to reserve surgery for those who do not benefit from physical therapy alone.

For more information, see the Meniscus tears topic in DynaMed.

Earn CME Credit for reading this e-Newsletter.
For more information on this educational activity, see the CME sidebar.

DynaMed Events

American College of Physicians (ACP) Internal Medicine 2013, April 11- 13, 2013
Senior Deputy Editor Larissa Lucas, MD, FACP, and Deputy Editor Sheila Bond, MD, will be attending the American College of Physicians Internal Medicine 2013 conference, held at The Moscone Center in San Francisco, California. Representatives will be available at the DynaMed booth (1402) to discuss peer review, mobile access, and free trial information.

Visit the American College of Physicians website to learn more about the event and for registration information.

Massachusetts Academy of Family Physicians (MassAFP) 2013 Spring CME Refresher, April 12 – 13, 2013
Senior Deputy Editor Alan Ehrlich, MD, will be presenting at the Massachusetts Academy of Family Physicians 2013 Spring CME Refresher, held at the Four Points Sheraton in Leominster, Massachusetts. The title of the presentation is “Medical Marijuana” and will be presented at 10:30 AM on Friday April 12th.

Visit the Massachusetts Academy of Family Physicians website to learn more about the event and for registration information.

If you would like to meet with a DynaMed representative at any of our conferences, please contact us at

New Topic Added to DynaMed this Week

Tick avoidance and removal

Call for Peer Reviews

We are currently seeking reviewers for:

Olecranon bursitis

Tarsal tunnel syndrome