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Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: June 4, 2014
Expiration Date: June 4, 2015

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 above.

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 Education Company 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: This enduring material activity, DynaMed EBM Focus Volume 9, has been reviewed and is acceptable for up to 15.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 5, 2014. Term of approval is for one year from this date. Each EBM Focus is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. 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(s) of continuing education by the American Association of Nurse Practitioners. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards.

Program ID: 1405237D

DynaMed Careers

Looking for a change? The DynaMed editorial team is expanding and looking for talented and driven individuals. Visit the links below to learn about these exciting opportunities.

Deputy Editor of Oncology
Section Editor of Specialty Content

DynaMed Contribution Opportunities

DynaMed Peer Review
Editorial Policies for Reviewers
Education for Clinicians in Training

Last week 358 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 180 articles were added to DynaMed content.

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

Physical Therapy With Unsupervised Home Exercise Does Not Reduce Pain or Improve Function in Patients With Moderate-to-Severe Hip Osteoarthritis Pain
Reference: JAMA 2014 May 21;311(19):1987 (level 1 [likely reliable] evidence)

Symptomatic hip osteoarthritis is associated with joint pain and reduced physical function. The Osteoarthritis Research Society International (OARSI) guideline recommends referral to a physical therapist (OARSI Level IV) for patients with symptomatic hip osteoarthritis (Osteoarthritis Cartilage 2008 Feb;16(2):137). These recommendations state that physical therapy can provide initial evaluation and instruction in appropriate exercises to reduce pain and improve functional capacity, and may also help by providing assistive devices (canes or walkers) when appropriate. However, clinical data supporting physical therapy for this patient population have been lacking. A recent randomized trial compared a multimodal physical therapy regimen to a sham therapy in 102 community-dwelling patients (mean age 64 years) with radiograph-confirmed symptomatic hip osteoarthritis.

Patients were randomized to physical therapy vs. sham therapy for 10 sessions over 12 weeks and followed to 36 weeks. The physical therapy group received education and advice, manual therapy, and a walking stick if deemed appropriate, followed by 4-6 unsupervised home exercises performed 4 times weekly. The sham group received an inactive ultrasound plus inert gel followed by self-applied gel 3 times weekly during follow-up. At baseline, all patients had a hip pain score ≥ 40 mm (mean 58 mm) on a visual analog scale (range 0-100 mm, with higher scores indicating more severe pain). The mean hip physical function score at baseline was 32.4 points on Western Ontario and McMaster Universities Osteoarthritis Index hip-specific physical function subscale (range 0-68 points, with higher scores indicating worse function). Minimal clinically important differences were defined as 18 mm for the pain score and 6 points for the physical function score. The primary outcome was based on assessments at 13 weeks and secondary outcomes were based on results at 36 weeks.

The loss to follow-up was 6% at week 13 and 19% at week 36, but all patients were included in the efficacy analyses. Patients in the physical therapy group attended mean 9.6 of 10 treatment sessions and adherence to home exercise was mean 85% based on self-reported questionnaires. The mean overall hip pain score at 13 weeks was 40.1 mm with physical therapy vs. 35.2 mm with sham therapy. The 95% confidence interval for the between-group difference ranged from 3.9 mm in favor of physical therapy to 17.7 mm in favor of sham therapy. Similarly, the mean hip physical function score at 13 weeks was 27.5 points with physical therapy vs. 26.4 points with sham therapy. The 95% confidence interval for the between-group difference ranged from 3.8 points in favor of physical therapy to 6.5 points in favor of sham therapy. The frequency of mild adverse events, primarily increased hip pain or pain in other regions, by 13 weeks was 41% with physical therapy vs. 14% with sham therapy (p = 0.003, NNH 3). The results at 36 weeks also did not show significant differences between the 2 groups for either hip pain or hip physical function scores. The proportion of patients believing they were receiving active treatment was 62% in the physical therapy group vs. 25% in the sham group at week 36. The cost of the multimodal physical therapy intervention evaluated was not reported.

Physical therapy for patients with symptomatic hip osteoarthritis often employs a multimodal approach, including education, manual therapy, and various exercises. Although some previous studies have evaluated some of the specific components involved, this is the first study to rigorously evaluate several aspects of physical therapy using a credible sham control, which potentially reduces the risk of bias in outcomes such as pain scores that are subjective in nature. Because of this, these data provide the best evidence to date for the effect of a broad set of physical therapy components, most importantly a combination of manual therapy and unsupervised home exercise, on hip pain or function. The findings suggest that physical therapy including manual therapy and unsupervised home exercise is of limited value for these patients, and may even harm patients by increasing the frequency of mild adverse events such as increased hip pain or pain in other regions. Although a higher proportion of patients in the physical therapy group were aware that they received active treatment at 36 weeks, this is unlikely to have made a substantial impact on either the pain or physical function outcomes.

A recent update of a Cochrane review identified 10 randomized trials comparing land-based exercise (aquatic exercise is reviewed separately) vs. nonexercise active control or no treatment in 554 adults with hip osteoarthritis (Cochrane Database Syst Rev 2014 Apr 22;(4):CD007912). The inclusion criteria allowed both supervised exercise as well as home exercise with minimal monitoring. In a meta-analysis of 9 trials, exercise was associated with a statistically significant but clinically unimportant improvement in pain. Similarly, a separate meta-analysis of 9 trials showed that exercise was associated with a statistically significant improvement in physical function, with a 95% confidence interval including both clinically important and unimportant differences.

The term “physical therapy” is an umbrella term that may refer to many different interventions, and this makes it difficult to make general conclusions about its use in patients with symptomatic hip osteoarthritis. In particular, the use of unsupervised home exercise evaluated in this study may be a limitation, since therapists had limited ability to ensure that exercises were being done correctly. Furthermore, although adherence to home exercise was reported to be about 85% in patients receiving physical therapy, this was by necessity a self-reported estimate among unsupervised patients. Nonetheless, the evidence from this trial does not support physical therapy as an effective treatment in this clinical context.

For more information see the Degenerative joint disease of the hip topic in DynaMed.

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

EBSCO Health Launches Pediatric Clinical Information Mobile App

PEMSoft Now Available For iPhone, iPad, and Android Devices

A mobile app designed specifically for pediatricians, emergency department physicians, physicians-in-training and other medical providers caring for children with acute illnesses and injury, is now available from EBSCO Health, the leading provider of clinical decision support solutions for the healthcare industry.

Designed by pediatricians, emergency physicians and other medical specialists, PEMSoft is a pediatric evidence-based point-of-care medical reference tool for hospitals, emergency departments, clinics, pediatric group practices, transport services, and medical schools. The vast content in PEMSoft addresses the entire spectrum of neonatal, infant, child, adolescent and young adult health. PEMSoft authors adhere to a strict evidence-based editorial policy focused on systematic identification, evaluation and consolidation of practice-changing clinical literature.

The PEMSoft Mobile app includes explicit step-by-step emergency critical care procedures, information about common pediatric signs and symptoms and content covering pediatric injuries and management approaches. More than 3,000 evidence-based pediatric topics and a similar number of medical illustrations, clinical images and videos are also available via the mobile app.

The PEMSoft Mobile App is accessible from both Apple and Android devices.

For more information and technical support, visit the PEMSoft Mobile Access page. To view the official press release, click here.

DynaMed Events

Medical Marijuana: Regs, Responsibilities & Communication
June 18, 2014 / 8am-12:30pm

Senior Deputy Editor Alan Ehrlich, MD, will be attending the Massachusetts Medical Society (MMS) CME Event and Conference on Medical Marijuana: Regs, Responsibilities & Communication, held at the MMS Headquarters at Waltham Woods in Waltham, Massachusetts. Representatives will be available to discuss peer review, mobile access, and free trial information.

Visit the MMS 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 DynaMedCommunity@ebscohost.com.

Call for Peer Reviews

We are currently seeking subspecialty reviewers for our Patient Education Resource Center (PERC). PERC provides fact sheets and discharge instructions for patients leaving the hospital or emergency room. These hand-outs fulfill the meaningful use requirements for the Medicare & Medicare Services Incentive Programs.

Click here to speak with us about becoming a peer reviewer.