Sandra Sauereisen, MD, MPH

ILLUSTRATIVE CASE

A 27-year-old daycare worker was tested for tuberculosis (TB) as part of a recent work physical. She presents to your office for follow-up for her positive purified protein derivative (PPD) skin test. You confirm the result with a quantiferon gold test and ensure she does not have active TB. What medication should you prescribe to treat her latent TB infection (LTBI)?

In 2017, there were 9093 cases of new active TB in the United States.² It’s estimated that one-fourth of the world’s population has latent TB.³ Identifying and treating latent TB ­infection is vital to achieving TB’s elimination.^4,5

Primary care clinicians are at the forefront of screening high-risk populations for TB. Once identified, treating LTBI can be challenging for providers and patients. Treatment guidelines recommend 4 to 9 months of daily isoniazid.^5-8 Shorter treatment regimens were recommended previously; they tended to be rigorous, to involve multiple drugs, and to require high adherence rates. As such, they included directly observed therapy, which prevented widespread adoption.

Consequently, the mainstay for treating LTBI has been 9 months of daily isoniazid. However, isoniazid use is limited by hepatoxicity and by suboptimal treatment completion rates. A 2018 retrospective analysis of patients treated for LTBI reported a completion rate of only 49% for 9 months of isoniazid.⁹ Additionally, a Cochrane review last updated in 2013 suggests that shorter courses of rifampin are similar in efficacy to isoniazid (although with a wide confidence interval [CI]), and likely have higher adherence rates.¹⁰

STUDY SUMMARY

Rifampin is as effective as isoniazid with fewer adverse effects

The study by Menzies et al¹ was a multisite, 9-country, open-label, randomized controlled trial (RCT) that compared 4 months of daily rifampin to 9 months of daily isoniazid for the treatment of LTBI in adults. Participants were eligible if they had a positive tuberculin skin test or interferon-gamma-release assay, were ≥ 18 years of age, had an increased risk for reactivation of active TB, and if their health care provider had recommended treatment with isoniazid. Exclusion criteria included current pregnancy or plans to become pregnant, exposure to a patient with TB whose isolates were resistant to either trial drug, an allergy to either of the trial drugs, use of a medication with serious potential interactions with the trial drugs, or current active TB.

Method, outcomes, patient characteristics. Patients received either isoniazid 5 mg/kg body weight (maximum dose 300 mg) daily for 9 months or rifampin 10 mg/kg (maximum dose 600 mg) daily for 4 months and were followed for 28 months. Patients in the isoniazid group also received pyridoxine (vitamin B₆) if they were at risk for neuropathy. The primary outcome was the rate of active TB. Secondary outcomes included adverse events, medication regimen completion rate, and drug resistance, among others.

This study found that a shorter rifampinbased regimen is associated with improved adherence and fewer adverse events than a longer isoniazid-based regimen for the treatment of latent TB infection.

A total of 2989 patients were treated with isoniazid; 3023 patients were treated with rifampin. The mean age of the participants was 38.4 years, 41% of the population was male, and 71% of the groups had confirmed active TB in close contacts.

Continue to: Results

Results. Overall, rates of active TB were low with 9 cases in the isoniazid group and 8 in the rifampin group. In the ­intention-to-treat analysis, the rate difference for confirmed active TB was < 0.01 cases per 100 person-years (95% CI; −0.14 to 0.16). This met the prespecified noninferiority endpoint, but did not show superiority. A total of 79% of patients treated with rifampin vs 63% treated with isoniazid completed their respective medication courses (difference of 15.1 percentage points; 95% CI, 12.7-17.4; P < .001). Compared with patients in the isoniazid group, those taking rifampin had fewer adverse events, leading to discontinuation (5.6% vs 2.8%).

WHAT’S NEW?

First high-quality study to show that less is more

This is the first large, high-quality study to show that a shorter (4 month) rifampin-based regimen is not inferior to a longer (9 months) isoniazid-based regimen for the treatment of LTBI, and that rifampin is associated with improved adherence and fewer adverse events.

CAVEATS

Low rate of active TB infection and potential bias

The current study had lower-than-­anticipated rates of active TB infection, which made the study’s conclusions less compelling. This may have been because of a small number of patients with human immunodeficiency virus enrolled in the study and/or that even participants who discontinued treatment received a median of 3 months of partial treatment.

In addition, the study was an open-label RCT, subjecting it to potential bias. However, the diagnosis of active TB and attribution of adverse events were made by an independent, blinded review panel.

CHALLENGES TO IMPLEMENTATION

No challenges to speak of

We see no challenges to implementing this recommendation.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

ILLUSTRATIVE CASE

A 27-year-old daycare worker was tested for tuberculosis (TB) as part of a recent work physical. She presents to your office for follow-up for her positive purified protein derivative (PPD) skin test. You confirm the result with a quantiferon gold test and ensure she does not have active TB. What medication should you prescribe to treat her latent TB infection (LTBI)?

In 2017, there were 9093 cases of new active TB in the United States.² It’s estimated that one-fourth of the world’s population has latent TB.³ Identifying and treating latent TB ­infection is vital to achieving TB’s elimination.^4,5

Primary care clinicians are at the forefront of screening high-risk populations for TB. Once identified, treating LTBI can be challenging for providers and patients. Treatment guidelines recommend 4 to 9 months of daily isoniazid.^5-8 Shorter treatment regimens were recommended previously; they tended to be rigorous, to involve multiple drugs, and to require high adherence rates. As such, they included directly observed therapy, which prevented widespread adoption.

Consequently, the mainstay for treating LTBI has been 9 months of daily isoniazid. However, isoniazid use is limited by hepatoxicity and by suboptimal treatment completion rates. A 2018 retrospective analysis of patients treated for LTBI reported a completion rate of only 49% for 9 months of isoniazid.⁹ Additionally, a Cochrane review last updated in 2013 suggests that shorter courses of rifampin are similar in efficacy to isoniazid (although with a wide confidence interval [CI]), and likely have higher adherence rates.¹⁰

STUDY SUMMARY

Rifampin is as effective as isoniazid with fewer adverse effects

The study by Menzies et al¹ was a multisite, 9-country, open-label, randomized controlled trial (RCT) that compared 4 months of daily rifampin to 9 months of daily isoniazid for the treatment of LTBI in adults. Participants were eligible if they had a positive tuberculin skin test or interferon-gamma-release assay, were ≥ 18 years of age, had an increased risk for reactivation of active TB, and if their health care provider had recommended treatment with isoniazid. Exclusion criteria included current pregnancy or plans to become pregnant, exposure to a patient with TB whose isolates were resistant to either trial drug, an allergy to either of the trial drugs, use of a medication with serious potential interactions with the trial drugs, or current active TB.

Method, outcomes, patient characteristics. Patients received either isoniazid 5 mg/kg body weight (maximum dose 300 mg) daily for 9 months or rifampin 10 mg/kg (maximum dose 600 mg) daily for 4 months and were followed for 28 months. Patients in the isoniazid group also received pyridoxine (vitamin B₆) if they were at risk for neuropathy. The primary outcome was the rate of active TB. Secondary outcomes included adverse events, medication regimen completion rate, and drug resistance, among others.

This study found that a shorter rifampinbased regimen is associated with improved adherence and fewer adverse events than a longer isoniazid-based regimen for the treatment of latent TB infection.

A total of 2989 patients were treated with isoniazid; 3023 patients were treated with rifampin. The mean age of the participants was 38.4 years, 41% of the population was male, and 71% of the groups had confirmed active TB in close contacts.

Continue to: Results

Results. Overall, rates of active TB were low with 9 cases in the isoniazid group and 8 in the rifampin group. In the ­intention-to-treat analysis, the rate difference for confirmed active TB was < 0.01 cases per 100 person-years (95% CI; −0.14 to 0.16). This met the prespecified noninferiority endpoint, but did not show superiority. A total of 79% of patients treated with rifampin vs 63% treated with isoniazid completed their respective medication courses (difference of 15.1 percentage points; 95% CI, 12.7-17.4; P < .001). Compared with patients in the isoniazid group, those taking rifampin had fewer adverse events, leading to discontinuation (5.6% vs 2.8%).

WHAT’S NEW?

First high-quality study to show that less is more

This is the first large, high-quality study to show that a shorter (4 month) rifampin-based regimen is not inferior to a longer (9 months) isoniazid-based regimen for the treatment of LTBI, and that rifampin is associated with improved adherence and fewer adverse events.

CAVEATS

Low rate of active TB infection and potential bias

The current study had lower-than-­anticipated rates of active TB infection, which made the study’s conclusions less compelling. This may have been because of a small number of patients with human immunodeficiency virus enrolled in the study and/or that even participants who discontinued treatment received a median of 3 months of partial treatment.

In addition, the study was an open-label RCT, subjecting it to potential bias. However, the diagnosis of active TB and attribution of adverse events were made by an independent, blinded review panel.

CHALLENGES TO IMPLEMENTATION

No challenges to speak of

We see no challenges to implementing this recommendation.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

ILLUSTRATIVE CASE

A 27-year-old daycare worker was tested for tuberculosis (TB) as part of a recent work physical. She presents to your office for follow-up for her positive purified protein derivative (PPD) skin test. You confirm the result with a quantiferon gold test and ensure she does not have active TB. What medication should you prescribe to treat her latent TB infection (LTBI)?

In 2017, there were 9093 cases of new active TB in the United States.² It’s estimated that one-fourth of the world’s population has latent TB.³ Identifying and treating latent TB ­infection is vital to achieving TB’s elimination.^4,5

Primary care clinicians are at the forefront of screening high-risk populations for TB. Once identified, treating LTBI can be challenging for providers and patients. Treatment guidelines recommend 4 to 9 months of daily isoniazid.^5-8 Shorter treatment regimens were recommended previously; they tended to be rigorous, to involve multiple drugs, and to require high adherence rates. As such, they included directly observed therapy, which prevented widespread adoption.

Consequently, the mainstay for treating LTBI has been 9 months of daily isoniazid. However, isoniazid use is limited by hepatoxicity and by suboptimal treatment completion rates. A 2018 retrospective analysis of patients treated for LTBI reported a completion rate of only 49% for 9 months of isoniazid.⁹ Additionally, a Cochrane review last updated in 2013 suggests that shorter courses of rifampin are similar in efficacy to isoniazid (although with a wide confidence interval [CI]), and likely have higher adherence rates.¹⁰

STUDY SUMMARY

Rifampin is as effective as isoniazid with fewer adverse effects

The study by Menzies et al¹ was a multisite, 9-country, open-label, randomized controlled trial (RCT) that compared 4 months of daily rifampin to 9 months of daily isoniazid for the treatment of LTBI in adults. Participants were eligible if they had a positive tuberculin skin test or interferon-gamma-release assay, were ≥ 18 years of age, had an increased risk for reactivation of active TB, and if their health care provider had recommended treatment with isoniazid. Exclusion criteria included current pregnancy or plans to become pregnant, exposure to a patient with TB whose isolates were resistant to either trial drug, an allergy to either of the trial drugs, use of a medication with serious potential interactions with the trial drugs, or current active TB.

Method, outcomes, patient characteristics. Patients received either isoniazid 5 mg/kg body weight (maximum dose 300 mg) daily for 9 months or rifampin 10 mg/kg (maximum dose 600 mg) daily for 4 months and were followed for 28 months. Patients in the isoniazid group also received pyridoxine (vitamin B₆) if they were at risk for neuropathy. The primary outcome was the rate of active TB. Secondary outcomes included adverse events, medication regimen completion rate, and drug resistance, among others.

This study found that a shorter rifampinbased regimen is associated with improved adherence and fewer adverse events than a longer isoniazid-based regimen for the treatment of latent TB infection.

A total of 2989 patients were treated with isoniazid; 3023 patients were treated with rifampin. The mean age of the participants was 38.4 years, 41% of the population was male, and 71% of the groups had confirmed active TB in close contacts.

Continue to: Results

Results. Overall, rates of active TB were low with 9 cases in the isoniazid group and 8 in the rifampin group. In the ­intention-to-treat analysis, the rate difference for confirmed active TB was < 0.01 cases per 100 person-years (95% CI; −0.14 to 0.16). This met the prespecified noninferiority endpoint, but did not show superiority. A total of 79% of patients treated with rifampin vs 63% treated with isoniazid completed their respective medication courses (difference of 15.1 percentage points; 95% CI, 12.7-17.4; P < .001). Compared with patients in the isoniazid group, those taking rifampin had fewer adverse events, leading to discontinuation (5.6% vs 2.8%).

WHAT’S NEW?

First high-quality study to show that less is more

This is the first large, high-quality study to show that a shorter (4 month) rifampin-based regimen is not inferior to a longer (9 months) isoniazid-based regimen for the treatment of LTBI, and that rifampin is associated with improved adherence and fewer adverse events.

CAVEATS

Low rate of active TB infection and potential bias

The current study had lower-than-­anticipated rates of active TB infection, which made the study’s conclusions less compelling. This may have been because of a small number of patients with human immunodeficiency virus enrolled in the study and/or that even participants who discontinued treatment received a median of 3 months of partial treatment.

In addition, the study was an open-label RCT, subjecting it to potential bias. However, the diagnosis of active TB and attribution of adverse events were made by an independent, blinded review panel.

CHALLENGES TO IMPLEMENTATION

No challenges to speak of

We see no challenges to implementing this recommendation.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

A 48-year-old man presents to your office for follow-up of right knee pain that has been bothering him for the past 12 months. He denies any trauma or inciting incident for the pain. On physical exam, he does not have crepitus but does have medial joint line tenderness of his right knee. An MRI shows a partial medial meniscal tear. Do you refer him to physical therapy (PT) or to orthopedics for arthroscopy and repair?

The meniscus—cartilage in the knee joint that provides support, stability, and lubrication to the joint during activity—can tear during a traumatic event or as a result of degeneration over time. Traumatic meniscal tears typically occur in those younger than 30 during sports (eg, basketball, soccer), whereas degenerative meniscal tears generally occur in patients ages 40 to 60.^2,3 The annual incidence of all meniscal tears is 79 per 100,000.⁴ While some clinicians can diagnose traumatic meniscal tears based on history and physical examination, degenerative meniscal tears are more challenging and typically warrant an MRI for confirmation.³

Meniscal tears can be treated either conservatively, with supportive care and exercise, or surgically. Unfortunately, there are no national orthopedic guidelines available to help direct care. In one observational study, 95 of 117 patients (81.2%) were generally satisfied with surgical treatment at four-year follow-up; satisfaction was higher among those with a traumatic meniscal tear than in those with a degenerative tear.⁵

Two systematic reviews of surgery versus nonoperative management or sham therapies found no additional benefit of surgery for meniscal tears in a variety of patients with and without osteoarthritis.^6,7 However, both studies were of only moderate quality, because of the number of patients in the nonoperative groups who ultimately underwent surgery. Neither of the studies directly compared surgery to nonoperative management.^6,7Another investigation—a multicenter, randomized, double-blind, sham-controlled study conducted in Finland involving 146 patients—compared sham surgery to arthroscopic partial meniscectomy. Both groups received instruction on performing post-procedure exercises, and both groups had similar and marked improvement in pain and function.⁸

Clinical practice recommendations devised from a vast systematic review of the literature recommend that the decision for surgery be based on patient-specific factors, such as symptoms, age, mechanism of tear, extent of damage, and occupational/social/activity needs.⁹

STUDY SUMMARY

Exercise is as good as surgery

The current superiority RCT compared exercise therapy to arthroscopic partial meniscectomy. Subjects (ages 35 to 60) presented to the orthopedic department of two hospitals in Norway with unilateral knee pain of more than two months’ duration and an MRI-delineated medial meniscal tear. They were included in the study only if they had radiographic evidence of minimal osteoarthritis (Kellgren-Lawrence classification grade ≤ 2). Exclusion criteria included acute trauma, locked knee, ligament injury, and knee surgery in the same knee within the previous two years.

The primary outcomes were change in patient-reported knee function (as determined by overall Knee injury and Osteoarthritis Outcome Score [KOOS] after two years) and thigh muscle strength at three months (as measured by physiotherapists). The researchers used four of the five KOOS subscales for this analysis: pain, other symptoms (swelling, grinding/noise from the joint, ability to straighten and bend), function in sports/recreation, and knee-related quality of life (QOL). The average score of each subscale was used.

Secondary outcomes included the five individual KOOS subscales (the four previously mentioned, plus activities of daily living [ADLs]), as well as thigh muscle strength and lower-extremity performance test results.

Methods. Testing personnel were blinded to group allocation; participants wore pants or neoprene sleeves to cover surgical scars. A total of 140 patients were randomized to either 12 weeks (24-36 sessions) of exercise therapy alone or a standardized arthroscopic partial meniscectomy; upon discharge, those in the latter group received written and oral encouragement to perform simple exercises at home, two to four times daily, to regain range of motion and reduce swelling.

Results. At two years, the overall mean improvement in KOOS4 score from baseline was similar between the exercise group and the meniscectomy group (25.3 pts vs 24.4 pts, respectively; mean difference [MD], 0.9). Additionally, muscle strength (measured as peak torque flexion and extension and total work flexion and extension) at both three and 12 months showed significant objective improvements favoring exercise therapy.

In the secondary analysis of the KOOS subscale scores, change from baseline was nonsignificant for four of the five (pain, ADL, sports/recreation, and QOL). Only the symptoms subscale had a significant difference favoring exercise therapy (MD, 5.3 pts); this was likely clinically insignificant on a grading scale of 0 to 100.

Of the patients allocated to exercise therapy alone, 19% crossed over and underwent surgery during the two-year study period.

WHAT’S NEW

Head-to-head comparison adds evidence

This is the first trial to directly compare exercise therapy to surgery in patients with meniscal tears. Interestingly, exercise therapy was as effective after a two-year follow-up period and was superior in the short term for thigh muscle strength.¹

The results of this study build on those from the aforementioned smaller study conducted in Finland.⁸ In that study, both groups received instruction for the same graduated exercise plan. The researchers found that exercise was comparable to surgery for meniscal tears in patients with no osteoarthritis.

CAVEATS

What about more severe osteoarthritis?

This trial included patients with no to mild osteoarthritis in addition to their meniscal tear.¹ It is unclear if the results would be maintained in those with more advanced disease. Additionally, 19% of patients crossed over from the exercise group to the surgery group, even though muscle strength improved. Therefore, education about the risks of surgery and the potential lack of benefit is important.

CHALLENGES TO IMPLEMENTATION

Cost and effort of PT

The cost of PT can be a barrier for patients who have adequate insurance coverage for surgery but inadequate coverage for PT. Additionally, exercise therapy requires significant and ongoing time and effort, which may deter those with busy lifestyles. Patients and clinicians may view surgery as an “easier” fix.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

Copyright © 2017. The Family Physicians Inquiries Network. All rights reserved.

Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice (2017;66[4]:250-252).

A 48-year-old man presents to your office for follow-up of right knee pain that has been bothering him for the past 12 months. He denies any trauma or inciting incident for the pain. On physical exam, he does not have crepitus but does have medial joint line tenderness of his right knee. An MRI shows a partial medial meniscal tear. Do you refer him to physical therapy (PT) or to orthopedics for arthroscopy and repair?

The meniscus—cartilage in the knee joint that provides support, stability, and lubrication to the joint during activity—can tear during a traumatic event or as a result of degeneration over time. Traumatic meniscal tears typically occur in those younger than 30 during sports (eg, basketball, soccer), whereas degenerative meniscal tears generally occur in patients ages 40 to 60.^2,3 The annual incidence of all meniscal tears is 79 per 100,000.⁴ While some clinicians can diagnose traumatic meniscal tears based on history and physical examination, degenerative meniscal tears are more challenging and typically warrant an MRI for confirmation.³

Meniscal tears can be treated either conservatively, with supportive care and exercise, or surgically. Unfortunately, there are no national orthopedic guidelines available to help direct care. In one observational study, 95 of 117 patients (81.2%) were generally satisfied with surgical treatment at four-year follow-up; satisfaction was higher among those with a traumatic meniscal tear than in those with a degenerative tear.⁵

Two systematic reviews of surgery versus nonoperative management or sham therapies found no additional benefit of surgery for meniscal tears in a variety of patients with and without osteoarthritis.^6,7 However, both studies were of only moderate quality, because of the number of patients in the nonoperative groups who ultimately underwent surgery. Neither of the studies directly compared surgery to nonoperative management.^6,7Another investigation—a multicenter, randomized, double-blind, sham-controlled study conducted in Finland involving 146 patients—compared sham surgery to arthroscopic partial meniscectomy. Both groups received instruction on performing post-procedure exercises, and both groups had similar and marked improvement in pain and function.⁸

Clinical practice recommendations devised from a vast systematic review of the literature recommend that the decision for surgery be based on patient-specific factors, such as symptoms, age, mechanism of tear, extent of damage, and occupational/social/activity needs.⁹

STUDY SUMMARY

Exercise is as good as surgery

The current superiority RCT compared exercise therapy to arthroscopic partial meniscectomy. Subjects (ages 35 to 60) presented to the orthopedic department of two hospitals in Norway with unilateral knee pain of more than two months’ duration and an MRI-delineated medial meniscal tear. They were included in the study only if they had radiographic evidence of minimal osteoarthritis (Kellgren-Lawrence classification grade ≤ 2). Exclusion criteria included acute trauma, locked knee, ligament injury, and knee surgery in the same knee within the previous two years.

The primary outcomes were change in patient-reported knee function (as determined by overall Knee injury and Osteoarthritis Outcome Score [KOOS] after two years) and thigh muscle strength at three months (as measured by physiotherapists). The researchers used four of the five KOOS subscales for this analysis: pain, other symptoms (swelling, grinding/noise from the joint, ability to straighten and bend), function in sports/recreation, and knee-related quality of life (QOL). The average score of each subscale was used.

Secondary outcomes included the five individual KOOS subscales (the four previously mentioned, plus activities of daily living [ADLs]), as well as thigh muscle strength and lower-extremity performance test results.

Methods. Testing personnel were blinded to group allocation; participants wore pants or neoprene sleeves to cover surgical scars. A total of 140 patients were randomized to either 12 weeks (24-36 sessions) of exercise therapy alone or a standardized arthroscopic partial meniscectomy; upon discharge, those in the latter group received written and oral encouragement to perform simple exercises at home, two to four times daily, to regain range of motion and reduce swelling.

Results. At two years, the overall mean improvement in KOOS4 score from baseline was similar between the exercise group and the meniscectomy group (25.3 pts vs 24.4 pts, respectively; mean difference [MD], 0.9). Additionally, muscle strength (measured as peak torque flexion and extension and total work flexion and extension) at both three and 12 months showed significant objective improvements favoring exercise therapy.

In the secondary analysis of the KOOS subscale scores, change from baseline was nonsignificant for four of the five (pain, ADL, sports/recreation, and QOL). Only the symptoms subscale had a significant difference favoring exercise therapy (MD, 5.3 pts); this was likely clinically insignificant on a grading scale of 0 to 100.

Of the patients allocated to exercise therapy alone, 19% crossed over and underwent surgery during the two-year study period.

WHAT’S NEW

Head-to-head comparison adds evidence

This is the first trial to directly compare exercise therapy to surgery in patients with meniscal tears. Interestingly, exercise therapy was as effective after a two-year follow-up period and was superior in the short term for thigh muscle strength.¹

The results of this study build on those from the aforementioned smaller study conducted in Finland.⁸ In that study, both groups received instruction for the same graduated exercise plan. The researchers found that exercise was comparable to surgery for meniscal tears in patients with no osteoarthritis.

CAVEATS

What about more severe osteoarthritis?

This trial included patients with no to mild osteoarthritis in addition to their meniscal tear.¹ It is unclear if the results would be maintained in those with more advanced disease. Additionally, 19% of patients crossed over from the exercise group to the surgery group, even though muscle strength improved. Therefore, education about the risks of surgery and the potential lack of benefit is important.

CHALLENGES TO IMPLEMENTATION

Cost and effort of PT

The cost of PT can be a barrier for patients who have adequate insurance coverage for surgery but inadequate coverage for PT. Additionally, exercise therapy requires significant and ongoing time and effort, which may deter those with busy lifestyles. Patients and clinicians may view surgery as an “easier” fix.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

Copyright © 2017. The Family Physicians Inquiries Network. All rights reserved.

Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice (2017;66[4]:250-252).

A 48-year-old man presents to your office for follow-up of right knee pain that has been bothering him for the past 12 months. He denies any trauma or inciting incident for the pain. On physical exam, he does not have crepitus but does have medial joint line tenderness of his right knee. An MRI shows a partial medial meniscal tear. Do you refer him to physical therapy (PT) or to orthopedics for arthroscopy and repair?

The meniscus—cartilage in the knee joint that provides support, stability, and lubrication to the joint during activity—can tear during a traumatic event or as a result of degeneration over time. Traumatic meniscal tears typically occur in those younger than 30 during sports (eg, basketball, soccer), whereas degenerative meniscal tears generally occur in patients ages 40 to 60.^2,3 The annual incidence of all meniscal tears is 79 per 100,000.⁴ While some clinicians can diagnose traumatic meniscal tears based on history and physical examination, degenerative meniscal tears are more challenging and typically warrant an MRI for confirmation.³

Meniscal tears can be treated either conservatively, with supportive care and exercise, or surgically. Unfortunately, there are no national orthopedic guidelines available to help direct care. In one observational study, 95 of 117 patients (81.2%) were generally satisfied with surgical treatment at four-year follow-up; satisfaction was higher among those with a traumatic meniscal tear than in those with a degenerative tear.⁵

Two systematic reviews of surgery versus nonoperative management or sham therapies found no additional benefit of surgery for meniscal tears in a variety of patients with and without osteoarthritis.^6,7 However, both studies were of only moderate quality, because of the number of patients in the nonoperative groups who ultimately underwent surgery. Neither of the studies directly compared surgery to nonoperative management.^6,7Another investigation—a multicenter, randomized, double-blind, sham-controlled study conducted in Finland involving 146 patients—compared sham surgery to arthroscopic partial meniscectomy. Both groups received instruction on performing post-procedure exercises, and both groups had similar and marked improvement in pain and function.⁸

Clinical practice recommendations devised from a vast systematic review of the literature recommend that the decision for surgery be based on patient-specific factors, such as symptoms, age, mechanism of tear, extent of damage, and occupational/social/activity needs.⁹

STUDY SUMMARY

Exercise is as good as surgery

The current superiority RCT compared exercise therapy to arthroscopic partial meniscectomy. Subjects (ages 35 to 60) presented to the orthopedic department of two hospitals in Norway with unilateral knee pain of more than two months’ duration and an MRI-delineated medial meniscal tear. They were included in the study only if they had radiographic evidence of minimal osteoarthritis (Kellgren-Lawrence classification grade ≤ 2). Exclusion criteria included acute trauma, locked knee, ligament injury, and knee surgery in the same knee within the previous two years.

The primary outcomes were change in patient-reported knee function (as determined by overall Knee injury and Osteoarthritis Outcome Score [KOOS] after two years) and thigh muscle strength at three months (as measured by physiotherapists). The researchers used four of the five KOOS subscales for this analysis: pain, other symptoms (swelling, grinding/noise from the joint, ability to straighten and bend), function in sports/recreation, and knee-related quality of life (QOL). The average score of each subscale was used.

Secondary outcomes included the five individual KOOS subscales (the four previously mentioned, plus activities of daily living [ADLs]), as well as thigh muscle strength and lower-extremity performance test results.

Methods. Testing personnel were blinded to group allocation; participants wore pants or neoprene sleeves to cover surgical scars. A total of 140 patients were randomized to either 12 weeks (24-36 sessions) of exercise therapy alone or a standardized arthroscopic partial meniscectomy; upon discharge, those in the latter group received written and oral encouragement to perform simple exercises at home, two to four times daily, to regain range of motion and reduce swelling.

Results. At two years, the overall mean improvement in KOOS4 score from baseline was similar between the exercise group and the meniscectomy group (25.3 pts vs 24.4 pts, respectively; mean difference [MD], 0.9). Additionally, muscle strength (measured as peak torque flexion and extension and total work flexion and extension) at both three and 12 months showed significant objective improvements favoring exercise therapy.

In the secondary analysis of the KOOS subscale scores, change from baseline was nonsignificant for four of the five (pain, ADL, sports/recreation, and QOL). Only the symptoms subscale had a significant difference favoring exercise therapy (MD, 5.3 pts); this was likely clinically insignificant on a grading scale of 0 to 100.

Of the patients allocated to exercise therapy alone, 19% crossed over and underwent surgery during the two-year study period.

WHAT’S NEW

Head-to-head comparison adds evidence

This is the first trial to directly compare exercise therapy to surgery in patients with meniscal tears. Interestingly, exercise therapy was as effective after a two-year follow-up period and was superior in the short term for thigh muscle strength.¹

The results of this study build on those from the aforementioned smaller study conducted in Finland.⁸ In that study, both groups received instruction for the same graduated exercise plan. The researchers found that exercise was comparable to surgery for meniscal tears in patients with no osteoarthritis.

CAVEATS

What about more severe osteoarthritis?

This trial included patients with no to mild osteoarthritis in addition to their meniscal tear.¹ It is unclear if the results would be maintained in those with more advanced disease. Additionally, 19% of patients crossed over from the exercise group to the surgery group, even though muscle strength improved. Therefore, education about the risks of surgery and the potential lack of benefit is important.

CHALLENGES TO IMPLEMENTATION

Cost and effort of PT

The cost of PT can be a barrier for patients who have adequate insurance coverage for surgery but inadequate coverage for PT. Additionally, exercise therapy requires significant and ongoing time and effort, which may deter those with busy lifestyles. Patients and clinicians may view surgery as an “easier” fix.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

Copyright © 2017. The Family Physicians Inquiries Network. All rights reserved.

Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice (2017;66[4]:250-252).

ILLUSTRATIVE CASE

A 48-year-old man presents to your office for follow-up of right knee pain that has been bothering him for the last 12 months. He denies any trauma or inciting incident for the pain. On physical exam, he does not have crepitus, but has medial joint line tenderness of his right knee. A magnetic resonance image (MRI) shows a partial, medial meniscal tear. Do you refer him to Physical Therapy (PT) or Orthopedics for arthroscopy and repair?

The meniscus—cartilage in the knee joint that provides support, stability, and lubrication to the joint during activity—can tear during a traumatic event or because of degeneration over time. Traumatic meniscal tears typically happen to younger adults and teens (<30 years of age) during sports, such as basketball and soccer,whereas degenerative meniscal tears generally present in patients ages 40 to 60 years.^2,3 The annual incidence of all meniscal tears is 79 per 100,000.⁴ While some physicians can diagnose traumatic meniscal tears based on history and physical examination, degenerative meniscal tears are generally more challenging, and typically warrant an MRI for confirmation.³

Meniscal tears can be treated either conservatively, with supportive care and exercise, or with surgery. Unfortunately, there are no national orthopedic guidelines available to help direct care. In one observational study of surgery as treatment for both traumatic and degenerative meniscal tears, 95 out of 117 patients (81.2%) were generally satisfied with this treatment at the 4-year follow-up, with higher satisfaction in the traumatic meniscal tear group than in the degenerative tear group.⁵

Two systematic reviews of surgery vs nonoperative management or sham therapies found no additional benefit of surgery for meniscal tears in a variety of patients with and without osteoarthritis.^6,7 However, both studies were of only moderate quality because of the number of patients in the nonoperative groups who ultimately obtained surgery. And neither of the studies directly compared surgery to nonoperative management.^6,7

Yet another investigation, a multicenter, randomized, double-blind, sham-controlled study conducted in Finland involving 146 patients, compared sham surgery to arthroscopic partial meniscectomy. Both groups received instruction on performing post-procedure exercises, and both groups had similar and marked improvement in pain and function.⁸

Clinical practice recommendations devised from a systematic and vast review of the literature recommend that the decision for surgery be based on patient-specific factors such as symptoms, age, mechanism of tear, extent of damage, and occupational/­social/activity needs.⁹

STUDY SUMMARY

Exercise is as good as—and in one way, better than—surgery

The current randomized controlled superiority trial compared exercise therapy to arthroscopic partial meniscectomy in patients ages 35 to 60 years presenting to the orthopedic departments of 2 hospitals in Norway with unilateral knee pain for more than 2 months and an MRI-delineated medial meniscal tear. Patients were included only if they had radiographic evidence of minimal osteoarthritis (Kellgren-Lawrence classification grade ≤2). Exclusion criteria were acute trauma, locked knee, ligament injury, and knee surgery in the same knee within the previous 2 years.

The primary outcomes were change in patient-reported knee function as determined by overall knee injury and osteoarthritis outcome score (KOOS₄) after 2 years and thigh muscle strength at 3 months as measured by physiotherapists. The KOOS₄ consists of 4 out of the 5 KOOS subscales: pain, other symptoms (swelling, grinding/noise from the joint, ability to straighten and bend), function in sports/recreation, and knee-related quality of life (QOL). This study utilized the average score of each subscale.

Secondary outcomes were the 5 individual KOOS subscales (the 4 previously mentioned plus activities of daily living [ADLs]), as well as thigh muscle strength and lower extremity performance test results.

Methods. Testing personnel were blinded to group allocation; participants wore pants or neoprene sleeves to cover surgical scars. A total of 140 patients were randomized to either 12 weeks (24-36 sessions) of exercise therapy alone or a standardized arthroscopic partial meniscectomy with written and oral encouragement upon discharge to perform simple exercises at home 2 to4 times daily (to regain range of motion and reduce swelling).

Results. The overall mean improvement in KOOS₄ score from baseline at 2 years was similar between the exercise group and the meniscectomy group (25.3 points vs 24.4 points, respectively; mean difference [MD], 0.9; 95% confidence interval [CI], -4.3 to 6.1; P=.72). Additionally, muscle strength (measured as peak torque flexion and extension and total work flexion and extension) at both 3 and 12 months showed significant objective improvements favoring exercise therapy.

Exercise therapy was as effective as surgery after a 2-year follow-up period and was superior in the short term for thigh muscle strength.

Secondary outcomes comparing the change from baseline of KOOS subscale scores showed 4 of the 5 having non-significant differences (pain, ADL, sports/­recreation, and QOL). Only the symptoms subscale had a significant difference favoring exercise therapy (MD, 5.3 points; 95% CI, 0.5 to 10.2; P=.03), which was likely clinically insignificant when using a grading scale of 0 to 100.

Of those patients allocated to exercise therapy alone, 19% crossed over and underwent surgery during the 2 years of the study.

WHAT'S NEW

Head-to-head comparison adds evidence to previous findings

This is the first trial to directly compare exercise therapy to surgery in patients with meniscal tears. Interestingly, exercise therapy was as effective after a 2-year follow-up period and was superior in the short term for thigh muscle strength.¹ The results of this study build on those from the smaller study conducted in Finland mentioned earlier.⁸ In that study, both groups received instruction for the same graduated exercise plan. The researchers found that exercise was comparable to surgery for meniscal tears in patients with no osteoarthritis.

CAVEATS

Results may not translate to those with more severe osteoarthritis

This trial included patients with only mild to no osteoarthritis in addition to their meniscal tear.¹ It is unclear if the results would be maintained in patients with more advanced disease. Additionally, 19% of patients crossed over from the exercise group to the surgery group, even though muscle strength improved. Therefore, education about the risks of surgery and the potential lack of benefit is important.

CHALLENGES TO IMPLEMENTATION

The cost and effort of physical therapy may be a deterrent

The cost of PT can be a barrier for some patients who have adequate insurance coverage for surgery, but inadequate coverage for PT. Additionally, exercise therapy requires significant and ongoing amounts of time and effort, which may be a deterrent for patients with busy lifestyles. Patients and physicians may view surgery as an “easier” fix.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

ILLUSTRATIVE CASE

A 48-year-old man presents to your office for follow-up of right knee pain that has been bothering him for the last 12 months. He denies any trauma or inciting incident for the pain. On physical exam, he does not have crepitus, but has medial joint line tenderness of his right knee. A magnetic resonance image (MRI) shows a partial, medial meniscal tear. Do you refer him to Physical Therapy (PT) or Orthopedics for arthroscopy and repair?

The meniscus—cartilage in the knee joint that provides support, stability, and lubrication to the joint during activity—can tear during a traumatic event or because of degeneration over time. Traumatic meniscal tears typically happen to younger adults and teens (<30 years of age) during sports, such as basketball and soccer,whereas degenerative meniscal tears generally present in patients ages 40 to 60 years.^2,3 The annual incidence of all meniscal tears is 79 per 100,000.⁴ While some physicians can diagnose traumatic meniscal tears based on history and physical examination, degenerative meniscal tears are generally more challenging, and typically warrant an MRI for confirmation.³

Meniscal tears can be treated either conservatively, with supportive care and exercise, or with surgery. Unfortunately, there are no national orthopedic guidelines available to help direct care. In one observational study of surgery as treatment for both traumatic and degenerative meniscal tears, 95 out of 117 patients (81.2%) were generally satisfied with this treatment at the 4-year follow-up, with higher satisfaction in the traumatic meniscal tear group than in the degenerative tear group.⁵

Two systematic reviews of surgery vs nonoperative management or sham therapies found no additional benefit of surgery for meniscal tears in a variety of patients with and without osteoarthritis.^6,7 However, both studies were of only moderate quality because of the number of patients in the nonoperative groups who ultimately obtained surgery. And neither of the studies directly compared surgery to nonoperative management.^6,7

Yet another investigation, a multicenter, randomized, double-blind, sham-controlled study conducted in Finland involving 146 patients, compared sham surgery to arthroscopic partial meniscectomy. Both groups received instruction on performing post-procedure exercises, and both groups had similar and marked improvement in pain and function.⁸

Clinical practice recommendations devised from a systematic and vast review of the literature recommend that the decision for surgery be based on patient-specific factors such as symptoms, age, mechanism of tear, extent of damage, and occupational/­social/activity needs.⁹

STUDY SUMMARY

Exercise is as good as—and in one way, better than—surgery

The current randomized controlled superiority trial compared exercise therapy to arthroscopic partial meniscectomy in patients ages 35 to 60 years presenting to the orthopedic departments of 2 hospitals in Norway with unilateral knee pain for more than 2 months and an MRI-delineated medial meniscal tear. Patients were included only if they had radiographic evidence of minimal osteoarthritis (Kellgren-Lawrence classification grade ≤2). Exclusion criteria were acute trauma, locked knee, ligament injury, and knee surgery in the same knee within the previous 2 years.

The primary outcomes were change in patient-reported knee function as determined by overall knee injury and osteoarthritis outcome score (KOOS₄) after 2 years and thigh muscle strength at 3 months as measured by physiotherapists. The KOOS₄ consists of 4 out of the 5 KOOS subscales: pain, other symptoms (swelling, grinding/noise from the joint, ability to straighten and bend), function in sports/recreation, and knee-related quality of life (QOL). This study utilized the average score of each subscale.

Secondary outcomes were the 5 individual KOOS subscales (the 4 previously mentioned plus activities of daily living [ADLs]), as well as thigh muscle strength and lower extremity performance test results.

Methods. Testing personnel were blinded to group allocation; participants wore pants or neoprene sleeves to cover surgical scars. A total of 140 patients were randomized to either 12 weeks (24-36 sessions) of exercise therapy alone or a standardized arthroscopic partial meniscectomy with written and oral encouragement upon discharge to perform simple exercises at home 2 to4 times daily (to regain range of motion and reduce swelling).

Results. The overall mean improvement in KOOS₄ score from baseline at 2 years was similar between the exercise group and the meniscectomy group (25.3 points vs 24.4 points, respectively; mean difference [MD], 0.9; 95% confidence interval [CI], -4.3 to 6.1; P=.72). Additionally, muscle strength (measured as peak torque flexion and extension and total work flexion and extension) at both 3 and 12 months showed significant objective improvements favoring exercise therapy.

Exercise therapy was as effective as surgery after a 2-year follow-up period and was superior in the short term for thigh muscle strength.

Secondary outcomes comparing the change from baseline of KOOS subscale scores showed 4 of the 5 having non-significant differences (pain, ADL, sports/­recreation, and QOL). Only the symptoms subscale had a significant difference favoring exercise therapy (MD, 5.3 points; 95% CI, 0.5 to 10.2; P=.03), which was likely clinically insignificant when using a grading scale of 0 to 100.

Of those patients allocated to exercise therapy alone, 19% crossed over and underwent surgery during the 2 years of the study.

WHAT'S NEW

Head-to-head comparison adds evidence to previous findings

This is the first trial to directly compare exercise therapy to surgery in patients with meniscal tears. Interestingly, exercise therapy was as effective after a 2-year follow-up period and was superior in the short term for thigh muscle strength.¹ The results of this study build on those from the smaller study conducted in Finland mentioned earlier.⁸ In that study, both groups received instruction for the same graduated exercise plan. The researchers found that exercise was comparable to surgery for meniscal tears in patients with no osteoarthritis.

CAVEATS

Results may not translate to those with more severe osteoarthritis

This trial included patients with only mild to no osteoarthritis in addition to their meniscal tear.¹ It is unclear if the results would be maintained in patients with more advanced disease. Additionally, 19% of patients crossed over from the exercise group to the surgery group, even though muscle strength improved. Therefore, education about the risks of surgery and the potential lack of benefit is important.

CHALLENGES TO IMPLEMENTATION

The cost and effort of physical therapy may be a deterrent

The cost of PT can be a barrier for some patients who have adequate insurance coverage for surgery, but inadequate coverage for PT. Additionally, exercise therapy requires significant and ongoing amounts of time and effort, which may be a deterrent for patients with busy lifestyles. Patients and physicians may view surgery as an “easier” fix.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

ILLUSTRATIVE CASE

A 48-year-old man presents to your office for follow-up of right knee pain that has been bothering him for the last 12 months. He denies any trauma or inciting incident for the pain. On physical exam, he does not have crepitus, but has medial joint line tenderness of his right knee. A magnetic resonance image (MRI) shows a partial, medial meniscal tear. Do you refer him to Physical Therapy (PT) or Orthopedics for arthroscopy and repair?

The meniscus—cartilage in the knee joint that provides support, stability, and lubrication to the joint during activity—can tear during a traumatic event or because of degeneration over time. Traumatic meniscal tears typically happen to younger adults and teens (<30 years of age) during sports, such as basketball and soccer,whereas degenerative meniscal tears generally present in patients ages 40 to 60 years.^2,3 The annual incidence of all meniscal tears is 79 per 100,000.⁴ While some physicians can diagnose traumatic meniscal tears based on history and physical examination, degenerative meniscal tears are generally more challenging, and typically warrant an MRI for confirmation.³

Meniscal tears can be treated either conservatively, with supportive care and exercise, or with surgery. Unfortunately, there are no national orthopedic guidelines available to help direct care. In one observational study of surgery as treatment for both traumatic and degenerative meniscal tears, 95 out of 117 patients (81.2%) were generally satisfied with this treatment at the 4-year follow-up, with higher satisfaction in the traumatic meniscal tear group than in the degenerative tear group.⁵

Two systematic reviews of surgery vs nonoperative management or sham therapies found no additional benefit of surgery for meniscal tears in a variety of patients with and without osteoarthritis.^6,7 However, both studies were of only moderate quality because of the number of patients in the nonoperative groups who ultimately obtained surgery. And neither of the studies directly compared surgery to nonoperative management.^6,7

Yet another investigation, a multicenter, randomized, double-blind, sham-controlled study conducted in Finland involving 146 patients, compared sham surgery to arthroscopic partial meniscectomy. Both groups received instruction on performing post-procedure exercises, and both groups had similar and marked improvement in pain and function.⁸

Clinical practice recommendations devised from a systematic and vast review of the literature recommend that the decision for surgery be based on patient-specific factors such as symptoms, age, mechanism of tear, extent of damage, and occupational/­social/activity needs.⁹

STUDY SUMMARY

Exercise is as good as—and in one way, better than—surgery

The current randomized controlled superiority trial compared exercise therapy to arthroscopic partial meniscectomy in patients ages 35 to 60 years presenting to the orthopedic departments of 2 hospitals in Norway with unilateral knee pain for more than 2 months and an MRI-delineated medial meniscal tear. Patients were included only if they had radiographic evidence of minimal osteoarthritis (Kellgren-Lawrence classification grade ≤2). Exclusion criteria were acute trauma, locked knee, ligament injury, and knee surgery in the same knee within the previous 2 years.

The primary outcomes were change in patient-reported knee function as determined by overall knee injury and osteoarthritis outcome score (KOOS₄) after 2 years and thigh muscle strength at 3 months as measured by physiotherapists. The KOOS₄ consists of 4 out of the 5 KOOS subscales: pain, other symptoms (swelling, grinding/noise from the joint, ability to straighten and bend), function in sports/recreation, and knee-related quality of life (QOL). This study utilized the average score of each subscale.

Secondary outcomes were the 5 individual KOOS subscales (the 4 previously mentioned plus activities of daily living [ADLs]), as well as thigh muscle strength and lower extremity performance test results.

Methods. Testing personnel were blinded to group allocation; participants wore pants or neoprene sleeves to cover surgical scars. A total of 140 patients were randomized to either 12 weeks (24-36 sessions) of exercise therapy alone or a standardized arthroscopic partial meniscectomy with written and oral encouragement upon discharge to perform simple exercises at home 2 to4 times daily (to regain range of motion and reduce swelling).

Results. The overall mean improvement in KOOS₄ score from baseline at 2 years was similar between the exercise group and the meniscectomy group (25.3 points vs 24.4 points, respectively; mean difference [MD], 0.9; 95% confidence interval [CI], -4.3 to 6.1; P=.72). Additionally, muscle strength (measured as peak torque flexion and extension and total work flexion and extension) at both 3 and 12 months showed significant objective improvements favoring exercise therapy.

Exercise therapy was as effective as surgery after a 2-year follow-up period and was superior in the short term for thigh muscle strength.

Secondary outcomes comparing the change from baseline of KOOS subscale scores showed 4 of the 5 having non-significant differences (pain, ADL, sports/­recreation, and QOL). Only the symptoms subscale had a significant difference favoring exercise therapy (MD, 5.3 points; 95% CI, 0.5 to 10.2; P=.03), which was likely clinically insignificant when using a grading scale of 0 to 100.

Of those patients allocated to exercise therapy alone, 19% crossed over and underwent surgery during the 2 years of the study.

WHAT'S NEW

Head-to-head comparison adds evidence to previous findings

This is the first trial to directly compare exercise therapy to surgery in patients with meniscal tears. Interestingly, exercise therapy was as effective after a 2-year follow-up period and was superior in the short term for thigh muscle strength.¹ The results of this study build on those from the smaller study conducted in Finland mentioned earlier.⁸ In that study, both groups received instruction for the same graduated exercise plan. The researchers found that exercise was comparable to surgery for meniscal tears in patients with no osteoarthritis.

CAVEATS

Results may not translate to those with more severe osteoarthritis

This trial included patients with only mild to no osteoarthritis in addition to their meniscal tear.¹ It is unclear if the results would be maintained in patients with more advanced disease. Additionally, 19% of patients crossed over from the exercise group to the surgery group, even though muscle strength improved. Therefore, education about the risks of surgery and the potential lack of benefit is important.

CHALLENGES TO IMPLEMENTATION

The cost and effort of physical therapy may be a deterrent

The cost of PT can be a barrier for some patients who have adequate insurance coverage for surgery, but inadequate coverage for PT. Additionally, exercise therapy requires significant and ongoing amounts of time and effort, which may be a deterrent for patients with busy lifestyles. Patients and physicians may view surgery as an “easier” fix.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.