Wednesday, October 31, 2018 JAMA Study Supports Physical Therapy as First-Line Approach to Meniscal Tears A new study has turned the debate over physical therapy-versus-surgery for meniscal tears on its head—and even from that angle, the results again point to the validity of physical therapy as first-line option for treatment. In an article published in JAMA (abstract only available for free), researchers from the Netherlands analyzed outcomes for adults aged 45-70 with nonobstructive meniscal tears, not by trying to find out whether physical therapy is better than surgery but by evaluating whether physical therapy is "noninferior" to surgery. The logic behind the approach is fairly simple: given that arthroscopic partial meniscectomy (APM) is 1 of the most frequently performed orthopedic surgeries, given that it comes with a hefty price tag ($4 billion annually in 2006), and given that it's, well, surgery, it would make sense that physical therapy would simply need to be no worse than surgery to qualify for consideration as a first-line treatment. The study assigned 321 participants with nonobstructive meniscal tears to 1 of 2 groups: one that underwent APM, and another that participated in 16 30-minute sessions of physical therapy over 8 weeks that included "cardiovascular, coordination/balance, and closed kinetic chain strength exercises." Individuals who experienced locking of the knee, instability caused by an anterior or posterior cruciate ligament rupture, or severe osteoarthritis were not included in the study. Additionally, patients who had received prior knee surgery or whose BMI was higher than 35 were excluded. To gauge improvement, researchers monitored outcomes from the International Knee Documentation Committee Subjective Knee Form (IKDC) a self-assessment measure that uses a 0-100 scale to rate knee function, symptoms, and ability to engage in physical activities. Assessments were taken at baseline, 3 months, 6 months, 12 months, and 24 months after randomization. As for the participants, both groups were similar, with a mean age of 58, 56% women, and comparable baseline knee function and pain during weight-bearing. Here's what researchers found: Overall, the physical therapy group IKDC scores demonstrated noninferiority—defined by authors as average IKDC scores no more than 8 points apart—compared with the APM group. During the 24-month study period, knee function improved from 44.8 points to 71.5 points for the APM group, and from 46.5 points to 67.7 points for the physical therapy group. While the score differences between physical therapy and APM showed physical therapy as noninferior at 3 months and 6 months, the gap widened at 12 months and 24 months. But those differences weren't enough to move physical therapy from an overall "noninferior" rating. Participants who were obese tended to report higher improvement scores related to pain during weight-bearing than did their physical therapy counterparts. Other factors—location of the tear, education level of the participant, osteoarthritis severity, mechanical complaints, sex, and age—did not seem to significantly affect treatment outcomes. "The results of this trial support the recommendations from the current guidelines that [physical therapy] may be considered an appropriate alternative to APMs as first-line therapy for patients with meniscal tears," authors write, adding that their study echoes the consensus that "APM should not be the first treatment in middle-aged and older patients with meniscal tears." Authors of an accompanying editorial cast the results as yet another affirmation of physical therapy's effectiveness as a treatment for meniscal tears but wonder why "the orthopedic community [has been] slow to reduce APM." The editorial authors speculate on several possible explanations, including "community norms" around the expected treatment, surgeons simply doing what they've always done, and the power of a volume-based health care environment that incentivizes more procedures. Change may only come, they write, when payers take a more informed approach to what is and isn't authorized—but even that change may be slow to happen until everyone can agree on treatment guidelines. "To change clinical practice, it may be necessary to establish a consortium of all groups involved in the management of this knee condition—orthopedic surgeons, physiatrists, physical therapists, professional organizations, and insurance companies—to develop evidence-based treatment guidelines that each group can support," editorial authors write. "The guidelines should be focused on the best interests of the patients, rather than the clinicians, therapists, and other groups or entities who may gain from the different treatments." [Editor's note: check out APTA's PTNow online resource for a clinical practice guideline on meniscal and articular cartilage lesions, updated earlier this year.] Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.