[Skip to Content]
[Skip to Content Landing]

Effectiveness of Later-Stage Exercise Programs vs Usual Medical Care on Physical Function and Activity After Total Knee ReplacementA Randomized Clinical Trial

Educational Objective
To review the effectiveness of exercise programs delivered at a later stage after total knee replacement
1 Credit CME
Key Points

Question  Can exercise programs delivered at a later stage (>2 months) after total knee replacement improve the functional limitations that persist after surgery?

Findings  In this randomized clinical trial of 240 individuals at a later stage after knee replacement, all arms (physical therapy, community, and control) improved physical function. There were no differences between arms in the primary outcome of patient-reported physical function, whereas the secondary outcome of performance-based physical function demonstrated greater improvement in the physical therapy arm.

Meaning  While the primary outcome suggests no benefit of later-stage exercise programs, the secondary outcomes suggest beneficial effects of physical therapy but require confirmation.


Importance  Several functional limitations persist after total knee replacement (TKR). Intensive exercise programs could resolve these limitations but are not well tolerated by many patients until a later stage (>2 months) after surgery. Evidence for exercise at a later stage after TKR is limited.

Objectives  To compare the effectiveness of later-stage exercise programs after TKR and to explore heterogeneity of treatment effects.

Design, Setting, and Participants  Three-arm single-blind randomized clinical trial (January 7, 2015, to November 9, 2017) using an intent-to-treat approach with follow-ups at 3 months and 6 months. The setting was Allegheny County, Pennsylvania (an outpatient physical therapy clinic and 4 community centers). Participants had primary TKR performed more than 2 months previously, were 60 years or older, experienced moderate functional limitations, and were medically cleared to exercise.

Interventions  Clinic-based physical therapy exercise (physical therapy arm), community-based group exercise (community arm), and usual care (control arm). The control arm continued their usual care, whereas the exercise arms participated in supervised exercise programs lasting 12 weeks.

Main Outcomes and Measures  The primary outcome was arm differences in the Western Ontario and McMaster Universities Osteoarthritis Index–Physical Function (WOMAC-PF) at 3 months. The secondary outcomes included performance-based tests germane to knee replacement and additional surveys of physical function. Data were analyzed by linear mixed models and responder analysis.

Results  A total of 240 participants (mean [SD] age, 70 [7] years; 61.7% female) were allocated to physical therapy (n = 96), community exercise (n = 96), or control (n = 48). All 3 arms demonstrated clinically important improvement. At 3 months, between-arm analyses for the WOMAC-PF demonstrated no differences between physical therapy and community (−2.2; 98.3% CI, −4.5 to 0.1), physical therapy and control (−2.1; 98.3% CI, −4.9 to 0.7), and community and control (0.1; 98.3% CI, −2.7 to 2.9). Performance-based tests demonstrated greater improvement in the physical therapy arm compared with both the community (0.1 z score units; 98.3% CI, 0.0-0.2) and control (0.3 z score units; 98.3% CI, 0.1-0.4) arms and the community arm compared with the control arm (0.2 z score units; 98.3% CI, 0.0-0.3). The physical therapy arm had more than 17.7% responders than the community arm and more than 19.0% responders than the control arm. There was no difference in responder rates between the community and control arms.

Conclusions and Relevance  Based on the primary outcome, participation in late-stage exercise programs after TKR offered no benefit over usual care. The benefits of physical therapy identified by the secondary outcomes and responder analysis require confirmation.

Trial Registration  ClinicalTrials.gov Identifier: NCT02237911

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: December 21, 2018.

Published: February 22, 2019. doi:10.1001/jamanetworkopen.2019.0018

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Piva SR et al. JAMA Network Open.

Corresponding Author: Sara R. Piva, PT, PhD, OCS, Department of Physical Therapy, University of Pittsburgh, 100 Technology Dr, Bridgeside Point 1, Ste 480, Pittsburgh, PA 15219 (spiva@pitt.edu).

Author Contributions: Drs Piva and Moore had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Dr Piva was the primary investigator, and Dr Moore was the biostatistician.

Concept and design: Piva, Schneider, Almeida, Sowa, Irrgang.

Acquisition, analysis, or interpretation of data: Piva, Schneider, Moore, Catelani, Gil, Klatt, DiGioia, Almeida, Khoja, Irrgang.

Drafting of the manuscript: Piva, Schneider, Moore, Gil.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Moore.

Obtained funding: Piva.

Administrative, technical, or material support: Piva, Schneider, Catelani, Gil, Klatt, DiGioia, Almeida, Khoja, Sowa.

Supervision: Piva, Gil, Klatt, Almeida.

Conflict of Interest Disclosures: Dr Piva reported receiving grants from the Patient-Centered Outcomes Research Institute (PCORI). Dr Schneider reported receiving grants from PCORI, being a member of the National Chiropractic Mutual Insurance Company speaker’s bureau, and conducting medicolegal consulting for State Farm Insurance. Dr Moore reported receiving grants from PCORI. Ms Catelani reported receiving grants from the University of Pittsburgh. Dr Klatt reported receiving grants from the University of Pittsburgh, receiving royalties from SLACK Orthopedics and from Elsevier, reported serving on the editorial board for The Journal of Arthroplasty, and serving as a reviewer for Clinical Orthopaedics and Related Research and Journal of the American Academy of Orthopaedic Surgeons. Dr Irrgang reported receiving grants from PCORI. No other disclosures were reported.

Funding/Support: This research was funded through a Patient-Centered Outcomes Research Institute award (CER-1310-06994) (Dr Piva, principal investigator).

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views in this article are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute, its board of governors, or the methodology committee.

Data Sharing Statement: See Supplement 3.

Kurtz  SM, Ong  KL, Schmier  J, Zhao  K, Mowat  F, Lau  E.  Primary and revision arthroplasty surgery caseloads in the United States from 1990 to 2004.  J Arthroplasty. 2009;24(2):195-203. doi:10.1016/j.arth.2007.11.015PubMedGoogle ScholarCrossref
Franklin  PD, Li  W, Ayers  DC.  The Chitranjan Ranawat Award: functional outcome after total knee replacement varies with patient attributes.  Clin Orthop Relat Res. 2008;466(11):2597-2604. doi:10.1007/s11999-008-0428-8PubMedGoogle ScholarCrossref
Walsh  M, Woodhouse  LJ, Thomas  SG, Finch  E.  Physical impairments and functional limitations: a comparison of individuals 1 year after total knee arthroplasty with control subjects.  Phys Ther. 1998;78(3):248-258. doi:10.1093/ptj/78.3.248PubMedGoogle ScholarCrossref
Woolhead  GM, Donovan  JL, Dieppe  PA.  Outcomes of total knee replacement: a qualitative study.  Rheumatology (Oxford). 2005;44(8):1032-1037. doi:10.1093/rheumatology/keh674PubMedGoogle ScholarCrossref
Beswick  AD, Wylde  V, Gooberman-Hill  R, Blom  A, Dieppe  P.  What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? a systematic review of prospective studies in unselected patients.  BMJ Open. 2012;2(1):e000435. doi:10.1136/bmjopen-2011-000435PubMedGoogle ScholarCrossref
Freburger  JK, Heatwole Shank  K, Knauer  SR, Montmeny  RM.  Delivery of physical therapy in the acute care setting: a population-based study.  Phys Ther. 2012;92(2):251-265. doi:10.2522/ptj.20100337PubMedGoogle ScholarCrossref
Bozic  KJ, Wagie  A, Naessens  JM, Berry  DJ, Rubash  HE.  Predictors of discharge to an inpatient extended care facility after total hip or knee arthroplasty.  J Arthroplasty. 2006;21(6)(suppl 2):151-156. doi:10.1016/j.arth.2006.04.015PubMedGoogle ScholarCrossref
American Academy of Orthopaedic Surgeons. Surgical management of osteoarthritis of the knee: evidence-based clinical practice guideline. https://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/guidelines/SMOAK%20CPG_4.22.2016.pdf. Published December 4, 2015. Accessed June 29, 2018.
Piva  SR, Moore  CG, Schneider  M, Gil  AB, Almeida  GJ, Irrgang  JJ.  A randomized trial to compare exercise treatment methods for patients after total knee replacement: protocol paper.  BMC Musculoskelet Disord. 2015;16:303. doi:10.1186/s12891-015-0761-5PubMedGoogle ScholarCrossref
Williams  MA, Haskell  WL, Ades  PA,  et al; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Nutrition, Physical Activity, and Metabolism.  Resistance exercise in individuals with and without cardiovascular disease: 2007 update: a scientific statement from the American Heart Association Council on Clinical Cardiology and Council on Nutrition, Physical Activity, and Metabolism.  Circulation. 2007;116(5):572-584. doi:10.1161/CIRCULATIONAHA.107.185214PubMedGoogle ScholarCrossref
Zhao  W, Hill  MD, Palesch  Y.  Minimal sufficient balance: a new strategy to balance baseline covariates and preserve randomness of treatment allocation.  Stat Methods Med Res. 2015;24(6):989-1002. doi:10.1177/0962280212436447PubMedGoogle ScholarCrossref
Zhao  W.  Mass weighted urn design: a new randomization algorithm for unequal allocations.  Contemp Clin Trials. 2015;43:209-216. doi:10.1016/j.cct.2015.06.008PubMedGoogle ScholarCrossref
Park  KK, Chang  CB, Kang  YG, Seong  SC, Kim  TK.  Correlation of maximum flexion with clinical outcome after total knee replacement in Asian patients.  J Bone Joint Surg Br. 2007;89(5):604-608. doi:10.1302/0301-620X.89B5.18117PubMedGoogle ScholarCrossref
Lim  JB, Chi  CH, Lo  LE,  et al.  Gender difference in outcome after total knee replacement.  J Orthop Surg (Hong Kong). 2015;23(2):194-197. doi:10.1177/230949901502300216PubMedGoogle ScholarCrossref
Bellamy  N, Buchanan  WW, Goldsmith  CH, Campbell  J, Stitt  LW.  Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee.  J Rheumatol. 1988;15(12):1833-1840.PubMedGoogle Scholar
Dobson  F, Hinman  RS, Roos  EM,  et al.  OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis.  Osteoarthritis Cartilage. 2013;21(8):1042-1052. doi:10.1016/j.joca.2013.05.002PubMedGoogle ScholarCrossref
Stratford  PW, Kennedy  DM.  Performance measures were necessary to obtain a complete picture of osteoarthritic patients.  J Clin Epidemiol. 2006;59(2):160-167. doi:10.1016/j.jclinepi.2005.07.012PubMedGoogle ScholarCrossref
Terwee  CB, van der Slikke  RMA, van Lummel  RC, Benink  RJ, Meijers  WGH, de Vet  HCW.  Self-reported physical functioning was more influenced by pain than performance-based physical functioning in knee-osteoarthritis patients.  J Clin Epidemiol. 2006;59(7):724-731. doi:10.1016/j.jclinepi.2005.11.019PubMedGoogle ScholarCrossref
Stratford  PW, Kennedy  DM, Woodhouse  LJ.  Performance measures provide assessments of pain and function in people with advanced osteoarthritis of the hip or knee.  Phys Ther. 2006;86(11):1489-1496. doi:10.2522/ptj.20060002PubMedGoogle ScholarCrossref
Almeida  GJ, Schroeder  CA, Gil  AB, Fitzgerald  GK, Piva  SR.  Interrater reliability and validity of the stair ascend/descend test in subjects with total knee arthroplasty.  Arch Phys Med Rehabil. 2010;91(6):932-938. doi:10.1016/j.apmr.2010.02.003PubMedGoogle ScholarCrossref
Hardy  SE, Perera  S, Roumani  YF, Chandler  JM, Studenski  SA.  Improvement in usual gait speed predicts better survival in older adults.  J Am Geriatr Soc. 2007;55(11):1727-1734. doi:10.1111/j.1532-5415.2007.01413.xPubMedGoogle ScholarCrossref
Simonsick  EM, Newman  AB, Nevitt  MC,  et al; Health ABC Study Group.  Measuring higher level physical function in well-functioning older adults: expanding familiar approaches in the Health ABC study.  J Gerontol A Biol Sci Med Sci. 2001;56(10):M644-M649. doi:10.1093/gerona/56.10.M644PubMedGoogle ScholarCrossref
Brito  LB, Ricardo  DR, Araújo  DS, Ramos  PS, Myers  J, Araújo  CG.  Ability to sit and rise from the floor as a predictor of all-cause mortality.  Eur J Prev Cardiol. 2014;21(7):892-898. doi:10.1177/2047487312471759PubMedGoogle ScholarCrossref
Cesari  M, Kritchevsky  SB, Newman  AB,  et al; Health, Aging and Body Composition Study.  Added value of physical performance measures in predicting adverse health–related events: results from the Health, Aging and Body Composition Study.  J Am Geriatr Soc. 2009;57(2):251-259. doi:10.1111/j.1532-5415.2008.02126.xPubMedGoogle ScholarCrossref
Bobko  P, Roth  PL, Buster  MA.  The usefulness of unit weights in creating composite scores: a literature review, application to content validity, and meta-analysis.  Organ Res Methods. 2007;10(4):689-709. doi:10.1177/1094428106294734Google ScholarCrossref
Law  M, Baptiste  S, Carswell  A, McColl  MA, Polatajko  H, Pollock  N.  Canadian Occupational Performance Measure (COPM). 5th ed. Ottawa, ON: CAOT Publications ACE; 2014.
Rose  M, Bjorner  JB, Gandek  B, Bruce  B, Fries  JF, Ware  JE  Jr.  The PROMIS Physical Function item bank was calibrated to a standardized metric and shown to improve measurement efficiency.  J Clin Epidemiol. 2014;67(5):516-526. doi:10.1016/j.jclinepi.2013.10.024PubMedGoogle ScholarCrossref
Hays  RD, Sherbourne  CD, Mazel  RM.  The RAND 36-Item Health Survey 1.0.  Health Econ. 1993;2(3):217-227. doi:10.1002/hec.4730020305PubMedGoogle ScholarCrossref
Almeida  GJ, Wasko  MC, Jeong  K, Moore  CG, Piva  SR.  Physical activity measured by the SenseWear Armband in women with rheumatoid arthritis.  Phys Ther. 2011;91(9):1367-1376. doi:10.2522/ptj.20100291PubMedGoogle ScholarCrossref
Stewart  AL, Verboncoeur  CJ, McLellan  BY,  et al.  Physical activity outcomes of CHAMPS II: a physical activity promotion program for older adults.  J Gerontol A Biol Sci Med Sci. 2001;56(8):M465-M470. doi:10.1093/gerona/56.8.M465PubMedGoogle ScholarCrossref
Andresen  EM, Malmgren  JA, Carter  WB, Patrick  DL.  Screening for depression in well older adults: evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale).  Am J Prev Med. 1994;10(2):77-84. doi:10.1016/S0749-3797(18)30622-6PubMedGoogle ScholarCrossref
Beck  AT, Epstein  N, Brown  G, Steer  RA.  An inventory for measuring clinical anxiety: psychometric properties.  J Consult Clin Psychol. 1988;56(6):893-897. doi:10.1037/0022-006X.56.6.893PubMedGoogle ScholarCrossref
French  DJ, France  CR, Vigneau  F, French  JA, Evans  RT.  Fear of movement/(re)injury in chronic pain: a psychometric assessment of the original English version of the Tampa scale for kinesiophobia (TSK).  Pain. 2007;127(1-2):42-51. doi:10.1016/j.pain.2006.07.016PubMedGoogle ScholarCrossref
Lorig  K, Chastain  RL, Ung  E, Shoor  S, Holman  HR.  Development and evaluation of a scale to measure perceived self-efficacy in people with arthritis.  Arthritis Rheum. 1989;32(1):37-44. doi:10.1002/anr.1780320107PubMedGoogle ScholarCrossref
Piva  SR, Gil  AB, Almeida  GJ, DiGioia  AM  III, Levison  TJ, Fitzgerald  GK.  A balance exercise program appears to improve function for patients with total knee arthroplasty: a randomized clinical trial.  Phys Ther. 2010;90(6):880-894. doi:10.2522/ptj.20090150PubMedGoogle ScholarCrossref
Twisk  J, de Boer  M, de Vente  W, Heymans  M.  Multiple imputation of missing values was not necessary before performing a longitudinal mixed-model analysis.  J Clin Epidemiol. 2013;66(9):1022-1028. doi:10.1016/j.jclinepi.2013.03.017PubMedGoogle ScholarCrossref
Peters  SA, Bots  ML, den Ruijter  HM,  et al; METEOR Study Group.  Multiple imputation of missing repeated outcome measurements did not add to linear mixed-effects models.  J Clin Epidemiol. 2012;65(6):686-695. doi:10.1016/j.jclinepi.2011.11.012PubMedGoogle ScholarCrossref
Fitzmaurice  GMLN, Ware  JH.  Applied Longitudinal Analysis. 2nd ed. Hoboken, NJ: John Wiley & Sons Inc; 2011. doi:10.1002/9781119513469
Uryniak  T, Chan  ISF, Fedorov  VV,  et al.  Responder analyses: a PhRMA position paper.  Stat Biopharm Res. 2011;3(3):476-487. doi:10.1198/sbr.2011.10070Google ScholarCrossref
Kamper  SJ, Maher  CG, Mackay  G.  Global rating of change scales: a review of strengths and weaknesses and considerations for design.  J Man Manip Ther. 2009;17(3):163-170. doi:10.1179/jmt.2009.17.3.163PubMedGoogle ScholarCrossref
Tubach  F, Ravaud  P, Martin-Mola  E,  et al.  Minimum clinically important improvement and patient acceptable symptom state in pain and function in rheumatoid arthritis, ankylosing spondylitis, chronic back pain, hand osteoarthritis, and hip and knee osteoarthritis: results from a prospective multinational study.  Arthritis Care Res (Hoboken). 2012;64(11):1699-1707. doi:10.1002/acr.21747PubMedGoogle ScholarCrossref
Pham  T, van der Heijde  D, Altman  RD,  et al.  OMERACT-OARSI initiative: Osteoarthritis Research Society International set of responder criteria for osteoarthritis clinical trials revisited.  Osteoarthritis Cartilage. 2004;12(5):389-399. doi:10.1016/j.joca.2004.02.001PubMedGoogle ScholarCrossref
Rothwell  PM.  Treating individuals, 2: subgroup analysis in randomised controlled trials: importance, indications, and interpretation.  Lancet. 2005;365(9454):176-186. doi:10.1016/S0140-6736(05)17709-5PubMedGoogle ScholarCrossref
Hudon  C, Fortin  M, Vanasse  A.  Cumulative Illness Rating Scale was a reliable and valid index in a family practice context.  J Clin Epidemiol. 2005;58(6):603-608. doi:10.1016/j.jclinepi.2004.10.017PubMedGoogle ScholarCrossref
Parent  E, Moffet  H.  Comparative responsiveness of locomotor tests and questionnaires used to follow early recovery after total knee arthroplasty.  Arch Phys Med Rehabil. 2002;83(1):70-80. doi:10.1053/apmr.2002.27337PubMedGoogle ScholarCrossref
Disantis  AY, Piva  SR, Irrgang  JJ.  Standardized patient reported outcomes do not capture functional deficits of patients following contemporary total knee replacement: descriptive study.  J Exerc Sports Orthop. 2018;5(1):1-10. doi:10.15226/2374-6904/5/3/00167PubMedGoogle Scholar
Perera  S, Mody  SH, Woodman  RC, Studenski  SA.  Meaningful change and responsiveness in common physical performance measures in older adults.  J Am Geriatr Soc. 2006;54(5):743-749. doi:10.1111/j.1532-5415.2006.00701.xPubMedGoogle ScholarCrossref
Bennell  K, Dobson  F, Hinman  R.  Measures of physical performance assessments: Self-Paced Walk Test (SPWT), Stair Climb Test (SCT), Six-Minute Walk Test (6MWT), Chair Stand Test (CST), Timed Up & Go (TUG), Sock Test, Lift and Carry Test (LCT), and Car Task.  Arthritis Care Res (Hoboken). 2011;63(suppl 11):S350-S370. doi:10.1002/acr.20538PubMedGoogle ScholarCrossref
Meretta  BM, Whitney  SL, Marchetti  GF, Sparto  PJ, Muirhead  RJ.  The five times sit to stand test: responsiveness to change and concurrent validity in adults undergoing vestibular rehabilitation.  J Vestib Res. 2006;16(4-5):233-243.PubMedGoogle Scholar
Tuntland  H, Aaslund  MK, Langeland  E, Espehaug  B, Kjeken  I.  Psychometric properties of the Canadian Occupational Performance Measure in home-dwelling older adults.  J Multidiscip Healthc. 2016;9:411-423. doi:10.2147/JMDH.S113727PubMedGoogle ScholarCrossref
Ward  MM, Guthrie  LC, Alba  MI.  Clinically important changes in Short Form 36 health survey scales for use in rheumatoid arthritis clinical trials: the impact of low responsiveness.  Arthritis Care Res (Hoboken). 2014;66(12):1783-1789. doi:10.1002/acr.22392PubMedGoogle ScholarCrossref
Bjorner  JB, Lyng Wolden  M, Gundgaard  J, Miller  KA.  Benchmarks for interpretation of score differences on the SF-36 health survey for patients with diabetes.  Value Health. 2013;16(6):993-1000. doi:10.1016/j.jval.2013.06.022PubMedGoogle ScholarCrossref
Larsen  K, Hansen  TB, Søballe  K, Kehlet  H.  Patient-reported outcome after fast-track knee arthroplasty.  Knee Surg Sports Traumatol Arthrosc. 2012;20(6):1128-1135. doi:10.1007/s00167-012-1919-4PubMedGoogle ScholarCrossref
Kennedy  DM, Stratford  PW, Riddle  DL, Hanna  SE, Gollish  JD.  Assessing recovery and establishing prognosis following total knee arthroplasty.  Phys Ther. 2008;88(1):22-32. doi:10.2522/ptj.20070051PubMedGoogle ScholarCrossref
McCambridge  J, Witton  J, Elbourne  DR.  Systematic review of the Hawthorne effect: new concepts are needed to study research participation effects.  J Clin Epidemiol. 2014;67(3):267-277. doi:10.1016/j.jclinepi.2013.08.015PubMedGoogle ScholarCrossref
Mujika  I, Padilla  S.  Muscular characteristics of detraining in humans.  Med Sci Sports Exerc. 2001;33(8):1297-1303. doi:10.1097/00005768-200108000-00009PubMedGoogle ScholarCrossref
Madsen  K, Pedersen  PK, Djurhuus  MS, Klitgaard  NA.  Effects of detraining on endurance capacity and metabolic changes during prolonged exhaustive exercise.  J Appl Physiol (1985). 1993;75(4):1444-1451. doi:10.1152/jappl.1993.75.4.1444PubMedGoogle ScholarCrossref
Coyle  EF, Martin  WH  III, Sinacore  DR, Joyner  MJ, Hagberg  JM, Holloszy  JO.  Time course of loss of adaptations after stopping prolonged intense endurance training.  J Appl Physiol Respir Environ Exerc Physiol. 1984;57(6):1857-1864.PubMedGoogle Scholar
Patient-Centered Outcomes Research Institute. What is PCORI’s official policy on cost and cost-effectiveness analysis? https://help.pcori.org/hc/en-us/articles/213716587-What-is-PCORI-s-official-policy-on-cost-and-cost-effectiveness-analysis-. Published 2014. Accessed April 22, 2018.
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience

Lookup An Activity


My Saved Searches

You currently have no searches saved.


My Saved Courses

You currently have no courses saved.