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Window P, Raymer M, McPhail SM, Vicenzino B, Hislop A, Vallini A, Elwell B, O'Gorman H, Phillips B, Wake A, Cush A, McCaskill S, Garsden L, Dillon M, McLennan A, O'Leary S. Prospective validity of a clinical prediction rule for response to non-surgical multidisciplinary management of knee osteoarthritis in tertiary care: a multisite prospective longitudinal study. BMJ Open 2024; 14:e078531. [PMID: 38521532 PMCID: PMC10961565 DOI: 10.1136/bmjopen-2023-078531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 03/11/2024] [Indexed: 03/25/2024] Open
Abstract
OBJECTIVES We tested a previously developed clinical prediction tool-a nomogram consisting of four patient measures (lower patient-expected benefit, lower patient-reported knee function, greater knee varus angle and severe medial knee radiological degeneration) that were related to poor response to non-surgical management of knee osteoarthritis. This study sought to prospectively evaluate the predictive validity of this nomogram to identify patients most likely to respond poorly to non-surgical management of knee osteoarthritis. DESIGN Multisite prospective longitudinal study. SETTING Advanced practice physiotherapist-led multidisciplinary service across six tertiary hospitals. PARTICIPANTS Participants with knee osteoarthritis deemed appropriate for trial of non-surgical management following an initial assessment from an advanced practice physiotherapist were eligible for inclusion. INTERVENTIONS Baseline clinical nomogram scores were collected before a trial of individualised non-surgical management commenced. PRIMARY OUTCOME MEASURE Clinical outcome (Global Rating of Change) was collected 6 months following commencement of non-surgical management and dichotomised to responder (a little better to a very great deal better) or poor responder (almost the same to a very great deal worse). Clinical nomogram accuracy was evaluated from receiver operating characteristics curve analysis and area under the curve, and sensitivity/specificity and positive/negative likelihood ratios were calculated. RESULTS A total of 242 participants enrolled. Follow-up scores were obtained from 210 participants (87% response rate). The clinical nomogram demonstrated an area under the curve of 0.70 (p<0.001), with greatest combined sensitivity 0.65 and specificity 0.64. The positive likelihood ratio was 1.81 (95% CI 1.32 to 2.36) and negative likelihood ratio 0.55 (95% CI 0.41 to 0.75). CONCLUSIONS The knee osteoarthritis clinical nomogram prediction tool may have capacity to identify patients at risk of poor response to non-surgical management. Further work is required to determine the implications for service delivery, feasibility and impact of implementing the nomogram in clinical practice.
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Affiliation(s)
- Peter Window
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- STARS Education and Research Alliance, Surgical Treatment and Rehabilitation Service, Metro North Health and University of Queensland, Brisbane, Queensland, Australia
| | - Maree Raymer
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation (AusHSI), Centre for Healthcare Transformation and School of Public Health & Social Work, Faculty of Health, QUT, Brisbane, Queensland, Australia
| | - Bill Vicenzino
- The University of Queensland School of Health and Rehabilitation Sciences, Saint Lucia, Queensland, Australia
| | - Andrew Hislop
- The University of Queensland School of Health and Rehabilitation Sciences, Saint Lucia, Queensland, Australia
- Physiotherapy Department, The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Alex Vallini
- Physiotherapy Department, The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Bula Elwell
- Physiotherapy Department, Ipswich Hospital, Ipswich, Queensland, Australia
| | - Helen O'Gorman
- Physiotherapy Department, Mater Hospital, South Brisbane, Queensland, Australia
| | - Ben Phillips
- Physiotherapy Department, Townsville Hospital, Townsville, Queensland, Australia
| | - Anneke Wake
- Physiotherapy Department, Townsville Hospital, Townsville, Queensland, Australia
| | - Adrian Cush
- Physiotherapy Department, Queen Elizabeth II Hospital, Coopers Plains, Queensland, Australia
| | - Stuart McCaskill
- Physiotherapy Department, Queen Elizabeth II Hospital, Coopers Plains, Queensland, Australia
| | - Linda Garsden
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Miriam Dillon
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Andrew McLennan
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Shaun O'Leary
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- The University of Queensland School of Health and Rehabilitation Sciences, Saint Lucia, Queensland, Australia
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Brandon SCE, Brown MJ, Clouthier AL, Campbell A, Richards JD, Deluzio KJ. Contributions of muscles and external forces to medial knee load reduction due to osteoarthritis braces. Knee 2019; 26:564-577. [PMID: 31097362 DOI: 10.1016/j.knee.2019.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 03/25/2019] [Accepted: 04/06/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Braces for medial knee osteoarthritis can reduce medial joint loads through a combination of three mechanisms: application of an external brace abduction moment, alteration of gait dynamics, and reduced activation of antagonistic muscles. Although the effect of knee bracing has been reported independently for each of these parameters, no previous study has quantified their relative contributions to reducing medial knee loads. METHODS In this study, we used a detailed musculoskeletal model to investigate immediate changes in medial and lateral loads caused by two different knee braces: OA Assist and OA Adjuster 3 (DJO Global). Seventeen osteoarthritis subjects and eighteen healthy controls performed overground gait trials in unbraced and braced conditions. RESULTS Across all subjects, bracing reduced medial loads by 0.1 to 0.3 times bodyweight (BW), or roughly 10%, and increased lateral loads by 0.03 to 0.2 BW. Changes in gait kinematics due to bracing were subtle, and had little effect on medial and lateral joint loads. The knee adduction moment was unaltered unless the brace moment was included in its computation. Only one muscle, biceps femoris, showed a significant change in EMG with bracing, but this did not contribute to altered peak medial contact loads. CONCLUSIONS Knee braces reduced medial tibiofemoral loads primarily by applying a direct, and substantial, abduction moment to each subject's knee. To further enhance brace effectiveness, future brace designs should seek to enhance the magnitude of this unloader moment, and possibly exploit additional kinematic or neuromuscular gait modifications.
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Affiliation(s)
- Scott C E Brandon
- Department of Mechanical and Materials Engineering, Queen's University, McLaughlin Hall, Kingston, Ontario K7L 3N6, Canada; Human Mobility Research Centre, Kingston General Hospital, Angada 2, Kingston, Ontario K7L 2V7, Canada; School of Engineering, University of Guelph, Guelph, Ontario N1G 2W1, Canada.
| | - Marcus J Brown
- Department of Mechanical and Materials Engineering, Queen's University, McLaughlin Hall, Kingston, Ontario K7L 3N6, Canada; Human Mobility Research Centre, Kingston General Hospital, Angada 2, Kingston, Ontario K7L 2V7, Canada
| | - Allison L Clouthier
- Department of Mechanical and Materials Engineering, Queen's University, McLaughlin Hall, Kingston, Ontario K7L 3N6, Canada; Human Mobility Research Centre, Kingston General Hospital, Angada 2, Kingston, Ontario K7L 2V7, Canada
| | - Aaron Campbell
- Human Mobility Research Centre, Kingston General Hospital, Angada 2, Kingston, Ontario K7L 2V7, Canada; Department of Surgery, Kingston General Hospital, Kingston, Ontario K7L 2V7, Canada
| | - Jim D Richards
- Allied Health Research Unit, University of Central Lancashire, Preston PR1 2HE, UK
| | - Kevin J Deluzio
- Department of Mechanical and Materials Engineering, Queen's University, McLaughlin Hall, Kingston, Ontario K7L 3N6, Canada; Human Mobility Research Centre, Kingston General Hospital, Angada 2, Kingston, Ontario K7L 2V7, Canada
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Cheung RTH, Ho KKW, Au IPH, An WW, Zhang JHW, Chan ZYS, Deluzio K, Rainbow MJ. Immediate and short-term effects of gait retraining on the knee joint moments and symptoms in patients with early tibiofemoral joint osteoarthritis: a randomized controlled trial. Osteoarthritis Cartilage 2018; 26:1479-1486. [PMID: 30081075 DOI: 10.1016/j.joca.2018.07.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 07/02/2018] [Accepted: 07/26/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of a knee adduction moment (KAM) gait retraining in patients with early knee osteoarthritis up to 6 months post-training. METHOD We conducted a single blinded randomized controlled trial on a total of 23 patients with early knee osteoarthritis who were randomly allocated to the gait retraining group and walking exercise group. Twenty of them completed the corresponding training and the 6-month evaluation. We measured KAM, knee flexion moment (KFM) and western ontario and McMaster universities osteoarthritis index (WOMAC) osteoarthritis index before, immediate after, and 6 months after training. A repeated measures analysis of covariance (ANCOVA) was used to compare KAM, KFM and WOMAC osteoarthritis index scores across the three time points i.e., pre-training, post-training, and 6-month follow-up with gender, knee osteoarthritis severity, and pre-training KAM, KFM and WOMAC scores set as covariates. Post-hoc analyses were conducted when indicated. RESULTS Significant time × group interactions were found for both KAM and WOMAC osteoarthritis index scores (P < 0.002). No interaction was found for KFM (P = 0.123). KAM after gait retraining was significantly lower than the pre-training value (P < 0.001) and such effect was maintained at 6-month follow-up (P = 0.01). There was no significant difference in the KAM across time in the walking exercise group (P > 0.208). WOMAC osteoarthritis index score after training and score at the 6-month follow-up were significantly improved in the gait retraining group (P = 0.001), while the WOMAC osteoarthritis index score remained similar. CONCLUSIONS Gait retraining is an effective intervention to reduce KAM during walking and to improve the symptoms of patients with early knee osteoarthritis in short term.
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Affiliation(s)
- R T H Cheung
- Gait & Motion Analysis Laboratory, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong.
| | - K K W Ho
- Department of Orthopedics & Traumatology, The Chinese University of Hong Kong, Hong Kong
| | - I P H Au
- Gait & Motion Analysis Laboratory, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong
| | - W W An
- Gait & Motion Analysis Laboratory, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong
| | - J H W Zhang
- Gait & Motion Analysis Laboratory, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong
| | - Z Y S Chan
- Gait & Motion Analysis Laboratory, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong
| | - K Deluzio
- Department of Mechanical & Materials Engineering, Queen's University, Canada
| | - M J Rainbow
- Department of Mechanical & Materials Engineering, Queen's University, Canada
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