Effects of a novel foot-ankle orthosis in the non-operative treatment of unicompartmental knee osteoarthritis

Comparing the effects of lower limb orthoses on knee pain, function, quality of life, and knee joint alignment in people with medial knee osteoarthritis

Introduction

The purpose of this study was to compare the impact of three types of orthoses (knee orthosis, ankle foot orthosis (AFO), and foot orthosis) on knee alignment, pain, function, and quality of life in individuals with medial knee osteoarthritis (MKOA).

Method

Thirty patients took part in this study and were randomly assigned to three groups (n = 10 in each group) based on the type of intervention. Knee function was assessed using the knee injury and osteoarthritis outcome score (KOOS) questionnaire, and knee alignment was evaluated by measuring angles using the images of bony prominence (AMI) method.

Results

After using knee orthosis and AFO, all subscales of KOOS showed significant improvement (p < .05). However, there was no significant difference in the results after using foot orthosis (p > .05).

Conclusion

The findings indicate that knee orthosis or AFO for 6 weeks can improve clinical outcomes for individuals with MKOA. This suggests that clinicians can consider using knee orthosis and AFO among the available treatment options to improve clinical outcomes.

A comparison of the biomechanical and clinical effects of a biaxial ankle-foot orthosis and lateral wedge insole in individuals with medial knee osteoarthritis

PURPOSE

This study aimed to compare a biaxial ankle-foot orthosis (AFO) with a lateral wedge insole in terms of the biomechanical and clinical outcomes in individuals with knee osteoarthritis.

MATERIALS AND METHODS

A cross-over randomized design was used where 31 individuals (25 females and six males, mean age of 52.19 ± 4.12 years) with knee osteoarthritis wore each intervention for two weeks with two weeks washout period. Three-dimensional kinematic and kinetic data and clinical outcomes were collected to evaluate the effects of each intervention on knee adduction moment (KAM), pain, stiffness, and function.

RESULTS

Both orthoses significantly improved pain by 17 and 22%, function by 11 and 14%, the first peak KAM by 15.7 and 19.2%, the second peak KAM by 10.4 and 16.7%, and KAM impulse by 14.8 and 22.2%, respectively. However, the biaxial AFO significantly reduced the KAM and improved function compared to the lateral wedge insole (p < 0.01).

CONCLUSIONS

The results of this study have shown that both orthoses have a potential role in the conservative management of medial knee osteoarthritis. The biaxial AFO proved statistically better at improving function and KAM; though these differences do not seem to be clinically significant.IMPLICATION FOR REHABILITATIONOrthotic interventions have been reported to be effective in the management of medial knee osteoarthritis.Lateral wedge insole and biaxial ankle-foot orthosis (AFO) are effective in the improvement of pain, function, and knee adduction moment (KAM) in people with medial knee osteoarthritis.The biaxial AFO, compared with lateral wedge insole, contributes to statistically more improvement of function and KAM. However, these differences do not seem to be clinically significant.

Knee adduction moment decomposition: Toward better clinical decision-making

Knee adduction moment (KAM) is correlated with the progression of medial knee osteoarthritis (OA). Although a generic gait modification can reduce the KAM in some patients, it may have a reverse effect on other patients. We proposed the "decomposed ground reaction vector" (dGRV) model to 1) distinguish between the components of the KAM and their contribution to the first and second peaks and KAM impulse and 2) examine how medial knee OA, gait speed, and a brace influence these components. Using inverse dynamics as the reference, we calculated the KAM of 12 healthy participants and 12 patients with varus deformity and medial knee OA walking with/without a brace and at three speeds. The dGRV model divided the KAM into four components defined by the ground reaction force (GRF) and associated lever arms described with biomechanical factors related to gait modifications. The dGRV model predicted the KAM profile with a coefficient of multiple correlations of 0.98 ± 0.01. The main cause of increased KAM in the medial knee OA group, the second component (generated by the vertical GRF and mediolateral distance between the knee and ankle joint centers), was decreased by the brace in the healthy group. The first peak increased, and KAM impulse decreased with increasing velocity in both groups, while no significant change was observed in the second peak. The four-component dGRV model successfully estimated the KAM in all tested conditions. It explains why similar gait modifications produce different KAM reductions in subjects. Thus, more personalized gait rehabilitation, targeting elevated components, can be considered.

Osteoarthritis of the Knee in Middle-age Athletes: Many Measures are Practiced, but Lack Sound Scientific Evidence

Osteoarthritis of the knee generally affects individuals from the fifth decade, the typical age of middle-age athletes. In the early stages, management is conservative and multidisciplinary. It is advisable to avoid sports with high risk of trauma, but it is important that patients continue to be physically active. Conservative management offers several options; however, it is unclear which ones are really useful. This narrative review briefly reports the conservative options for which there is no evidence of effectiveness, or there is only evidence of short-term effectiveness.

A comparison between laterally wedged insoles and ankle-foot orthoses for the treatment of medial osteoarthritis of the knee: A randomized cross-over trial

Objective:

To compare biomechanical and clinical outcome of laterally wedged insoles (LWI) and an ankle-foot orthosis (AFO) in patients with medial knee osteoarthritis.

Design:

Single-centre, block-randomized, cross-over controlled trial.

Setting:

Outpatient clinic.

Subjects:

About 39 patients with symptomatic medial knee osteoarthritis.

Interventions:

Patients started with either LWI or AFO, determined randomly, and six weeks later changed to the alternative.

Main measures:

Change in the 1st maximum of external knee adduction moment (eKAM) was assessed with gait analysis. Additional outcomes were other kinetic and kinematic changes and the patient-reported outcomes EQ-5D-5L, Oxford Knee Score (OKS), American Knee Society Clinical Rating System (AKSS), Hannover Functional Ability Questionnaire – Osteoarthritis and knee pain.

Results:

Mean age (SD) of the study population was 58 (8) years, mean BMI 30 (5). Both aids significantly improved OKS (LWI P = 0.003, AFO P = 0.001), AKSS Knee Score (LWI P = 0.01, AFO P = 0.004) and EQ-5D-5L Index (LWI P = 0.001, AFO P = 0.002). AFO reduced the 1st maximum of eKAM by 18% (P < 0.001). The LWI reduced both maxima by 6% (P = 0.02, P = 0.03). Both AFO and LWI reduced the knee adduction angular impulse (KAAI) by 11% (P < 0.001) and 5% (P = 0.05) respectively. The eKAM (1st maximum) and KAAI reduction was significantly larger with AFO than with LWI (P = 0.001, P = 0.004).

Conclusions:

AFO reduces medial knee load more than LWI. Nevertheless, no clinical superiority of either of the two aids could be shown.

[Insoles, knee braces and ankle-foot orthoses in the treatment of medial gonarthrosis : A literature review]

BACKGROUND

Osteoarthritis is the most common joint disease worldwide and mostly affects the knee joint (gonarthrosis). In treatment algorithms, technical aids in the form of laterally wedged insoles, valgizing knee braces and ankle-foot orthoses have an importance in the treatment of medial unicompartmental knee joint disease. However, national and international guidelines differ in their recommendations.

INSOLES

Taking into account a great amount of scientific work, the measurable effect of laterally wedged insoles appears to be low, so that a justifying indication only exists at low gonarthrosis levels.

KNEE BRACES

Valgizing knee braces have shown stronger biomechanical and clinical effects, but with a slightly increased complication potential and low compliance. Low to medium-grade arthrosis can be treated.

ANKLE-FOOT ORTHOSES

Ankle-foot arthroses have not yet been conclusively examined. Initial work indicates biomechanical and clinical efficacy. The overall effects and indications appear comparable to knee braces, probably with less complication potential.

Non-operative treatment of unicompartmental osteoarthritis of the knee: a prospective randomized trial with two different braces-ankle-foot orthosis versus knee unloader brace

BACKGROUND

The use of an unloader brace is a non-surgical treatment option for patients with medial osteoarthritis (OA). However, many patients do not adhere to brace treatment, because of skin irritation due to the pads at the level of the joint space and bad fit. A new concept to unload the medial compartment of the knee is a foot ankle brace with a lever arm pressing the thigh in valgus. The aim of this prospective randomized trial was to examine the outcomes of patients with medial OA after treatment with a conventional knee unloader brace (Unloader One^®) and the new foot ankle orthosis (Agilium FreeStep^®).

METHODS

For this multicenter trial, 160 patients (> 35 years) with medial OA were randomly allocated to treatment with a conventional knee unloader brace (Unloader One^®) or treatment with the new knee OA ankle brace (Agilium FreeStep^®). The primary outcome measure was pain (numerical analog scale) at baseline (T0), 8 weeks (T1), and 6 months (T2). Secondary outcome measures were knee function (Knee Injury and Osteoarthritis Outcome Score, KOOS), side effects, additional interventions, and compliance.

RESULTS

In both groups, walking pain improved between T0 and T1 and also between T0 and T2 without a significant group difference. For pain at sports, both groups showed a significant improvement between T0 and T2 without a significant group difference. The KOOS subscales symptoms, pain, activity, sport, and quality of life increased significantly in both treatment groups without any significant group differences at T 0, T1, and T2. There was also no significant group difference in additional interventions and weekly or daily brace use. In the Agilium FreeStep^® group (23.5%), significantly less patients reported bruises in contrast to the Unloader One^® group (66.7%).

DISCUSSION

The results of this clinical trial show that the foot ankle brace is as effective as a conventional knee unloader brace for the treatment of medial knee OA with regard to clinical outcome. The rate of side effects such as bruises was significantly lower in the Agilium FreeStep^® group.

TRIAL REGISTRATION

DRKS00009215, 13.8.2015.

Acute effects of different orthotic interventions on knee loading parameters in knee osteoarthritis patients with varus malalignment

BACKGROUND

Knee osteoarthritis (KOA) is the most common form of arthritis with an estimated lifetime prevalence of 45%. The use of orthotic devices is a generally accepted conservative therapy in KOA. A new conservative treatment is an ankle-foot orthosis (AFO); however, studies on the biomechanical effects are limited. The aim of this study was to examine the acute effects of different orthotic devices (AFO, knee brace and wedged shoes) on (un)loading parameters in subjects with KOA.

METHODS

Fifty-two medial KOA patients (mean age 59 (standard deviation (SD) 10) years and mean body mass index 27.5 (SD 4.9) kg/m²) were recruited. Three-dimensional gait analysis was undertaken with different interventions in a randomized order: control (own shoes), new AFO, conventional unloader brace and laterally wedged shoes (six degrees).

RESULTS

Significant decreases of 27% and nine percent in first peak knee adduction moment (KAM) were observed for the AFO and wedged shoes, respectively, in comparison with the control. Significant decreases of 21%, seven percent and 18% in the KAM impulse were observed for the AFO, brace and wedged shoes, respectively, compared to the control. The knee flexion moment (KFM) increased compared to the control for all conditions, but only significantly while using the AFO, showing an increase of 26% as compared to the control.

CONCLUSIONS

The AFO and wedged shoes were more effective in unloading the medial compartment of the knee compared to the unloader brace. However, the effect of an increased KFM on KOA remains unclear and requires further investigation.

The role of orthoses in knee osteoarthritis

OBJECTIVES

Taking into account that the role of orthoses in patients with knee osteoarthritis (OA) is unclear and controversial, the purpose of this article is to review recent literature with the aim of answering the following question: What is the current role of orthoses in the treatment of knee OA?

METHODS

A Cochrane Library and PubMed (MEDLINE) search related to the role of orthoses in knee OA was performed.

RESULTS

Unloader braces decrease the adduction moment of the knee. In patients with varus medial compartment knee OA bracing is beneficial for pain, stiffness, function and quality of life (low grade of evidence). Lateral wedge arch support insoles seem not to decrease knee load. Lateral wedge insoles appear inefficacious at attenuating structural changes in patients with medial knee OA.

CONCLUSIONS

The ideal option for an orthosis in patients with knee OA keeps on indeterminate, and long-run inferences are lacking.

Effectiveness of Foot Biomechanical Orthoses to Relieve Patients' Knee Pain: Changes in Neural Strategy After 9 Weeks of Treatment

Knee pain is one of the most common lower leg complaints. It is often treated with plantar orthoses to provide cushioning and correct locomotion, imbalances of the foot, and postural deficits. However, the published scientific data are poor concerning the mechanisms involved in pain reduction after wearing foot orthoses, and, to the best of our knowledge, no trial has investigated the mid-term effectiveness. The aim of the present study was to evaluate the effectiveness of foot orthoses according to sound biomechanical principles in the treatment of knee pain. Attention was mainly focused on changes in the central control strategies. Fifteen subjects were included in the protocol. The patients with knee pain were compared with healthy participants (control group) exhibiting no knee pain. In the patients with knee pain, pain perception, dynamic analysis of the gait, stabilometry, the soleus Hoffmann reflex at rest and during voluntary contraction, and V-wave were measured before and 3, 6, and 9 weeks after wearing orthoses. In the control group (n = 5), the same parameters were recorded at 0, 3, 6, and 9 weeks, but the subjects had not worn orthoses. In the patient group (n = 10), the results indicated that pain had significantly decreased from the third week onward, although the parameters of gait and stabilometry remained unchanged. From the sixth week, the soleus Hoffmann reflex during voluntary contraction wave was significantly reduced, suggesting an increase in motoneuronal presynaptic inhibition by non-nociceptive afferents. The V-wave amplitude increased throughout the 9 weeks of the experiment, suggesting a progressive increase in corticospinal and/or extrapyramidal descending pathway inputs, probably due to pain reduction. In the control group, no change was observed throughout the experimental sessions. Our data indicated that foot orthoses relieved patients' knee pain and reduced the descending motor inhibition. Changes in spinal modulation could contribute to a better quality of life. However, this treatment failed to change the altered gait, despite changes in spinal and supraspinal modulation.

Acute and mid-term (six-week) effects of an ankle-foot-orthosis on biomechanical parameters, clinical outcomes and physical activity in knee osteoarthritis patients with varus malalignment

BACKGROUND

Knee osteoarthritis (KOA) is a painful disease commonly caused by high loads on the articular cartilage. Orthotic interventions aim to reduce mechanical loading, thereby alleviating pain. Traditional orthotics appear effective, but high drop-out rates have been reported over prolonged periods.

RESEARCH QUESTION

The aim of this study was to examine the effect of a novel ankle-foot orthosis (AFO) on gait parameters, physical function and activity of KOA patients.

METHODS

29 clinically diagnosed KOA patients with varus malalignment wore an AFO for 6 weeks. Prior to and after the intervention period, 3D gait analysis, physical function tests and the KOOS questionnaire were administered. Physical activity was objectively assessed with accelerometers.

RESULTS

The AFO immediately reduced the first peak of the knee adduction moment (KAM) and the KAM impulse by 41% and 19%. The knee flexion moment (KFM) was increased by 48%. After six weeks, the first KAM peak and KAM impulse were decreased by 27% and 19% while using the AFO. The KFM was increased by 71%. Furthermore, patients completed the functional tests faster (1.4-2.6%). The KOOS scores decreased significantly. No significant differences were found in physical activity parameters.

SIGNIFICANCE

The six-week AFO application significantly reduced the KAM. The patients' physical function appeared improved; yet these improvements were only minor and therefore arguably clinically irrelevant. The KFM appeared to be negatively affected after six weeks, as were the scores on the KOOS subscales. In summary, even though the AFO reduced the KAM and improved physical function, the clinical benefit for KOA patients with varus malalignment after the 6-week AFO application is debatable.