Strength and Functional Improvement Using Pneumatic Brace with Extension Assist for End-Stage Knee Osteoarthritis: A Prospective, Randomized trial

KNEE BRACES FOR KNEE OSTEOARTHRITIS: A SCOPING REVIEW AND NARRARIVE SYNTHESIS OF INTERVENTIONS IN RANDOMISED CONTROLLED TRIALS

OBJECTIVE

To identify and synthesise the content of knee bracing interventions in randomised controlled trials (RCTs) of knee osteoarthritis (OA).

DESIGN

In this scoping review, three electronic databases (PubMed, Web of Science, Cochrane) were searched up to 10th June 2024. Nineteen previous systematic reviews of knee bracing for knee OA and four recent international clinical practice guidelines were also hand searched. Identified studies were screened for eligibility by two independent reviewers. Information on bracing interventions was extracted from included RCT reports, informed by Template for Intervention Description and Replication (TIDieR) guidelines. Data were synthesised narratively.

RESULTS

Thirty-one RCTs testing 47 different bracing interventions were included. Braces were broadly grouped as valgus/varus, patellofemoral, sleeve, neutral hinged, or control/placebo knee braces. Brace manufacturer and models varied, as did amount of recommended brace use. Only three interventions specifically targeted brace adherence. Information on brace providers, setting, number of treatment sessions, and intervention modification over time was poorly reported. Adherence to brace use was described for 32 (68%) interventions, most commonly via self-report. Several mechanisms of action for knee braces were proposed, broadly grouped as biomechanical, neuromuscular, and psychological.

CONCLUSIONS

Many different knee brace interventions have been tested for knee OA, with several proposed mechanisms of action, a lack of focus on adherence, and a lack of full reporting. These issues may be contributing to the heterogeneous findings and inconsistent guideline recommendations about the clinical effectiveness of knee bracing for knee OA to date.

There is more to the knee joint than just the quadriceps: A systematic review with meta-analysis and evidence gap map of hamstring strength, flexibility, and morphology in individuals with gradual-onset knee disorders

BACKGROUND

Impairments in hamstring strength, flexibility, and morphology have been associated with altered knee biomechanics, pain, and function. Determining the presence of these impairments in individuals with gradual-onset knee disorders is important and may indicate targets for assessment and rehabilitation. This systematic review aimed to synthesize the literature to determine the presence of impairments in hamstring strength, flexibility, and morphology in individuals with gradual-onset knee disorders.

METHODS

Five databases (MEDLINE, Embase, CINAHL, SPORTDiscus, and Web of Science) were searched from inception to September 2022. Only studies comparing hamstring outcomes (e.g., strength, flexibility, and/or morphology) between individuals with gradual-onset knee disorders and their unaffected limbs or pain-free controls were included. Meta-analyses for each knee disorder were performed. Outcome-level certainty was assessed using the Grading of Recommendations Assessment, Development, and Evaluation, and evidence gap maps were created.

RESULTS

Seventy-nine studies across 4 different gradual-onset knee disorders (i.e., knee osteoarthritis (OA), patellofemoral pain (PFP), chondromalacia patellae, and patellar tendinopathy) were included. Individuals with knee OA presented with reduced hamstring strength compared to pain-free controls during isometric (standard mean difference (SMD) = -0.76, 95% confidence interval (95%CI) : -1.32 to -0.21) and concentric contractions (SMD = -0.97, 95%CI : -1.49 to -0.45). Individuals with PFP presented with reduced hamstring strength compared to pain-free controls during isometric (SMD = -0.48, 95%CI : -0.82 to -0.14), concentric (SMD = -1.07, 95%CI : -2.08 to -0.06), and eccentric contractions (SMD = -0.59, 95%CI : -0.97 to -0.21). No differences were observed in individuals with patellar tendinopathy. Individuals with PFP presented with reduced hamstring flexibility when compared to pain-free controls (SMD = -0.76, 95%CI : -1.15 to -0.36). Evidence gap maps identified insufficient evidence for chondromalacia patellae and hamstring morphology across all gradual-onset knee disorders.

CONCLUSION

Our findings suggest that assessing and targeting impairments in hamstring strength and flexibility during rehabilitation may be recommended for individuals with knee OA or PFP.

Preliminary Evaluation of a New Orthotic for Patellofemoral and Multicompartment Knee Osteoarthritis

Purpose

Traditional knee osteoarthritis (OA) braces are usually indicated for a minority of patients with knee OA, as they are only suitable for those with unicompartmental disease affecting the tibiofemoral joint. A new assistive brace design is intended for use in a wider range of knee OA patients with heterogeneous symptoms characteristic of patellofemoral, tibiofemoral, or multicompartmental knee OA. The purpose of this case series was to explore whether the use of this novel “tricompartment offloader” (TCO) brace was associated with clinically relevant improvements in pain and function.

Materials and Methods

A retrospective analysis of individuals with knee OA (n = 40) was conducted to assess pain, function, physical activity, and use of medication and other treatments before and after brace use. Validated outcome measures including the Visual Analog Scale (VAS) and Lower Extremity Functional Scale (LEFS) were used to assess pain and physical function (primary outcome measures). Exploratory measures were used to quantify physical activity levels and use of medication and other treatments (secondary outcome measures).

Results

Average total pain (VAS) scores decreased by 36.6 mm and physical function (LEFS) scores increased by 16.0 points following the use of the TCO brace. Overall, 70% of the participants indicated increased weekly physical activity and 60% reported a decrease in their use of at least one other treatment.

Conclusions

Results from this case series suggest that the TCO brace shows strong potential to fill a conservative treatment gap for patients with heterogeneous symptoms of knee OA that are characteristic of patellofemoral or multicompartment disease. Further investigation is warranted.

Development and Functional Testing of An Unloading Concept for Knee Osteoarthritis Patients: A Pilot Study

This paper presents a knee brace design that applies an extension moment to unload the muscles in stance phase during gait, and thereby the knee, as alternative to conventional valgus braces for knee osteoarthritis patients. The concept was tested on one healthy subject during normal gait with a prototype, which was designed to activate and deactivate in order to apply the extension moment in the stance phase only and hereby avoid any interference during the swing phase. Electromyography measurements and musculoskeletal models were used to evaluate the brace effects on muscle activation and knee compressive forces respectively. Simulations predicted an ideal reduction of up to 36%, whereas experimental tests revealed a reduction of up to 24% with the current prototype. The prototype brace also reduced the knee joint force impulse up to 9% and EMG peak signal of the vasti muscles with up to 19%. Due to these reductions on a healthy subject, this bracing approach seem promising for reducing knee loads during normal gait. However, further clinical experiments on knee osteoarthritis patients are required to evaluate the effect on both pain and disease progression.

Clinical and cost-effectiveness of bracing in symptomatic knee osteoarthritis management: protocol for a multicentre, primary care, randomised, parallel-group, superiority trial

BACKGROUND

Brace effectiveness for knee osteoarthritis (OA) remains unclear and international guidelines offer conflicting recommendations. Our trial will determine the clinical and cost-effectiveness of adding knee bracing (matched to patients' clinical and radiographic presentation and with adherence support) to a package of advice, written information and exercise instruction delivered by physiotherapists.

METHODS AND ANALYSIS

A multicentre, pragmatic, two-parallel group, single-blind, superiority, randomised controlled trial with internal pilot and nested qualitative study. 434 eligible participants with symptomatic knee OA identified from general practice, physiotherapy referrals and self-referral will be randomised 1:1 to advice, written information and exercise instruction and knee brace versus advice, written information and exercise instruction alone. The primary analysis will be intention-to-treat comparing treatment arms on the primary outcome (Knee Osteoarthritis Outcomes Score (KOOS)-5) (composite knee score) at the primary endpoint (6 months) adjusted for prespecified covariates. Secondary analysis of KOOS subscales (pain, other symptoms, activities of daily living, function in sport and recreation, knee-related quality of life), self-reported pain, instability (buckling), treatment response, physical activity, social participation, self-efficacy and treatment acceptability will occur at 3, 6, and 12 months postrandomisation. Analysis of covariance and logistic regression will model continuous and dichotomous outcomes, respectively. Treatment effect estimates will be presented as mean differences or ORs with 95% CIs. Economic evaluation will estimate cost-effectiveness. Semistructured interviews to explore acceptability and experiences of trial interventions will be conducted with participants and physiotherapists delivering interventions.

ETHICS AND DISSEMINATION

North West Preston Research Ethics Committee, the Health Research Authority and Health and Care Research in Wales approved the study (REC Reference: 19/NW/0183; IRAS Reference: 247370). This protocol has been coproduced with stakeholders including patients and public. Findings will be disseminated to patients and a range of stakeholders.

TRIAL REGISTRATION NUMBER

ISRCTN28555470.

Can Medical Cannabis Therapies be Cost-Effective in the Non-Surgical Management of Chronic Knee Pain?

Introduction:

Chronic knee pain is a common musculoskeletal condition, which usually leads to decreased quality of life and a substantial financial burden. Various non-surgical treatments have been developed to relieve pain, restore function and delay surgical intervention. Research on the benefits of medical cannabis (MC) is emerging supporting its use for chronic pain conditions. The purpose of this study was to evaluate the cost-effectiveness of MC compared to current non-surgical therapies for chronic knee pain conditions.

Methods:

We conducted a cost-utility analysis from a Canadian, single payer perspective and compared various MC therapies (oils, soft gels and dried flowers at different daily doses) to bracing, glucosamine, pharmaceutical-grade chondroitin oral non-steroidal anti-inflammatory drugs (NSAIDs), and opioids. We estimated the quality-adjusted life years (QALYs) gained with each treatment over 1 year and calculated incremental cost-utility ratios (ICURs) using both the mean and median estimates for costs and utilities gained across the range of reported values. The final ICURs were compared to willingness-to-pay (WTP) thresholds of $66 714, $133 428 and $200 141 Canadian dollars (CAD) per QALY gained.

Results:

Regardless of the estimates used (mean or median), both MC oils and soft gels at both the minimal and maximal recommended daily doses were cost-effective compared to all current knee pain therapies at the lowest WTP threshold. Dried flowers were only cost-effective up to a certain dosage (0.75 and 1 g/day based on mean and median estimates, respectively), but all dosages were cost-effective when the WTP was increased to $133 428/QALY gained.

Conclusion:

Our study showed that MC may be a cost-effective strategy in the management of chronic knee pain; however, the evidence on the medical use of cannabis is limited and predominantly low-quality. Additional trials on MC are definitely needed, specifically in patients with chronic knee pain.

Effect of knee braces and insoles on clinical outcomes of individuals with medial knee osteoarthritis: A systematic review and meta-analysis

Knee osteoarthritis is a disabling disease, causing pain and reduced function.Orthoses are used to manage this problem, including knee braces and lateral wedge insoles. However, there is still controversy on which type of intervention is more effective. This systematic review and meta-analysis aimed toevaluate the effect of knee braces and lateral wedge insoles and compare their clinical outcomes onindividuals with medial knee osteoarthritis. We conducted the search strategy based on the population, intervention, comparison, andoutcome (PICO) method. We searched with PubMed, EMBASE, Web of Science, and Scopus databases for the related studies. The articles quality assessment was done based on the modified Downs and Black checklist. Totally, we chose 32 controlled trials, including 1.849 participants, for the final evaluation. Almosttwo-thirds of the studies had a moderate quality. The overall outcome suggested that both interventionshad improved pain and function. The difference between both interventions on pain reduction was not significant (standardized mean difference = 0.12, 95% confidence interval = 0.34 to 0.1) based on meta-analysis. Both knee brace and lateral wedge insole can improve pain and function in people with knee osteoarthritis. Using either separately or both of them together are effective.

An evaluation of the use of a lateral wedged insole and a valgus knee brace in combination in subjects with medial compartment knee osteoarthritis (OA)

Aim: The aim of this study was to evaluate the effect (6 weeks) of the use of a knee brace and a lateral wedge insole, both in isolation and combined, on the knee adduction moment (KAM), pain levels, kinematics (velocity, stride length, cadence), knee ROM, function, and satisfaction in patients with knee osteoarthritis (OA).Methods: Twenty-one patients with medial compartment knee OA were participated in this study. A relatively light three-point valgus knee brace (VB) and full length custom-made lateral wedge insole with arch support were prepared for each subject. Patients divided into three groups at random.Results: The use of a custom fit valgus brace with lateral edge insole concurrently can reduce a greater peak KAM than use in isolation (30%). In addition, the use of both interventions can improve walking velocity, cadence, and reduce levels of pain in patients with medial compartment OA.Conclusion: All parameters except stride length and KAM in comparison with first day of wearing interventions improved significantly in the combined, concurrent usage group. The use of a lateral wedge insole and a valgus knee brace in combination can improve the kinetic and kinematic parameters in patients with medial compartment knee OA.

Different Prevention and Treatment Strategies for Knee Osteoarthritis (KOA) with Various Lower Limb Exoskeletons – A Comprehensive Review

It was reported that about 10% of people suffer from painful knee arthritis, and a quarter of them were severely disabled. The core activities of daily living were severely limited by knee osteoarthritis (KOA). In order to reduce knee pain and prolong the life of the knee joint, there has been an increasing demand on the development of exoskeletons, for prevention and treatment. The course of KOA was closely related to the biomechanics of knee joint, and the pathogenesis was summarized based on the biomechanics of knee joint. For the prevention and clinical treatment, exoskeletons are classified into three categories: prevention, treatment, and rehabilitation after the operation. Furthermore, the design concepts, actuators, sensors, control strategies, and evaluation criteria were presented. Finally, the shortcomings and limitations were summarized. It is useful for researchers to develop suitable exoskeletons in the future.

Systematic Review of Exoskeletons towards a General Categorization Model Proposal

Exoskeletons are an essential part of humankind’s future. The first records regarding the subject were published several decades ago, and the field has been expanding ever since. Their developments will be imperative for humans in the coming decades due to our constant pursuit of physical enhancement, and the physical constraints the human body has. The principal purpose of this article is to formalize research in the field of exoskeletons and introduce the field to more researchers in hopes of expanding research in the area. Exoskeletons can assist and/or aid in the rehabilitation of a person. Recovery exoskeletons are mostly used in medical and research areas; performance exoskeletons can be used in any area. This systematic review explains the precedents of the exoskeletons and gives a general perspective on their general present-day use, and provides a general categorization model with a brief description of each category. Finally, this paper provides a discussion of the state-of-the-art, and the current control techniques used in exoskeletons.

Orthoses versus gait retraining: Immediate response in improving physical performance measures in healthy and medial knee osteoarthritic adults

The conservative techniques of treating knee osteoarthritis (kOA) include wearing orthoses such as knee braces and laterally wedged insoles and applying gait modification techniques such as toe-in gait and toe-out gait. This study aimed at assessing the immediate effects of these techniques in improving physical function of healthy and kOA participants. Five Osteoarthritis Research Society International (OARSI) recommended performance-based tests were randomly applied to measure physical function: (1) 30-second chair stand test (30CST), (2) 40-m (4 × 10) fast-paced walk test (40FPW), (3) stair climb test (SCT), (4) timed up and go test (TUGT) and (5) 6-minute walk test (6MWT) during a single-visit on 20 healthy and 20 kOA patients (age: 59.5 ± 7.33 and 61.5 ± 8.63 years, BMI: 69.95 ± 9.86 and 70.45 ± 8.80 kg/m²). The interventions included natural gait, toe-out gait, toe-in gait, laterally wedged insoles and knee brace. Analysis was performed through repeated-measures ANOVA and independent sample t-test. 30CST and TUGT showed no significant differences for the five test conditions (p > 0.05). Toe-out showed profound effects via pairwise comparison in impairing the physical function while knee brace improved it during 40FPW, SCT and 6MWT. In general, all the tested conservative techniques except laterally wedged insoles had immediate effects on physical performance measures in both healthy and medial knee osteoarthritis participants. The valgus knee brace improved the parameters the most, while toe-out gait impaired them the most. Future studies can develop strategies for improving gait retraining methods on the basis of issues identified by this study.

Design Evaluation in Novel Orthoses for Patients with Medial Knee Osteoarthritis

Osteoarthritis of the knee is a debilitating condition affecting increasing numbers of individuals each year. One option for treatment is orthotic knee braces, but a little independent reviews have taken place to date on their relative outcomes for users. This study therefore evaluates the efficacy of different types of knee orthoses (braces) with regard to key aspects of use, including gait parameters, mobility and levels of comfort and compliance in subjects presenting with osteoarthritis (OA) of the knee. The collated data is presented with relevant supporting literature and appropriate descriptions in relation to each knee orthosis type that was identified, within appropriate subsections with advantages and disadvantages appropriately allocated. An analysis of each brace as presented by the corresponding article is then described further in terms of the design and structure, user outcomes and assessment summaries. According to the study carried out in this paper, it is presented and proved that applying the use of knee braces can reduce the knee adduction moment (KAM), but the amount of reduction afforded varies between designs. All of the studies reported significant pain reduction and functional improvement with the use of a knee brace, although their effect on the knee joint range of motion vary. Knee braces long-term use depends upon high levels of comfort and patient compliance, and further studies need to be conducted on larger numbers of subjects over greater time periods to reflect the long-term outcomes accurately

Design Evaluation of a Novel Multicompartment Unloader Knee Brace

Knee osteoarthritis (OA) is a significant problem in the aging population, causing pain, impaired mobility, and decreased quality of life. Conservative treatment methods are necessary to reduce rapidly increasing rates of knee joint surgery. Recommended strategies include weight loss and knee bracing to unload knee joint forces. Although weight loss can be beneficial for joint unloading, knee OA patients often find it difficult to lose weight or begin exercise due to knee pain, and not all patients are overweight. Unicompartment offloader knee braces can redistribute joint forces away from one tibiofemoral (TF) compartment; however, <5% of patients have unicompartmental tibiofemoral osteoarthritis (TFOA), while patients with isolated patellofemoral or multicompartmental OA are much more common. By absorbing body weight (BW) and assisting the knee extension moment using a spring-loaded hinge, sufficiently powerful knee-extension-assist (KEA) braces could be useful for unloading the whole knee. This paper (1) describes the design of a spring-loaded tricompartment unloader (TCU) knee brace intended to provide unloading in all three compartments of the knee while weight-bearing, (2) measures and compares the force output of the TCU against the only published and commercially available KEA brace, and (3) calculates the static unloading capacity of each device. The TCU and KEA braces delivered maximum assistive moments equivalent to reducing BW by approximately 45 and 6 lbs, respectively. The paper concludes that sufficiently powerful spring-loaded knee braces show promise in a new class of multicompartment unloader knee orthoses, capable of providing a clinically meaningful unloading effect across all three knee compartments.

The effect of extension assist orthosis with pneumatic bladders on pain and function for patients with early knee osteoarthritis

Background

There are few non-invasive treatment options to slow the progression of osteoarthritis (OA). Recently, a novel knee unloader brace with knee extension assist has become commercially available. Therefore, the purpose of this study was to evaluate the preliminary effectiveness of using a novel unloader brace with extension assist to improve pain and functional outcomes for patients with knee OA.

Methods

Thirty subjects (17 control group, 13 brace group) completed baseline and 6-week follow up testing with no brace. Patients were randomized into a Brace or No Brace group after baseline testing. Functional tests [timed up and go (TUG), stair climbing test (SCT) and six-minute walk (6MW)], self-reported measures [Knee Outcome Survey (KOS), pain, Patient Specific Functional Scale (PSFS)] and isometric knee extension strength were assessed. Repeated measure ANOVAs were used to identify differences in group and time. Pearson correlation coefficients were calculated for both average number of steps in the brace and exercises compliance compared to change in clinical scores for each group.

Results

There was a significant interaction effect for "worst pain" (P=0.002), the brace group improved from a 7.3/10 to 4.7/10 at follow-up (P=0.006) while the control group had no change. There was an effect of time for the SCT (P=0.02), "best knee pain" (P=0.050), and knee extension range of motion (ROM) (P=0.041). There were no significant correlations between exercise compliance and change in outcomes, but when the groups were collapsed there was a significant correlation between compliance and change in knee extension ROM (r=0.526; P=0.025).

Conclusions

The extension assist pneumatic unloader brace group demonstrated a significant and important reduction in the "worst knee pain". This may indicate that wearing the brace was able to reduce painful flares. Both groups improved over time for the SCT, "best knee pain", and knee extension ROM, which can be attributed to the stretching protocol. This unloader brace is a promising non-invasive treatment option for patients with knee OA when combined with a stretching program.

Innovations in functional and rehabilitative knee bracing

New knee brace designs are available that have the potential to improve patient outcomes relative to traditional bracing. For the indications of post-knee injury/surgery recovery, conservative management of knee osteoarthritis (OA), total knee arthroplasty (TKA) pre-habilitation, and the treatment of post-surgical extension deficits/flexion contractures, innovative new bracing designs merit review and discussion. The researchers requested information from industry brace manufacturers, and from the information received, have selected those products considered significant improvements over traditional functional brace designs for review in this article. Clinical research supporting the benefits of the innovative products listed in the article have been cited when available. The authors are both Certified Orthotists with over 50 years of combined knee bracing experience.

Combined effects of knee brace, laterally wedged insoles, and toe-out gait on knee adduction moment and fall risk in moderate medial knee osteoarthritis patients

BACKGROUND:

Knee osteoarthritis is a major contributor to the global burden of disease. There is a need of reducing knee joint load and to improve balance and physical function among knee osteoarthritis patients.

OBJECTIVES:

To test the hypothesis that toe-out gait will reduce second peak knee adduction moment further and increase fall risk when combined with knee brace and laterally wedged insole in knee osteoarthritis patients.

STUDY DESIGN:

Single visit study with repeated measures.

METHODS:

First and second peak knee adduction moments, fall risk and comfort level. First and second peak knee adduction moments were determined from three-dimensional gait analysis, completed under six randomized conditions: (1) natural, (2) knee brace, (3) knee brace + toe-out gait, (4) laterally wedged insole, (5) laterally wedged insole + toe-out gait, and (6) knee brace + laterally wedged insole + toe-out gait. Fall risk was assessed by Biodex Balance System using three randomized stability settings: (1) static, (2) moderate dynamic setting (FR12), and (3) high dynamic setting (FR8).

RESULTS:

The reduction in first peak knee adduction moment and second peak knee adduction moment was greatest (7.16% and 25.55%, respectively) when toe-out gait combine with knee brace and laterally wedged insole. Significant increase in fall risk was observed with knee brace + laterally wedged insole + toe-out gait (42.85%) at FR12. Similar significant balance reductions were found at FR8 condition for knee brace + toe-out gait (35.71%), laterally wedged insole + toe-out gait (28.57%), and knee brace + laterally wedged insole + toe-out gait (50%) as compared to natural. However, knee brace decreased fall risk at FR12 by 28.57%.

CONCLUSION:

There is a synergistic effect of toe-out when combined with knee brace and laterally wedged insole concurrently in second peak knee adduction moment reduction but with a greater degree of fall risk. Simultaneous use of conservative treatments also decreases comfort level.

CLINICAL RELEVANCE

Patients with mild and moderate knee osteoarthritis are usually prescribed conservative treatment techniques. This study will provide an insight whether or not a combination of these techniques have a synergistic effect in reducing knee joint load.

A systematic review of randomised controlled trials assessing effectiveness of prosthetic and orthotic interventions

BACKGROUND

Assistive products are items which allow older people and people with disabilities to be able to live a healthy, productive and dignified life. It has been estimated that approximately 1.5% of the world's population need a prosthesis or orthosis.

OBJECTIVE

The objective of this study was to systematically identify and review the evidence from randomized controlled trials assessing effectiveness and cost-effectiveness of prosthetic and orthotic interventions.

METHODS

Literature searches, completed in September 2015, were carried out in fourteen databases between years 1995 and 2015. The search results were independently screened by two reviewers. For the purpose of this manuscript, only randomized controlled trials which examined interventions using orthotic or prosthetic devices were selected for data extraction and synthesis.

RESULTS

A total of 342 randomised controlled trials were identified (319 English language and 23 non-English language). Only 4 of these randomised controlled trials examined prosthetic interventions and the rest examined orthotic interventions. These orthotic interventions were categorised based on the medical conditions/injuries of the participants. From these studies, this review focused on the medical condition/injuries with the highest number of randomised controlled trials (osteoarthritis, fracture, stroke, carpal tunnel syndrome, plantar fasciitis, anterior cruciate ligament, diabetic foot, rheumatoid and juvenile idiopathic arthritis, ankle sprain, cerebral palsy, lateral epicondylitis and low back pain). The included articles were assessed for risk of bias using the Cochrane Risk of Bias tool. Details of the clinical population examined, the type of orthotic/prosthetic intervention, the comparator/s and the outcome measures were extracted. Effect sizes and odds ratios were calculated for all outcome measures, where possible.

CONCLUSIONS

At present, for prosthetic and orthotic interventions, the scientific literature does not provide sufficient high quality research to allow strong conclusions on their effectiveness and cost-effectiveness.

Combined effects of knee brace, laterally wedged insoles and toe-in gait on knee adduction moment and balance in moderate medial knee osteoarthritis patients

OBJECTIVE

To test the hypothesis that toe-in gait (TI) will further reduce first peak (Knee Adduction Moment) KAM and decrease balance when combined with a knee brace (KB) and laterally wedged insoles (LWI) in medial knee osteoarthritis (kOA) patients.

PARTICIPANTS

Twenty patients with bilateral symptomatic medial kOA.

INTERVENTIONS

4-point leverage-based KB, full-length LWI with 5° inclination and toe-in gait (TI).

MAIN OUTCOME MEASURES

First and second peak knee adduction moment (fKAM and sKAM respectively), balance and pain.

METHODS

The fKAM and sKAM were determined from 3-dimensional gait analysis with six randomized conditions: (1) N (without any intervention), (2) KB, (3) KB + TI, (4) LWI, (5) LWI + TI, (6) KB + LWI + TI. Balance was assessed by Biodex Balance System using three stability settings, (i) Static (ii) Moderate dynamic setting for fall risk (FR12) and (iii) High dynamic setting for fall risk (FR8).

RESULTS

The reduction in fKAM and sKAM was greatest (19.75% and 12%) when TI was combined with KB and LWI respectively. No change in balance was observed when TI combined with KB, and LWI and when used concurrently with both the orthosis at static and FR12 conditions. Significant balance reduction was found at FR8 for KB + TI (22.22%), and KB + LWI + TI (35.71%). Pain increased significantly for KB (258%), KB + TI (305%), LWI + TI (210%) and KB + LWI + TI (316%). LWI showed no effect on pain.

CONCLUSIONS

There is a synergistic effect of TI when combined with KB and LWI concurrently in sKAM reduction. However, the concurrent use of TI, KB and LWI decreases balance and pain as assessed on a highly dynamic platform.

Knee Osteoarthritis: A Primer

The purpose of this article is to provide a synopsis of the current medical understanding of knee osteoarthritis. We describe the prevalence, causes and associated risk factors, symptoms, diagnosis and classification, and treatment options. A quiz serves to assist readers in their understanding of the presented material.

The effects of various physical non-operative modalities on the pain in osteoarthritis of the knee

The purpose of this study was to evaluate the effect of various non-operative modalities of treatment (transcutaneous electrical nerve stimulation (TENS); neuromuscular electrical stimulation (NMES); insoles and bracing) on the pain of osteoarthritis (OA) of the knee. We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify the therapeutic options which are commonly adopted for the management of osteoarthritis (OA) of the knee. The outcome measurement tools used in the different studies were the visual analogue scale and The Western Ontario and McMaster Universities Arthritis Index pain index: all pain scores were converted to a 100-point scale. A total of 30 studies met our inclusion criteria: 13 on insoles, seven on TENS, six on NMES, and four on bracing. The standardised mean difference (SMD) in pain after treatment with TENS was 1.796, which represented a significant reduction in pain. The significant overall effect estimate for NMES on pain was similar to that of TENS, with a SMD of 1.924. The overall effect estimate of insoles on pain was a SMD of 0.992. The overall effect of bracing showed a significant reduction in pain of 1.34. Overall, all four non-operative modalities of treatment were found to have a significant effect on the reduction of pain in OA of the knee. This study shows that non-operative physical modalities of treatment are of benefit when treating OA of the knee. However, much of the literature reviewed evaluates studies with follow-up of less than six months: future work should aim to evaluate patients with longer follow-up.

Osteoarthritis year in review 2015: rehabilitation and outcomes

OBJECTIVE

The purpose of this narrative review was to highlight recent research in the rehabilitation of people with osteoarthritis (OA) by summarizing findings from selected key systematic reviews and randomized controlled trials (RCTs).

METHODS

A systematic search was conducted using the PubMed, Physiotherapy Evidence Database (PEDro) and Cochrane databases from April 1st 2014 to March 31st 2015. A selection of these is discussed based on study quality, relevance, contribution to new knowledge or controversial findings. Methodological quality of RCTs was assessed using guidelines from PEDro.

RESULTS

From 274 articles, 74 were deemed to meet the eligibility criteria including 24 systematic reviews and 50 studies reporting on findings from RCTs. Overall the methodological quality of the RCTs was moderate. The studies were grouped into several themes covering; evidence of rehabilitation outcomes in less studied joints including the hand and hip; new insights into exercise in knee OA; effects of biomechanical treatments on symptoms and structure in knee OA; and effects of acupuncture.

CONCLUSIONS

Exercise was the most common treatment evaluated. Although little evidence supported benefit of exercise for hand OA, exercise has positive effects for hip and knee OA symptoms and these benefits may depend upon patient phenotypes. The first evidence that a brace can influence knee joint structure emerged. The latest evidence suggests that acupuncture has, at best, small treatment effects on knee OA pain of unlikely clinical relevance.