Changes in knee moments with contralateral versus ipsilateral cane usage in females with knee osteoarthritis

Biomechanical Effect of 3D-Printed Foot Orthoses in Patients with Knee Osteoarthritis

Lateral wedges are a common conservative treatment for medial knee osteoarthritis (OA). However, use of lateral wedges might increase the ankle eversion moment. To minimize the risk of ankle symptoms, lateral wedges with custom arch support are suggested. However, the manufacturing process of a custom foot orthosis (FO) is complicated, labor-intensive, and time-consuming. The technology of 3D printing is an ideal method for mass customization. Therefore, the purpose of this study was to develop custom FOs using 3D-printing techniques and to evaluate the effects of 3D-printed FOs in patients with knee OA. Fifteen patients with medial knee OA were enrolled into this study. Kinematic and kinetic data were collected during walking by using an optical motion capture system. A paired-sample t-test was conducted to compare biomechanical variables under two conditions: walking in standard shoes (Shoe) and walking in shoes embedded with 3D-printed FOs (Shoe + FO). The results show that the first and second peak knee adduction moments were significantly reduced by 4.08% and 9.09% under the Shoe + FO condition. The FOs alter the biomechanical environment in a way that reduces the variables used to infer abnormal loads at the knee and ankle that could result in painful symptoms.

A novel walking cane with haptic biofeedback reduces knee adduction moment in the osteoarthritic knee

Knee osteoarthritis is a leading cause of ambulatory disability in adults. The most prescribed mobility aid, the walking cane, is often underloaded and therefore fails to reduce knee joint loading and provide symptomatic relief. For this study, a novel walking cane with haptic biofeedback was designed to improve cane loading and reduce the knee adduction moment (KAM). To determine; 1) the short-term efficacy of a novel walking cane using haptic biofeedback to encourage proper cane loading and 2) the effects of the novel cane on KAM. Cane loading and KAM, peak knee adduction moment (PKAM), and knee adduction angular impulse (KAAI)) while walking were calculated under five conditions: 1) naïve, 2A) after scale training (apply 20%BW to cane while standing, using a beam scale), 2B) scale recall (attempt to load the cane to 20%BW), 3A) after haptic training (vibrotactile biofeedback delivered when target cane load achieved), and 3B) haptic recall (attempt to load the cane to 20%BW with vibrotactile biofeedback delivered). Compared to the naïve condition all interventions significantly increased cane loading and reduced PKAM and KAAI. No differences between haptic recall and scale recall condition were observed. The haptic biofeedback cane was shown to be an effective and simple way to increase cane loading and reduced knee loading. Haptic biofeedback and scale training were equally effective at producing immediate short-term improvements in cane loading and knee loading. Future studies should examine the long-term effects of scale training and canes with haptic biofeedback on knee joint health, pain, and osteoarthritis disease progression.

Biomechanical analysis on total knee replacement patients during gait: Medial pivot or posterior stabilized design?

BACKGROUND

Total Knee Replacement surgery restores joint function in patients with advanced osteoarthritis. There are several prostheses available based on different mechanisms, which guarantee knee stability during Activities of Daily Living. The aim of this study is to compare ball-in-socket (or Medial Pivot) and post-cam mechanisms to detect possible differences in terms of biomechanical parameters between these two prosthesis designs and to evaluate which design is closer to physiological biomechanics.

METHODS

A kinematics, kinetics and electromyography lower limb analyses were performed during gait on sixty subjects: twenty with Medial Pivot prosthesis, twenty with posterior stabilized prosthesis and twenty healthy subjects to obtain a physiologic reference.

FINDINGS

Total Knee Replacement gait pattern for both patient groups were characterized by reduced walking speed, reduced stride length and increased stance time respect to control group. Comparison between Medial Pivot and Posterior Stabilized groups showed a reduction of knee flexion and flexor moment in patients with ball-in-socket mechanism. A prolonged muscular activity of rectus femoris was observed in Medial Pivot patients compared to Posterior Stabilized and control groups.

INTERPRETATION

"Stiff knee pattern" mechanism was showed for both patient groups but more enhanced in Medial Pivot patients. Even though the Posterior Stabilized design introduces the non-physiological paradoxical motion and the Medial Pivot design seems to better reproduce the physiological condylar movement as gait analysis parameters, including kinematics, kinetics and electromyographic parameters were closer to control group and, in turn, to physiological gait for the Posterior Stabilized than Medial Pivot group parameters.

Contralateral canes for knee osteoarthritis

Introduction

Knee osteoarthritis is a relevant health problem given its high prevalence and associated disability. Within the non-pharmacological management alternatives, the use of canes has been proposed, however, there is no consensus in the literature regarding its indication.

Methods

We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach.

Results and conclusions

We identified three systematic reviews including four studies overall, of which one was randomized trials. We conclude that the use of a contralateral cane in patients with knee osteoarthritis probably reduces pain. In addition, it could slightly increase function, but the certainty of the evidence is low.

Effect of contralateral cane use on hip moment impulse in the frontal plane during the stance phase

BACKGROUND

Recent reports have shown that the daily cumulative moment in the frontal plane (i.e., product of hip moment impulse in the frontal plane during the stance phase and mean steps per day) is a risk factor for hip osteoarthritis. This study aimed to clarify the effect of contralateral cane use on hip moment impulse in the frontal plane of the stance limb.

METHODS

This study included 15 healthy subjects who walked under four experimental conditions: (1) without a cane and (2-4) contralateral cane use with 10%, 15%, and 20% body weight support (BWS), respectively. To maintain the same walking speed in all conditions, the cadence was set to 80 steps/min, and the step length was fixed. The hip moment impulses in the frontal plane (i.e., area under the hip ab-adduction moment waveform) and peak hip adduction moments in all conditions were calculated.

RESULTS

Contralateral cane use significantly decreased the hip moment impulse in the frontal plane and peak hip adduction moment compared to non-cane use. Moreover, the hip moment impulse in the frontal plane and peak hip adduction moment decreased significantly with increased cane BWS. There were no significant differences in walking speed, cadence, and step length between the four conditions.

CONCLUSION

Contralateral cane use decreases the hip moment impulse in the frontal plane and peak hip adduction moment in the stance limb. These findings may help clarify how to delay the progression of hip osteoarthritis.

Body weight support through a walking cane in inexperienced users with knee osteoarthritis

BACKGROUND

Walking canes are a self-management strategy recommended for people with knee osteoarthritis (OA) by clinical practice guidelines. Ensuring that an adequate amount of body-weight support (%BWS) is taken through the walking cane is important as this reduces measures of knee joint loading.

RESEARCH QUESTION

1) How much body weight support do people with knee OA place through a cane? 2) Do measures of body weight support increase following a brief simple training session?

METHODS

Seventeen individuals with knee pain who had not used a walking cane before were recruited. A standard-grip aluminum cane was then used for 1 week with limited manufacturer instructions. Following this, participants were evaluated using an instrumented force-measuring cane to assess body weight support (% total body weight) through the cane. Force data were recorded during a 430-metre walk undertaken twice; once before 10 min of cane training administered by a physiotherapist, and once immediately after training. Measures of BWS (peak force, average force, impulse equal to the average cane force times duration, and cane-ground contact duration) were extracted. Using bathroom scales, training aimed to take at least 10% body weight support through the cane.

RESULTS

Before training, the average peak BWS was 7.2 ± 2.5% of total body weight. Following 10 min of training, there was a significant increase in average peak BWS by 28%, average BWS by 25%, and BWS impulse by 54% (p < 0.05). However, individual BWS responses to training were variable. Duration of cane placement increased by 22% after training (p = 0.02). Timing of peak BWS through the cane occurred at 51% of contact phase before training, and at 53% after training (p = 0.05).

SIGNIFICANCE

A short training session can increase the transfer of body weight through a walking cane. However, more sophisticated feedback may be needed to achieve target levels of BWS.

Does crutch length influence gait parameters after total hip replacement surgery?

After total hip replacement surgery, crutches are often prescribed to enable patients to walk independently. Purpose of this study was to evaluate possible crutch length influence on gait performance and symmetry, including spatiotemporal and kinetics parameters. Thirty patients were randomly assigned to elbow flexed (EF) or elbow extended (EE) crutch setup. Subjects were asked to walk on the laboratory path, instrumented with motion tracking system and force platforms. Spatiotemporal gait parameters and ground reaction force (GRF) parameters for both limbs and crutch support were evaluated. In addition, limb symmetry was evaluated for both gait and force parameters using the symmetry index. Variability was quantified for base of support width, stride time and length as the coefficient of variation. Results showed that cadence and walking speed were not significantly different, but stride length significantly decreased and base of support width increased for the EF group when compared to the EE group. Operated limb GRF parameters were significantly decreased for the EF group, while crutch force parameters decreased for the EE group. Furthermore, the EF group showed greater stride length variability and asymmetry of force and spatiotemporal parameters than EE group did. The results of the present study showed that EF and EE setups did not assist patients equally during walking, with EE setup allowing more load bearing on the operated side, reducing load on the crutch and asymmetries in gait parameters when compared to the EF setup. This may help clinicians in rationalizing crutch setup for patients after total hip replacement surgery.

Accuracy evaluation of a method to partition ground reaction force and center of pressure in cane-assisted gait using an instrumented cane with a triaxial force sensor

Clarifying the biomechanics of cane-assisted gait in elderly individuals and patients with gait disorders is important for developing better therapeutic interventions in the fields of rehabilitation and orthopedics. However, if the foot and the cane in the ipsilateral hand are placed on the same force plate simultaneously, the force plate cannot separate the forces as it records the sum of the forces. To overcome this indeterminacy problem of the ground reaction force (GRF) and the center of pressure (COP) in cane-assisted gait analysis, a method to partition the GRF and COP using an instrumented cane with a force transducer has been proposed. However, the accuracy and precision of the estimated GRF and COP has not been evaluated previously. We therefore reestablished a framework to partition the foot and cane forces during walking using an instrumented cane with a triaxial force sensor and evaluated the accuracy and precision of the method using a force plate array. Cane-assisted gait of healthy adults and hemiplegic patients were measured. Mean accuracy and precision associated with the GRF and COP measurements were approximately 0.4±1.4N and 0.2±2.7mm, respectively, indicating that the separations of the GRF and COP were sufficiently accurate for kinetic gait analysis. Although some methodological limitations certainly apply, this system will serve as a useful tool for improved therapeutic interventions.

Effects of contralateral versus ipsilateral cane use on gait in people with knee osteoarthritis

OBJECTIVE

To compare the immediate effects of contralateral versus ipsilateral cane use on spatiotemporal gait parameters and peak vertical ground force in overweight or obese adults with symptomatic knee osteoarthritis (OA).

DESIGN

Prospective observational study.

SETTING

An academic tertiary Veterans Affairs Healthcare Center.

PARTICIPANTS

Thirty-eight overweight or obese subjects with symptomatic knee OA who had not used a cane for the past 30 days.

METHODS

Spatiotemporal gait data were obtained with an optical motion capture system while subjects walked without a cane, with a cane contralateral to the more painful lower limb, or with a cane ipsilateral to the more painful lower limb at self-selected speeds. An in-shoe dynamic pressure distribution system was used to measure the vertical ground reaction force.

MAIN OUTCOME MEASUREMENTS

Spatiotemporal measures of gait and peak vertical ground reaction force on both lower limbs were recorded for each walking condition: no cane, contralateral cane, and ipsilateral cane.

RESULTS

Walking with a cane either contralateral or ipsilateral to the more symptomatic limb led to significant reductions in gait velocity (14%-16%), cadence (12%-14%), and peak vertical ground reaction force (normalized for body weight; 11%-12%) on the more painful lower limb compared with walking unaided (P < .05). There were no significant differences in the peak vertical ground reaction force on either lower limbs when comparing walking with a cane contralateral to the more painful limb or walking with a cane ipsilateral to the more painful limb. Subjects also experienced a significant decrease in gait velocity with contralateral or ipsilateral cane use compared with walking without a cane; the lower walking speed was due to a decrease in cadence.

CONCLUSIONS

These results support the prescription of a single-point cane to offload a lower limb with painful knee OA by holding the cane either ipsilateral or contralateral to the more painful lower limb.

Joint loading asymmetries in knee replacement patients observed both pre- and six months post-operation

BACKGROUND

Studies have highlighted asymmetries in knee joint moments in individuals with osteoarthritis and joint replacements. However, there is a need to investigate the forces at the knee joints to establish the extent of loading asymmetries.

METHODS

Twenty healthy (mean age, 62; range, 55-79 years) and 34 pre- to post-knee arthroplasty (mean age, 64; range, 39-79 years) participants performed gait and sit-stand activities in a motion capture laboratory. Knee joint forces and moments were predicted using inverse dynamics and used to calculate peak loading and impulse data which were normalized to body weight. Comparisons were made between affected and contralateral limbs, and changes from pre- to post-knee arthroplasty.

FINDINGS

Pre-knee arthroplasty peak vertical knee forces were greater in the contralateral limb compared to the affected limb during both gait 3.5 vs. 3.2 ∗ body weight and sit-stand 1.8 vs. 1.5 ∗ body weight. During gait, peak knee adduction moment asymmetries significantly changed from pre- to post-knee arthroplasty (-0.3 to 0.8 ∗ % body weight ∗ m ∗ height), although differences in vertical knee forces remained. There were no significant changes in loading during sit-stand from pre- to post-knee arthroplasty. The healthy participants showed no noteworthy asymmetries.

INTERPRETATION

This study showed loading asymmetries in knee forces between affected and contralateral limbs both pre- and post-knee arthroplasty. Continued over reliance of the contralateral limb could lead to pathology.

A biomechanical perspective on physical therapy management of knee osteoarthritis

SYNOPSIS

Altered knee joint biomechanics and excessive joint loading have long been considered as important contributors to the development and progression of knee osteoarthritis. Therefore, a better understanding of how various treatment options influence the loading environment of the knee joint could have practical implications for devising more effective physical therapy management strategies. The aim of this clinical commentary was to review the pertinent biomechanical evidence supporting the use of treatment options intended to provide protection against excessive joint loading while offering symptomatic relief and functional improvements for better long-term management of patients with knee osteoarthritis. The biomechanical and clinical evidence regarding the effectiveness of knee joint offloading strategies, including contralateral cane use, laterally wedged shoe insoles, variable-stiffness shoes, valgus knee bracing, and gait-modification strategies, within the context of effective disease management is discussed. In addition, the potential role of therapeutic exercise and neuromuscular training to improve the mechanical environment of the knee joint is considered. Management strategies for treatment of joint instability and patellofemoral compartment disease are also mentioned. Based on the evidence presented as part of this clinical commentary, it is argued that special considerations for the role of knee joint biomechanics and excessive joint loading are necessary in designing effective short- and long-term management strategies for treatment of patients with knee osteoarthritis.

LEVEL OF EVIDENCE

Therapy, level 5.

The effect of walking poles on the knee adduction moment in patients with varus gonarthrosis

OBJECTIVES

(1) Test the hypothesis that walking poles decrease the external knee adduction moment during gait in patients with varus gonarthrosis, and (2) explore potential mechanisms.

DESIGN

Thirty-four patients with medial compartment knee osteoarthritis (OA) and varus alignment underwent three dimensional (3D) gait analysis with and without using walking poles. Conditions were randomized and walking speed was maintained ±5% of the self-selected speed of the initial condition. The pole held in the hand of the unaffected side was instrumented with a compression load cell.

RESULTS

Student's t tests for paired samples indicated small but statistically significant increases (P < 0.001) in knee adduction moment (calculated from inverse dynamics) for its first peak, second peak and angular impulse when using the poles; mean increases (95% confidence interval - CI) were 0.17%BW*Ht (0.08, 0.27), 0.17%BW*Ht (0.04, 0.30) and 0.15%BW*Ht*s (0.09, 0.22), respectively. There was a decrease (P = 0.015) in vertical ground reaction force (-0.02 BW (-0.04, -0.01)), yet increase (P < 0.001) in its frontal plane lever arm about the knee (0.30 cm (0.15, 0.44)), at the time of the first peak knee adduction moment. Pole force in the vertical direction was inversely related (r = -0.34, P = 0.05) to the increase in first peak adduction moment.

CONCLUSION

Although results are variable among patients, and may be related to individual technique, these overall findings suggest that walking poles do not decrease knee adduction moments, and therefore likely do not decrease medial compartment loads, in patients with varus gonarthrosis. Decreases in knee joint loading should not be used as rationale for walking pole use in these patients.

Assistive walking device use and knee osteoarthritis: results from the Health, Aging and Body Composition Study (Health ABC Study)

OBJECTIVES

To identify factors that predicted incident use of assistive walking devices (AWDs) and to explore whether AWD use was associated with changes in osteoarthritis of the knee.

DESIGN

Prospective cohort study.

SETTING

Community.

PARTICIPANTS

Older adults (N=2639) in the Health, Aging and Body Composition (Health ABC) Study including a subset of 874 patients with prevalent knee pain.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Incident use of AWDs, mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores, and the frequency of joint space narrowing on knee radiographs over a 3-year time period.

RESULTS

AWD use was initiated by 9% of the entire Health ABC cohort and 12% of the knee pain subset. Factors that predicted use in both groups were age ≥73 (entire cohort: odds ratio [OR]=2.07; 95% confidence interval [CI], 1.43-3.01; knee pain subset: OR=1.87; 95% CI, 1.16-3.03), black race (entire cohort: OR=2.95; 95% CI, 2.09-4.16; knee pain subset: OR=3.21; 95% CI, 2.01-5.11), and lower balance ratios (entire cohort: OR=3.18; 95% CI, 2.21-4.59; knee pain subset: OR=3.77; 95% CI, 2.34-6.07). Mean WOMAC pain scores decreased slightly over time in both AWD and non-AWD users. Twenty percent of non-AWD users and 28% of AWD users had radiographic progression in joint space narrowing of the tibiofemoral joint in at least 1 knee. Fourteen percent of non-AWD users and 12% of AWD users had radiographic progression in joint space narrowing in the patellofemoral joint in at least 1 knee.

CONCLUSIONS

AWDs are frequently used by older adults. Knee pain and balance problems are significant reasons why older adults initiate use of an AWD. In an exploratory analysis, there was no consistent relation between the use or nonuse of an AWD and WOMAC pain scores or knee joint space narrowing progression. Further studies of the relation of use of AWDs to changes in knee osteoarthritis are needed.

Evaluation of immediate impact of cane use on energy expenditure during gait in patients with knee osteoarthritis

PURPOSE

The aim of the present study was to assess the immediate impact of cane use on energy expenditure during gait in patients with knee OA analyzing VO(2).

METHODS

An observational, cross-sectional study was carried out on 64 symptomatic patients with a diagnosis of knee OA. The assessment of energy expenditure was performed through an analysis of expired gases using the portable K4 apparatus (Cosmed, Model K4 b2, Italy) during the six-min walk test (6MWT). Two tests were performed with a cane and two without a cane on two different days within a seven-day period.

RESULTS

The patients walked farther on the test without the cane (p<0.001). Oxygen expenditure (VO(2)) and the O(2) cost of walking at the end of the 6MWT increased approximately 50% and 80% during cane-assisted gait when compared to gait without the use of a cane (p<0.001). Pain (Borg scale) decreased approximately 20% at the end of the 6MWT with cane-assisted gait in comparison to gait without a cane (p<0.001).

CONCLUSION

Cane use causes an immediate increase in energy expenditure (VO(2)) during gait and O(2) cost of walking and an immediate decrease of pain during gait. It is necessary to do a more prolonged follow up in order to assess the impact of daily cane use on energy expenditure among these patients and determine whether adaptation occurs. Furthermore, it is necessary to study whether daily cane use has a positive impact on important parameters in these patients, such as pain, function and quality of life.

Knee joint forces: prediction, measurement, and significance

Knee forces are highly significant in osteoarthritis and in the survival and function of knee arthroplasty. A large number of studies have attempted to estimate forces around the knee during various activities. Several approaches have been used to relate knee kinematics and external forces to internal joint contact forces, the most popular being inverse dynamics, forward dynamics, and static body analyses. Knee forces have also been measured in vivo after knee arthroplasty, which serves as valuable validation of computational predictions. This review summarizes the results of published studies that measured knee forces for various activities. The efficacy of various methods to alter knee force distribution, such as gait modification, orthotics, walking aids, and custom treadmills are analyzed. Current gaps in our knowledge are identified and directions for future research in this area are outlined.

Contralateral cane use and knee joint load in people with medial knee osteoarthritis: the effect of varying body weight support

OBJECTIVE

To evaluate the effect of varying body weight support (BWS) with contralateral cane use on medial knee load, measured by external knee adduction moment (KAM), in medial knee osteoarthritis (OA) participants. Influences of cane use technique, pain and malalignment on the cane's load-reducing effects were investigated.

METHOD

Participants (n=23) underwent three-dimensional gait analysis to measure KAM peaks (early and late stance) and impulse. Unaided walking was firstly analyzed. Following cane use training, participants placed pre-determined magnitudes of BWS through the cane (10%, 15% and 20% in random order), with visual feedback provided via a force-instrumented cane and projection screen. Contributions of cane use technique (peak BWS magnitude and timing, cane impulse (BWS∗time) anterior and lateral cane distance from limb) and Western Ontario McMaster Universities OA Index (WOMAC) pain and malalignment to KAM outcomes were evaluated using linear mixed models.

RESULTS

Cane use reduced all KAM variables, with a dose-response effect apparent. Cane BWS impulse was important in reducing the early stance peak KAM (P<0.001), peak BWS for late stance KAM (P<0.001) and both BWS measures for KAM impulse reductions (P<0.001). Variables contributing to efficacy of load-reduction differed across outcomes. Generally, greater reductions were achieved with longer lateral cane distances, peak BWS timing similar to KAM peaks, and shorter anterior cane distances. Greater pain and varus alignment improved load-reduction for some outcomes.

CONCLUSION

Contralateral cane use significantly reduced medial knee load, with a dose-response effect. Medial knee OA patients should be encouraged to maintain greater BWS across stance, with cane placement more lateral for optimum benefit.

Conservative biomechanical strategies for knee osteoarthritis

Knee osteoarthritis (OA) is one of the most prevalent forms of this disease, with the medial compartment most commonly affected. The direction of external forces and limb orientation during walking results in an adduction moment that acts around the knee, and this parameter is regarded as a surrogate measure of medial knee compression. The knee adduction moment is intimately linked with the development and progression of knee OA and is, therefore, a target for conservative biomechanical intervention strategies, which are the focus of this Review. We examine the evidence for walking barefoot and the use of lateral wedge insoles and thin-soled, flexible shoes to reduce the knee adduction moment in patients with OA. We review strategies that directly affect the gait, such as walking with the foot externally rotated ('toe-out gait'), using a cane, lateral trunk sway and gait retraining. Valgus knee braces and muscle strengthening are also discussed for their effect upon reducing the knee adduction moment.

Effective management strategies for osteoarthritis

Osteoarthritis (OA) is a chronic disease which affects a significant number of people during working life and retirement. The principle symptoms of OA are pain, stiffness, and potentially reduced movement and function of the affected joint. In severe OA the ability to engage in work or social activity may be restricted and as a result, the health-related quality of life of the patient may be affected. There are a variety of approaches which can be implemented to manage symptoms, including the use of orthoses, exercise programmes or in severe cases, arthroplasty. It is important that emphasis is placed on patient empowerment and shared decision-making with regard to managing symptoms and preserving or improving function or the affected joint(s).

Características da marcha de um paciente com osteoartrose de quadril com e sem auxílio de bengala

O objetivo deste estudo foi comparar características espaciais, temporais e espaço-temporais da marcha de um paciente com osteoartrose de quadril com e sem o auxílio de dispositivo (bengala). O caso é o de um sujeito com osteoartrose de quadril esquerdo de 63 anos, 97,8 kg e 1,76 m. Um sistema de reconstrução tridimensional de movimento foi utilizado para análise da marcha. Foram registrados três ciclos completos da marcha com e sem a utilização da bengala, sendo analisadas variáveis espaciais, temporais e espaço-temporais. Foi feita análise estatística, com nível de significância de 5%. Os principais resultados indicam que o comprimento de passo direito (CPD) e esquerdo (CPE), bem como o comprimento total do ciclo, foram superiores com o uso da bengala durante a marcha; o CPE foi significativamente maior do que o CPD quando o sujeito utilizava a bengala; todas as variáveis temporais foram estatisticamente menores com o uso da bengala; a cadência da marcha e a velocidade foram estatisticamente superiores com a bengala. Pode-se concluir que o uso da bengala gerou diferenças significativas no comportamento das variáveis espaciais, temporais e espaço-temporais durante a marcha, melhorando de forma significativa a eficiência do movimento do paciente com osteoatrose de quadril.

Load-relief of walking AIDS on osseointegrated fixation: instrument for evidence-based practice

Clinicians are currently in demand of tools enabling individual assessment during their daily practice of load-relief of walking aids. The first aim of this article is to describe a portable kinetic system that could be used to measure directly the true load applied on the residuum during assisted walking. The second aim is to present the information that can be derived from the raw loading data. The third aim is to provide an example for a participant. One active transfemoral amputee fitted with an osseointegrated fixation was asked to walk in straight level line with no aid, one stick, one and two elbow crutches on a 20 m walkway. The load-relief was measured using a six-channel transducer and recorded using a data logger. The overall loading was decreased by 2% using one stick, 5% using one crutch and by 10% using two crutches. This study presents a method that can be used by clinicians facing the challenge of prescribing and assessing walking aids to restore the locomotion of lower limb amputees in the framework of an evidence-based practice.

Immediate effects of contralateral and ipsilateral cane use on normal adult gait

OBJECTIVE

To determine the effects of ipsilateral and contralateral cane use on gait kinematics and peak vertical force in young healthy adults.

DESIGN

Prospective observational study.

SETTING

Veterans Affairs Healthcare Center.

PARTICIPANTS

Fifteen healthy adults of aged 26 to 52 years (mean age 31 years) with no gait impairment and minimal experience using single-point canes.

METHODS

The Pedar-X Mobile System plantar pressure measurement system was used to collect kinematic data from subjects walking in 3 different conditions (relative to a randomly "assigned" limb): contralateral cane (C), ipsilateral cane (I), and no cane (N).

MAIN OUTCOME MEASURES

Peak vertical force, cadence, percentage swing phase and double limb support, and regional plantar pressure ratios.

RESULTS

Peak vertical force (normalized for body weight) was reduced during both cane use conditions on the randomly assigned limb when compared to walking unaided (P<.001). The peak vertical force was 7% to 11% lower for the assigned limb than the opposite limb when a cane was used on either side (P<.016). Mean cadence was higher when participants ambulated without a cane (113 steps/min) than with a cane used on either the contralateral (98 steps/min) or ipsilateral (98 steps/min) side (P<.0001). Mean cadence did not significantly differ between the cane use conditions (P=.93). Regional plantar pressure ratios did not significantly change on either limb in any of the tested conditions. Double limb support slightly increased with cane use (P<.016).

CONCLUSION

Both ipsilateral and contralateral cane use reduced cadence and mean peak vertical plantar force on the limb advanced with the cane in healthy young adults. Double limb support increased with cane use likely due to the reduced cadence and initial unfamiliarity with using an assistive device. A clinical implication of these findings is that prescription of canes for either ipsilateral or contralateral use effectively offloads a designated lower limb.

OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines

PURPOSE

To develop concise, patient-focussed, up to date, evidence-based, expert consensus recommendations for the management of hip and knee osteoarthritis (OA), which are adaptable and designed to assist physicians and allied health care professionals in general and specialist practise throughout the world.

METHODS

Sixteen experts from four medical disciplines (primary care, rheumatology, orthopaedics and evidence-based medicine), two continents and six countries (USA, UK, France, Netherlands, Sweden and Canada) formed the guidelines development team. A systematic review of existing guidelines for the management of hip and knee OA published between 1945 and January 2006 was undertaken using the validated appraisal of guidelines research and evaluation (AGREE) instrument. A core set of management modalities was generated based on the agreement between guidelines. Evidence before 2002 was based on a systematic review conducted by European League Against Rheumatism and evidence after 2002 was updated using MEDLINE, EMBASE, CINAHL, AMED, the Cochrane Library and HTA reports. The quality of evidence was evaluated, and where possible, effect size (ES), number needed to treat, relative risk or odds ratio and cost per quality-adjusted life years gained were estimated. Consensus recommendations were produced following a Delphi exercise and the strength of recommendation (SOR) for propositions relating to each modality was determined using a visual analogue scale.

RESULTS

Twenty-three treatment guidelines for the management of hip and knee OA were identified from the literature search, including six opinion-based, five evidence-based and 12 based on both expert opinion and research evidence. Twenty out of 51 treatment modalities addressed by these guidelines were universally recommended. ES for pain relief varied from treatment to treatment. Overall there was no statistically significant difference between non-pharmacological therapies [0.25, 95% confidence interval (CI) 0.16, 0.34] and pharmacological therapies (ES=0.39, 95% CI 0.31, 0.47). Following feedback from Osteoarthritis Research International members on the draft guidelines and six Delphi rounds consensus was reached on 25 carefully worded recommendations. Optimal management of patients with OA hip or knee requires a combination of non-pharmacological and pharmacological modalities of therapy. Recommendations cover the use of 12 non-pharmacological modalities: education and self-management, regular telephone contact, referral to a physical therapist, aerobic, muscle strengthening and water-based exercises, weight reduction, walking aids, knee braces, footwear and insoles, thermal modalities, transcutaneous electrical nerve stimulation and acupuncture. Eight recommendations cover pharmacological modalities of treatment including acetaminophen, cyclooxygenase-2 (COX-2) non-selective and selective oral non-steroidal anti-inflammatory drugs (NSAIDs), topical NSAIDs and capsaicin, intra-articular injections of corticosteroids and hyaluronates, glucosamine and/or chondroitin sulphate for symptom relief; glucosamine sulphate, chondroitin sulphate and diacerein for possible structure-modifying effects and the use of opioid analgesics for the treatment of refractory pain. There are recommendations covering five surgical modalities: total joint replacements, unicompartmental knee replacement, osteotomy and joint preserving surgical procedures; joint lavage and arthroscopic debridement in knee OA, and joint fusion as a salvage procedure when joint replacement had failed. Strengths of recommendation and 95% CIs are provided.

CONCLUSION

Twenty-five carefully worded recommendations have been generated based on a critical appraisal of existing guidelines, a systematic review of research evidence and the consensus opinions of an international, multidisciplinary group of experts. The recommendations may be adapted for use in different countries or regions according to the availability of treatment modalities and SOR for each modality of therapy. These recommendations will be revised regularly following systematic review of new research evidence as this becomes available.

Biomechanical analysis of rollator walking

BACKGROUND

The rollator is a very popular walking aid. However, knowledge about how a rollator affects the walking patterns is limited. Thus, the purpose of the study was to investigate the biomechanical effects of walking with and without a rollator on the walking pattern in healthy subjects.

METHODS

The walking pattern during walking with and without rollator was analyzed using a three-dimensional inverse dynamics method. Sagittal joint dynamics and kinematics of the ankle, knee and hip were calculated. In addition, hip joint dynamics and kinematics in the frontal plane were calculated. Seven healthy women participated in the study.

RESULTS

The hip was more flexed while the knee and ankle joints were less flexed/dorsiflexed during rollator walking. The ROM of the ankle and knee joints was reduced during rollator-walking. Rollator-walking caused a reduction in the knee extensor moment by 50% when compared to normal walking. The ankle plantarflexor and hip abductor moments were smaller when walking with a rollator. In contrast, the angular impulse of the hip extensors was significantly increased during rollator-walking.

CONCLUSION

Walking with a rollator unloaded the ankle and especially the knee extensors, increased the hip flexion and thus the contribution of hip extensors to produce movement. Thus, rollator walking did not result in an overall unloading of the muscles and joints of the lower extremities. However, the long-term effect of rollator walking is unknown and further investigation in this field is needed.