Effect of unloading brace treatment on pain and function in patients with symptomatic knee osteoarthritis: the ROTOR randomized clinical trial

Knee braces for knee osteoarthritis: A scoping review and narrative 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.

Bone marrow lesions in osteoarthritis: biomarker or treatment target? A narrative review

Osteoarthritis (OA) is a leading cause of pain, functional impairment, and disability in older adults. However, there are no effective treatments to delay and reverse OA. Magnetic resonance imaging (MRI) can assess structural abnormalities of OA by directly visualizing damage and inflammatory reactions within the tissues and detecting abnormal signals in the subchondral bone marrow region. While some studies have shown that bone marrow lesions (BMLs) are one of the early signs of the development of OA and predict structural and symptomatic progression of OA, others claimed that BMLs are prevalent in the general population and have no role in the progression of OA. In this narrative review, we screened and summarized studies with different designs that evaluated the association of BMLs with joint symptoms and structural abnormalities of OA. We also discussed whether BMLs may serve as an imaging biomarker and a treatment target for OA based on existing clinical trials.

Functions and Effectiveness of Unloader, Patellofemoral, and Knee Sleeve Orthoses: A Review

Background

Knee orthoses have been extensively used as a nonsurgical approach to improving knee deficiencies. Currently, arthritic knee conditions remain the leading cause of disability, and this number is expected to increase. As the use of knee orthoses varies widely, so has their effectiveness which is still largely debatable. Here, we present the functions and effectiveness of the three most prominent knee orthotic models dedicated to supporting knee osteoarthritis-unloader, patellofemoral, and knee sleeves.

Purpose/Research Question

Considering the depth and diversity of the many clinical studies and documented laboratory reports published to date, this literature review was created to educate the clinician, patient, and researcher on common knee orthoses used for the management of arthritic knee conditions. In doing so, we discuss their design, biomechanical effects, and clinical efficacy, as well as broader outcomes, limitations, and recommendations for use.

Results/Synthesis

The knee orthoses discussed within the scope of this paper are dedicated to protecting the knee against strenuous compressive loads that may affect the patellofemoral and tibiofemoral joints of the knee. Since the knee has multiple axes of motion and articulating surfaces that experience different loads during functional activities, it can be implied that, to a large extent, knee brace designs can differ drastically. Unloader knee orthoses are designed to decrease tibiofemoral and patellofemoral joint pressures. Patellofemoral knee orthoses are designed to decrease strain on the patellofemoral and quadriceps tendons while stabilizing the patella. Knee sleeves are designed to stabilize movements, reduce pain in joints, and improve proprioception across the knee joint.

Conclusion

Although patients often report benefits from wearing braces, these benefits have not been confirmed by clinicians and scientific investigators. Results from these three orthosis types show that clinical efficacy is still elusive due to the different methodologies used by researchers.

Layman Summary

Knee orthoses also referred to as knee brace are commonly used for support and stability of the knee. Unloader knee braces are designed to relieve and support those suffering from knee osteoarthritis by improving physical impairment and reducing pain. Patellofemoral knee braces aim to help patients manage patellofemoral pain syndrome. Rehabilitative compression sleeves, also known as knee sleeves, are often used to assist patients suffering from knee pain and laxity. Important findings on the three knee braces discussed show discrepancies in results. Their effectiveness and validity are yet to be understood.

A Hybrid Anchoring Technology Composed of Reinforced Flexible Shells for a Knee Unloading Exosuit

Soft robotic wearables have emerged as an ergonomic alternative to rigid robotic wearables, commonly utilizing tension-based actuation systems. However, their soft structure's natural tendency to buckle limits their use for compression bearing applications. This study presents reinforced flexible shell (RFS) anchoring, a compliant, low-profile, ergonomic wearable platform capable of high compression resistance. RFS anchors are fabricated with soft and semirigid materials that typically buckle under compressive loads. Buckling is overcome using the wearer's leg as a support structure, reinforcing the shells with straps, and minimizing the space between the shells and the wearer's skin-enabling force transmission orders of magnitude larger. RFS anchoring performance was evaluated comparatively by examining the shift-deformation profiles of three identically designed braces fabricated with different materials: rigid, strapped RFS, and unstrapped RFS. The unstrapped RFS severely deformed before 200 N of force could be applied. The strapped RFS successfully supported 200 N of force and exhibited a nearly identical transient shift-deformation profile with the rigid brace condition. RFS anchoring technology was applied to a compression-resistant hybrid exosuit, Exo-Unloader, for knee osteoarthritis. Exo-Unloader utilizes a tendon-driven linear sliding actuation system that unloads the medial and lateral compartments of the knee. Exo-Unloader can deliver 200 N of unloading force without deforming, as indicted by its similar transient shift-deformation profile with a rigid unloader baseline. Although rigid braces effectively withstand and transmit high compressive loads, they lack compliance; RFS anchoring technology expands the application of soft and flexible materials to compression-based wearable assistive systems.

Combined Rehabilitation Protocol in the Treatment of Osteoarthritis of the Knee: Comparative Study of Extremely Low-Frequency Magnetic Fields and Soft Elastic Knee Brace Effect

The investigation of this observational case-control study aimed at determining the effectiveness of a combined treatment of extremely low-frequency electromagnetic fields (ELF) with a soft elastic knee brace versus ELF alone in knee osteoarthritis (KOA) with respect to a reduction in pain and functional recovery. We hypothesized that the combined use of ELF and a soft elastic knee brace may provide better results. Thirty-five patients (N = 35, divided into Group 1 = ELF and Group 2 = ELF with the soft elastic knee brace) were analyzed. The rehabilitative protocol consisted of 10 sessions of antiphlogistic and antiedema programs (first cycle) for 2 weeks, followed by twelve sessions of bone repair and connective tissue repair programs (second cycle) in patients with knee osteoarthritis (KOA) for 4 weeks. Patient evaluations were conducted at baseline (T0) and after 2 (T1) and 4 (T2) weeks of treatment. A follow-up evaluation was conducted 6 weeks after treatment (T3). The LIMFA© Therapy System was used to create multifrequency magnetoelectric fields with an intensity of 100 µT and a low-frequency field. The Incrediwear Cred 40 knee sleeve (Incred) was used for alleviating knee pain. The Visual Analogue Scale (VAS), the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Lysholm score (Ls) were used as outcome measures. The results showed that pain at rest (Vr), pain in motion (Vm), KOOS, and Ls were significantly affected by ELF over time. In conclusion, Group 2 had a better response in terms of pain resolution at rest (p < 0.05) and a concurrent better response at T3 in terms of functional recovery (p < 0.05).

Adjunctive therapies in addition to land-based exercise therapy for osteoarthritis of the hip or knee

BACKGROUND

Land-based exercise therapy is recommended in clinical guidelines for hip or knee osteoarthritis. Adjunctive non-pharmacological therapies are commonly used alongside exercise in hip or knee osteoarthritis management, but cumulative evidence for adjuncts to land-based exercise therapy is lacking.

OBJECTIVES

To evaluate the benefits and harms of adjunctive therapies used in addition to land-based exercise therapy compared with placebo adjunctive therapy added to land-based exercise therapy, or land-based exercise therapy only for people with hip or knee osteoarthritis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro) and clinical trials registries up to 10 June 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs of people with hip or knee osteoarthritis comparing adjunctive therapies alongside land-based exercise therapy (experimental group) versus placebo adjunctive therapies alongside land-based exercise therapy, or land-based exercise therapy (control groups). Exercise had to be identical in both groups. Major outcomes were pain, physical function, participant-reported global assessment, quality of life (QOL), radiographic joint structural changes, adverse events and withdrawals due to adverse events. We evaluated short-term (6 months), medium-term (6 to 12 months) and long-term (12 months onwards) effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias and certainty of evidence for major outcomes using GRADE.

MAIN RESULTS

We included 62 trials (60 RCTs and 2 quasi-RCTs) totalling 6508 participants. One trial included people with hip osteoarthritis, one hip or knee osteoarthritis and 59 included people with knee osteoarthritis only. Thirty-six trials evaluated electrophysical agents, seven manual therapies, four acupuncture or dry needling, or taping, three psychological therapies, dietary interventions or whole body vibration, two spa or peloid therapy and one foot insoles. Twenty-one trials included a placebo adjunctive therapy. We presented the effects stratified by different adjunctive therapies along with the overall results. We judged most trials to be at risk of bias, including 55% at risk of selection bias, 74% at risk of performance bias and 79% at risk of detection bias. Adverse events were reported in eight (13%) trials. Comparing adjunctive therapies plus land-based exercise therapy against placebo therapies plus exercise up to six months (short-term), we found low-certainty evidence for reduced pain and function, which did not meet our prespecified threshold for a clinically important difference. Mean pain intensity was 5.4 in the placebo group on a 0 to 10 numerical pain rating scale (NPRS) (lower scores represent less pain), and 0.77 points lower (0.48 points better to 1.16 points better) in the adjunctive therapy and exercise therapy group; relative improvement 10% (6% to 15% better) (22 studies; 1428 participants). Mean physical function on the Western Ontario and McMaster (WOMAC) 0 to 68 physical function (lower scores represent better function) subscale was 32.5 points in the placebo group and reduced by 5.03 points (2.57 points better to 7.61 points better) in the adjunctive therapy and exercise therapy group; relative improvement 12% (6% better to 18% better) (20 studies; 1361 participants). Moderate-certainty evidence indicates that adjunctive therapies did not improve QOL (SF-36 0 to 100 scale, higher scores represent better QOL). Placebo group mean QOL was 81.8 points, and 0.75 points worse (4.80 points worse to 3.39 points better) in the placebo adjunctive therapy group; relative improvement 1% (7% worse to 5% better) (two trials; 82 participants). Low-certainty evidence (two trials; 340 participants) indicates adjunctive therapies plus exercise may not increase adverse events compared to placebo therapies plus exercise (31% versus 13%; risk ratio (RR) 2.41, 95% confidence interval (CI) 0.27 to 21.90). Participant-reported global assessment was not measured in any studies. Compared with land-based exercise therapy, low-certainty evidence indicates that adjunctive electrophysical agents alongside exercise produced short-term (0 to 6 months) pain reduction of 0.41 points (0.17 points better to 0.63 points better); mean pain in the exercise-only group was 3.8 points and 0.41 points better in the adjunctive therapy plus exercise group (0 to 10 NPRS); relative improvement 7% (3% better to 11% better) (45 studies; 3322 participants). Mean physical function (0 to 68 WOMAC subscale) was 18.2 points in the exercise group and 2.83 points better (1.62 points better to 4.04 points better) in the adjunctive therapy plus exercise group; relative improvement 9% (5% better to 13% better) (45 studies; 3323 participants). These results are not clinically important. Mean QOL in the exercise group was 56.1 points and 1.04 points worse in the adjunctive therapies plus exercise therapy group (1.04 points worse to 3.12 points better); relative improvement 2% (2% worse to 5% better) (11 studies; 1483 participants), indicating no benefit (low-certainty evidence). Moderate-certainty evidence indicates that adjunctive therapies plus exercise probably result in a slight increase in participant-reported global assessment (short-term), with success reported by 45% in the exercise therapy group and 17% more individuals receiving adjunctive therapies and exercise (RR 1.37, 95% CI 1.15 to 1.62) (5 studies; 840 participants). One study (156 participants) showed little difference in radiographic joint structural changes (0.25 mm less, 95% CI -0.32 to -0.18 mm); 12% relative improvement (6% better to 18% better). Low-certainty evidence (8 trials; 1542 participants) indicates that adjunctive therapies plus exercise may not increase adverse events compared with exercise only (8.6% versus 6.5%; RR 1.33, 95% CI 0.78 to 2.27).

AUTHORS' CONCLUSIONS

Moderate- to low-certainty evidence showed no difference in pain, physical function or QOL between adjunctive therapies and placebo adjunctive therapies, or in pain, physical function, QOL or joint structural changes, compared to exercise only. Participant-reported global assessment was not reported for placebo comparisons, but there is probably a slight clinical benefit for adjunctive therapies plus exercise compared with exercise, based on a small number of studies. This may be explained by additional constructs captured in global measures compared with specific measures. Although results indicate no increased adverse events for adjunctive therapies used with exercise, these were poorly reported. Most studies evaluated short-term effects, with limited medium- or long-term evaluation. Due to a preponderance of knee osteoarthritis trials, we urge caution in extrapolating the findings to populations with hip osteoarthritis.

Effect of lower limb orthoses on cartilage in patients with knee osteoarthritis: A narrative review

The objective of this review was to infer how the use of an orthosis affects cartilage in patients with knee osteoarthritis. A search was performed in four different databases (Web of Science, Scopus, EMBASE, and PubMed) up to the 21st of November of 2020 to evaluate how the patient's condition was monitored. The parameters chosen for this review were medial tibial cartilage volume, x-ray evaluation, Lequesne Index, pain visual analog scale score, Western Ontario and McMaster Universities Arthritis Index pain score, and Knee Injury and Osteoarthritis Outcome Score pain subscale score. The initial search yielded a total of 12,622 documents. After thoroughly screening them, 38 were selected for analysis. Of the resulting data, only two objectively evaluated the cartilage (medial tibial cartilage volume, n = 1; x-ray evaluation, n = 1), with the remainder evaluating subjective symptoms (Lequesne Index, n = 8; pain visual analog scale score, n = 18; Western Ontario and McMaster Universities Arthritis Index pain score, n = 10; Knee Injury and Osteoarthritis Outcome Score pain subscale score, n = 10). The data did not converge toward any general outcome. The articles read demonstrated a great tendency to evaluate qualitative parameters pertinent to the symptoms of this condition or quantitative parameters related to the biomechanics of the knee. However, these parameters are not ideal because they are ambiguous. As such, a shift toward more objective quantitative parameters that directly assess the cartilage volume of the knee should be considered in future clinical trials.

It Hurts to Move! Intervention Effects and Assessment Methods for Movement-Evoked Pain in Patients With Musculoskeletal Pain: A Systematic Review with Meta-analysis

OBJECTIVES

To estimate the effects of musculoskeletal rehabilitation interventions on movementevoked pain and to explore the assessment methods/protocols used to evaluate movement-evoked pain in adults with musculoskeletal pain.

DESIGN

Systematic review with meta-analysis.

LITERATURE SEARCH

Three electronic databases (PubMed, Web of Science, and Scopus) were searched.

STUDY SELECTION CRITERIA

Randomized controlled trials investigating musculoskeletal rehabilitation interventions for movement-evoked pain in adults with musculoskeletal pain were included.

DATA SYNTHESIS

Meta-analysis was conducted for outcomes with homogeneous data from at least 2 trials. The mean change in movementevoked pain was the primary outcome measure. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation framework.

RESULTS

Thirty-eight trials were included, and 60 different interventions were assessed. There was moderate-certainty evidence of a beneficial effect of exercise therapy compared to no treatment (standardized mean difference [SMD], -0.65; 95% confidence interval [CI]: -0.83, -0.47; P<.001) on movement-evoked pain in adults with musculoskeletal pain. There was low-certainty evidence of a beneficial effect of transcutaneous electrical nerve stimulation compared to no treatment (SMD, -0.46; 95% CI: -0.71, -0.21; P = .0004). There was no benefit of transcutaneous electrical nerve stimulation when compared to sham transcutaneous electrical nerve stimulation (SMD, -0.28; 95% CI: -0.60, 0.05; P = .09; moderate-certainty evidence).

CONCLUSION

There was moderate-certainty evidence that exercise therapy is effective for reducing movement-evoked pain in patients with musculoskeletal pain compared to no treatment. Consider exercise therapy as the first-choice treatment for movement-evoked pain in clinical practice. J Orthop Sports Phys Ther 2022;52(6):345-374. Epub: 05 Feb 2022. doi:10.2519/jospt.2022.10527.

An up to date on clinical prospects and management of osteoarthritis

The rising prevalence of osteoarthritis (OA) in the general population has necessitated the development of novel treatment options. It is critical to recognize the joint as a separate entity participating in degenerative processes, as well as the multifaceted nature of OA. OA is incurable because there is currently no medication that can stop or reverse cartilage or bone loss. As this point of view has attracted attention, more research is being directed toward determining how the various joint components are impacted and how they contribute to OA pathogenesis. Over the next few years, several prospective therapies focusing on inflammation, cartilage metabolism, subchondral bone remodelling, cellular senescence, and the peripheral nociceptive pathway are predicted to transform the OA therapy landscape. Stem cell therapies and the use of various biomaterials to target articular cartilage (AC) and osteochondral tissues are now being investigated in considerable detail. Currently, laboratory-made cartilage tissues are on the verge of being used in clinical settings. This review focuses on the update of clinical prospects and management of osteoarthritis, as well as future possibilities for the treatment of OA.

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Osteoarthritis (OA) is a general term that incorporates several different joint diseases.

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The exact pathophysiology of OA remains unclear.

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OA is incurable because there is currently no medication that can stop or reverse cartilage or bone loss.

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Nonsteroidal anti-inflammatory drugs are the most frequently prescribed medications to alleviate arthritic discomfort.

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Stem cell therapies to target articular cartilage and osteochondral tissues are now under investigation.

Effect of using knee valgus brace on pain and activity level over different time intervals among patients with medial knee OA: systematic review

Background

The Knee valgus brace is one of the accepted conservative interventions for patients with medial compartment knee osteoarthritis to correct the knee varus and increase functional activity level. Nevertheless, comprehensive overview of the effects of using this brace on self-reported pain activity level over time is not available. Thus, this study aimed to systematically review the effect of using this brace on pain and activity levels in the last 20 years in patients with medial compartment knee osteoarthritis.

Methods

Five databases were searched to find articles from the year 2000 to the end of November 2020: Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, PubMed, Web of Science, and Scopus. Two reviewers independently evaluated the available articles for eligibility and assessed quality. The risk of bias in each study was assessed by two reviewers independently according to the Strengthening the Reporting of Observational Studies in Epidemiology tool (STROBE) for the non-randomized controlled studies and the Cochrane risk-of-bias tool for the randomized controlled studies.

Results

Seven randomized controlled studies and 17 cohort studies (in total 579 participants) were included in the systematic review. Most of these studies found using a knee valgus brace effective in reducing pain and improving activity level over different time intervals. The majority of the included studies (14 studies) evaluated the impact of the brace for a considerably short-term (less than 6 months). Thus, limited evidence is available on the long-term use of the knee valgus brace and its associated complications.

Conclusion

The knee valgus brace is an effective conservative intervention to improve the quality of life and reduce pain during daily activities for some patients. However, the long term of using this brace is still not very convenient, and the patients who benefit most from using the brace should be identified with high methodological quality studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04513-0.

Advantages and challenges of stem cell therapy for osteoarthritis (Review)

Osteoarthritis (OA) is a degenerative disorder of the cartilage and is one of the leading causes of disability, particularly amongst the elderly, wherein patients with advanced-stage OA experience chronic pain and functional impairment of the limbs, thus resulting in a significantly reduced quality of life. The currently available treatments primarily revolve around symptom management, and is thus palliative rather than curative. The aim of the present review is to briefly discuss the limitations of some of the currently available treatments for patients with OA, and highlight the value of the potential use of stem cells in cellular therapy, which is widely regarded as the breakthrough that can address the present unmet medical needs for treatment of degenerative diseases, such as OA. The advantages of stem cell therapy, particularly mesenchymal stem cells, and the challenges involved are also discussed in this review.

Effectiveness, safety, and cost-utility of a knee brace in medial knee osteoarthritis: the ERGONOMIE randomized controlled trial

OBJECTIVE

This pragmatic, multicenter, open-label, randomized controlled trial (RCT) aimed to compare the effectiveness, safety, and cost-utility of a custom-made knee brace versus usual care over 1 year in medial knee osteoarthritis (OA).

DESIGN

120 patients with medial knee OA (VAS pain at rest >40/100), classified as Kellgren-Lawrence grade II-IV, were randomized into two groups: ODRA plus usual care (ODRA group) and usual care alone (UCA group). The primary effectiveness outcome was the change in VAS pain between M0 and M12. Secondary outcomes included changes over 1 year in KOOS (function) and OAKHQOL (quality of life) scores. Drug consumption, compliance, safety of the knee brace, and cost-utility over 1 year were also assessed.

RESULTS

The ODRA group was associated with a higher improvement in: VAS pain (adjusted mean difference of -11.8; 95% CI: -21.1 to -2.5); all KOOS subscales (pain: +8.8; 95% CI: 1.4-16.2); other symptoms (+10.4; 95% CI: 2.7-18); function in activities of daily living (+9.2; 95% CI: 1.1-17.2); function in sports and leisure (+12.3; 95% CI: 4.3-20.3); quality of life (+9.9; 95% CI: 0.9-15.9), OAKHQOL subscales (pain: +14.8; 95% CI: 5.0-24.6); and physical activities (+8.2; 95% CI: 0.6-15.8), and with a significant decrease in analgesics consumption at M12 compared with the UCA group. Despite localized side-effects, observance was good at M12 (median: 5.3 h/day). The ODRA group had a more than 85% chance of being cost-effective for a willingness-to-pay threshold of €45 000 per QALY.

CONCLUSIONS

The ERGONOMIE RCT demonstrated significant clinical benefits of an unloader custom-made knee brace in terms of improvements in pain, function, and some aspects of quality of life over 1 year in medial knee OA, as well as its potential cost-utility from a societal perspective.

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.

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.

Design and Preliminary Implementation of an Air Microfluidics Enabled Soft Robotic Knee Brace Towards the Management of Osteoarthritis

A dynamic and low-profile unloader tibiofemoral knee brace is designed and prototyped by synergizing concepts from the fields of microfluidics and soft robotics. Microfluidics provides strategies for miniaturization and multiplexing while soft robotics afford the tools to create soft fluidic actuators and allow compliant and inherently safe robotic assistance as part of clothing. The unloader knee brace provides dynamic response during the gait cycle, where a three-point leverage torque is provided only during the stance phase to contribute to joint stability when required and enhance comfort and compliance.Clinical Relevance- This novel soft robotic brace has the potential to reduce device abandonment due to aesthetics, user non-compliance and discomfort due to a constant three-point leverage torque during the gait cycle. Also, this air microfluidics enabled soft robotic knee brace could be expanded upon to improve the efficacy of braces in general and augment the effects of physical therapy, rehabilitation and treatment of musculoskeletal conditions.

Where Two Common Conditions of Aging Meet: Osteoarthritis and Sarcopenia

Osteoarthritis and sarcopenia are the most frequently described musculoskeletal disorders in older persons but the intertwining of these conditions and of their functional and cellular causes is complex. This narrative review aims to identify the links between osteoarthritis and sarcopenia described 1-in clinical studies, 2-in in vitro studies, and 3-the available treatment strategies for both conditions. Electronic databases were used for the literature search of all studies investigating the relationship between sarcopenia and the presence of concomitant osteoarthritis. This review identified a limited number of clinical and morphometric studies on the complex relationship between osteoarthritis and sarcopenia. Studies present a number of methodological limitations due to definition and assessment of both entities. Low lean mass is one of the main actors of this cross-talk between muscle and bone, and adipose tissue plays a major role that had been underestimated. Bone Morphogenetic Proteins and myostatin pathways are key mediators and play an important role in both muscle and bone homeostasis. Common therapeutic recommendations are still missing. There is a need for good quality prospective studies on concomitant sarcopenia and osteoarthritis, more translational research, and pharmacological and non-pharmacological therapies in order to identify common denominators for the management of sarcopenia, osteoarthritis, and their comorbidities.

Valgus knee bracing may have no long-term effect on pain improvement and functional activity in patients with knee osteoarthritis: a meta-analysis of randomized trials

Background

Knee osteoarthritis (KOA), with a high incidence in old-age population, adversely affects their life quality. The valgus knee bracing is an important physical therapy for KOA, but its clinical effects on pain release and functional improvement remained unclear. This meta-analysis is to systematically evaluate the clinical outcomes of valgus knee bracing in patients with KOA.

Methods

A meta-analysis of clinical randomized controlled trials (RCTs) on pain and functional changes in patients with KOA after using valgus knee braces. The search period was ranged from the inception of the database to May 2020. The enrolled research databases included PubMed, Embase, and Web of Science databases. Two investigators independently formulated inclusion criteria and exclusion criteria and screened and determined the final enrolled literature. Then the outcome indicators were extracted and organized from the included literature, and the risk of bias was assessed by Cochrane Handbook 5.0.1.

Results

A total of 10 articles were included in this study, including 739 patients. Eight articles were related to the visual analog scale (VAS) pain score, and the results showed that RR = − 0.29, 95% CI − 0.73, 0.15], P = 0.20; four articles were related to the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score, and the results showed that RR = − 0.15, 95% CI [− 0.41, 0.11], P = 0.26; two articles were related to the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the results showed that RR = 0.58, 95% CI [− 4.25, 5.42], P = 0.81; and three articles were related to the KOOS Activities of Daily Living (KOOS-ADL), and the results showed that RR = 0.04, 95% CI [− 0.62, 0.69], P = 0.91. These results indicated that the valgus knee bracing has no statistical significance in pain and functional activity improvement of patients with KOA. The subgroup analysis showed that the follow-up time was the source of the heterogeneity of the VAS pain score.

Conclusion

Our current evidence suggests that valgus knee bracing may not improve pain release and function activates in KOA patients in the long-term period, but only being beneficial to the short-term rehabilitation.

Methods for evaluating effects of unloader knee braces on joint health: a review

The paper aims to provide a state-of-the-art review of methods for evaluating the effectiveness and effect of unloader knee braces on the knee joint and discuss their limitations and future directions. Unloader braces are prescribed as a non-pharmacological conservative treatment option for patients with medial knee osteoarthritis to provide relief in terms of pain reduction, returning to regular physical activities, and enhancing the quality of life. Methods used to evaluate and monitor the effectiveness of these devices on patients' health are categorized into three broad categories (perception-, biochemical-, and morphology-based), depending upon the process and tools used. The main focus of these methods is on the short-term clinical outcome (pain or unloading efficiency). There is a significant technical, research, and clinical literature gap in understanding the short- and long-term consequences of these braces on the tissues in the knee joint, including the cartilage and ligaments. Future research directions may complement existing methods with advanced quantitative imaging (morphological, biochemical, and molecular) and numerical simulation are discussed as they offer potential in assessing long-term and post-bracing effects on the knee joint.