Intensive Gait Training for Older Adults with Symptomatic Knee Osteoarthritis

Clinically significant effects of gait modification on knee pain: A systematic review and meta-analysis

BACKGROUND

Knee pain is the main symptom of knee osteoarthritis. Walking is effective against knee pain, and some studies have shown that gait modification can also relieve this condition. However, the quality of evidence for the clinically significant effects of gait modification on knee pain has not been examined.

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the level of evidence for the clinically significant effects of gait modification on knee pain and determine if the effects are greater than the minimal clinically important difference (MCID).

METHODS

We comprehensively searched electronic databases such as MEDLINE, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, and Cumulative Index to Nursing and Allied Health Literature. Intervention studies with experimental groups who received gait modification and control groups who did not were evaluated. The Grading of Recommendations Assessment, Development and Evaluation system was used to assess the level of evidence.

RESULTS

Nine studies met the inclusion criteria. All were included in the systematic review and two in the meta-analysis. Results showed that gait modification have significant effects (p= 0.02), and the quality of evidence was very low. However, several studies have revealed that the effects of gait modification, when used as a foot-focused intervention, were greater than the MCID.

CONCLUSIONS

We concluded that there is a lack of high-quality evidence that supports the general efficacy of gait modification. Although based on low-quality evidence, when applied to the foot, it may have clinically significant effects.

Fundamentals of osteoarthritis. Rehabilitation: Exercise, diet, biomechanics, and physical therapist-delivered interventions

Insights related to the pathogenesis of osteoarthritis (OA) have informed rehabilitative treatments that aim to mitigate the influence of several known impairments and risk factors for OA, with the goal to improve pain, function, and quality of life. The purpose of this invited narrative review is to provide fundamental knowledge to non-specialists about exercise and education, diet, biomechanical interventions, and other physical therapist-delivered treatments. In addition to summarizing the rationale for common rehabilitative therapies, we provide a synthesis of current core recommendations. Robust evidence based on randomized clinical trials supports exercise with education and diet as core treatments for OA. Structured, supervised exercise therapy is advised. The mode of exercise may vary but should be individualized. The dose should be based on an initial assessment, the desired physiological changes, and progressed when appropriate. Diet combined with exercise is strongly recommended and studies demonstrate a dose-response relationship between the magnitude of weight loss and symptom improvement. Recent evidence suggests the use of technology to remotely deliver exercise, diet and education interventions is cost-effective. Although several studies support the mechanisms for biomechanical interventions (e.g., bracing, shoe inserts) and physical therapist-delivered (passive) treatments (e.g., manual therapy, electrotherapeutic modalities) fewer rigorous randomized trials support their clinical use; these therapies are sometimes recommended as adjuncts to core treatments. The mechanisms of action for all rehabilitative interventions include contextual factors such as attention and placebo effects. These effects can challenge our interpretation of treatment efficacy from clinical trials, yet also provide opportunities to maximize patient outcomes in clinical practice. When evaluating rehabilitative interventions, the field may benefit from increased emphasis on research that considers contextual factors while evaluating mechanistic, longer-term, clinically-important and policy-relevant outcome measures.

The effectiveness of exercise with behavior change techniques in people with knee osteoarthritis: A systematic review with meta-analysis

OBJECTIVE

The purpose of this systematic review with meta-analysis was to examine the effectiveness of exercise with behavior change techniques (BCTs) on core outcome sets in people with knee osteoarthritis.

LITERATURE SURVEY

We searched randomized controlled trials (RCTs) in eight databases (MEDLINE, Embase, CENTRAL, CINAHL, PsycINFO, PEDro, ICTRP, and ClinicalTrials.gov) up to November 4, 2021.

METHODOLOGY

Eligible participants were people with knee osteoarthritis. The intervention was exercise with BCTs. Primary outcomes included physical function, quality of life (QOL) 6 to 12 months after intervention, and adverse events. Secondary outcomes were knee pain, exercise adherence, mobility, and self-efficacy 3 months or more after intervention. The bias risk was assessed using the Risk of Bias 2 tool. The random-effects model was used for the meta-analysis.

SYNTHESIS

We found 16 individual BCTs, and 37.7% of trials used a single BCT. For meta-analysis, we included 21 RCTs (n = 1623). Most outcomes had a very low certainty of evidence, and the risk of bias was the consistent reason for downgrading evidence levels. The standardized mean difference (SMD) with 95% confidence interval (95% CI) was 0.00 (-0.24, 0.24) in physical function, 0.33 (-0.51, 1.17) in exercise adherence, and 0.04 (-0.39, 0.47) in self-efficacy. The risk ratio (95% CI) of adverse events was 3.6 (0.79, 16.45). QOL was not pooled due to insufficient data (very low certainty of evidence). In contrast, the SMD (95% CI) for knee pain reduction and mobility improvement was -0.33 (-0.53, -0.13) and 0.21 (-0.05, 0.47) with moderate and low certainty of evidence, respectively.

CONCLUSION

The evidence is inconclusive regarding the effectiveness of BCTs with exercises on core outcome sets. Further research should explore the effectiveness of BCTs with valid design.

PROTOCOL REGISTRATION

PROSPERO (CRD42020212904).

A Case Report on Core Muscles Training for Knee Osteoarthritis Through Core Muscles Activations and Gait Analysis

Knee osteoarthritis (OA) is a chronic joint disease that can affect all ages, but it is more common in the elderly. Pharmacological and non-pharmacological treatments have been invented evolutionarily over the years to halt this disease. Exercise is one of the first-line treatments for knee OA as well as for prevention. This case study features a 47-year-old man who has grade IV bilateral knee OA and has never had any surgery and takes fish oil daily as a supplement. His walking pattern was significantly impacted by the chronic knee discomfort he had in both legs. Thus, the walking gait of this patient was analyzed together with core muscle activation before and after two weeks of core resistance exercise intervention. The knee pain score was assessed using the Western Ontario and McMaster Universities Index (WOMAC). The outcomes of this research depict that core resistance training has the potential to be used as an alternative, non-surgical and non-pharmacological treatment for a patient with knee OA.

Sensory substitution for orthopaedic gait rehabilitation: A systematic review and meta-analysis for clinical practice guideline development

Introduction

Sensory Substitution is a biofeedback intervention whereby at least sensory system is utilised to supplement environmental information which is traditionally gathered by another sense.

Objective

To present an evidence-based overview of the feasibility and effectiveness of wearable Sensory Substitution devices on gait outcomes in orthopaedic patient populations.

Methods

This Systematic Review and Meta-Analysis was reported according to the PRISMA 2020 statement. PubMed, the Cochrane Library, Web of science and PEDro were searched for relevant published literature. Inclusion criteria limited the search strictly to patients diagnosed with an orthopaedic condition and who were randomly grouped to a Sensory Substitution intervention or conventional therapy/training or an equivalent placebo intervention.

Results

Nine Randomised Controlled Trials and three Crossover Trials investigating the effectiveness of Sensory Substitution supplemented gait training were identified and included participants with a variety of orthopaedic conditions. Meta-Analyses revealed positive findings of feasibility as well as statistical and clinical effect of the interventions in improving measures of gait speed, weight-bearing control, measures of functionality and subjective self-reporting. Meta-Analyses also revealed the interventions effects were not significant in the management of pain and retention of gait speed. Negatively reinforced Sensory Substitution biofeedback was statistically and clinically effective, whilst positively reinforced biofeedback was not.

Conclusion

For orthopaedic patient populations to improve gait speed, weight-bearing control, functionality, pain and self-report measures, the authors recommend a Sensory Substitution supplemented gait training programme with negative biofeedback on performance. The intervention should be undertaken for 20 min per day, 3 days per week for 5 weeks. The intervention should coincide with structured analgesia administration to facilitate effective pain management. Limitations of the data included some low sample sizes and large age-ranges. No financial support was provided for this study.

Effect of a programme of muscular endurance, balance and gait exercises with and without the use of flexible and minimalist shoes in older women with medial knee osteoarthritis: study protocol for a randomised controlled trial

INTRODUCTION

Studies have indicated that gait intervention programmes with minimalist shoes are effective for reducing pain, improving functionality and reducing knee joint overload in older women with knee osteoarthritis (OA). Other clinical trials with knee and foot muscle strength training and/or dynamic balance training have also shown clinical and functional effectiveness. Despite promising strategies, there is no evidence of the combination of shoes with gait intervention programmes. Thus, the objective of this randomised clinical trial is to investigate the effects of therapeutic programme of muscular resistance, balance and gait exercises with and without the use of low-cost, flexible shoes on the clinical, functional and biomechanical aspects of older women with medial knee OA.

METHODS AND ANALYSIS

This randomised controlled trial with blinded evaluators will involve 36 older women. Twenty-four older women with knee OA (medial compartment) will be randomised to the intervention groups with minimalist shoes (GIC; n=12) or in a barefoot condition (GID; n=12), and 12 older women to the control group (n=12). The intervention protocol will consist of knee-foot muscle resistance and static balance training, reactive and proactive dynamic balance training, and gait training with visual feedback. The intervention will have a duration of two consecutive months, twice a week, totalling 16 sessions. The primary outcomes will be walking pain measured by Visual Analogue Scale and questionnaires: Western Ontario McMaster Universities Osteoarthritis Index and Lequesne Algofunctional. The secondary outcomes will be: 6-min walk test, Falls Risk Awareness Questionnaire, Timed Up and Go Test, and distribution of plantar load during gait and balance by pressure platform. Data will be analysed according to an intention-to-treat approach.

ETHICS AND DISSEMINATION

This study involves human participants and was approved by the ethics committee of the Universidade Santo Amaro, School Medicine, São Paulo/SP, Brazil (N°4.091.006). Participants gave informed consent to participate in the study before taking part. Investigators will communicate trial results to participants and healthcare professionals through scientific databases, social media, publications and conferences.

TRIAL REGISTRATION NUMBER

RBR-10j4bw25 in Brazilian Clinical Trial Registry.

Effectiveness of gait retraining interventions in individuals with hip or knee osteoarthritis: A systematic review and meta-analysis

BACKGROUND

Osteoarthritis is a chronic synovial joint disease leading to pain, stiffness, and gait dysfunction, resulting in a significant health and economic burden. Gait retraining strategies and tools are used to address biomechanical gait dysfunction and symptoms in individuals with osteoarthritis. However, there is limited evidence relating to their effectiveness.

QUESTION

Do gait retraining strategies and tools improve gait biomechanics and symptoms in individuals with hip or knee osteoarthritis compared to control or alternate intervention?

METHODS

Seven databases were searched using key words relating to osteoarthritis, gait retraining, and biomechanics. A best evidence synthesis was conducted on included studies. Where available, a meta-analysis was performed, and the standardised mean difference (SMD) and 95% confidence internals (CI) were reported.

RESULTS

Eighteen studies were included. One study investigated gait retraining in participants with hip osteoarthritis and demonstrated limited evidence for improving gait biomechanics. Seventeen studies on knee osteoarthritis were included in the best evidence synthesis with six included in the meta-analysis. Gait retraining strategies which incorporated a real-time biofeedback tool, appear to have strong evidence for effectively modifying walking biomechanics. Moderate evidence was identified to support kinesiology taping improving pain scores. The meta-analysis pooled effect demonstrated significant improvements for knee adduction moment [SMD, -1.10; 95% CI. -1.85, -0.35] and the Western Ontario and McMaster Osteoarthritis Index in favour of gait retraining than a control intervention [SMD, -0.86; 95% CI. -1.33, -0.39]. All other interventions demonstrated evidence that was conflicting, limited, or not in favour of gait retraining.

CONCLUSION

Gait retraining may be beneficial for improving biomechanics and symptoms in knee osteoarthritis, however due to the high heterogeneity and limited studies in the analysis, further research is required. Further high quality randomised controlled trials for knee and especially hip osteoarthritis investigating the effects of gait retraining on biomechanics and symptoms are required.

Effectiveness of aquatic exercise in lower limb osteoarthritis: a meta-analysis of randomized controlled trials

The objective of this study was to evaluate the short-term and follow-up effectiveness of aquatic training on the health status of lower limb osteoarthritis. Randomized controlled trials (RCTs) on related topics were systematically searched in PubMed, Embase, Web of Science, the Cochrane Library, Physiotherapy Evidence Database (PEDro), the China National Knowledge Infrastructure and Wanfang databases from inception to January 2021. RevMan 5.3 was used for statistical analysis, and the standardized mean difference (SMD) was used to present pooled effect sizes. As a result, 19 RCTs (1592 patients) were included. Compared with unsupervised home exercise or usual care (land-based training excluded), aquatic training showed short-term pain relief (SMD, -0.54; 95% CI, -0.81 to -0.28), physical function improvement (SMD, -0.64; 95% CI, -1.00 to -0.28), stiffness reduction (SMD, -0.40; 95% CI, -0.79 to -0.01) and improved function in sport and recreation (SMD, -0.30; 95% CI, -0.59 to -0.02). Analyses restricted to patients with knee osteoarthritis only also confirmed the positive effects of aquatic training on most dimensions excluding physical function. At medium-term follow-ups, improvements in physical function and function in sport and recreation were observed. No significant difference was observed between arms in the above four outcomes at long-term follow-ups. All studies reported no major adverse event with relation to aquatic training, and the minor adverse events were not common. It is concluded that aquatic training likely has short-term benefits on pain, physical function, stiffness and sport ability in lower limb osteoarthritis patients, but these positive effects may not last long.

Versatile GCH Control Software for Correction of Loads Applied to Forearm Crutches During Gait Recovery Through Technological Feedback: Development and Implementation Study

Background

Measuring weight bearing is an essential aspect of clinical care for lower limb injuries such as sprains or meniscopathy surgeries. This care often involves the use of forearm crutches for partial loads progressing to full loads. Therefore, feasible methods of load monitoring for daily clinical use are needed.

Objective

The main objective of this study was to design an innovative multifunctional desktop load-measuring software that complements GCH System 2.0–instrumented forearm crutches and monitors the applied loads, displaying real-time graphical and numerical information, and enabling the correction of inaccuracies through feedback technology during assisted gait. The secondary objective was to perform a preliminary implementation trial.

Methods

The software was designed for indoor use (clinics/laboratories). This software translates the crutch sensor signal in millivolts into force units, records and analyzes data (10-80 Hz), and provides real-time effective curves of the loads exerted on crutches. It covers numerous types of extrinsic feedback, including visual, acoustic (verbal/beeps), concurrent, terminal, and descriptive feedback, and includes a clinical and research use database. An observational descriptive pilot study was performed with 10 healthy subjects experienced in bilateral assisted gait. The Wilcoxon matched-pairs signed-rank test was used to evaluate the load accuracy evolution of each subject (ie, changes in the loads exerted on crutches for each support) among various walks, which was interpreted at the 95% confidence level.

Results

GCH Control Software was developed as a multifunctional desktop tool complementing GCH System 2.0–instrumented forearm crutches. The pilot implementation of the feedback mechanism observed 96/100 load errors at baseline (walk 0, no feedback) with 7/10 subjects exhibiting crutch overloading. Errors ranged from 61.09% to 203.98%, demonstrating heterogeneity. The double-bar feedback found 54/100 errors in walk 1, 28/100 in walk 2, and 14/100 in walk 3. The first walk with double-bar feedback (walk 1) began with errors similar to the baseline walk, generally followed by attempts at correction. The Wilcoxon matched-pairs signed-rank test used to evaluate each subject’s progress showed that all participants steadily improved the accuracy of the loads applied to the crutches. In particular, Subject 9 required extra feedback with two single-bar walks to focus on the total load. The participants also corrected the load balance between crutches and fluency errors. Three subjects made one error of load balance and one subject made six fluctuation errors during the three double-bar walks. The latter subject performed additional feedback with two balance-bar walks to focus on the load balance.

Conclusions

GCH Control Software proved to be useful for monitoring the loads exerted on forearm crutches, providing a variety of feedback for correcting load accuracy, load balance between crutches, and fluency. The findings of the complementary implementation were satisfactory, although clinical trials with larger samples are needed to assess the efficacy of the different feedback mechanisms and to select the best alternatives in each case.

Load Auditory Feedback Boosts Crutch Usage in Subjects With Central Nervous System Lesions: A Pilot Study

Background: Crutches are the most common walking aids prescribed to improve mobility in subjects with central nervous system (CNS) lesions. To increase adherence to the appropriate level of crutch usage, providing load-related auditory feedback (aFB) may be a useful approach. We sensorized forearm crutches and developed a custom software to provide aFB information to both user and physical therapist (PhT).

Aim: Evaluate aFB effects on load control during gait by a self-controlled case series trial.

Methods: A single experimental session was conducted enrolling 12 CNS lesioned participants. Load on crutch was recorded during 10 Meter Walk Test performed with and without aFB. In both cases, crutch load data, and gait speed were recorded. Usability and satisfaction questionnaires were administered to participants and PhTs involved.

Results: Reliable data were obtained from eight participants. Results showed that compared to the no FB condition, aFB yielded a significant reduction in the mean load on the crutches during gait (p = 0.001). The FB did not influence gait speed or fatigue (p > 0.05). The experience questionnaire data indicated a positive experience regarding the use of aFB from both participants' and PhTs' perspectives.

Conclusion: aFB significantly improves compliance with crutch use and does not affect gait speed or fatigue by improving the load placed on crutches. The FB is perceived by users as helpful, safe, and easy to learn, and does not interfere with attention or concentration while walking. Furthermore, the PhTs consider the system to be useful, easy to learn and reliable.

Could the Evaluation of Muscle Strength Imbalances Be Used as a Predictor of Total Hip Arthroplasty?

Loss of muscle strength characterizes the period before total hip arthroplasty (THA). Little is known about whether muscle strength imbalances caused by muscle strength decline could be considered another clinical predictor for THA. This study aimed to determine whether muscle imbalances may be used as a clinical predictor for THA surgery. Thirty-six participants were enrolled in the study. Eighteen patients had THA (THA group), while 18 were healthy elders (CON group). Ipsilateral (H/Q) and bilateral (% Def) muscle imbalances of the knee were assessed. THA patients showed impairment of the extensors on the affected extremity compared to those unaffected. A comparison between the groups proved there were weakened flexors in the THA group on both extremities. A comparison of the imbalances revealed a significant bilateral imbalance of the extensors and ipsilateral imbalance of both extremities in the THA group. We computed two logistic regressions using bilateral and ipsilateral imbalance as the predictors of THA surgery. We found that bilateral extensor imbalance may be used as a predictor for THA (Nagelkerke R² = 0.22). A decrease of the bilateral extensors imbalance by 8% decreases the probability of THA by 8%. The most interesting finding is that the evaluation of the bilateral extensor imbalance may be used as another clinical predictor for THA.

The Role of Physical Activity as Conservative Treatment for Hip and Knee Osteoarthritis in Older People: A Systematic Review and Meta-Analysis

The aim of this systematic review and meta-analysis is to determine the role of physical activity as a conservative treatment for older people with knee or hip osteoarthritis. The effect on pain, physical function, stiffness, quality of life, and dynamic balance of Aquatic Exercise, Land-based Exercise, and Sports were compared in a specific population composed of osteoarthritic patients aged 65 or over. A systematic search using Pubmed-Medline, Google Scholar, and the Cochrane Library was carried out to select randomized clinical trials, observational studies, or case series that evaluated outcome measures after physical activity. Twenty randomized controlled trials (RCTs) and two case series were included in this review. Four trials were at low risk of bias (A), 12 at unclear risk of bias (B), and four at high risk of bias (C). Compared to controls, Aquatic Exercise, Land-based Exercise, Tai Chi, and Yoga showed a small to high effect for improving pain, physical function, quality of life, and stiffness. Active exercise and sport are effective to improve pain and physical function in elderly people with osteoarthritis. Nevertheless, further studies are required to validate the use of land-based exercise, aquatic exercise, or sport to treat the symptoms of older adults that suffer from knee and hip osteoarthritis.

Effectiveness of behaviour change techniques in physiotherapy interventions to promote physical activity adherence in lower limb osteoarthritis patients: A systematic review

Background

Lower limb osteoarthritis (OA) causes high levels of individual pain and disability and is an increasing socio-economic burden to global healthcare systems. Physical Activity interventions are commonly provided by physiotherapists to help patients with lower limb OA manage their clinical symptoms.

Objective

To identify and evaluate the effectiveness of behavioural change techniques (BCTs) within physiotherapy interventions to increase physical activity (PA) adherence in patients with lower limb OA.

Design

A systematic review was conducted, following Cochrane guidelines according to a published and registered protocol (CRD42016039932). Two independent researchers conducted searches, determined eligibility, assessed risk of bias (Cochrane tool), intervention fidelity (NIHBCC checklist), and coded randomised controlled trials (RCTs) for BCTs (V1 taxonomy). BCT effectiveness ratios were calculated and RCT risk of bias and intervention fidelity were summarised narratively.

Data sources

A highly sensitive search strategy was conducted on Medline, Embase, PsycINFO, CENTRAL, CINAHL and PEDro and grey literature databases from inception to January 2^nd, 2018. Reference lists of included RCTs and relevant articles were reviewed, and a citation search was conducted using Web of Science.

Eligibility criteria for selecting studies

RCTs that evaluated the effectiveness of a physiotherapy intervention that incorporated ≥1 BCT that promoted home or community-based PA adherence in patients with lower limb osteoarthritis.

Results

Twenty-four RCTs (n = 2366 participants) of variable risk of bias (RoB) (5 low; 7 moderate; 12 high) and poor intervention reporting from 10 countries were included. Heterogeneity of intervention BCTs and PA adherence outcome measures precluded meta-analysis. Thirty-one distinct BCTs were identified in 31 interventions across RCTs. In general, BCTs demonstrated higher effectiveness ratios for short-term and long-term PA adherence compared with medium-term outcomes. The BCTs ‘behavioural contract’, ‘non-specific reward’, ‘patient-led goal setting’ (behaviour), ‘self-monitoring of behaviour’, and ‘social support (unspecified) demonstrated the highest effectiveness ratios across time points to promote PA adherence.

Conclusions

BCTs demonstrate higher short and long-term than medium-term effectiveness ratios. Further research involving low RoB RCTs incorporating transparently reported interventions with pre-specified BCTs aimed at optimising lower limb OA patient PA adherence is required.

Effect of 6-week retro or forward walking program on pain, functional disability, quadriceps muscle strength, and performance in individuals with knee osteoarthritis: a randomized controlled trial (retro-walking trial)

BACKGROUND

Previous studies reported the beneficial effects of walking in individual with mild to moderate knee osteoarthritis (OA). The current study aimed to compare the effect of 6-week retro versus forward walking program versus control group on pain, functional disability, quadriceps muscle strength and physical performance in individuals with knee OA.

METHODS

A three-arm single-blinded, randomized, controlled trial and intention-to-treat analysis was conducted in outpatient physiotherapy department, King Saud University, Saudi Arabia. Sixty-eight individuals (mean age, 55.6 years; 38 female) with knee OA participated. The participants in the retro or forward walking group completed 10 min of supervised retro or forward walking training in addition to usual care, 3 days/week for 6 weeks. The control group received a routine physiotherapy program. This program comprises a combination of closed and open kinematic chain exercises, including straight leg raising, isometric quadriceps, isometric hip adduction, terminal knee extension, semi-squat, and leg press. The primary outcomes were mean pain and knee function score measured by the numerical rating scale and the Western Ontario and McMaster Universities Osteoarthritis Index, respectively. The secondary outcomes were mean score of quadriceps muscle strength and timed up and go test scores. All the outcomes were analyzed at baseline and week 6.

RESULTS

In total, 68 subjects participated in this 6-week randomized, controlled trial. The completion rates of the primary and secondary outcome measures at week 6 were 91, 87, and 82% in the retro walking, forward walking, and control groups, respectively. In the intention-to-treat analysis, the retro walking group had a greater reduction in pain intensity (mean changes, 1.8 versus 1; p = 0.01) and functional disability (mean changes, 4.8 versus 2.2; p = 0.008) than the control group. Similarly, the retro walking group had a greater improvement in the quadriceps muscle strength (mean changes, 1.7 kg versus 0.7 kg; p = 0.008) and the timed up and go test (mean changes, 0.6 s versus 0.1 s; p = 0.003) than the control group.

CONCLUSIONS

The 6-week retro walking program compared with forward walking or control groups resulted in greater reduction in pain and functional disability and improved quadriceps muscle strength and performance in individuals with knee OA.

TRIAL REGISTRATION

Controlled Trials ISRCTN12850845 , Registered 26 January 2015.

Responsiveness of the PROMIS and FAAM Instruments in Foot and Ankle Orthopedic Population

BACKGROUND:

Investigating the responsiveness of an instrument is important in order to provide meaningful interpretation of clinical outcomes. This study examined the responsiveness of the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), the PROMIS Pain Interference (PI), and the Foot and Ankle Ability Measure (FAAM) Sports subscale in an orthopedic sample with foot and ankle ailments.

METHODS:

Patients presenting to an orthopedic foot and ankle clinic during the years 2014-2017 responded to the PROMIS and FAAM instruments prior to their clinical appointments. The responsiveness of the PROMIS PF v1.2, PROMIS PI v1.1, and FAAM Sports were assessed using paired samples t test, effect size (ES), and standardized response mean (SRM) at 4 different follow-up points. A total of 785 patients with an average age of 52 years (SD = 17) were included.

RESULTS:

The PROMIS PF had ESs of 0.95 to 1.22 across the 4 time points (3, >3, 6, and <6 months) and SRMs of 1.04 to 1.43. The PROMIS PI had ESs of 1.04 to 1.63 and SRMs of 1.17 to 1.23. For the FAAM Sports, the ESs were 1.25 to 1.31 and SRMs were 1.07 to 1.20. The ability to detect changes via paired samples t test provided mixed results. But in general, the patients with improvement had statistically significant improved scores, and the worsening patients had statistically significant worse scores.

CONCLUSION:

The PROMIS PF, PROMIS PI, and FAAM Sports were sensitive and responsive to changes in patient-reported health.

LEVEL OF EVIDENCE:

Level II, prospective comparative study.

Responsiveness of the Patient-Reported Outcomes Measurement Information System (PROMIS), Neck Disability Index (NDI) and Oswestry Disability Index (ODI) instruments in patients with spinal disorders

BACKGROUND CONTEXT

The Patient-Reported Outcomes Information System (PROMIS) instruments are an important advancement in the use of PROs, but need to be evaluated with longitudinal data to determine whether they are responsive to change in specific clinical populations.

PURPOSE

The purpose of this study was to assess the responsiveness of the PROMIS Physical Function (PF), PROMIS Pain Interference (PI), Neck Disability Index (NDI), and the Oswestry Disability Index (ODI).

STUDY DESIGN/SETTING

This study entailed prospective data collection from consecutive patients aged 18 and older, visiting a university-based orthopaedic spine clinic between October 2013 and January 2017.

PATIENT SAMPLE

A total of 763 participants in the sample had a mean age of 58 (SD = 15) years and the sample was 50.2% male and 92.8% Caucasian.

OUTCOME MEASURES

The PROMIS PF and PROMIS PI Computerized Adaptive Tests along with either the NDI or ODI instruments were administered on tablet computers before clinic visits. Global rating of change questions relating to pain and function levels was also administered.

METHODS

Baseline scores were compared with follow-up scores at four different time-points from 3-months to 6-months and beyond. Patient demographics, mean scores, paired-sample t tests, Standardized Response Mean (SRM), and Effect Size (ES) were analyzed to determine instrument responsiveness. This project was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under award number U01AR067138 and the authors have no conflicts of interest to disclose.

RESULTS

The PROMIS instruments were strongly correlated with each other as well as with the NDI and ODI. Responsiveness was significant on all four instruments at every time-point assessed (paired sample t tests ranged from p < .001 to p = .049). SRM's were large and over 0.94 for every instrument at every time-point. Cohen's d ES were large and over 0.96 for all at all time-points, except for the NDI which had ES ranging from 0.74 to 0.83. This study showed large effect sizes and responsiveness of the PROMIS PF, PROMIS PI, NDI and ODI in a population of orthopaedic patients with spine pathologies.

CONCLUSION

This study demonstrates strong responsiveness of the PROMIS PF and PROMIS PI in a spine clinic population.

PROMIS and FAAM Minimal Clinically Important Differences in Foot and Ankle Orthopedics

BACKGROUND:

Establishing score points that reflect meaningful change from the patient perspective is important for interpreting patient-reported outcomes. This study estimated the minimum clinically important difference (MCID) values of 2 Patient-Reported Outcomes Measurement Information System (PROMIS) instruments and the Foot and Ankle Ability Measure (FAAM) Sports subscale within a foot and ankle orthopedic population.

METHODS:

Patients seen for foot and ankle conditions at an orthopedic clinic were administered the PROMIS Physical Function (PF) v1.2, the PROMIS Pain Interference (PI) v1.1, and the FAAM Sports at baseline and all follow-up visits. MCID estimation was conducted using anchor-based and distribution-based methods.

RESULTS:

A total of 3069 patients, mean age of 51 years (range = 18-94), were included. The MCIDs for the PROMIS PF ranged from approximately 3 to 30 points (median = 11.3) depending on the methods being used. The MCIDs ranged from 3 to 25 points (median = 8.9) for the PROMIS PI, and from 9 to 77 points (median = 32.5) for the FAAM Sports.

CONCLUSIONS:

This study established a range of MCIDs in the PROMIS PF, PROMIS PI, and FAAM Sports indicating meaningful change in patient condition. MCID values were consistent across follow-up periods, but were different across methods. Values below the 25th percentile of MCIDs may be useful for low-risk clinical decisions. Midrange values (eg, near the median) should be used for high stakes decisions in clinical practice (ie, surgery referrals). The MCID values within the interquartile range should be utilized for most decision making.

LEVEL OF EVIDENCE:

Level I, diagnostic study, testing of previously developed diagnostic measure on consecutive patients with reference standard applied.

What Are the MCIDs for PROMIS, NDI, and ODI Instruments Among Patients With Spinal Conditions?

BACKGROUND

As new Patient-Reported Outcomes Measurement Information System (PROMIS) instruments are incorporated into clinical practice, determining how large a change on these instruments represents a clinically relevant difference is important; the metric that describes this is the minimum clinically important difference (MCID). Prior research on MCIDs of the Neck Disability Index (NDI) and Oswestry Disability Index (ODI) has produced values ranging from 5 to 10 points, but these measures have not been presented in relation to MCID values of PROMIS instruments.

QUESTIONS/PURPOSES

To establish a comprehensive repository of MCID values calculated both with distribution-based and anchor-based methods for four outcomes instruments in spine care, we asked: (1) What are the MCIDs of the PROMIS Physical Function (PF); (2) the PROMIS Pain Interference (PI); (3) the NDI; and (4) the ODI among spine patients?

METHODS

We conducted a prospective study of previously tested diagnostic measures on 1945 consecutive patients with a reference standard applied. All patients aged 18 years and older visiting an orthopaedic spine clinic between October 2013 and January 2017 completed the PROMIS PF and PI, NDI, and ODI on tablet computers before their clinic visits. Patients were grouped by change level (self-report of meaningful change versus slight or no change) using an anchor question in comparison to baseline. Descriptive statistics, two anchor-based MCID values (mean change and receiver operating characteristic curve), and five distribution-based values (SD at 1/2 and 1/3 values and minimum detectable change [MDC] at 90%, 95%, and 99%) were analyzed four different times between 3 months and > 6 months of followup. A total of 1945 included patients with a wide range of spine conditions and varying treatments had a mean age of 58 years (SD = 15.5), were 51% (988 of 1945) male, 90% (1754 of 1945) self-identified as white, and 5% (94 of 1945) as Hispanic with 1% to 2% of patients refusing participation.

RESULTS

The PROMIS PF mean change scores in the changed group (much worse, worse, improved, or much improved) ranged between 7 and 8 points. MCID values ranged from 3 to 23 points depending on the method of calculation with a median of 8. For the PROMIS PI, mean change scores ranged from 8 to 9 points and MCID values from 1 to 24 points with a median of 8. For the NDI, mean change scores ranged from 13 to 18 points and MCID values ranged from 6 to 43 points with a median of 18. For the ODI, mean change ranged from 17 to 19 points and MCID values ranged from 7 to 51 points with a median of 24. For each instrument, distribution-based SD yielded the smallest values, followed by anchor-based methods, with MDC yielding the largest MCID values.

CONCLUSIONS

This study uses a range of methods for determining MCIDs of the PROMIS PF and PI, NDI, and ODI from anchor-based to distribution-based methods. MCIDs do not have a static value for a given outcome measure, but have a range of values and are dependent on the method calculated. The lowest MCIDs identified for the NDI and ODI are consistent with prior studies, but those at the upper range are much higher. Anchor-based methods are thought to be most relevant in the clinical setting and are more easily understood by clinicians, whereas the distribution-based MCIDs are useful in understanding population breadth. Lower MCID values may be most appropriate for screening purposes or low-risk effects, and the median or higher MCID values should be used for high-risk effects or outcomes.

LEVEL OF EVIDENCE

Level I, diagnostic study.

Validation of wearable visual feedback for retraining foot progression angle using inertial sensors and an augmented reality headset

Background

Gait retraining interventions using real-time biofeedback have been proposed to alter the loading across the knee joint in patients with knee osteoarthritis. Despite the demonstrated benefits of these conservative treatments, their clinical adoption is currently obstructed by the high complexity, spatial demands, and cost of optical motion capture systems. In this study we propose and evaluate a wearable visual feedback system for gait retraining of the foot progression angle (FPA).

Methods

The primary components of the system are inertial measurement units, which track the human movement without spatial limitations, and an augmented reality headset used to project the visual feedback in the visual field. The adapted gait protocol contained five different target angles ranging from 15 degrees toe-out to 5 degrees toe-in. Eleven healthy participants walked on an instrumented treadmill, and the protocol was performed using both an established laboratory visual feedback driven by optical motion capture, and the proposed wearable system.

Results and conclusions

The wearable system tracked FPA with an accuracy of 2.4 degrees RMS and ICC=0.94 across all target angles and subjects, when compared to an optical motion capture reference. In addition, the effectiveness of the biofeedback, reflected by the number of steps with FPA value ±2 degrees from the target, was found to be around 50% in both wearable and laboratory approaches. These findings demonstrate that retraining of the FPA using wearable inertial sensing and visual feedback is feasible with effectiveness matching closely an established laboratory method. The proposed wearable setup may reduce the complexity of gait retraining applications and facilitate their transfer to routine clinical practice.

Walking speed changes in response to novel user-driven treadmill control

Implementing user-driven treadmill control in gait training programs for rehabilitation may be an effective means of enhancing motor learning and improving functional performance. This study aimed to determine the effect of a user-driven treadmill control scheme on walking speeds, anterior ground reaction forces (AGRF), and trailing limb angles (TLA) of healthy adults. Twenty-three participants completed a 10-m overground walking task to measure their overground self-selected (SS) walking speeds. Then, they walked at their SS and fastest comfortable walking speeds on an instrumented split-belt treadmill in its fixed speed and user-driven control modes. The user-driven treadmill controller combined inertial-force, gait parameter, and position based control to adjust the treadmill belt speed in real time. Walking speeds, peak AGRF, and TLA were compared among test conditions using paired t-tests (α = 0.05). Participants chose significantly faster SS and fast walking speeds in the user-driven mode than the fixed speed mode (p > 0.05). There was no significant difference between the overground SS walking speed and the SS speed from the user-driven trials (p < 0.05). Changes in AGRF and TLA were caused primarily by changes in walking speed, not the treadmill controller. Our findings show the user-driven treadmill controller allowed participants to select walking speeds faster than their chosen speeds on the fixed speed treadmill and similar to their overground speeds. Since user-driven treadmill walking increases cognitive activity and natural mobility, these results suggest user-driven treadmill control would be a beneficial addition to current gait training programs for rehabilitation.

Clinical and biomechanical changes following a 4-month toe-out gait modification program for people with medial knee osteoarthritis: a randomized controlled trial

OBJECTIVE

To compare changes in knee pain, function, and loading following a 4-month progressive walking program with or without toe-out gait modification in people with medial tibiofemoral knee osteoarthritis.

DESIGN

Individuals with medial knee osteoarthritis were randomized to a 4-month program to increase walking activity with (toe-out) or without (progressive walking) concomitant toe-out gait modification. The walking program was similar between the two groups, except that the gait modification group was trained to walk with 15° more toe-out. Primary outcomes included: knee joint pain (WOMAC), foot progression angles and knee joint loading during gait (knee adduction moment (KAM)). Secondary outcomes included WOMAC function, timed stair climb, and knee flexion moments during gait.

RESULTS

Seventy-nine participants (40 in toe-out group, 39 in progressive walking group) were recruited. Intention-to-treat analysis showed no between-group differences in knee pain, function, or timed stair climb. However, the toe-out group exhibited significantly greater changes in foot progression angle (mean difference = -9.04° (indicating more toe-out), 95% CI: -11.22°, -6.86°; P < 0.001), late stance KAM (mean difference = -0.26 %BW*ht, 95% CI: -0.39 %BW*ht, -0.12 %BW*ht, P < 0.001) and KAM impulse (-0.06 %BW*ht*s, 95% CI: -0.11 %BW*ht*s, -0.01 %BW*ht*s; P = 0.031) compared to the progressive walking group at follow-up. The only between-group difference that remained at a 1-month retention assessment was foot progression angle, with greater changes in the toe-out group (mean difference = -6.78°, 95% CI: -8.82°, -4.75°; P < 0.001).

CONCLUSIONS

Though both groups experienced improvements in self-reported pain and function, only the toe-out group experienced biomechanical improvements.

TRIALS REGISTRY NUMBER

NCT02019108.

How Do Physical Therapists in the United Kingdom Manage Patients With Hip Osteoarthritis? Results of a Cross-Sectional Survey

BACKGROUND

Hip osteoarthritis (OA) is common, painful, and disabling. Physical therapists have an important role in managing patients with hip OA; however, little is known about their current management approach and whether it aligns with clinical guideline recommendations.

OBJECTIVE

The objective of this study is to describe United Kingdom (UK) physical therapists' current management of patients with hip OA and to determine whether it aligns with clinical guidelines.

DESIGN

The design is a cross-section questionnaire.

METHODS

A questionnaire was mailed to 3126 physical therapists in the UK that explored physical therapists' self-reported management of a patient with hip OA using a case vignette and clinical management questions.

RESULTS

The response rate was 52.7% (n = 1646). In total, 1148 (69.7%) physical therapists had treated a patient with hip OA in the last 6 months and were included in the analyses. A treatment package was commonly provided incorporating advice, exercise (strength training 95.9%; general physical activity 85.4%), and other nonpharmacological modalities, predominantly manual therapy (69.6%), and gait retraining (66.4%). There were some differences in reported management between physical therapists based in the National Health Service (NHS) and non-NHS-based physical therapists, including fewer treatment sessions being provided by NHS-based therapists.

LIMITATIONS

Limitations include the potential for nonresponder bias and, in clinical practice, physical therapists may manage patients with hip OA differently.

CONCLUSION

UK-based physical therapists commonly provide a package of care for patients with hip OA that is broadly in line with current clinical guidelines, including advice, exercise, and other nonpharmacological treatments. There were some differences in clinical practice between NHS and non-NHS-based physical therapists, but whether these differences impact on clinical outcomes remains unknown.

Establishing minimum clinically important difference values for the Patient-Reported Outcomes Measurement Information System Physical Function, hip disability and osteoarthritis outcome score for joint reconstruction, and knee injury and osteoarthritis outcome score for joint reconstruction in orthopaedics

AIM

To establish minimum clinically important difference (MCID) for measurements in an orthopaedic patient population with joint disorders.

METHODS

Adult patients aged 18 years and older seeking care for joint conditions at an orthopaedic clinic took the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS^® PF) computerized adaptive test (CAT), hip disability and osteoarthritis outcome score for joint reconstruction (HOOS JR), and the knee injury and osteoarthritis outcome score for joint reconstruction (KOOS JR) from February 2014 to April 2017. MCIDs were calculated using anchor-based and distribution-based methods. Patient reports of meaningful change in function since their first clinic encounter were used as an anchor.

RESULTS

There were 2226 patients who participated with a mean age of 61.16 (SD = 12.84) years, 41.6% male, and 89.7% Caucasian. Mean change ranged from 7.29 to 8.41 for the PROMIS^® PF CAT, from 14.81 to 19.68 for the HOOS JR, and from 14.51 to 18.85 for the KOOS JR. ROC cut-offs ranged from 1.97-8.18 for the PF CAT, 6.33-43.36 for the HOOS JR, and 2.21-8.16 for the KOOS JR. Distribution-based methods estimated MCID values ranging from 2.45 to 21.55 for the PROMIS^® PF CAT; from 3.90 to 43.61 for the HOOS JR, and from 3.98 to 40.67 for the KOOS JR. The median MCID value in the range was similar to the mean change score for each measure and was 7.9 for the PF CAT, 18.0 for the HOOS JR, and 15.1 for the KOOS JR.

CONCLUSION

This is the first comprehensive study providing a wide range of MCIDs for the PROMIS^® PF, HOOS JR, and KOOS JR in orthopaedic patients with joint ailments.

Technology-Based Feedback and Its Efficacy in Improving Gait Parameters in Patients with Abnormal Gait: A Systematic Review

This systematic review synthesized and analyzed clinical findings related to the effectiveness of innovative technological feedback for tackling functional gait recovery. An electronic search of PUBMED, PEDro, WOS, CINAHL, and DIALNET was conducted from January 2011 to December 2016. The main inclusion criteria were: patients with modified or abnormal gait; application of technology-based feedback to deal with functional recovery of gait; any comparison between different kinds of feedback applied by means of technology, or any comparison between technological and non-technological feedback; and randomized controlled trials. Twenty papers were included. The populations were neurological patients (75%), orthopedic and healthy subjects. All participants were adults, bar one. Four studies used exoskeletons, 6 load platforms and 5 pressure sensors. The breakdown of the type of feedback used was as follows: 60% visual, 40% acoustic and 15% haptic. 55% used terminal feedback versus 65% simultaneous feedback. Prescriptive feedback was used in 60% of cases, while 50% used descriptive feedback. 62.5% and 58.33% of the trials showed a significant effect in improving step length and speed, respectively. Efficacy in improving other gait parameters such as balance or range of movement is observed in more than 75% of the studies with significant outcomes.

CONCLUSION

Treatments based on feedback using innovative technology in patients with abnormal gait are mostly effective in improving gait parameters and therefore useful for the functional recovery of patients. The most frequently highlighted types of feedback were immediate visual feedback followed by terminal and immediate acoustic feedback.

Visual knee-kinetic biofeedback technique normalizes gait abnormalities during high-demand mobility after total knee arthroplasty

BACKGROUND

Abnormal knee mechanics frequently follow total knee arthroplasty (TKA) surgery with these deficits amplifying as task demands increase. Knee-kinetic biofeedback could provide a means of attenuating gait abnormalities. The purposes of this study were as follows: (1) to describe the gait characteristic differences between patients with TKA and non-TKA adults during level (low-demand) and decline (high-demand) walking; and (2) where differences existed, to determine the impact of knee-kinetic biofeedback on normalizing these abnormalities.

METHODS

Twenty participants six months following a primary TKA and 15 non-TKA peers underwent gait analysis testing during level and decline walking. Knee-kinetic biofeedback was implemented to patients with TKA to correct abnormal gait characteristics if observed.

RESULTS

Patients with TKA had lower knee extensor angular impulse (p<0.001), vGRF (p=0.001) and knee flexion motion (p=0.005) compared to the non-TKA group during decline walking without biofeedback. Patients with TKA normalized their knee extensor angular impulse (p=0.991) and peak vGRF (p=0.299) during decline walking when exposed to biofeedback. No between-group differences were observed during level walking. Groups were similar in age, gender, body mass index, physical activity level, pain interference and depression scores (p>0.05).

CONCLUSION

Patients with TKA demonstrate abnormal gait characteristics during a high-demand walking task when compared to non-TKA peers. Our findings indicate that knee-kinetic biofeedback can induce immediate improvements in gait characteristics during a high-demand walking task. There may be a potential role for the use of visual knee-kinetic biofeedback techniques to improve gait abnormalities during high-demand tasks following TKA.

Relationship between Kellgren-Lawrence score and 3D kinematic gait analysis of patients with medial knee osteoarthritis using a new gait system

Knee osteoarthritis (KOA) is reported to have characteristic kinematics during walking. However, the relationship between Kellgren-Lawrence (K/L) score and the 3D kinematic gait of patients with medial KOA remains unclear. Here, ninety-seven patients with medial KOA and thirty-eight asymptomatic participants were involved. Patients with medial KOA were divided into early, moderate, and severe KOA based on the K/L score. Through kinematic gait analysis, we found a relationship between K/L score and 3D kinematic gait for patients. All KOA knees had a significantly reduced range of motion. As the K/L score was increasing, the knee flexion at the heel strike and 50% of the stance phase increased while the peak knee flexion in the swing phase decreased. In addition, the adduction and femoral rotation increased internally at the heel strike, 50% of the stance phase, and maximum angle of the swing phase. Femoral translation increased anteriorly and distally at the heel strike and 50% of the stance phase. The severe group had more medial translation than the asymptomatic groups. Significant alterations of three-dimensional joint kinematics were identified in subjects suffering various severities in Chinese patients. This study provides an important reference for the treatment options, therapy assessment, and rehabilitation of KOA.

Gait deviations associated with plantar heel pain: A systematic review

BACKGROUND

Plantar heel pain is a common foot disorder associated with significant pain and gait-related disability. The aim of this systematic review was to identify gait deviations associated with plantar heel pain.

METHODS

A systematic review of articles with quantitative gait variables in individuals with plantar heel pain was conducted using the CINAHL, MEDLINE, Scopus, and Embase databases. Methodological quality was assessed using the modified Downs and Black criteria and used along with the number of studies per gait variable to determine level of evidence.

FINDINGS

Nineteen articles were included. There was strong evidence that stance phase duration is unchanged. There was moderate to strong evidence of decreased rearfoot center of pressure duration, impulse, and peak vertical ground reaction force at loading response. In compensation there was increased contact time of the midfoot and forefoot, increased midfoot and forefoot impulse, delayed time to the mid-stance vertical ground reaction force valley, and decreased peak force at terminal stance. The only quantitative measure of pronation/supination included limited evidence of increased medial forefoot and rearfoot inversion-eversion total mobility, and medial forefoot plantar flexion.

INTERPRETATION

Studies included in this review identified specific foot and ankle gait deviations in individuals with plantar heel pain compared to asymptomatic cases or limbs. The variables identified in this review may be used to assist in identifying movement-related gait dysfunction for treatment decisions or as outcome measures of recovery. Additional research is needed to increase confidence and clinical relevance of gait variables used to assess and treat individuals with PHP.

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.