The effects of a sleeve knee brace during stair negotiation in patients with symptomatic patellofemoral osteoarthritis

BACKGROUND

The patellofemoral joint is an important source of pain in knee osteoarthritis. Most biomechanical research in knee osteoarthritis has focused on the tibiofemoral joint during level walking. It is unknown what happens during stair negotiation in patients with patellofemoral joint osteoarthritis, a task commonly increasing pain. Conservative therapy for patellofemoral joint osteoarthritis includes the use of a sleeve knee brace. We aimed to examine the effect of a sleeve knee brace on knee biomechanics during stair negotiation in patellofemoral joint osteoarthritis patients.

METHODS

30 patellofemoral joint osteoarthritis patients (40-70 years) ascended and descended an instrumented staircase with force plates under two conditions - wearing a Lycra flexible knee support (Bioskin Patellar Tracking Q Brace) and no brace (control condition). Knee joint kinematics (VICON) and kinetics were recorded.

FINDINGS

During stair ascent, at the knee, the brace significantly reduced the maximal flexion angle (2.70, P = 0.002), maximal adduction angle (2.00, P = 0.044), total sagittal range of motion (2.00, P = 0.008), total frontal range of motion (1.70, P = 0.023) and sagittal peak extension moment (0.05 Nm/kg, P = 0.043) compared to control. During stair descent, at the knee, the brace significantly reduced the maximal flexion angle (1.80, P = 0.039) and total sagittal range of motion (1.50, P = 0.045) compared to control.

INTERPRETATION

The small changes in knee joint biomechanics during stair negotiation observed in our study need to be investigated further to help explain mechanisms behind the potential benefits of a sleeve knee brace for painful patellofemoral joint osteoarthritis.

Individuals with knee osteoarthritis demonstrate increased passive stiffness of the hip flexor muscles

BACKGROUND

People with knee osteoarthritis stand and walk with increased trunk flexion. This altered postural alignment increases hamstring activation, elevating mechanical knee loads during walking. Increased hip flexor stiffness may lead to increased trunk flexion. Therefore, this study compared hip flexor stiffness between healthy individuals and individuals with knee osteoarthritis. This study also sought to understand the biomechanical effect of a simple instruction to reduce trunk flexion by 5° during walking.

METHODS

Twenty individuals with confirmed knee osteoarthritis and 20 healthy individuals participated. The Thomas test was used to quantity passive stiffness of the hip flexor muscles and three-dimensional motion analysis used to quantify trunk flexion during normal walking. Using a controlled biofeedback protocol, each participant was then instructed to decrease trunk flexion by 5°.

RESULTS

Passive stiffness was greater in the group with knee osteoarthritis (effect size = 1.04). For both groups, there was relatively strong correlation between passive stiffness and trunk flexion in walking (r = 0.61-0.72). The instruction to decrease trunk flexion produced only small, non-significant, reductions in hamstring activation during early stance.

CONCLUSIONS

This is the first study to demonstrate that individuals with knee osteoarthritis exhibit increased passive stiffness of the hip muscles. This increased stiffness appears to be linked to increased trunk flexion and may therefore underlie the increased hamstring activation which is associated with this disease. As simple postural instruction does not appear to reduce hamstring activity, interventions may be required which can improve postural alignment by reducing passive stiffness of the hip muscles.

The use of technology to support lifestyle interventions in knee osteoarthritis: A scoping review

Introduction

Technological tools that promote the adoption of physical activity to increase individuals' functional ability in knee osteoarthritis (OA) are desired to support lifestyle interventions. However, there is little consensus as to the current use of such supportive interventions for knee OA. The aim of this scoping review is therefore to provide an overview on the current use of technology within lifestyle interventions for individuals with knee OA.

Methods

Scoping review as per PRISMA guidance. Structured search of Cochrane Central Register for Controlled Trials, ELSEVIER, IEEExplore, GOOGLE Scholar, MEDLINE, PEDRO, PUBMED, WEB OF SCIENCE from 2010 to 2020 inclusive. Hits were screened by title and abstract and then full text review based on pre-defined criteria. Results were synthesised and pooled by theme for reporting.

Results

2508 papers were identified, and following review, 78 studies included. Papers included interventions for individuals with knee osteoarthritis (n ​= ​31), total or partial knee arthroplasty (n ​= ​20) and developmental work in healthy controls (n ​= ​27). Of the 78 studies, 47 were carried out in laboratory settings and 31 in the field. The identified themes included Movement measurement (n ​= ​24), Tele-rehabilitation (n ​= ​22), Biofeedback (n ​= ​20), Directly applied interventions (n ​= ​3), Virtual or augmented reality (n ​= ​5) and Machine learning (n ​= ​4).

Conclusions

The predominant current use of technology in OA lifestyle interventions is through well-established telecommunication and commercially available activity, joint angle and loading based measurement devices, while integrating new advanced technologies seems a longer-term goal. There is great potential for the engineering and clinical community to use technology to develop systems that offer real-time feedback to patients and clinician as part of rehabilitative interventions to inform treatment.

The effect of sex, stature, and limb length on the preferred walk-to-run transition speed

BACKGROUND

The preferred walk-to-run transition speed (PTS) for healthy adults is approximately 2 m∙s^-1, however, PTS is influenced by anthropometric factors. Yet despite known sex differences in anthropometrics, studies have reported no sex differences in PTS.

RESEARCH QUESTION

Do stature and limb length affect PTS in the same way for both male and female healthy adults?

METHODS

Thirty-seven (19 female) non-injured adults volunteered for this study. Participants completed a walk-to-run transition protocol, where the treadmill speed was increased from 1.2 m∙s^-1 to 2.2 m∙s^-1, in increments of 0.1 m∙s^-1 every two minutes. An independent t-test compared PTS between sexes. Multiple regression analysis determined the effect of sex and stature and sex and limb length on PTS.

RESULTS

Female participants transitioned at a lower PTS than male participants (1.8 (0.2) m∙s^-1 versus 1.9 (0.1) m∙s^-1; p ≤ 0.026). Sex and stature explained 19% of the variance in PTS, while sex and limb length explained 21% of the variance. Including interactions increased the variance explained by 23% and 2% for sex and stature and sex and limb length, respectively. The significant interaction between sex and stature showed PTS was inversely proportional to stature for male participants but directly proportional for female participants.

SIGNIFICANCE

These findings suggest that the extent to which stature and limb length influence the preferred transition speed may differ between sexes.

Research priorities to reduce the impact of musculoskeletal disorders: a priority setting exercise with the child health and nutrition research initiative method

Involving research users in setting priorities for research is essential to ensure the outcomes are patient-centred and maximise its value and impact. The Musculoskeletal Disorders Research Advisory Group Versus Arthritis led a research priority setting exercise across musculoskeletal disorders. The Child Health and Nutrition Research Initiative (CHNRI) method of setting research priorities with a range of stakeholders was used, involving four stages and two surveys, to: (1) gather research uncertainties, (2) consolidate these, (3) score uncertainties against importance and impact, and (4) analyse scoring for prioritisation. 213 people responded to the first survey and 285 people to the second, representing clinicians, researchers, and people with musculoskeletal disorders. Key priorities included developing and testing new treatments, better treatment targeting, early diagnosis, prevention, and better understanding and management of pain, with an emphasis on understanding underpinning mechanisms. We present a call to action to researchers and funders to target these priorities.

P100 Research priorities to reduce the impact of musculoskeletal disorders

Background/Aims

Involving research users in setting priorities for research is essential to ensure research outcomes are patient-centred and to maximise research value and impact. In 2019, Versus Arthritis convened a Musculoskeletal Disorders (MSKD) Research Advisory Group (RAG) which included 25 members: people with musculoskeletal conditions, researchers and healthcare professionals. The RAG identified a need for a research prioritisation exercise for adult non-inflammatory MSKD.

Methods

The Child Health and Nutrition Research Initiative (CHNRI) method was selected. The MSKD RAG identified, through consensus, four research Domains: Mechanisms of Disease; Diagnosis and Impact; Living Well with MSK disorders and Successful Translation. Following ethical approval, an initial electronic survey was distributed to stakeholders (people with musculoskeletal conditions, researchers, healthcare professionals, industry, research funders, healthcare providers, government and charities) asking for important research uncertainties in the four domains. Uncertainties were organised into themes and refined into research questions using a series of MSKD RAG workshops. Research questions underwent lay review to optimise readability. A second e-survey was distributed to stakeholders as above, where participants were asked to score each research question for two criteria, importance and impact, on a 1-10 numeric rating scale. Median criterion scores for impact and importance were calculated for each question and summed to create a total score. Research questions were ranked according to total score.

Results

The first survey had 209 respondents, who described 1290 research uncertainties, which were refined into 68 research questions. 285 people responded to the second survey, of which 189 fully completed. 74(39.2%) were public/lay responders, 48(25.4%) researchers, 43(22.8%) clinicians, 24(12.6%) other/unrecorded. The research questions, total scores and rankings are summarised in Table 1. Total scores ranged from 12 to 18 (maximum possible score 20).

Conclusion

For the first time, we have summarised priorities for research across MSKD, from discovery science to applied clinical and health research, including translation. Key priorities include developing and testing new treatments, better targeting of treatments, early diagnosis, prevention and better understanding and management of pain, with an emphasis on understanding the underpinning mechanisms. We present a call to action to researchers and funders to target these priorities.

Disclosure

Z. Paskins: Grants/research support; NIHR, Versus Arthritis, Royal Osteoporosis Society. C.E. Farmer: None. R.K. Jones: None. A. Clark: None. L. Troeberg: Grants/research support; Versus Arthritis. H. Pandit: Consultancies; Depuy J&J, Zimmer Biomet, Smith and Nephew, Medacta International, Meril Life, JRI Orthopaedics, Invibio and Kennedy’s Law. Grants/research support; NIHR, VA (Versus Arthritis) and UKIERI (UK India Education and Research Initiative). S.M. Richardson: None. J. Loughlin: None. C.A. Brown: Grants/research support; Versus Arthrtitis. E.J. Taylor: None. C.L. Le Maitre: None. R.K. Wilcox: Grants/research support; EPSRC, Versus Arthritis, NIHR, DePuy Synthes. F.L. Bishop: None. E. Salt: None. E.M. Clark: Grants/research support; Versus Arthritis, NIHR. Other; I am Associate Editor of Journal of Bone and Mineral Research Plus for which I receive a salary, I am part of the Lot 2 provider for analysis of the national Joint Registry of England and Wales, funded by HQIP. D.A. Andersson: None. M. McCarron: None. D.J. Mason: None. C.M. Wilkinson: None. T. Barlow: None. G.M. Peat: None. F.E. Watt: Consultancies; Pfizer.

Effect of a cervical collar on head and neck acceleration profiles during emergency spinal immobilisation and extrication procedures in elite football (soccer) players: protocol for a randomised, controlled cross-over trial

When immobilisation after a cervical spine or head injury is required, the role of the rigid cervical collar is unclear and controversial. There is a need for further studies investigating the use of a rigid cervical collar when head and neck trauma occurs in sport. This study will compare present practice (immobilisation with a cervical collar) to the same procedure without a collar during a simulated spinal immobilisation and extraction scenario from the field of play to the side-line in football (soccer). It will use a prospective cohort within-subjects cross over randomised, controlled trial design. Healthy participants will assume the role of players with a head or neck injury. Clinical practitioners will perform the immobilisation and extrication procedure according to current clinical guidelines. Three dimensional linear and angular acceleration profiles of the head and torso will be measured and the time taken to complete the procedure. The interventions will be a ‘cervical collar’ or ‘no collar’ in random order. Data from the IMUs will be transferred wirelessly to a computer for analysis. Accordingly, within-subject differences between each condition (collar vs no collar) will be assessed with parametric or non-parametric inferential statistics. Statistical significance will be set at p<0.05.

Trial registration number:ISRCTN16515969

A new integrated behavioural intervention for knee osteoarthritis: development and pilot study

Background

Exercise-based approaches have been a cornerstone of physiotherapy management of knee osteoarthritis for many years. However, clinical effects are considered small to modest and the need for continued adherence identified as a barrier to clinical efficacy. While exercise-based approaches focus on muscle strengthening, biomechanical research has identified that people with knee osteoarthritis over activate their muscles during functional tasks. Therefore, we aimed to create a new behavioural intervention, which integrated psychologically informed practice with biofeedback training to reduce muscle overactivity, and which was suitable for delivery by a physiotherapist.

Methods

Through literature review, we created a framework linking theory from pain science with emerging biomechanical concepts related to overactivity of the knee muscles. Using recognised behaviour change theory, we then mapped a set of intervention components which were iteratively developed through ongoing testing and consultation with patients and physiotherapists.

Results

The underlying framework incorporated ideas related to central sensitisation, motor responses to pain and also focused on the idea that increased knee muscle overactivity could result from postural compensation. Building on these ideas, we created an intervention with five components: making sense of pain, general relaxation, postural deconstruction, responding differently to pain and functional muscle retraining. The intervention incorporated a range of animated instructional videos to communicate concepts related to pain and biomechanical theory and also used EMG biofeedback to facilitate visualization of muscle patterns. User feedback was positive with patients describing the intervention as enabling them to “create a new normal” and to be “in control of their own treatment.” Furthermore, large reductions in pain were observed from 11 patients who received a prototype version of the intervention.

Conclusion

We have created a new intervention for knee osteoarthritis, designed to empower individuals with capability and motivation to change muscle activation patterns and beliefs associated with pain. We refer to this intervention as Cognitive Muscular Therapy. Preliminary feedback and clinical indications are positive, motivating future large-scale trials to understand potential efficacy. It is possible that this new approach could bring about improvements in the pain associated with knee osteoarthritis without the need for continued adherence to muscle strengthening programmes.

Trial registration

ISRCTN51913166 (Registered 24-02-2020, Retrospectively registered).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04389-0.

Frontal plane knee alignment mediates the effect of frontal plane rearfoot motion on knee joint load distribution during walking in people with medial knee osteoarthritis

OBJECTIVE

To examine the nature of differences in the relationship between frontal plane rearfoot kinematics and knee adduction moment (KAM) magnitudes.

DESIGN

Cross-sectional study resulting from a combination of overground walking biomechanics data obtained from participants with medial tibiofemoral osteoarthritis at two separate sites. Statistical models were created to examine the relationship between minimum frontal plane rearfoot angle (negative values = eversion) and different measures of the KAM, including examination of confounding, mediation, and effect modification from knee pain, radiographic disease severity, static rearfoot alignment, and frontal plane knee angle.

RESULTS

Bivariable relationships between minimum frontal plane rearfoot angle and the KAM showed consistent negative correlations (r = -0.411 to -0.447), indicating higher KAM magnitudes associated with the rearfoot in a more everted position during stance. However, the nature of this relationship appears to be mainly influenced by frontal plane knee kinematics. Specifically, frontal plane knee angle during gait was found to completely mediate the relationship between minimum frontal plane rearfoot angle and the KAM, and was also an effect modifier in this relationship. No other variable significantly altered the relationship.

CONCLUSIONS

While there does appear to be a moderate relationship between frontal plane rearfoot angle and the KAM, any differences in the magnitude of this relationship can likely be explained through an examination of frontal plane knee angle during walking. This finding suggests that interventions derived distal to the knee should account for the effect of frontal plane knee angle to have the desired effect on the KAM.

Effects of intermittent claudication due to arterial disease on pain-free gait

INTRODUCTION

Studies of intermittent claudication gait report inconsistent outcomes. Changes in gait are often attributed to degradation of calf muscles, but causation has not been proven through real-time electromyographic data. Neither have effects of walking speed been fully considered. This study aimed to investigate the effect of intermittent claudication on kinematics, kinetics and muscle activity during pain-free gait.

METHODS

18 able bodied individuals and 18 with intermittent claudication walked at their preferred speed while lower limb kinematic, kinetic and electromyography data were collected.

FINDINGS

People with intermittent claudication walk slower and with reduced step length. Internal ankle plantarflexion moment (P = 0.004, effect size = 0.96) and ankle power generation (P < 0.001, effect size = 1.36) in late stance were significantly reduced for individuals with intermittent claudication. Significant moment and power reductions at the knee and power reduction at hip occurred in early stance, with similar reductions in early and late stance for ground reaction forces. Peak electromyography of soleus activity was significantly reduced in late stance (P = 0.01, effect size = 1.1, n = 13). Effects were independent of walking speed.

INTERPRETATION

Reductions in ankle plantarflexion moments and power generation were consistent with reduced soleus electromyography activity and reduced peak vertical ground reaction forces during late stance. These effects are not due to a reduced walking speed. Changes in knee and hip function are also unrelated to walking speed. These outcomes provide a platform for the design and evaluation of interventions that seek to restore normal walking and improve pain-free walking distances for people with intermittent claudication.

Could Relative Movement Between the Adductor Muscles and the Skin Invalidate Surface Electromyography Measurement?

The superficial hip adductor muscles are situated in close proximity to each other. Therefore, relative movement between the overlying skin and the muscle belly could lead to a shift in the position of surface electromyography (EMG) electrodes and contamination of EMG signals with activity from neighboring muscles. The aim of this study was to explore whether hip movements or isometric contraction could lead to relative movement between the overlying skin and 3 adductor muscles: adductor magnus, adductor longus, and adductor gracilis. The authors also sought to investigate isometric torque-EMG relationships for the 3 adductor muscles. Ultrasound measurement showed that EMG electrodes maintained a position which was at least 5 mm within the muscle boundary across a range of hip flexion-extension angles and across different contraction levels. The authors also observed a linear relationship between torque and EMG amplitude. This is the first study to use ultrasound to track the relative motion between skin and muscle and provides new insight into electrode positioning. The findings provide confidence that ultrasound-based positioning of EMG electrodes can be used to derive meaningful information on output from the adductor muscles and constitute a step toward recognized guidelines for surface EMG measurement of the adductors.

Change in pain and its relation to change in activity in osteoarthritis

Objective

Trials testing promising interventions in knee osteoarthritis (OA) often fail to show pain reductions. This may be due to change in activity whereby a person's pain decreases, leading them to increase their activity levels, in turn increasing pain back to baseline levels. Using data from a trial of a beneficial treatment for knee pain, we explored whether activity changes might mask a treatment's effect on pain, by looking at whether activity levels increased with effective treatment and whether change in activity level related to change in pain.

Design

During the InRespond trial (ISRCTN55059760) participants wore an accelerometer for 7 days before and during treatments. We assessed change in pain on treatment using scores for overall knee pain and pain in a nominated pain-aggravating activity both in the last week and evaluated change in different types of activity using accelerometer data. Principal components analysis tested whether change in activity and pain outcomes were correlated and created composites combining them. We then tested whether activity, pain or the composites showed a treatment effect, and examined their responsiveness.

Results

In the 61 participants (mean age 64.5 years, 38% women, mean overall knee pain score 5.08 (0-10)), activity levels mostly decreased during the trial. Principal component analyses suggested that pain and activity did not correlate highly, loading on different components. Treatment that showed significant effects on pain did not show similar effects on either activity (e.g. the active treatment had a slightly greater reduction in total steps taken than the control treatment (difference 1942.6 steps/week, p = 0.42) nor on composites combining activity and pain. Pain outcomes were the most responsive; static loading (standing) outcomes were the most responsive activity outcome.

Conclusion

We found no evidence to support the hypothesis that activity levels increase during effective OA treatment and might account for the negligible pain effects of OA treatments.

Effect of Biomechanical Footwear on Knee Pain in People With Knee Osteoarthritis: The BIOTOK Randomized Clinical Trial

IMPORTANCE

Individually calibrated biomechanical footwear therapy may improve pain and physical function in people with symptomatic knee osteoarthritis, but the benefits of this therapy are unclear.

OBJECTIVE

To assess the effect of a biomechanical footwear therapy vs control footwear over 24 weeks of follow-up.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial conducted at a Swiss university hospital. Participants (N = 220) with symptomatic, radiologically confirmed knee osteoarthritis were recruited between April 20, 2015, and January 10, 2017. The last participant visit occurred on August 15, 2017.

INTERVENTIONS

Participants were randomized to biomechanical footwear involving shoes with individually adjustable external convex pods attached to the outsole (n = 111) or to control footwear (n = 109) that had visible outsole pods that were not adjustable and did not create a convex walking surface.

MAIN OUTCOMES AND MEASURES

The primary outcome was knee pain at 24 weeks of follow-up assessed with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscore standardized to range from 0 (no symptoms) to 10 (extreme symptoms). The secondary outcomes included WOMAC physical function and stiffness subscores and the WOMAC global score, all ranging from 0 (no symptoms) to 10 (extreme symptoms) at 24 weeks of follow-up, and serious adverse events.

RESULTS

Among the 220 randomized participants (mean age, 65.2 years [SD, 9.3 years]; 104 women [47.3%]), 219 received the allocated treatment and 213 (96.8%) completed follow-up. At 24 weeks of follow-up, the mean standardized WOMAC pain subscore improved from 4.3 to 1.3 in the biomechanical footwear group and from 4.0 to 2.6 in the control footwear group (between-group difference in scores at 24 weeks of follow-up, -1.3 [95% CI, -1.8 to -0.9]; P < .001). The results were consistent for WOMAC physical function subscore (between-group difference, -1.1 [95% CI, -1.5 to -0.7]), WOMAC stiffness subscore (between-group difference, -1.4 [95% CI, -1.9 to -0.9]), and WOMAC global score (between-group difference, -1.2 [95% CI, -1.6 to -0.8]) at 24 weeks of follow-up. Three serious adverse events occurred in the biomechanical footwear group compared with 9 in the control footwear group (2.7% vs 8.3%, respectively); none were related to treatment.

CONCLUSIONS AND RELEVANCE

Among participants with knee pain from osteoarthritis, use of biomechanical footwear compared with control footwear resulted in an improvement in pain at 24 weeks of follow-up that was statistically significant but of uncertain clinical importance. Further research would be needed to assess long-term efficacy and safety, as well as replication, before reaching conclusions about the clinical value of this device.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02363712.

Trunk flexion during walking in people with knee osteoarthritis

BACKGROUND

Over 50% of the body's mass is concentrated within the head, arms and trunk. Thus, small deviations in the orientation of the trunk, during normal walking, could influence the position of the centre of mass relative to the lower limb joint centres and impact on lower limb biomechanics. However, there are minimal data available on sagittal kinematics of the trunk in people with knee osteoarthritis (OA) during walking.

RESEARCH QUESTION

Do people with knee OA have altered kinematic patterns of the trunk, pelvis or hip compared with healthy control participants during walking?

METHODS

Statistical parametric mapping was used to compare sagittal and frontal plane kinematic patterns, during walking, between a healthy group and cohort of people with knee OA.

RESULTS

Individuals with knee OA walked with a mean increase in trunk flexion of 2.6°. Although this difference was more pronounced during early stance, it was maintained across the whole of stance phase. There were no differences, between the groups, in sagittal plane pelvic or hip kinematics. There were also no differences in trunk, pelvic or hip kinematics in the frontal plane.

SIGNIFICANCE

Most previous gait research investigating trunk motion in people with knee OA has focused on the frontal plane. However, our data suggest that an increase in sagittal trunk flexion may be a clinical hallmark of people with this disease. Altered trunk flexion could affect joint moments and muscle patterns and therefore our results motivate further research in this area.

The Efficacy of a Lateral Wedge Insole for Painful Medial Knee Osteoarthritis After Prescreening: A Randomized Clinical Trial

OBJECTIVE

Lateral wedge shoe insoles decrease medial knee loading, but trials have shown no effect on pain in medial knee osteoarthritis (OA). However, loading effects of insoles are inconsistent, and they can increase patellofemoral loading. We undertook this study to investigate the hypothesis that insoles would reduce pain in preselected patients.

METHODS

Among patients with painful medial knee OA, we excluded those with patellofemoral OA and those with a pain rating of <4 of a possible 10. We further excluded participants who, in a gait analysis using lateral wedges, did not show at least a 2% reduction in knee adduction moment (KAM), compared to wearing their shoes and a neutral insole. We then randomized subjects to lateral wedge versus neutral insole for 8-week periods, separated by an 8-week washout. The primary outcome measure was knee pain (0-10 scale) during the past week, and secondary outcome measures included activity pain and pain rated in the Knee Injury and Osteoarthritis Outcome Score questionnaire. We carried out mixed model analyses adjusted for baseline pain.

RESULTS

Of 83 participants, 21 (25.3%) were excluded from analysis because of insufficient reduction in KAM. In the 62 patients included in analysis, the mean ± SD age was 64.2 ± 9.1 years, and 37.1% were women. Lateral wedge insoles produced a greater reduction in knee pain than neutral insoles (mean difference of 0.7 on 0-10 scale [95% confidence interval 0.1, 1.2]) (P = 0.02). Findings for secondary outcome measures were mixed.

CONCLUSION

In participants prescreened to eliminate those with patellofemoral OA and biomechanical nonresponders, lateral wedge insoles reduced knee pain, but the effect of treatment was small and is likely of clinical significance in only a minority of patients. Targeting patients may identify those who respond to this treatment.

WITHDRAWN: Fighting for access: Research at the National Abortion Federation's 43rd Annual Meeting

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

The value of tibial mounted inertial measurement units to quantify running kinetics in elite football (soccer) players. A reliability and agreement study using a research orientated and a clinically orientated system

In elite football, measurement of running kinetics with inertial measurement units (IMUs) may be useful as a component of periodic health examination (PHE). This study determined the reliability of, and agreement between a research orientated IMU and clinically orientated IMU system for initial peak acceleration (IPA) and IPA symmetry index (SI) measurement during running in elite footballers. On consecutive days, 16 participants performed treadmill running at 14kmph and 18kmph. Both IMUs measured IPA and IPA SI concurrently. All measurements had good or excellent within-session reliability (intraclass correlation coefficient (ICC_2,1) range = 0.79-0.96, IPA standard error of measurement (SEM) range = 0.19-0.62 g, IPA SI SEM range = 2.50-8.05%). Only the research orientated IMU demonstrated acceptable minimal detectable changes (MDCs) for IPA at 14kmph (range = 7.46-9.80%) and IPA SI at both speeds (range = 6.92-9.21%). Considering both systems, between-session IPA reliability ranged from fair to good (ICC_2,1 range = 0.63-0.87, SEM range = 0.51-1.10 g) and poor to fair for IPA SI (ICC_2,1 range = 0.32-0.65, SEM range = 8.07-11.18%). All MDCs were >10%. For IPA and SI, the 95% levels of agreement indicated poor between system agreement. Therefore, the use of IMUs to evaluate treadmill running kinetics cannot be recommended in this population as a PHE test to identify prognostic factors for injuries or for rehabilitation purposes.

Orbital decompression for thyroid eye disease: methods, outcomes, and complications

PurposeTo determine the safety and effectiveness of orbital decompression for thyroid eye disease (TED) in our unit. To put this in the context of previously published literature.Patients and methodsA retrospective case review of all patients undergoing orbital decompression for TED under the care of one orbital surgeon (SMS) between January 2009 and December 2015. A systematic literature review of orbital decompression for TED.ResultsWithin the reviewed period, 93 orbits of 55 patients underwent decompression surgery for TED. There were 61 lateral (single) wall decompressions, 17 medial one-and-a-half wall, 11 two-and-a-half wall, 2 balanced two wall, and 2 orbital fat only decompressions. For the lateral (single) wall decompressions, mean reduction in exophthalmometry (95% confidence interval (CI) was 4.2 mm (3.7-4.8), for the medial one-and-a-half walls it was 2.9 mm (2.1-3.7), and for the two-and-a-half walls it was 7.6 mm (5.8-9.4). The most common complications were temporary postoperative numbness (29% of lateral decompressions, 17% of other bony decompressions, OR 0.50, 95% CI 0.12-2.11) and new postoperative diplopia (9% of lateral decompressions, 39% of other bony decompressions, OR 6.8, 95% CI 1. 5-30.9). Systematic literature searching showed reduction in exophthalmometry for lateral wall surgery of 3.6-4.8 mm, with new diplopia 0-38% and postoperative numbness 12-50%. For other bony decompressions, reduction in exophthalmometry was 2.5-8.0 mm with new diplopia 0-45% and postoperative numbness up to 52%.ConclusionDiffering approaches to orbital decompression exist. If the correct type of surgery is chosen, then safe, adequate surgical outcomes can be achieved.

Does the Powers™ strap influence the lower limb biomechanics during running?

Previous research has reported a prevalence of running related injuries in 25.9% to 72% of all runners. A greater hip internal rotation and adduction during the stance phase in running has been associated with many running related injuries, such as patellofemoral pain. Researchers in the USA designed a treatment device 'the Powers™ strap' to facilitate an external rotation of the femur and to thereby control abnormal hip and knee motion during leisure and sport activities. However, to date no literature exists to demonstrate whether the Powers™ strap is able to reduce hip internal rotation during running. 22 healthy participants, 11 males and 11 females (age: 27.45±4.43 years, height: 1.73±0.06m, mass: 66.77±9.24kg) were asked to run on a 22m track under two conditions: without and with the Powers™ strap. Three-dimensional motion analysis was conducted using ten Qualisys OQUS 7 cameras (Qualisys AB, Sweden) and force data was captured with three AMTI force plates (BP600900, Advanced Mechanical Technology, Inc.USA). Paired sample t-tests were performed at the 95% confidence interval on all lower limb kinematic and kinetic data. The Powers™ strap significantly reduced hip and knee internal rotation throughout the stance phase of running. These results showed that the Powers™ strap has the potential to influence hip motion during running related activities, in doing so this might be beneficial for patients with lower limb injuries. Future research should investigate the influence of the Powers™ strap in subjects who suffer from running related injuries, such as patellofemoral pain.

Challenging the foundations of the clinical model of foot function: further evidence that the root model assessments fail to appropriately classify foot function

BACKGROUND

The Root model of normal and abnormal foot function remains the basis for clinical foot orthotic practice globally. Our aim was to investigate the relationship between foot deformities and kinematic compensations that are the foundations of the model.

METHODS

A convenience sample of 140 were screened and 100 symptom free participants aged 18-45 years were invited to participate. The static biomechanical assessment described by the Root model was used to identify five foot deformities. A 6 segment foot model was used to measure foot kinematics during gait. Statistical tests compared foot kinematics between feet with and without foot deformities and correlated the degree of deformity with any compensatory motions.

RESULTS

None of the deformities proposed by the Root model were associated with distinct differences in foot kinematics during gait when compared to those without deformities or each other. Static and dynamic parameters were not correlated.

CONCLUSIONS

Taken as part of a wider body of evidence, the results of this study have profound implications for clinical foot health practice. We believe that the assessment protocol advocated by the Root model is no longer a suitable basis for professional practice. We recommend that clinicians stop using sub-talar neutral position during clinical assessments and stop assessing the non-weight bearing range of ankle dorsiflexion, first ray position and forefoot alignments and movement as a means of defining the associated foot deformities. The results question the relevance of the Root assessments in the prescription of foot orthoses.

The effectiveness of an exercise programme on dynamic balance in patients with medial knee osteoarthritis: A pilot study

BACKGROUND

Dynamic balance and quiet standing balance are decreased in knee osteoarthritis (OA), with dynamic balance being more affected. This study aimed to investigate the effectiveness of a group exercise programme of lower extremity muscles integrated with education on dynamic balance using the Star Excursion Balance test (SEBT) in knee OA.

METHODS

Experimental before-and-after pilot study design. Nineteen participants with knee OA attended the exercise sessions once a week for six weeks, in addition to home exercises. Before and after the exercise programme, dynamic balance was assessed using the SEBT in the anterior and medial directions in addition to hip and knee muscle strength, pain, and function.

RESULTS

Fourteen participants completed the study. Dynamic balance on the affected side demonstrated significant improvements in the anterior and medial directions (p=0.02 and p=0.01, respectively). The contralateral side demonstrated significant improvements in dynamic balance in the anterior direction (p<0.001). However, balance in the medial direction did not change significantly (p=0.07). Hip and knee muscle strength, pain, and function significantly improved (p<0.05) after the exercise programme.

CONCLUSIONS

This is the first study to explore the effect of an exercise programme on dynamic balance using the SEBT in knee OA. The exercise programme was effective in improving dynamic balance which is required in different activities of daily living where the patients might experience the risk of falling. This might be attributed to the improvement in muscle strength and pain after the exercise programme.

Harmonising data collection from osteoarthritis studies to enable stratification: recommendations on core data collection from an Arthritis Research UK clinical studies group

Objective. Treatment of OA by stratifying for commonly used and novel therapies will likely improve the range of effective therapy options and their rational deployment in this undertreated, chronic disease. In order to develop appropriate datasets for conducting post hoc analyses to inform approaches to stratification for OA, our aim was to develop recommendations on the minimum data that should be recorded at baseline in all future OA interventional and observational studies.

Methods. An Arthritis Research UK study group comprised of 32 experts used a Delphi-style approach supported by a literature review of systematic reviews to come to a consensus on core data collection for OA studies.

Results. Thirty-five systematic reviews were used as the basis for the consensus group discussion. For studies with a primary structural endpoint, core domains for collection were defined as BMI, age, gender, racial origin, comorbidities, baseline OA pain, pain in other joints and occupation. In addition to the items generalizable to all anatomical sites, joint-specific domains included radiographic measures, surgical history and anatomical factors, including alignment. To demonstrate clinical relevance for symptom studies, the collection of mental health score, self-efficacy and depression scales were advised in addition to the above.

Conclusions. Currently it is not possible to stratify patients with OA into therapeutic groups. A list of core and optional data to be collected in all OA interventional and observational studies was developed, providing a basis for future analyses to identify predictors of progression or response to treatment.

The effectiveness of an exercise programme on knee loading, muscle co-contraction, and pain in patients with medial knee osteoarthritis: A pilot study

BACKGROUND

Osteoarthritis (OA), which increases knee loading, muscle co-contraction, and pain, is a mechanical disease that requires biomechanical exploration to reduce pain in the knee. Therefore, this article aims to investigate the effectiveness of an exercise programme on the aforementioned outcomes in people with medial knee OA.

METHODS

Cohort pilot study design. A total of 19 patients with knee OA attended a six-week group exercise programme integrated with self-management education. The following outcomes were assessed before and after the exercise programme: external knee adduction moment (EKAM), knee adduction angular impulse (KAAI), knee antagonist muscle co-contraction, and pain subscale of the knee injury and osteoarthritis outcome score (KOOS).

RESULTS

Of the 19 patients, 14 completed the study. The EKAM and KAAI did not show statistical significance post-exercise intervention (p=0.21-0.7 and 0.56, respectively). Muscle co-contraction between vastus lateralis and biceps femoris muscles decreased in early-stance (64.78 (44.35) compared with 38.10 (23.10), p=0.01) and mid-stance (27.62 (32.12) compared with 14.94 (17.40), p=0.04). A corresponding significant pain reduction was observed (p=0.00) with a median (range) of 51.50 (47.00 to 62.50) at week 6 compared with 34.50 (29.25 to 41.25) at baseline.

CONCLUSION

This is the first known study to explore the effect of an exercise programme on knee loading and muscle co-contraction in patients with OA. Although the value of EKAM did not change, the findings suggest that the reduction in vastus lateralis and biceps femoris co-contraction might be the mechanism behind the reduction of pain.

The effect of different types of insoles or shoe modifications on medial loading of the knee in persons with medial knee osteoarthritis: a randomised trial

Many conservative treatments exist for medial knee osteoarthritis (OA) which aims to reduce the external knee adduction moment (EKAM). The objective of this study was to determine the difference between different shoes and lateral wedge insoles on EKAM, knee adduction angular impulse (KAAI), external knee flexion moment, pain, and comfort when walking in individuals with medial knee OA. Seventy individuals with medial knee OA underwent three-dimensional walking gait analysis in five conditions (barefoot, control shoe, typical wedge, supported wedge, and mobility shoe) with pain and comfort recorded concurrently. The change in EKAM, KAAI, external knee flexion moment, pain, and comfort were assessed using multiple linear regressions and pairwise comparisons. Compared with the control shoe, lateral wedge insoles and barefoot walking significantly reduced early stance EKAM and KAAI. The mobility shoe showed no effect. A significant reduction in latter stance EKAM was seen in the lateral wedge insoles compared to the other conditions, with only the barefoot condition reducing the external knee flexion moment. However, the mobility shoe showed significant immediate knee pain reduction and improved comfort scores. Different lateral wedge insoles show comparable reductions in medial knee loading and in our study, the mobility shoe did not affect medial loading.

Recommendations for the conduct of efficacy trials of treatment devices for osteoarthritis: a report from a working group of the Arthritis Research UK Osteoarthritis and Crystal Diseases Clinical Studies Group

OBJECTIVE

There are unique challenges to designing and carrying out high-quality trials testing therapeutic devices in OA and other rheumatic diseases. Such challenges include determining the mechanisms of action of the device and the appropriate sham. Design of device trials is more challenging than that of placebo-controlled drug trials. Our aim was to develop recommendations for designing device trials.

METHODS

An Arthritis Research UK study group comprised of 30 rheumatologists, physiotherapists, podiatrists, engineers, orthopaedists, trialists and patients, including many who have carried out device trials, met and (using a Delphi-styled approach) came to consensus on recommendations for device trials.

RESULTS

Challenges unique to device trials include defining the mechanism of action of the device and, therefore, the appropriate sham that provides a placebo effect without duplicating the action of the active device. Should there be no clear-cut mechanism of action, a three-arm trial including a no-treatment arm and one with presumed sham action was recommended. For individualized devices, generalizable indications and standardization of the devices are needed so that treatments can be generalized.

CONCLUSION

A consensus set of recommendations for device trials was developed, providing a basis for improved trial design, and hopefully improvement in the number of effective therapeutic devices for rheumatic diseases.

Ankle motion influences the external knee adduction moment and may predict who will respond to lateral wedge insoles?: an ancillary analysis from the SILK trial

OBJECTIVE

Lateral wedge insoles are a potential simple treatment for medial knee osteoarthritis (OA) patients by reducing the external knee adduction moment (EKAM). However in some patients, an increase in their EKAM is seen. Understanding the role of the ankle joint complex in the response to lateral wedge insoles is critical in understanding and potentially identifying why some patients respond differently to lateral wedge insoles.

METHOD

Participants with medial tibiofemoral OA underwent gait analysis whilst walking in a control shoe and a lateral wedge insole. We evaluated if dynamic ankle joint complex coronal plane biomechanical measures could explain and identify those participants that increased (biomechanical non-responder) or decreased (biomechanical responder) EKAM under lateral wedge conditions compared to the control shoe.

RESULTS

Of the 70 participants studied (43 male), 33% increased their EKAM and 67% decreased their EKAM. Overall, lateral wedge insoles shifted the centre of foot pressure laterally, increased eversion of the ankle/subtalar joint complex (STJ) and the eversion moment compared to the control condition. Ankle angle at peak EKAM and peak eversion ankle/STJ complex angle in the control condition predicted if individuals were likely to decrease EKAM under lateral wedge conditions.

CONCLUSIONS

Coronal plane ankle/STJ complex biomechanical measures play a key role in reducing EKAM when wearing lateral wedge insoles. These findings may assist in the identification of those individuals that could benefit more from wearing lateral wedge insoles.

Movement of the human foot in 100 pain free individuals aged 18-45: implications for understanding normal foot function

BACKGROUND

Understanding motion in the normal healthy foot is a prerequisite for understanding the effects of pathology and thereafter setting targets for interventions. Quality foot kinematic data from healthy feet will also assist the development of high quality and research based clinical models of foot biomechanics. To address gaps in the current literature we aimed to describe 3D foot kinematics using a 5 segment foot model in a population of 100 pain free individuals.

METHODS

Kinematics of the leg, calcaneus, midfoot, medial and lateral forefoot and hallux were measured in 100 self reported healthy and pain free individuals during walking. Descriptive statistics were used to characterise foot movements. Contributions from different foot segments to the total motion in each plane were also derived to explore functional roles of different parts of the foot.

RESULTS

Foot segments demonstrated greatest motion in the sagittal plane, but large ranges of movement in all planes. All foot segments demonstrated movement throughout gait, though least motion was observed between the midfoot and calcaneus. There was inconsistent evidence of movement coupling between joints. There were clear differences in motion data compared to foot segment models reported in the literature.

CONCLUSIONS

The data reveal the foot is a multiarticular structure, movements are complex, show incomplete evidence of coupling, and vary person to person. The data provide a useful reference data set against which future experimental data can be compared and may provide the basis for conceptual models of foot function based on data rather than anecdotal observations.

The relationship between reductions in knee loading and immediate pain response whilst wearing lateral wedged insoles in knee osteoarthritis

Studies of lateral wedge insoles (LWIs) in medial knee osteoarthritis (OA) have shown reductions in the average external knee adduction moment (EKAM) but no lessening of knee pain. Some treated patients actually experience increases in the EKAM which could explain the overall absence of pain response. We examined whether, in patients with painful medial OA, reductions in the EKAM were associated with lessening of knee pain. Each patient underwent gait analysis whilst walking in a control shoe and two LWI's. We evaluated the relationship between change in EKAM and change in knee pain using Spearman Rank Correlation coefficients and tested whether dichotomizing patients into biomechanical responders (decreased EKAM) and non-responders (increased EKAM) would identify those with reductions in knee pain. In 70 patients studied, the EKAM was reduced in both LWIs versus control shoe (-5.21% and -6.29% for typical and supported wedges, respectively). The change in EKAM using LWIs was not significantly associated with the direction of knee pain change. Further, 54% were biomechanical responders, but these persons did not have more knee pain reduction than non-responders. Whilst LWIs reduce EKAM, there is no clearcut relationship between change in medial load when wearing LWIs and corresponding change in knee pain.

Lateral wedge insoles as a conservative treatment for pain in patients with medial knee osteoarthritis: a meta-analysis

IMPORTANCE

There is no consensus regarding the efficacy of lateral wedge insoles as a treatment for pain in medial knee osteoarthritis.

OBJECTIVE

To evaluate whether lateral wedge insoles reduce pain in patients with medial knee osteoarthritis compared with an appropriate control.

DATA SOURCES

Databases searched include the Cochrane Central Register of Controlled Trials, EMBASE, AMED, MEDLINE, CINAHL Plus, ScienceDirect, SCOPUS, Web of Science, and BIOSIS from inception to May 2013, with no limits on study date or language. The metaRegister of Controlled Trials and the NHS Evidence website were also searched.

STUDY SELECTION

Included were randomized trials comparing shoe-based treatments (lateral heel wedge insoles or shoes with variable stiffness soles) aimed at reducing medial knee load, with a neutral or no wedge control condition in patients with painful medial knee osteoarthritis. Studies must have included patient-reported pain as an outcome.

DATA EXTRACTION AND SYNTHESIS

Trial data were extracted independently by 2 researchers using a standardized form. Risk of bias was assessed using the Cochrane Risk of Bias tool by 2 observers. Eligible studies were pooled using a random-effects approach.

MAIN OUTCOME AND MEASURES

Change in self-reported knee pain at follow-up.

RESULTS

Twelve trials met inclusion criteria with a total of 885 participants of whom 502 received lateral wedge treatment. The pooled standardized mean difference (SMD) suggested a favorable association with lateral wedges compared with control (SMD, -0.47; 95% CI, -0.80 to -0.14); however, substantial heterogeneity was present (I2 = 82.7%). This effect size represents an effect of -2.12 points on the 20-point Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain scale. Larger trials with a lower risk of bias suggested a null association. Meta-regression analyses showed that higher effect sizes (unstandardized β, 1.07 [95% CI, 0.28 to 1.87] for trials using a no treatment control) were seen in trials using a no wedge treatment control group (n = 4 trials; SMD, -1.20 [95% CI, -2.09 to -0.30]) and lower effect sizes (unstandardized β, 0.26 [95% CI, 0.002 to 0.52] for each bias category deemed low risk) when the study method was deemed at low risk of bias. Among trials in which the control treatment was a neutral insole (n = 7), lateral wedges showed no association (SMD, -0.03 [95% CI, -0.18 to 0.12] on WOMAC; this represents an effect of -0.12 points), and results showed little heterogeneity (I2 = 7.1%).

CONCLUSIONS AND RELEVANCE

Although meta-analytic pooling of all studies showed a statistically significant association between use of lateral wedges and lower pain in medial knee osteoarthritis, restriction of studies to those using a neutral insole comparator did not show a significant or clinically important association. These findings do not support the use of lateral wedges for this indication.

A comparison of the biomechanical effects of valgus knee braces and lateral wedged insoles in patients with knee osteoarthritis

Increases in the external knee adduction moment (EKAM) have been associated with increased mechanical load at the knee and progression of knee osteoarthritis. Valgus knee braces and lateral wedged insoles are common approaches to reducing this loading; however no study has directly compared the biomechanical and clinical effects of these two treatments in patients with medial tibiofemoral osteoarthritis. A cross-over randomised design was used where each intervention was worn by 28 patients for a two week period. Pre- and post-intervention gait kinematic/kinetic data and clinical outcomes were collected to evaluate the biomechanical and clinical effects on the knee joint. The valgus knee brace and the lateral wedged insole significantly increased walking speed, reduced the early stance EKAM by 7% and 12%, and the knee adduction angular impulse by 8.6 and 16.1% respectively. The lateral wedged insole significantly reduced the early stance EKAM compared to the valgus knee brace (p=0.001). The valgus knee brace significantly reduced the knee varus angle compared to the baseline and lateral wedged insole. Improvements in pain and function subscales were comparable for the valgus knee brace and lateral wedged insole. There were no significant differences between the two treatments in any of the clinical outcomes; however the lateral wedged insoles demonstrated greater levels of acceptance by patients. This is the first study to biomechanically compare these two treatments, and demonstrates that given the potential role of knee loading in osteoarthritis progression, that both treatments reduce this but lateral wedge insoles appear to have a greater effect.

A new approach to prevention of knee osteoarthritis: reducing medial load in the contralateral knee

OBJECTIVE

Few if any prevention strategies are available for knee osteoarthritis (OA). In those with symptomatic medial OA, the contralateral knee may be at high risk of disease, and a reduction in medial loading in that knee might prevent disease or its progression there. Our aim was to determine how often persons with medial OA on 1 side had either concurrent or later medial OA on the contralateral side, and whether an intervention known to reduce medial loading in affected knees with medial OA might reduce medial loading in the contralateral knee. Lateral wedge insoles reduce loading across an affected medial knee but their effect on the contralateral knee is unknown.

METHODS

To determine the proportion of persons with medial knee OA who had concurrent medial contralateral OA or developed contralateral medial OA later, we examined knee radiographs from the longitudinal Framingham Osteoarthritis Study. Then, to examine an approach to reducing medial load in the contralateral knee, 51 people from a separate study with painful medial tibiofemoral OA underwent gait analysis wearing bilateral controlled shoes with no insoles, and then with 2 types of wedge insoles laterally posted by 5°. Primary outcome was the external knee adduction moment (EKAM) in the contralateral knee. Nonparametric CI were constructed around the median differences in percentage change in the affected and contralateral sides.

RESULTS

Of Framingham subjects with medial radiograph knee OA, 137/152 (90%) either had concurrent contralateral medial OA or developed it within 10 years. Of those with medial symptomatic knee OA, 43/67 (64%) had or developed the same disease state in the contralateral knee. Compared to a control shoe, medial loading was reduced substantially on both the affected (median percentage EKAM change -4.84%; 95% CI -11.33% to -0.65%) and contralateral sides (median percentage EKAM change -9.34%; 95% CI -10.57% to -6.45%).

CONCLUSION

In persons with medial OA, the contralateral knee is also at high risk of medial OA. Bilateral reduction in medial loading in knees by use of strategies such as lateral wedge insoles might not only reduce medial load in affected knees but prevent knee OA or its progression on the contralateral side.

The physiological cost index of walking with mechanical and powered gait orthosis in patients with spinal cord injury

OBJECTIVES

Mechanical orthoses, such as the hip knee ankle foot orthosis (HKAFO) and the isocentric reciprocating gait orthosis (IRGO), are both used for walking in spinal cord injury (SCI) patients. The aim of this study was to analyze the energy expenditure during walking with these orthoses compared with a powered gait orthosis (PGO) in patients with SCI.

METHODS

Five patients with SCI who were experienced users of HKAFOs participated in this study. Subjects were also fitted with an IRGO and PGO and underwent a specific gait training program. Patients walked along a flat walkway using the three types of orthosis at their self-selected walking speed. A stop watch and a polar heart rate monitor were used to measure the speed of walking and heart rate.

RESULTS

Walking speed, the distance walked and the physiological cost index (PCI) all improved with both the new PGO and the IRGO as compared with the HKAFO.

CONCLUSIONS

A PGO can improve walking speed and the distance walked and reduce the PCI of walking as compared with mechanical orthoses, probably due to the activated movements of the lower limb joints.

Inter-assessor reliability of practice based biomechanical assessment of the foot and ankle

Background

There is no consensus on which protocols should be used to assess foot and lower limb biomechanics in clinical practice. The reliability of many assessments has been questioned by previous research. The aim of this investigation was to (i) identify (through consensus) what biomechanical examinations are used in clinical practice and (ii) evaluate the inter-assessor reliability of some of these examinations.

Methods

Part1: Using a modified Delphi technique 12 podiatrists derived consensus on the biomechanical examinations used in clinical practice. Part 2: Eleven podiatrists assessed 6 participants using a subset of the assessment protocol derived in Part 1. Examinations were compared between assessors.

Results

Clinicians choose to estimate rather than quantitatively measure foot position and motion. Poor inter-assessor reliability was recorded for all examinations. Intra-class correlation coefficient values (ICC) for relaxed calcaneal stance position were less than 0.23 and were less than 0.14 for neutral calcaneal stance position. For the examination of ankle joint dorsiflexion, ICC values suggest moderate reliability (less than 0.61). The results of a random effects ANOVA highlight that participant (up to 5.7°), assessor (up to 5.8°) and random (up to 5.7°) error all contribute to the total error (up to 9.5° for relaxed calcaneal stance position, up to 10.7° for the examination of ankle joint dorsiflexion). Kappa Fleiss values for categorisation of first ray position and mobility were less than 0.05 and for limb length assessment less than 0.02, indicating slight agreement.

Conclusion

Static biomechanical assessment of the foot, leg and lower limb is an important protocol in clinical practice, but the key examinations used to make inferences about dynamic foot function and to determine orthotic prescription are unreliable.

Effects of ramp negotiation, paving type and shoe sole geometry on toe clearance in young adults

Trips are a major cause of falls and result from involuntary contact of the foot with the ground during the swing phase of gait. Adequate toe clearance during swing is therefore crucial for safe locomotion. To date, little is known about the effects of environmental factors and footwear on toe clearance. This study reports on modulation of toe clearance and toe clearance variability in response to changes in ground inclination, paving type, and shoe sole geometry. Toe clearance and toe clearance variability for ten healthy young adults were calculated two-fold: a) for the commonly-used position on the foremost part of the sole of the shoe and b) for the lowest of a total of 7 sole positions, located between the metatarsals and the toe tip across the entire width of the sole. Utilizing a full-factorial design we found that toe clearance was affected by ground inclination, paving type, and sole geometry regardless of the computational method used (with p-values<0.01) but the use of the foremost part of the sole for toe clearance calculation results is an overestimation of this value. Our findings highlight the importance of considering footwear and environmental factors when assessing the risk of tripping. Future work needs to investigate to which extent the same factors affect toe clearance in more vulnerable parts of the population.

Orthotic control of rear foot and lower limb motion during running in participants with chronic Achilles tendon injury

This study examined the kinematic effects of orthoses in participants with a history of chronic Achilles tendon injury. Twelve participants ran at self-selected speeds on a treadmill with and without customized orthoses. Joint and segment angles including leg abduction, calcaneal, eversion, ankle dorsiflexion, and knee flexion angles were calculated from three-dimensional data throughout stance. Five footfalls were obtained for each participant and condition. Statistical tests revealed an increase in maximum eversion with orthoses (P < 0.001, eta(p)2 = 0.642). In the individual participant analysis, this was evident in 9 of 12 participants. Trends towards increased eversion range of motion and decreased ankle dorsiflexion maximum and range of motion angles were also observed. Increased eversion was unexpected as all devices were designed to provide pronation control as deemed necessary by the podiatrist. Despite this, participants reported between 50 and 100% (average 92%) relief from symptoms with the use of orthoses. Further analysis of the angle-time curves and coordination between angular measures is recommended.