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The Effect of Bracing on Varus Gonarthrosis*
Abstract
The purpose of this study was to compare a custom-made valgus-producing functional knee (unloader) brace, a neoprene sleeve, and medical treatment only (control group) with regard to their ability to improve the disease-specific quality of life and the functional status of patients who had osteoarthritis in association with a varus deformity of the knee (varus gonarthrosis).
The study design was a prospective, parallel-group, randomized clinical trial. Patients who had varus gonarthrosis were screened for eligibility. The criteria for exclusion included arthritides other than osteoarthritis; an operation on the knee within the previous six months; symptomatic disease of the hip, ankle, or foot; a previous fracture of the tibia or femur; morbid obesity (a body-mass index of more than thirty-five kilograms per square meter); skin disease; peripheral vascular disease or varicose veins that would preclude use of a brace; a severe cardiovascular deficit; blindness; poor English-language skills; and an inability to apply a brace because of physical limitations such as arthritis in the hand or an inability to bend over. Treatment was assigned on the basis of a computer-generated block method of randomization with use of sealed envelopes. The patients were stratified according to age (less than fifty years or at least fifty years), deformity (the mechanical axis in less than 5 degrees of varus or in at least 5 degrees of varus), and the status of the anterior cruciate ligament (torn or intact). The patients were randomly assigned to one of three treatment groups: medical treatment only (control group), medical treatment and use of a neoprene sleeve, or medical treatment and use of an unloader brace. The disease-specific quality of life was measured with use of the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and the McMaster-Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR), and function was assessed with use of the six-minute walking and thirty-second stair-climbing tests. The primary outcome measure consisted of an analysis of covariance of the change in scores between the baseline and six-month evaluations.
One hundred and nineteen patients were randomized. The control group consisted of forty patients (thirty-one men and nine women; mean age, 60.9 years); the neoprene-sleeve group, of thirty-eight patients (twenty-seven men and eleven women; mean age, 58.2 years); and the unloader-brace group, of forty-one patients (twenty-eight men and thirteen women; mean age, 59.5 years). Nine patients withdrew from the study. At the six-month follow-up evaluation, there was a significant improvement in the disease-specific quality of life (p = 0.001) and in function (p< or =0.001) in both the neoprene-sleeve group and the unloader-brace group compared with the control group. There was a significant difference between the unloader-brace group and the neoprene-sleeve group with regard to pain after both the six-minute walking test (p = 0.021) and the thirty-second stair-climbing test (p = 0.016). There was a strong trend toward a significant difference between the unloader-brace group and the neoprene-sleeve group with regard to the change in the WOMAC aggregate (p = 0.062) and WOMAC physical function scores (p = 0.081).
The results indicate that patients who have varus gonarthrosis may benefit significantly from use of a knee brace in addition to standard medical treatment. The unloader brace was, on the average, more effective than the neoprene sleeve. The ideal candidates for each of these bracing options remain to be identified.
... We identified 14 systematic reviews [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15] including nine primary studies [16], [17], [18], [19], [20], [21], [22], [23], [24], all of which corresponds to randomized trials. ...
... This table and the summary in general are based on six randomized trials [17], [18], [20], [22], [23], [24], since three trials [16], [19], [ 21] were excluded from the analysis due to their study design (cross-over). ...
... What types of patients were included* All trials [17], [18], [20], [22], [23], [24] included adult patients with diagnosis of symptomatic knee osteoarthritis (pain). ...
INTRODUCTION Knee osteoarthritis is a relevant health problem given its high prevalence and associated disability. Within the non-pharmacological management alternatives, the use of offloader knee braces has been proposed, however, there is no consensus in the literature regarding its indication. METHODS We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS We identified 14 systematic reviews including nine studies overall, all of which were randomized trials. We conclude that the use of offloader knee braces in patients with knee osteoarthritis probably increases physical function through walking distance. However, its use may make little or no difference to physical function measured with the Hospital for Special Surgery Knee score, it may slightly worsen the quality of life and increase adverse events, but the certainty of the evidence is low. In addition, we are uncertain whether the use of offloader knee braces reduces pain as the certainty of the evidence has been assessed as very low.
... The functional impact on activity or sport is also valuable. Upon examination of the knee, clothing should be removed to examine overall body habitus and lower extremity alignment 23 . Gait analysis, foot posture both static and dynamic is recorded. ...
... Gait analysis, foot posture both static and dynamic is recorded. Single leg weightbearing alignment recorded estimating degrees of varus or valgus and possible compartment overload conditions 23 . Hip and pelvis, quadriceps, hamstring recruitment as well as girth differences side to side are recorded. ...
... Mechanical axis abnormalities are quite easy to assess radiographically as well as on physical exam as was outlined earlier 40 . Treatment options can be as simple as adding a lateral heel wedge to shoes, or use of an unloader brace on the non-operative end of the spectrum 15,23,74 . The braces can be very effective at shifting the painful forces from the joint line to more proximal distal thigh, and more distal proximal leg. ...
The author reports that in a specialized center for musculoskeletal disorders, the presentation of patients with failure after arthroscopic knee procedures for degenerative conditions is very common and increasing in frequency. The commonly accepted notion that arthroscopic knee surgery is reserved for those with mechanical symptoms is accurate and leads to good outcomes.
However, as suggested by many, arthroscopy for pain, the results are quite unpredictable. Thus, the aim of this article is to present the concept of thinking about the degenerative painful knee not as a summation of discrete focal lesions requiring immediate surgical treatment, but as an overall diseased system that should be individually assessed, characterized, and optimized prior to ultimate intervention. Presented is an outline of alternative strategy in managing the patient with a degenerative, predominantly painful knee, utilizing many 21 st century treatment modalities.
... According to Kirkley et al [12], mal-alignment is induced over a long period by anatomic alterations of the joint and it is the most potent risk factor for structural deterioration and would eventually allow a large area of cartilage loss and bony remodeling thereby causing the joint to become tilted and thus, mal-alignment in the same joint and the lower extremity further develops [10]. For example, in the assessment of tibia torsion which is the angle formed between the transmalleoli axis and transverse axis of the knee joint [13,14,15], abnormal tibia torsion as a result of mal-alignment causes changes in the ankle and knee biomechanics during gait thus affecting external loading of the knee joint which in turn may lead to osteoarthritis [3]. ...
... The absence of relationship may be due to joint overloading or even an early onset of osteoarthritis and in comparison with healthy individuals (asymptomatic limbs) the presence of relationships among the lower extremity alignment variables is due to alignment in the absence of osteoarthritis. [19] This study agrees with Metcalfe et al, [17] and Kirkley, [12] who reported that abnormal loading of the unaffected knee of subjects with unilateral knee osteoarthritis would eventually lead to anatomic joint alterations, structural deviations of the joint and malalignment over a period of time and that individuals with a painful (symptomatic) joint may accelerate the disease of the other joint. ...
Background and Purpose: Osteoarthritis (OA) leads to destruction of cartilage and mal-alignment of structures in the knee joint leading to anatomic alterations of the joint. It has been identified that mal-alignment in the lower extremity is a potential factor that increases the risk of acute injury and osteoarthritis. Therefore, the purpose of this study was to determine the relationship among selected lower extremity alignment variables in individuals with osteoarthritis of the knee. Methods: A total of 40 individuals (mean ± SD age of 56.35 ± 9.70) with knee Osteoarthritis (KOA) were recruited in this cross sectional observational study. Six anatomical alignment characteristics (Quadriceps angle, Tibiofemoral angle, Tibial Torsion, Femoral anteversion, Genu recurvatum, Navicular drop) were measured on the left and right lower extremities of each participant. Results: There was no significant relationship (P>0.05) among the lower extremity alignment variables in subjects with unilateral symptomatic KOA. There was a significant relationship between Femoral anteversion and Genu recurvatum (r=-0.443, p= 0.039) and between Tibiofemoral angle and Tibial torsion angle (r=-0.445, p= 0.038) respectively in the left and right limbs of participants with symptomatic bilateral KOA. There was also a significance gender difference for Femoral anteversion (t=-2.803, p= 0.016) and Navicular drop (t= 2.335, p= 0.038) in participants with unilateral symptomatic right KOA and significance in gender difference for Quadriceps angle (t=-2.148, p= 0.044) in the right limb of participants with bilateral symptomatic KOA. Discussion: Mal-alignment of the lower extremity exists in individuals with unilateral and bilateral symptomatic KOA. Therefore, emphasis should be placed on not only correcting mal-alignments at the knee but also correcting mal-alignment at other segments of the lower extremity so as to further prevent disease progression in the affected and unaffected limb. Cuvinte cheie: osteoartrita simptomatică, aliniament deficient, extremități inferioare Rezumat Introducere și scop: Osteoartrita (OA) conduce la distrugerea cartilajului și alinierea greșită a structurilor din articulația genunchiului, ceea ce duce la modificări anatomice ale articulației. S-a constatat că alinierea defectioasă a extremității inferioare este un factor potențial care crește riscul de leziuni acute și osteoartrită. Prin urmare, scopul acestui studiu a fost de a determina relația dintre variabilele privind aliniamentul extremităților inferioare selectate, la persoanele cu osteoartrita genunchiului. Metode: Un total de 40 de subiecți (media ± sd vârsta de 56.35 ± 9.70) cu osteoartrita genunchiului (KOA) au fost recrutați în acest studiu transversal observațional. Au fost măsurate șase caracteristici anatomice ale aliniamentului (unghiul cvadricepsului, unghiul tibiofemoral, torsiunea tibială, anteversia femurală, genu recurvatum, coborârea ocului navicular) pentru membrele inferioare stâng și drept ale fiecărui participant. Rezultate: Nu a existat o corelație semnificativă (P> 0,05) între variabilele de aliniament la extremitățile inferioare la subiecții cu KOA simptomatic unilateral. A existat o corelație semnificativă între anteversia femurală și genu recurvatum (r =-0,443, p = 0,039) și între unghiul tibiofemoral și unghiul de torsiune tibio-lateral (r =-0,445, p = 0,038) la pacienții cu osteoartrită bilaterală. De asemenea, a existat o diferență de gen semnificativă pentru anteversia femurală (t =-2,803, p = 0,016) și picătură Navicular (t = 2,335, p = 0,038) la participanți cu osteoartrită simptomatică unilaterală și semnificație a diferenței de gen pentru unghiul Quadriceps-2.148, p = 0.044) la membrul inferior drept, la participanții cu osteoartrită simptomatică bilaterală. Discuții: Alinierea greșită a membrului inferior există la persoanele cu osteoartrită simptomatică unilaterală și bilaterală. Prin urmare, ar trebui să se pună accent nu numai pe corectarea deficiențelor de aliniament la nivelul genunchiului, ci și pe corectarea alinierii la alte segmente ale extremităților inferioare, astfel încât să se prevină progresia bolii în membrul afectat și neafectat.
... Observou-se que a dor média pós-uso é menor no Grupo de Órteses e manteve seu valor numérico no Grupo Controle, mostrando que o uso da órtese atinge o objetivo de promover analgesia em pacientes com OA medial do joelho, de acordo com várias estudos (KIRKLEY et al., 1999;ORNETTI et al., 2010;ARAZPOUR et al., 2013;FATINI PAGANI et al., 2012;FEEHAN et al., 2012;MOYER et al., 2015) Os valores obtidos na análise estatística com o Índice de Lequesne, que avalia muitas dessas atividades, mostraram significância estatística para os dois grupos estudados, mas de maneiras diferentes. No Grupo Controle, houve um aumento no escore entre os dois períodos, sugerindo que indivíduos com OA que não recebem nenhum tipo de intervenção tendem a permanecer com sua função ou mesmo a piorá-la. ...
... Por outro lado, no grupo de órteses houve uma diminuição de até 2,70 pontos, aproximadamente 25% de diminuição, mostrando que os indivíduos que usaram as órteses tiveram a função aprimorada para realizar suas atividades da vida diária com mais facilidade. Assim, nosso estudo concorda com os estudos (KIRKLEY et al., 1999;BROUWER et al., 2006;m DRAPER et al, 2000;ORNETTO et al., 2010;FATINI PAGANI et al., 2012) Os valores obtidos com a Escala WOMAC seguem os mesmos padrões do Índice de ...
... Observou-se que a dor média pós-uso é menor no Grupo de Órteses e manteve seu valor numérico no Grupo Controle, mostrando que o uso da órtese atinge o objetivo de promover analgesia em pacientes com OA medial do joelho, de acordo com várias estudos (KIRKLEY et al., 1999;ORNETTI et al., 2010;ARAZPOUR et al., 2013;FATINI PAGANI et al., 2012;FEEHAN et al., 2012;MOYER et al., 2015) Os valores obtidos na análise estatística com o Índice de Lequesne, que avalia muitas dessas atividades, mostraram significância estatística para os dois grupos estudados, mas de maneiras diferentes. No Grupo Controle, houve um aumento no escore entre os dois períodos, sugerindo que indivíduos com OA que não recebem nenhum tipo de intervenção tendem a permanecer com sua função ou mesmo a piorá-la. ...
... Por outro lado, no grupo de órteses houve uma diminuição de até 2,70 pontos, aproximadamente 25% de diminuição, mostrando que os indivíduos que usaram as órteses tiveram a função aprimorada para realizar suas atividades da vida diária com mais facilidade. Assim, nosso estudo concorda com os estudos (KIRKLEY et al., 1999;BROUWER et al., 2006;m DRAPER et al, 2000;ORNETTO et al., 2010;FATINI PAGANI et al., 2012) Os valores obtidos com a Escala WOMAC seguem os mesmos padrões do Índice de ...
... Valgus knee bracing is found to effectively correct the lower limb force lines, release pain feelings and improve joint functions of KOA patients by optimizing their biomechanical axis [10][11][12][13]. Kirkley et al [14] showed that valgus knee bracing can effectively reduce the pain symptom and joint mobility of KOA patients. ...
... Unbalance of weight bearing will somehow change the knee force lines and cause lower limb abnormality, leading to progress of KOA [10][11]. Theoretically, the valgus knee bracing can optimize the direction of force line in knee joint, further reducing pain symptoms and improving joint function [12][13]. However, the clinical e cacy of valgus knee bracing in the treatment of KOA is not clear. ...
Background: KOA, with a high incidence in old-age population, adversely affects their life quality. The valgus knee bracing is an important physical therapy for KOA, but its clinical effects on pain release and functional improvment are remained unclear. This meta-analysis is to systematically evaluate the clinical outcomes of valgus knee bracing in patients with knee osteoarthritis (KOA).
Methods : A meta-analysis of clinical randomized controlled trials (RCTs) on pain and functional changes in patients with KOA after using valgus knee braces. The search period was ranged from the inception of the database to May, 2020. The enrolled research databases included PubMed, Embase, and Web of Science databases. Two investigators independently formulated inclusion criteria and exclusion criteria, screened and determined the final enrolled literatures. Then the outcome indicators were extracted and organized from the included literature, and the risk of bias was assessed by Cochrane Handbook 5.0.1.
Results :A total of 10 articles were included in this study, including 739 patients. Eight articles were related to the Visual Analogue Scale (VAS) pain score, the results showed that RR = -0.29, 95% CI [-0.73, 0.15], P = 0.20; Four articles were related to the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score, the results showed that RR = -0.15, 95% CI [-0.41,0.11], P = 0.26; Two articles were related to the Knee Injury and Osteoarthritis Outcome Score (KOOS), the results showed that RR = 0.58, 95% CI [-4.25, 5.42], P = 0.81; Three articles were related to the KOOS activities of daily living (KOOS-ADL), the results showed that RR = 0.04, 95% CI [-0.62,0.69], P = 0.91.These results indicated that the valgus knee bracing have no statistically significant in pain and functional activity improvement of patients with KOA. The subgroup analysis showed that the follow-up time was the source of the heterogeneity of the VAS pain score.
Conclusion : Our current evidence suggests that valgus knee bracing may not improve pain release and function activates in KOA patients in the long-term period, but only being beneficial to the short-term rehabilitation.
... Knee braces are frequently used for knee OA and the American Academy Orthopaedic Surgeons recommends bracing for biomechanical stability (5). Knee malalignment associated with OA can cause significant pain and dysfunction and knee braces have shown to help with stability and function, especially in unicompartmental arthritis (36)(37)(38)(39)(40)(41)(42). There are two types of braces that are commonly used for knee OA, an unloader brace and a support brace. ...
... Kirkley and colleagues performed a randomized controlled trial comparing unloader braces and neoprene sleeves to a control group (38). Significant differences in pain after the 6-minute walk test and 30-second stairclimbing test were reported with the unloader brace when compared to neoprene brace at 6 months (P<0.05). ...
Background:
Knee osteoarthritis (OA) is a prevalent and debilitating condition for which a wide range of non-surgical treatment options are available. Although there is plethora of literature investigating their safety and efficacy, for many treatment modalities, a consensus has not yet been reached concerning efficacy. Therefore, it is essential for practitioners to understand the risks and benefits of the available treatments for the successful management of knee OA. This study explored the efficacy of non-surgical treatment options for knee OA including: (I) non-steroidal anti-inflammatory drugs (NSAIDs); (II) weight loss; (III) intra-articular injections; (IV) physical therapy; and (V) bracing.
Methods:
A comprehensive literature review of studies between 1995 and 2018 was conducted using the electronic databases PubMed and EBSCO Host. Searches were performed using the following terms: total knee arthroplasty (TKA); cyclooxygenase-2 inhibitors; bracing; physical therapy; weight loss; knee; treatment; therapeutics; OA; intra-articular injection; hyaluronic acid; corticosteroid; and alternatives. The initial search yielded 7,882 reports from which 545 relevant studies were identified. After full-text analysis, 43 studies were included for this analysis.
Results:
NSAIDs are most effective when used continuously and may be used in conjunction with other forms of treatment for knee OA as they have been shown to provide some pain relief as well as functional improvements. Weight loss is a safe and effective way to improve knee pain, function, and stiffness without adverse effects. However, it can be very challenging for obese patients with knee OA due to their limited mobility and lack of adherence to a low-calorie diet. Intra-articular injections have had mixed results, with findings from recent studies indicating long-term outcomes to be equivocal. Physical therapy leads to significant improvements in pain and function. Decreased compliance with physical therapy is thought to be due to high copayments, pain with activities, lacks of transportation, and high time commitments. Brace modalities have demonstrated significant pain and functional improvements and prolongations of the time to TKA. Additionally, they limit the need for other treatment modalities which are associated with greater risks.
Conclusions:
NSAIDs, weight loss, intraarticular injections, and physical therapy have all been shown to be effective non-surgical treatment options for knee OA. However, these options have some limitations, and are best when used in conjunction. Bracing for knee OA is a noninvasive, non-pharmacologic option which can significantly reduce pain and improve function with minimal adverse effects. Therefore, a combination of knee braces along with other non-operative modalities should be one mainstay of treatment in conjunction with other treatment modalities to reduce pain, improve function, stiffness, and mobility in knee OA.
... Citations of all included studies were searched. All studies citing relevant systematic reviews (Coghill and Simkiss, 2010;MacRae et al, 2011;Born et al, 2013;Hammond et al, 2016) and frequently cited fabric orthosis studies (Blair et al, 1995;Birmingham et al, 1998;Kirkley et al, 1999;Gracies et al, 2000) were identified using Scopus and screened. ...
... It could be argued that if no short-term orthotic effect exists, the orthoses are unlike to have a longer-term therapeutic effect. Secondly, with a few exceptions (Kirkley et al, 1999;Birmingham et al, 2008;Cholewicki et al, 2010b;Priego et al, 2015), compression garment and joint support studies have rarely investigated longer-term effects. It is possible that regular, long-term use of compression garments and joint supports may be detrimental to training or may not have the predicted benefits to function that short-term studies suggest. ...
Background/Aims
Compression garments, joint supports and dynamic-movement orthoses all use elastic fibres and close-fitting designs and have been researched for their effects on movement. There is little cross-referencing between research into these interventions. This review aimed to improve interdisciplinary understanding by analysing key characteristics of the published evidence.
Methods
Systematic mapping reviews identify gaps in an evidence base and identify questions for more in-depth reviews. This review was conducted in line with current guidance. MEDLINE, CINAHL and Sports Discuss were searched for primary research investigating compression garments and orthoses for movement and function. The following search terms were used: ‘elastane’, ‘spandex’, ‘Lycra’, ‘elastomer*’ ‘Theratog*’, ‘compression’, ‘Neoprene’, ‘orthotic’, ‘orthosis’, ‘shorts’, ‘garment*’, ‘splint’, ‘brace’, ‘sock*’ and ‘stockings’. Studies were screened against predetermined criteria and key study characteristics extracted.
Findings
A total of 351 studies were selected and analysed. Compression garment research was most common (236 studies), followed by research into joint supports (64 studies) and dynamic-movement orthoses (42 studies). Research largely reflects the purpose for which each intervention was originally designed. Common topics investigated include posture and movement control, proprioception and muscle activity. Pressure applied beneath compression garments was measured in only 30% of studies.
Conclusions
The review highlights a need for more robust study designs in patient populations and accurate description of interventions. There is a need for a review on the possible effects of compression and support on movement control, which should be used to inform future primary research.
... Many knee orthoses are constructed from metal, thermoplastic or composite materials. Although they offer the means to offload the knee joint, their inherent rigidity and intimate fitting can lead to prolonged discomfort over longer periods [26,27]. The key requirements therefore for any successful knee orthoses treatment would be a device that enabled comfortable usage over time, but one that also provided the necessary loading capabilities, and adjustability, to offset and reduce any unwanted moments around the knee. ...
... The new design of the knee orthosis designed for patients with knee OA[27]. ...
Osteoarthritis of the knee is a debilitating condition affecting increasing numbers of individuals each year. One option for treatment is orthotic knee braces, but a little independent reviews have taken place to date on their relative outcomes for users. This study therefore evaluates the efficacy of different types of knee orthoses (braces) with regard to key aspects of use, including gait parameters, mobility and levels of comfort and compliance in subjects presenting with osteoarthritis (OA) of the knee. The collated data is presented with relevant supporting literature and appropriate descriptions in relation to each knee orthosis type that was identified, within appropriate subsections with advantages and disadvantages appropriately allocated. An analysis of each brace as presented by the corresponding article is then described further in terms of the design and structure, user outcomes and assessment summaries. According to the study carried out in this paper, it is presented and proved that applying the use of knee braces can reduce the knee adduction moment (KAM), but the amount of reduction afforded varies between designs. All of the studies reported significant pain reduction and functional improvement with the use of a knee brace, although their effect on the knee joint range of motion vary. Knee braces long-term use depends upon high levels of comfort and patient compliance, and further studies need to be conducted on larger numbers of subjects over greater time periods to reflect the long-term outcomes accurately.
... improve function. Although several studies have investigated the effectiveness of unloading brace treatment for knee OA [6][7][8][9][10][11][12] , the recently published Cochrane review that included 13 studies (4 investigating unloading knee braces) concluded that there is still very limited evidence for the benefits of bracing, mainly because of bias questioning the results from most studies 13 . In addition, the reported beneficial effect of unloading knee braces varies depending on whether they are compared to controls without brace, with neutral knee braces, with knee sleeves or with insoles 14 . ...
... Results showed that combination of the REBEL RELIEVER unloading knee brace with usual care was superior to usual care alone in terms of improvement of last 24h-pain, pain on motion, functional disability, disease evolution assessed by both the patient and the investigator, and clinical response rate after a 6-week treatment period. These results are consistent with previous published data suggesting that treatment with unloader braces improves pain and physical function 6,7,10,[17][18][19] . ...
Evidence is still inconclusive for the benefits of bracing in patients with knee osteoarthritis. To assess the effect of REBEL RELIEVER unloading knee brace in conservative treatment of knee osteoarthritis, a randomized controlled trial was conducted in 67 patients with symptomatic medial knee osteoarthritis, who randomly received 6-week treatment with either REBEL RELIVER unloading knee brace + usual care (Brace group, N = 32) or usual care alone (Control group, N = 35). Primary outcome was the global last 24h-pain relief (100-mm visual analogic scale [VAS]) at 6 weeks. Secondary endpoints included pain on motion (100-mm VAS), function (Lequesne index), safety and observance. At 6 weeks, mean [SD] last 24h-pain decreased significantly more in Brace group versus Control group (-41.35 [3.37] vs -15.37 [3.23], difference -25.98, 95% CI -41.64 to -10.33, P < 0.0001). Higher mean [SD] pain on motion decrease (-51.91 [3.49] vs -19.91 [3.34], difference -32.01, 95% CI -48.21 to -15.80, P < 0.0001) and better improvement of Lequesne index score (-5.8 [0.5] vs -2.3 [0.5], difference -3.5, 95% CI -5.0 to -2.0, P < 0.0001) were observed in Brace group. Safety and observance to the brace were excellent. The additive clinical benefit of wearing REBEL RELIEVER unloading knee brace was demonstrated in knee osteoarthritis patients.
... However, ideal candidates for specific therapies remain to be determined. [8,25] Malalignment treatment strategies include preventing the initial disease or progression, unloading the related compartment, or correcting the malalignment. The identification of the malalignment trajectory in this study could provide some theoretical basis for these therapies, especially for preventing worsening, since the greater the degree of malalignment, the more rapid the cartilage degradation and functional impairment. ...
Background:
Although various therapies have been developed to treat malalignment in osteoarthritic knees, the pattern of malalignment progression is still unclear. This study aimed to identify homogeneous subgroups with distinct trajectories of malalignment progression in subjects with symptomatic knee osteoarthritis (KOA) and to determine corresponding risk factors.
Methods:
Eight-year follow-up (from 2004 to 2012) data on 1252 participants with symptomatic KOA from the Osteoarthritis Initiative were included. Varus/valgus angle progression was characterized by group-based trajectory models. Time-varying covariates were introduced into the model to investigate how they affected trajectories. Multinomial logistic regression for trajectory group membership was applied to ascertain risk factors.
Results:
Five subgroups were identified. Participants in the varus worsening trajectory (n = 166) or valgus worsening trajectory (n = 118) proceeded to worsen malalignment over time. The neutral trajectory (n = 378), varus stable trajectory (n = 328), and valgus stable trajectory (n = 262) maintained close to the initial varus/valgus angle over 8 years. Higher baseline Kellgren and Lawrence grade (odds ratio [OR] = 4.35, P < 0.001 for varus; OR = 3.85, P < 0.001 for valgus) and "severe" baseline malalignment (OR = 13.57, P < 0.001 for varus; OR = 23.04, P < 0.001 for valgus) were risk factors for worsening trajectories. The cutoff point of the baseline varus/valgus angle to discriminate between stable or worsening trajectory was -4.5° for varus and 3.6° for valgus.
Conclusions:
This study identified the malalignment progression pattern - minor malalignment (-4.5° to +3.6°) tends to remain stable, while major baseline malalignment is likely to progress. This provides a reference for therapy to prevent malalignment from deteriorating and emphasizes the necessity of determining the trigger factors for malalignment onset.
... While some international clinical guidance recommend bracing for knee OA, 11 12 several others have been unable to make a recommendation due to the limited evidence base. [13][14][15][16] A Cochrane review, originally published in 2005 17 and updated in 2015, 18 identified five randomised controlled trials (RCTs), [19][20][21][22][23] with sample sizes ranging from 33 to 117, that compared a type of brace for OA of the knee versus no treatment or other treatment such as restricted activity, patient education, exercise, pharmacological treatment and orthoses or surgical treatment. The review concluded that 'low-quality evidence suggests that people with OA who use a knee brace may have little or no reduction in pain or improvements in knee function and quality of life'. ...
Background:
Brace effectiveness for knee osteoarthritis (OA) remains unclear and international guidelines offer conflicting recommendations. Our trial will determine the clinical and cost-effectiveness of adding knee bracing (matched to patients' clinical and radiographic presentation and with adherence support) to a package of advice, written information and exercise instruction delivered by physiotherapists.
Methods and analysis:
A multicentre, pragmatic, two-parallel group, single-blind, superiority, randomised controlled trial with internal pilot and nested qualitative study. 434 eligible participants with symptomatic knee OA identified from general practice, physiotherapy referrals and self-referral will be randomised 1:1 to advice, written information and exercise instruction and knee brace versus advice, written information and exercise instruction alone. The primary analysis will be intention-to-treat comparing treatment arms on the primary outcome (Knee Osteoarthritis Outcomes Score (KOOS)-5) (composite knee score) at the primary endpoint (6 months) adjusted for prespecified covariates. Secondary analysis of KOOS subscales (pain, other symptoms, activities of daily living, function in sport and recreation, knee-related quality of life), self-reported pain, instability (buckling), treatment response, physical activity, social participation, self-efficacy and treatment acceptability will occur at 3, 6, and 12 months postrandomisation. Analysis of covariance and logistic regression will model continuous and dichotomous outcomes, respectively. Treatment effect estimates will be presented as mean differences or ORs with 95% CIs. Economic evaluation will estimate cost-effectiveness. Semistructured interviews to explore acceptability and experiences of trial interventions will be conducted with participants and physiotherapists delivering interventions.
Ethics and dissemination:
North West Preston Research Ethics Committee, the Health Research Authority and Health and Care Research in Wales approved the study (REC Reference: 19/NW/0183; IRAS Reference: 247370). This protocol has been coproduced with stakeholders including patients and public. Findings will be disseminated to patients and a range of stakeholders.
Trial registration number:
ISRCTN28555470.
... They also reduce dependence on analgesics. 17,18 However, the effect of unloader braces in the long term is questionable. The long-term use of knee braces is not recommended as they may weaken the muscles and risk the onset of a cycle of pain, decreased mobility and muscle atrophy. ...
Osteoarthritis (OA) of the knee is an important cause of morbidity and significantly affects quality of life. A large proportion of the population seek medical attention for this condition. There is also a significant economic burden for the healthcare provider. This article covers the assessment of patients with OA and includes pertinent points in the history and examination. The various treatment options are discussed based on current guidelines and the published literature. The consent process for conservative and surgical treatments is also discussed in this article.
... Valgus knee bracing is found to effectively correct the lower limb force lines, release pain feelings, and improve joint functions of KOA patients by optimizing their biomechanical axis [10][11][12][13]. Kirkley et al. [14] showed that valgus knee bracing can effectively reduce the pain symptom and joint mobility of KOA patients. However, Hunter et al. [15] found that valgus knee bracing can inhibit the pain symptom of KOA patients, but cannot elevate the functions of joint mobility. ...
Background:
Knee osteoarthritis (KOA), with a high incidence in old-age population, adversely affects their life quality. The valgus knee bracing is an important physical therapy for KOA, but its clinical effects on pain release and functional improvement remained unclear. This meta-analysis is to systematically evaluate the clinical outcomes of valgus knee bracing in patients with KOA.
Methods:
A meta-analysis of clinical randomized controlled trials (RCTs) on pain and functional changes in patients with KOA after using valgus knee braces. The search period was ranged from the inception of the database to May 2020. The enrolled research databases included PubMed, Embase, and Web of Science databases. Two investigators independently formulated inclusion criteria and exclusion criteria and screened and determined the final enrolled literature. Then the outcome indicators were extracted and organized from the included literature, and the risk of bias was assessed by Cochrane Handbook 5.0.1.
Results:
A total of 10 articles were included in this study, including 739 patients. Eight articles were related to the visual analog scale (VAS) pain score, and the results showed that RR = - 0.29, 95% CI - 0.73, 0.15], P = 0.20; four articles were related to the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score, and the results showed that RR = - 0.15, 95% CI [- 0.41, 0.11], P = 0.26; two articles were related to the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the results showed that RR = 0.58, 95% CI [- 4.25, 5.42], P = 0.81; and three articles were related to the KOOS Activities of Daily Living (KOOS-ADL), and the results showed that RR = 0.04, 95% CI [- 0.62, 0.69], P = 0.91. These results indicated that the valgus knee bracing has no statistical significance in pain and functional activity improvement of patients with KOA. The subgroup analysis showed that the follow-up time was the source of the heterogeneity of the VAS pain score.
Conclusion:
Our current evidence suggests that valgus knee bracing may not improve pain release and function activates in KOA patients in the long-term period, but only being beneficial to the short-term rehabilitation.
... Knee braces are designed to alter contact pressures, especially with uni-compartmental knee OA, by exerting either valgus or varus force [53]. A knee brace can improve stability, reduce the muscular contraction needed to stabilize the affected knee and minimize the risk of falling [21,54]. ...
Abstract
Purpose: To provide evidence-based recommendations for patients with severe knee osteoarthritis (OA), who had their knee surgery postponed due to the COVID-19 pandemic.
Methods: PubMed/Medline, Scopus and Cochrane Central databases were systematically reviewed for studies reporting outcomes of home-based treatments for knee OA. Due to between-study differences in treatment strategy and reporting methods the results were not pooled and findings of the current review were presented in a narrative manner.
Results: The comprehensive literature search yielded 33 eligible studies that were included in this review. Management is performed at home and consists of exercise, proper nutrition, physical therapy and use of corrective and assistive orthotics. Virtual education on self-management strategies should be part of coping with knee OA. Initiating an exercise programme involving gymnastics, stretching, home cycling and muscle
strengthening is highly recommended. Obese patients are encouraged to set weight loss goals and adopt a healthy diet. Potential benefits but weak evidence has been shown for the use of knee braces, sleeves, foot
orthotics or cushioned footwear. Walking aids may be prescribed, when considered necessary, along with the provision of instructions for their use.
Conclusion: When bridging the time to rescheduled surgery, it is essential to use appropriate home-based tools for the management of knee OA if pain is to be reduced and need for analgesics or opioid use is to be diminished while maintaining or even improving the functioning and avoiding further limitation of range of motion and subsequent muscular atrophies. Finally, none of these treatments may completely substitute for the life-changing effect of a total knee arthroplasty in patients with severe knee OA. Hence, the subsequent goal is to gradually and safely reinstate elective surgery.
... The valgus knee braces can theoretically effectively correct the lower limb force lines, improve the pain and function of KOA patients by changing the biomechanical axis, and then delay the surgery, which is more cost-effective [10][11][12][13]. Kirkley et al [14] con rmed that valgus knee braces can effectively improve the pain symptom and joint mobility of KOA patients. ...
Background:KOA as a high incidence of old age seriously affects the quality of life of the elderly. The valgus knee bracesareaimportantphysical therapy for KOA, but its specific effect is not clear.This meta-analysisis to systematically evaluate the effectiveness of valgus knee braces on pain and function improvement in patients with knee osteoarthritis (KOA).
Methods :A meta-analysis of clinical randomized controlled trials(RCTs) on pain and functional changes in patients with KOA after using valgus knee braces. The search period is from the self-built database to May 2020, and the search range is PubMed, Embase, and Web of Science databases. First, two authors independently screened the literature, formulated inclusion criteria and exclusion criteria, and determined the included literature. The researchers then extracted the interventions and outcome indicators of included literature, and assessed the risk of bias through Cochrane Handbook 5.0.1. Finally, Revman5.3 was used for data analysis.
Results :A total of 10 articles were included in this study, including 739 patients. 8 articles related to the Visual Analogue Scale (VAS) pain score, the results showed that RR = -0.29, 95% CI [-0.73, 0.15], P = 0.20; There were 4 articles on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score, the results showed that RR = -0.15, 95% CI [-0.41,0.11], P = 0.26; Two articles related to the impact of Knee Injury and Osteoarthritis Outcome Score (KOOS) score, the results showed that RR = 0.58, 95% CI [-4.25, 5.42], P = 0.81; 3articles were related to KOOS activities of daily living (KOOS-ADL) score, the results showed that RR = 0.04, 95% CI [-0.62,0.69], P = 0.91.These results indicated that the valgus knee braces have no statistically significant in pain and functional activity improvement of patients with KOA. The subgroup analysis showed that the follow-up time was the source of the heterogeneity of the VAS pain score.
Conclusion :The current evidence suggests that valgus knee braces may not effectively improve pain symptom and functional activity in KOA patients in the long-term, but only benefit KOA patients in the short-term.
... Symptomatic relief is achieved by stabilising the joint, increasing joint opening and reducing local muscle contraction [120]. One study [123] demonstrated that patients with medial compartment knee OA treated with unloading knee braces had better functional and symptomatic outcomes at 6 months. These results were not replicated in other studies [124] although there is evidence they can improve quadricep strength and gait symmetry [125]. ...
Osteoarthritis (OA) is the most common joint condition worldwide. It can lead to chronic debilitating symptoms that can be definitively managed with surgical techniques at times. More frequently however, either due to age, extent of disease or patient choice, non-surgical approaches are preferred. They include topical therapies such as thermotherapy, ultrasound, laser treatment, non-steroidal anti-inflammatory drugs (NSAIDs) and capsaicin cream. Injections are another technique often implemented. These consist of intra-articular (IA) corticosteroid or hyaluronan injections, trigger point injections and subcutaneous sodium salicylate. Acupuncture and various types of external support are also widely used. This chapter examines the latest evidence and summarises the role of the various regional treatments available for use in the management of OA.
... the primary outcome measure was the western ontario mcmaster universities Osteoarthritis Index (WOMAC) functional score at 12 months after intervention. 8 womaC has been shown to be responsive, valid for patients with arthritis, 9,10 and user-friendly. 11 the best functional score (17-item) achievable is 0 and the worst score is 68, 12 with a minimum clinically important difference of eight points. ...
Aims
A pragmatic, single-centre, double-blind randomized clinical trial was conducted in a NHS teaching hospital to evaluate whether there is a difference in functional knee scores, quality-of-life outcome assessments, and complications at one-year after intervention between total knee arthroplasty (TKA) and patellofemoral arthroplasty (PFA) in patients with severe isolated patellofemoral arthritis.
Methods
This parallel, two-arm, superiority trial was powered at 80%, and involved 64 patients with severe isolated patellofemoral arthritis. The primary outcome measure was the functional section of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 12 months. Secondary outcomes were the full 24-item WOMAC, Oxford Knee Score (OKS), American Knee Society Score (AKSS), EuroQol five dimension (EQ-5D) quality-of-life score, the University of California, Los Angeles (UCLA) Physical Activity Rating Scale, and complication rates collected at three, six, and 12 months. For longer-term follow-up, OKS, EQ-5D, and self-reported satisfaction score were collected at 24 and 60 months.
Results
Among 64 patients who were randomized, five patients did not receive the allocated intervention, three withdrew, and one declined the intervention. There were no statistically significant differences in the patients’ WOMAC function score at 12 months (adjusted mean difference, -1.2 (95% confidence interval -9.19 to 6.80); p = 0.765). There were no clinically significant differences in the secondary outcomes. Complication rates were comparable (superficial surgical site infections, four in the PFA group versus five in the TKA group). There were no statistically significant differences in the patients’ OKS score at 24 and 60 months or self-reported satisfaction score or pain-free years.
Conclusion
Among patients with severe isolated patellofemoral arthritis, this study found similar functional outcome at 12 months and mid-term in the use of PFA compared with TKA. Cite this article: Bone Joint J 2020;102-B(3):310–318
... According to the type of deformity associated with knee OA (i.e., varus or valgus), corresponding biomechanical interventions are recommended to alter a non-anatomical mechanical axis. For instance, unloading knee braces, regular knee braces, knee pads, and foot orthoses may be applied to balance the load between the medial and lateral tibial plateau, which have been shown to be effective in reducing pain, joint stiffness, and medications use and dosage (26,(68)(69)(70)(71)(72)(73). ...
... Knee orthoses are also intended to relieve pain and improve joint function [34]. Five controlled trials (evidence level Ib) were evaluated in a Cochrane Review [35], using orthosis were found to have significantly reduced the pain and improves function than patients in the control groups. ...
Background: Osteoarthritis is one of the most common systemic diseases leading to physical disability reducing the quality of life. Osteoarthritis affects all the structures of the joint and the surrounding tissues. In the state of Kuwait, osteoarthritis of the knee joint is prevalent, especialy among women. The purpose of this article is to view our experience in the staged treatment of knee osteoarthritis in one of the leading privet hospitals in Kuwait.
... Mechanical receptors near the knee joint may be vulnerable to anatomical changes caused by osteoarthritis, thus increasing the risk of patient falls due to knee osteoarthritis [29]. Osteoarthritis damages the joint sensation, disturbs knee movement, and reduces muscle strength, thus increasing the risk of falls due to the loss of dynamic posture control [30,31]. Patients with severe knee osteoarthritis often suffer from weakened muscle strength limited quality of life, and increased risk of falls [32]. ...
Objective:
To investigate the risk factors for fall in the elderly population residing in rural areas of Korea and provide useful data for their prevention.
Methods:
As part of farmers' health promotion project, a retrospective study was conducted with a total of 350 elderly people recruited from March 2016 to December 2016. These subjects were divided into two groups: 254 non-fallers and 96 fallers. A person who fell to the floor at least once in the past year was defined as a faller. Participants were asked to visit the hospital once. The demographic characteristics, social environment, and educational levels were surveyed using a questionnaire. Physical examination was performed in the following order: cognitive function, lower leg strength and torque, body composition, and knee image test.
Results:
Statistically significant factors for falls in univariate analysis were female gender, age, living alone, educational level less than middle school, skeletal muscle mass, Mini-Mental State Exam, knee osteoarthritis, hip torque, hip power mean, knee torque, and knee power mean. Multivariate analysis was performed to identify variables most relevant to falls among statistically significant factors in univariate logistic analysis. It was confirmed that female gender and age of 70-79 years were statistically significant factors related to falls.
Conclusion:
Female gender and elderly status (70-79 years) are important risk factors for falls in rural areas underscoring the need for special attention when considering risk factors for falls among the elderly living in rural areas.
... The perception-based evaluation methods are mainly self- The WOMAC score has been used extensively in both observational and treatment monitoring studies to examine the changes due to bracing treatment during walking and stair-climbing tests [35][36][37][38][39][40]. The authors found that a positive relationship existed between brace wear usage and activity level, and improvements in WOMAC pain, stiffness, and function. ...
The paper aims to provide a state-of-the-art review of methods for evaluating the effectiveness and effect of unloader knee braces on the knee joint and discuss their limitations and future directions. Unloader braces are prescribed as a non-pharmacological conservative treatment option for patients with medial knee osteoarthritis to provide relief in terms of pain reduction, returning to regular physical activities, and enhancing the quality of life. Methods used to evaluate and monitor the effectiveness of these devices on patients’ health are categorized into three broad categories (perception-, biochemical-, and morphologybased), depending upon the process and tools used. The main focus of these methods is on the short-term clinical outcome (pain or unloading efficiency). There is a significant technical, research, and clinical literature gap in understanding the short- and long-term consequences of these braces on the tissues in the knee joint, including the cartilage and ligaments. Future research directions may complement existing methods with advanced quantitative imaging (morphological, biochemical, and molecular) and numerical simulation are discussed as they offer potential in assessing long-term and post-bracing effects on the knee joint.
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... There is a clinically and statistically significant improvement in KSS and KSS function for both groups at one year compared with baseline. These results are compatible with previously published studies [17,18]. There is also difference between groups but it is not statistically significant. ...
Background:
Treatment of patients with knee osteoarthritis is challenging. Unloader braces have been developed with various success. Unloader One® Knee Brace is light, easily-fitted and shown to be effective by the unloading of the affected compartment. The aim of the study was to assess the clinical outcome of the brace vs. a placebo on patients with knee osteoarthritis.
Methods:
Initially 150 patients were randomized to receive either the Unloader brace or a control placebo group look-alike brace where the active strips had been removed. The patients were followed up at 6,12,26 and 52 weeks with Knee Society Score (KSS) and Knee injury and Osteoarthritis Outcome Score (KOOS). The reason for dropout was recorded.
Results:
A total of 149 patients were included, 74 in the study and 75 in the control group. The mean age was 59.6 vs. 60.2, BMI was 27.5 vs. 26.9, 37% vs. 44% were women in the study vs. control group. Both groups showed improvement in KSS over 52 weeks, with the study group showing higher improvement in mean scores. KSS increased from 64.3 to 84.0 for the study group and from 64.0 to 74.6 for the control group (p = 0.009). The study group improved in KSS function from 67.0 to 78.6 (p < 0.001) and KOOS for knee related symptoms increased/improved from 64.3 to 72.4 (p < 0.001). Activity of daily living increased/improved from 65.3 to 75.2 and Sports/Recreation from 24.6 to 40.2 (p > 0.001) whereas the control group did not show significant improvements in any of the scores. The dropout was higher in the control group, 40 vs. 25.
Conclusions:
The brace seems to be more effective and better tolerated than the placebo.
Trial registration:
The trial was retrospectively registered with ClinicalTrials.gov ( NCT03454776 ) on March 6th 2018.
... Studies into knee braces date back into the 20th century. Although the studies of Lindenfeld et al, 12 in 1997, and Kirkley et al, 13 in 1999, are small, they found that valgus knee braces were able to reduce pain and improve function. Also, Katsuragawa et al 14 demonstrated that valgus bracing in patients with medial compartmental osteoarthritis can alter mechanical alignment and increase bone mineral density in the lateral side of the femur and tibia. ...
Background The incidence of osteoarthritis is increasing and it is one of the most common causes of chronic conditions. Total knee replacement is the mainstay of treatment for end-stage knee osteoarthritis; however, with long waiting lists and high levels of dissatisfaction, a treatment like knee braces could potentially delay surgery. Unicompartmental knee osteoarthritis is associated with misalignment of the knee, and unloader bracing has been recommended by various guidelines to correct this misalignment. The aim of this report was to provide an update of evidence from the past 10 years on knee braces.
Methods MEDLINE/EMBASE search was performed from the past 10 years.
Results We reviewed the evidence from 14 published articles. Almost all articles supported knee brace use and showed it to decrease pain, improve function, and improve the quality of life of patients. One study in 2017 followed patients for long term and found knee bracing to be more cost effective than total knee replacement, and could replace the need for surgery. Several minor complications were reported with bracing, like soft tissue irritation, which could be due to poor fitting. A management strategy for this could be regular follow-up at a nurse-led clinic.
Conclusions Unloader braces are an economical and effective treatment for unicompartmental knee osteoarthritis. They can significantly improve a patient's quality of life and potentially delay the need for surgery. Patients should be managed with a multidisciplinary approach with conservative management and knee bracing, before surgery is considered.
... Four randomized controlled clinical trials compared a valgus knee brace against no treatment. Of the four studies, three showed minor improvements in pain, function and health-related quality of life, which were of statistical significance [4][5][6]. The other study reported improvement, however this failed to reach significance [3]. ...
... OA is common in people who are obese, overweight, involved in heavy weight lifting and moving around, laborers and people living in areas where they have to climb stairs daily, etc. [11] Physiotherapy treatment has a big role in the treatment of pain that results in a functional loss. Physiotherapy treatment for knee OA includes use of thermal agents, traditional Chinese acupuncture, tai chi programs, taping, transcutaneous electrical nerve stimulation, manual therapy, aquatic exercises, orthoses in the form of medial or lateral insoles, and weight loss programs. ...
Objective: The objective of this study is to determine the outcome and efficacy of Mulligan’s mobilization with movement (MWM) with
Maitland mobilization along with conventional therapy in the patients with knee osteoarthritis (OA). Materials and Methods: A randomized
controlled trial study was performed at the Department of Physiotherapy, Mayo Hospital, Lahore, Pakistan. Sixty‑two patients were selected
for the study. MWM was introduced in half of the patients and Maitland mobilizations in the second half for 2 weeks. The goniometry, visual
analog scale (VAS), knee range of motion (ROM), and Western Ontario McMaster OA (WOMAC) Index for knee OA were the assessment
tools used to assess all patients before and after 2 weeks of intervention. Paired sample t‑test was used for analysis of results. Results: The
mean pre‑ and postdifferences in MWM group were 4.06 ± 0.99, 10.19 ± 3.87, and 19.41 ± 7.58 for VAS, ROM flexion, and WOMAC Index,
respectively, while the pre‑ and postmean difference values for Maitland mobilization group were 3.355 ± 1.05, 10.19 ± 5.5, and 12.28 ± 7.029
for VAS, ROM flexion, and WOMAC Index, respectively. The mean differences of both treatment interventions individually were significant
and showed that both were clinically effective in treating the patients of knee OA. Conclusion: It was concluded that patients in both groups
showed improvement in pain, ROM, and functions.
The Journal of Orthopaedic Experience and Innovation editorial (Kirschenbaum 2021) requesting knee osteoarthritis (OA) treatment protocols or algorithms is important. The American Academy of Orthopaedic Surgeons’ (AAOS) Treatment of Osteoarthritis of the Knee Evidence-Based Guideline (2nd Edition) (Jevsevar et al. 2013) provides evidence of the effectiveness of knee OA treatments, but does not provide a treatment algorithm or protocol. Neither does the clinical practice guideline provide a rank ordering of the effectiveness of different treatments or guidance regarding when to initiate or discontinue treatments. Consequently, information must be incorporated from other sources and synthesized into an evidence-based approach. “Approach” is used because the diversity of patients, their co-morbidities, and their responses is not amenable to a defined protocol or algorithm.
Background
Knee orthoses have been extensively used as a nonsurgical approach to improving knee deficiencies. Currently, arthritic knee conditions remain the leading cause of disability, and this number is expected to increase. As the use of knee orthoses varies widely, so has their effectiveness which is still largely debatable. Here, we present the functions and effectiveness of the three most prominent knee orthotic models dedicated to supporting knee osteoarthritis—unloader, patellofemoral, and knee sleeves.Purpose/Research QuestionConsidering the depth and diversity of the many clinical studies and documented laboratory reports published to date, this literature review was created to educate the clinician, patient, and researcher on common knee orthoses used for the management of arthritic knee conditions. In doing so, we discuss their design, biomechanical effects, and clinical efficacy, as well as broader outcomes, limitations, and recommendations for use.Results/SynthesisThe knee orthoses discussed within the scope of this paper are dedicated to protecting the knee against strenuous compressive loads that may affect the patellofemoral and tibiofemoral joints of the knee. Since the knee has multiple axes of motion and articulating surfaces that experience different loads during functional activities, it can be implied that, to a large extent, knee brace designs can differ drastically. Unloader knee orthoses are designed to decrease tibiofemoral and patellofemoral joint pressures. Patellofemoral knee orthoses are designed to decrease strain on the patellofemoral and quadriceps tendons while stabilizing the patella. Knee sleeves are designed to stabilize movements, reduce pain in joints, and improve proprioception across the knee joint.Conclusion
Although patients often report benefits from wearing braces, these benefits have not been confirmed by clinicians and scientific investigators. Results from these three orthosis types show that clinical efficacy is still elusive due to the different methodologies used by researchers.Layman SummaryKnee orthoses also referred to as knee brace are commonly used for support and stability of the knee. Unloader knee braces are designed to relieve and support those suffering from knee osteoarthritis by improving physical impairment and reducing pain. Patellofemoral knee braces aim to help patients manage patellofemoral pain syndrome. Rehabilitative compression sleeves, also known as knee sleeves, are often used to assist patients suffering from knee pain and laxity. Important findings on the three knee braces discussed show discrepancies in results. Their effectiveness and validity are yet to be understood.
As the world population structure has already exhibited an inevitable trend of aging, technical advances that can provide better eldercare are highly desired. Knee osteoarthritis, one of the most common age-associated diseases, can be effectively treated via total knee arthroplasty (TKA). However, patients are suffering from the recovery process due to inconvenience in post-hospital treatment. Here, a portable, modular, and wearable brace for self-assessment of TKA patients’ rehabilitation is reported. This system mainly consists of a force transducer for isometric muscle strength measurement and an active angle sensor for knee bending detection. Clinical experiments on TKA patients demonstrate the feasibility and significance of the system. Specifically, via brace-based personalized healthcare, the TKA patients’ rehabilitation process is quantified in terms of myodynamia, and a definite rehabilitation enhancement is obtained. Additionally, new indicators, that is, isometric muscle test score, for evaluating TKA rehabilitation are proposed. It is anticipated that, as the cloud database is employed and more rehabilitation data are collected in the near future, the brace system can not only facilitate rehabilitations of TKA patients, but also improve life quality for geriatric patients and open a new space for remote artificial intelligence medical engineering.
Unicompartmental knee osteoarthritis (UKOA) is a complex issue that is estimated to affect roughly 28% of patients with knee OA, and can result in severe cartilage degeneration, meniscus deficiency, and concomitant varus or valgus malalignment. This malalignment results in abnormally high joint reaction forces in the affected compartment, which can elicit pain, cause dysfunction, and exacerbate joint degradation. For more than two decades, the use of knee unloader braces has been advocated as a cost-effective option for symptomatic management of UKOA.
During bipedal ambulation with a normal lower extremity mechanical axis, ground reaction forces create a knee adduction moment (KAM) such that the medial compartment of the knee experiences approximately 60% of joint loading and the lateral compartment experiences approximately 40% of joint loading. UKOA disrupts the mechanical axis, altering KAM and joint loading and causing pain, dysfunction, and disease progression. In theory, knee unloader braces were designed to mitigate the symptoms of UKOA by normalizing KAM via shifts in the lever arms about the knee. However, studies vary, and suggest that push-mechanism knee unloaders do not consistently provide significant biomechanical benefits for medial or lateral UKOA. Current evidence suggests that pull-mechanism unloaders may be more effective, though contrasting data have also been reported, such that further validation is necessary. The purpose of our study was to synthesize current best evidence for use of knee unloader braces for management of UKOA to suggest evidence-based best practices as well as gaps in knowledge to target for future studies. Unloader bracing for patients with UKOA appears to be a cost-effective treatment option for patients with medial UKOA who have insurance coverage. Pull-mechanism unloader bracing should be considered in conjunction with other nonoperative management therapies for those who are willing to adhere to consistent brace use for weight-bearing activities.
Knee OA has been known as a degenerative change in which various causes, such as aging, obesity, and inflammatory changes, are compounded, resulting in repeated wear and tear of articular cartilage. In addition to pain, physical symptoms of knee OA include reduced muscle strength and range of motion, reduced lower limb balance due to decreased proprioception, and walking disability. Non-pharmacologic treatment is necessary to treat physical symptoms caused by knee OA. Non-pharmacologic treatment includes patient education, weight loss, exercise therapy, and physical therapy. Knee OA is a chronic disease, so it is important for patients to understand their condition and change their lifestyle. Therefore, patient education is necessary. Losing weight is an essential factor in improving pain caused by knee OA. Losing weight requires exercise therapy as well as diet therapy. Exercise therapy also helps strengthen muscles around the knee, improve the range of exercise and improve the sense of balance in the lower extremities. Physical therapy is useful for improving the pain and function of OA. Many kinds of the instrument are needed for physical therapy. Various methods are used for such non-pharmacologic treatments, but not only one method is used for treatment, but a combination of different treatment methods depending on the patient’s condition can lead to better treatment.
Objective:
Determine whether tibiofemoral contact stress predicts risk for worsening knee pain over 84-months in adults aged 50-79 years with or at elevated risk for knee osteoarthritis.
Design:
Baseline tibiofemoral contact stress was estimated using discrete element analysis. Other baseline measures included weight, height, hip-knee-ankle (HKA) alignment, Kellgren-Lawrence grade (KLG) and Western Ontario and McMaster Universities Osteoarthritis Index pain subscale (WOMAC-pain). Logistic regression models assessed the association between baseline contact stress and 84-month worsening of WOMAC-pain.
Results:
Data from the dominant knee (72.6% KLG 0/1 and 27.4% KLG ≥ 2) of 208 participants (64.4% female, mean ± SD body mass index 29.6 ± 5.1 kg/m2) were analyzed. Baseline mean and peak contact stress were 3.3 ± 0.9 MPa and 9.4 ± 4.3 MPa, respectively. 47 knees met the criterion for worsening pain. The highest tertiles in comparison to the lowest tertiles of mean {Odds Ratio (95% Confidence Interval) 2.47 (1.03, 5.95); p = 0.04} and peak {2.49 (1.03, 5.98); p = 0.04} contact stress were associated with worsening pain at 84-months, after adjustment for age, sex, race, clinic site and baseline pain. Post hoc sensitivity analyses including adjustment for BMI and HKA alignment attenuated the effect.
Conclusions:
These findings suggest that elevated tibiofemoral contact stress can predict the development of worsening of knee pain.
Objective
This pragmatic, multicenter, open-label, randomized controlled trial (RCT) aimed to compare the effectiveness, safety, and cost–utility of a custom-made knee brace versus usual care over 1 year in medial knee osteoarthritis (OA).
Design
120 patients with medial knee OA (VAS pain at rest >40/100), classified as Kellgren-Lawrence grade II-IV, were randomized into two groups: ODRA plus usual care (ODRA group) and usual care alone (UCA group). The primary effectiveness outcome was the change in VAS pain between M0 and M12. Secondary outcomes included changes over 1 year in KOOS (function) and OAKHQOL (quality of life) scores. Drug consumption, compliance, safety of the knee brace, and cost–utility over 1 year were also assessed.
Results
The ODRA group was associated with a higher improvement in: VAS pain (adjusted mean difference of −11.8; 95% CI: −21.1 to −2.5); all KOOS subscales (pain: +8.8; 95% CI: 1.4–16.2); other symptoms (+10.4; 95% CI: 2.7–18); function in activities of daily living (+9.2; 95% CI: 1.1–17.2); function in sports and leisure (+12.3; 95% CI: 4.3–20.3); quality of life (+9.9; 95% CI: 0.9–15.9), OAKHQOL subscales (pain: +14.8; 95% CI: 5.0–24.6); and physical activities (+8.2; 95% CI: 0.6–15.8), and with a significant decrease in analgesics consumption at M12 compared with the UCA group. Despite localized side-effects, observance was good at M12 (median: 5.3 hours/day). The ODRA group had a more than 85% chance of being cost-effective for a willingness-to-pay threshold of €45 000 per QALY.
Conclusions
The ERGONOMIE RCT demonstrated significant clinical benefits of an unloader custom-made knee brace in terms of improvements in pain, function, and some aspects of quality of life over 1 year in medial knee OA, as well as its potential cost–utility from a societal perspective.
Injuries to various structures of the knee joint, including the ligaments, menisci, and patellofemoral components, compose a significant portion of sports-related injuries seen by health care providers and compromise a patient's knee joint function and stability. Knee orthoses have been used in each step of the sport performance process, such as injury minimization, ligament rehabilitation after reconstruction, and treatment of functional instability of the knee joint. The knee joint allows for flexion and extension with some degree of translation and axial rotation. Shear forces act upon the knee during gait and in weight-bearing tasks. Proper functioning of knee braces must take into account these biomechanical factors. Both prefabricated (“off-the-shelf”) and custom-made knee brace designs have proven effective, and each has benefits with cost, fit, weight, and material components. More recently, braces have been manufactured with composite lightweight materials, such as carbon fiber and aluminum. Athletes have used knee orthoses both to prevent medial collateral ligament (MCL) and anterior cruciate ligament (ACL) injury and to protect ACL-deficient knees or an ACL-reconstructed graft while returning to full activity. Knee braces have become an important component in functional rehabilitation programs for treatment of MCL sprains. Acute grade I and II posterior cruciate ligament (PCL) tears have been shown to heal with bracing, protected weight bearing, and quadriceps muscle rehabilitation. Braces are now used in osteoarthritis to enhance function and reduce pain.
Knee-pain due to osteoarthritis (OA) is often located in the medial compartment. Concomitant varus malalignment is associated with the development of knee OA and its progression. Unloader-braces and ankle foot orthoses are devices which were invented to support the knee joint to relieve pain and to improve patients’ quality of life. Multiple case series showed positive effects when using them, especially in low-grade arthritis and mild varus malalignment. They can be used on a daily basis as an inherent part of nonsurgical treatment of knee OA or be worn activity-dependent. The brace test simulates the effect of a valgus osteotomy. It is a useful tool to test the unloading effect before indicating this operation.
Immediate biomechanical and functional effects of knee braces are often reported, however, the duration and type of knee brace treatment for knee osteoarthritis (KOA) remain unclear. The objective was to evaluate usage, comfort, pain, and knee adduction moment (KAM) of three knee braces each worn three months by patients. Twenty‐four patients with KOA were assigned in a randomized crossover trial a valgus three‐point bending system brace (V3P‐brace), an unloader brace with valgus and external rotation functions (VER‐brace) and a stabilizing brace used after ligament injuries (ACL‐brace). Functional questionnaires and gait assessment were carried out before and after each brace wear period of three months. A Friedman test was applied between brace wear diary recordings. Repeated measures analyses of variance contrasted the factors brace type (ACL, V3P and VER), time (pre and post) and wear (without and with) on comfort, pain, function and KAM. Brace usage was similar, but the V3P‐brace was slightly less worn. Discomfort was significantly lowered with the VER‐brace. All knee braces relieved pain and symptoms from 10% to 40%. KAM angular impulse was reduced with the three braces, but the VER‐brace obtained the lowest relative reduction of 9%. The interaction between time and wear indicated that part of the KAM reduction with brace wear was maintained post treatment. All three knee braces have great benefits for pain and function among the medial KOA population. The VER‐brace offers additional advantages on daily use, comfort and KAM, which could improve compliance to brace treatment.
Background
High-quality clinical practice guidelines are necessary for effective use of resources both at an individual patient- and national-level. Nordic clinical practice guidelines recommendations for orthotic treatment of knee osteoarthritis vary and little is known about their quality.
Objectives
The aim of the study was to critically evaluate the quality of clinical practice guidelines in orthotic management of knee osteoarthritis in the Nordic countries.
Study Design
Systematic review.
Methods
Four national clinical practice guidelines for treatment of knee osteoarthritis were assessed for methodological rigour and transparency by four independent assessors using the AGREE II instrument. Summary domain scores and inter-rater agreement (Kendall’s W) were calculated.
Results
Domain scores indicate that many guidelines have not sufficiently addressed stakeholder involvement (average score: 55%), applicability (20%) and editorial independence (33%) in the development process. Inter-rater agreement for assessors indicated ‘good’ agreement for clinical practice guidelines from Finland, Norway and Sweden ( W = 0.653, p < 0.001; W = 0.512, p = 0.003 and W = 0.532, p = 0.002, respectively) and ‘strong’ agreement for the clinical practice guideline from Denmark ( W = 0.800, p < 0.001).
Conclusion
Quality of clinical practice guidelines for orthotic treatment of knee osteoarthritis in the Nordic region is variable. Future guideline development should focus on improving methodology by involving relevant stakeholders (e.g. certified prosthetist/orthotists (CPOs)), specifying conflicts of interest and providing guidance for implementation.
Clinical relevance
The current review suggests that, for the Nordic region, there are areas of improvement which can be addressed, which ensure clinical practice guidelines are developed under stringent conditions and based on sound methods. These improvements would ensure knee osteoarthritis patients are receiving orthotic interventions based on appropriate guidance from published guidelines.
Background:
A medial meniscal tear is a common knee injury, especially following an anterior cruciate ligament injury. Decreasing the compressive force on the medial meniscus during dynamic activities using an unloader knee brace could reduce meniscal strain, effectively reducing injury risk and/or severity.
Objectives:
To investigate the efficacy of two unloader knee braces on medial meniscus strain during dynamic activities in intact & deficient anterior cruciate ligament states.
Study design:
Combined in vivo/in vitro study.
Methods:
In vivo knee kinematics and muscle force profiles from a healthy individual performing single/doubleleg squats and walking motions were simulated on 10 cadaveric specimens using a dynamic knee simulator system. Simulations were performed on knees in unbraced and braced scenarios, with and without the anterior cruciate ligament. Anterior and posterior medial meniscal strains were measured.
Results:
Two different braces each showed a significant reduction in the posteromedial meniscal strain ( p ⩽ 0.01) in an intact anterior cruciate ligament state. Neither brace mirrored this result for the anteromedial strain ( p > 0.05). In the deficient anterior cruciate ligament state, the braces had no significant effect on strain ( p > 0.05).
Conclusion:
Two unloader knee braces effectively reduced strain in the medial meniscus with an intact anterior cruciate ligament during dynamic activities. Neither brace made a significant reduction in strain for anterior cruciate ligament-deficient knees. Clinical relevance Unloader knee braces could be used to reduce the medial meniscus strain following meniscal surgery and during rehabilitation in patients with an isolated medial meniscus injury. However, these braces cannot be recommended for this purpose in patients with an anterior cruciate ligament deficiency.
A strong clinical impression exists that joint lavage often provides symptomatic relief for painful osteoarthritis of the knee. A controlled trial was conducted to test this hypothesis. A group of 37 painful osteoarthritic knees were treated by arthroscopic lavage and physiotherapy, and a control group of 24 knees were treated by physiotherapy alone. There was better relief of pain in the lavage group, and the effect was still present at one year. An improvement in the signs of inflammation lasted for about three months. Pain was relieved more effectively in patients with slight radiographic changes than in those with advanced changes. Our results confirm the effectiveness of joint lavage in the management of painful osteoarthritis of the knee.
We measured joint position sense in the knee by a new method which tests the proprioceptive contribution of the joint capsule and ligaments. The leg was supported on a splint, and held in several positions of flexion. The subjects' perception of the position was recorded on a visual analogue model and compared with the actual angle of flexion. Eighty-one normal and 45 osteoarthritic knees were examined, as were 10 knees with semi-constrained and 11 with hinged joint replacements. All were assessed with and without an elastic bandage around the knee. There was a steady decline in joint position sense with age in subjects with normal knees. Those with osteoarthritic knees had impaired joint position sense at all ages (p less than 0.001). Knee replacement improved the joint position sense slightly (p less than 0.02); semi-constrained replacement had a greater effect than hinged replacement. The effect of an elastic bandage in subjects with poor position sense was dramatic, improving accuracy by 40% (p less than 0.001). It is proposed that reduced proprioception in elderly and osteoarthritic subjects may be responsible for initiation or advancement of degeneration of the knee.
The objective of this study was to quantify the effect of degenerative joint change on the proprioceptive acuity of women with osteoarthritis (OA) of the knee. Middle-aged women with OA of the knee, age-matched healthy women, and younger healthy women were studied. Tests examined the ability of subjects to correctly reproduce knee angles in weightbearing and non-weightbearing situations. The knee angles were photographed and measured in degrees. The absolute error (AE) of each matching test was calculated and the mean AE of two tests was used as the criterion variable in a three-way analysis of variance (ANOVA). The relationship between the reproduction error and the osteoarthritic subjects' self-paced walking speed was also examined. Under both test conditions the AE of the osteoarthritic subjects was greater than that of the healthy subjects (p < .05). There was, however, no significant relationship between the AE measurements of the patients and their walking speed. These data indicate that while women with OA may have poorer proprioception than healthy controls, this impairment may not affect their walking ability.
The knee joint position sense of a control group of healthy women was compared with that of women diagnosed as having severe osteoarthritis (OA) of the knee. Movements monitored were multi-joint when weightbearing on one leg. All subjects completed two angle rematching tests on two separate test occasions, and the criterion and reproduction angles which lay in the range of 15-45 degrees knee flexion were recorded photographically on each occasion. The results showed that the OA group performed the rematching tests with less accuracy than the controls (p < 0.05). Additionally, the OA group displayed significantly higher average flexion error magnitudes than the controls. These results suggest that joint position sense is less accurate and may be systematically distorted during multi-joint movements of the affected legs of a high proportion of women with severe knee OA. They further suggest that to improve their functional performance, patients with knee OA probably require a carefully constructed sensorimotor rehabilitation programme in which pain, effusion and fatigue are minimised.
To assess the effect of a program of supervised fitness walking and patient education on functional status, pain, and use of medication in patients with osteoarthritis of the knee. An 8-week randomized, controlled trial. Inpatient and outpatient services of an orthopedic hospital in an academic medical center. A total of 102 patients with a documented diagnosis of primary osteoarthritis of one or both knees participated in the study. Data were obtained on 47 of 51 intervention patients and 45 of 51 control patients. An 8-week program of supervised fitness walking and patient education or standard routine medical care. Patients were evaluated and outcomes assessed before and after the intervention using a 6-minute test of walking distance and scores on the physical activity, arthritis impact, pain, and medication subscales of the Arthritis Impact Measurement Scale (AIMS). Patients randomly assigned to the walking program had a 70-meter increase in walking distance relative to their baseline assessment, which represents an improvement of 18.4% (95% Cl, 9.8% to 27.0%). In contrast, controls showed a 17-meter decrease in walking distance relative to their baseline assessment (P less than 0.001). Improvements in functional status as measured by the AIMS physical activity subscale were also observed in the walking group but not in the control group (P less than 0.001); patients assigned to the walking program improved 39% (Cl, 15.6% to 60.4%). Although changes in scores on the arthritis impact subscale were similar in the two groups (P = 0.093), the walking group experienced a decrease in arthritis pain of 27% (Cl, 9.6% to 41.4%) (P = 0.003). Medication use was less frequent in the walking group than in the control group at the post-test (P = 0.08). A program of supervised fitness walking and patient education can improve functional status without worsening pain or exacerbating arthritis-related symptoms in patients with osteoarthritis of the knee.
▪ Objective: To evaluate the effect of weight loss in preventing symptomatic knee osteoarthritis in women.
▪ Design: Cohort analytic study.
▪ Setting: The Framingham Study, based on a sample of a defined population.
▪ Patients: Women who participated in the Framingham Knee Osteoarthritis Study (1983 to 1985): Sixty-four out of 796 women studied had recent-onset symptomatic knee osteoarthritis (knee symptoms plus radiographically confirmed osteoarthritis) were compared with women without disease.
▪ Measurements: Recalled date of symptom onset was used as the incident date of disease. Historical weight was defined as baseline body mass index up to 12 years before symptom onset. Change in body mass index was assessed at several intervals before the current examination. Odds ratios assessing the association between weight change and knee osteoarthritis were adjusted for age, baseline body mass index, history of previous knee injury, habitual physical activity level, occupational physical labor, smoking status, and attained education.
▪ Results: Weight change significantly affected the risk for the development of knee osteoarthritis. For example, a decrease in body mass index of 2 units or more (weight loss, approximately 5.1 kg) over the 10 years before the current examination decreased the odds for developing osteoarthritis by over 50% (odds ratio, 0.46; 95% Cl, 0.24 to 0.86; P = 0.02). Among those women with a high risk for osteoarthritis due to elevated baseline body mass index (> 25), weight loss also decreased the risk (for 2 units of body mass index, odds ratio, 0.41 ; P = 0.02). Weight gain was associated with a slightly increased risk for osteoarthritis, which was not statistically significant.
▪ Conclusion: Weight loss reduces the risk for symptomatic knee osteoarthritis in women.
Osteoarthritis (OA) of the knees is a functionally limiting disability. Physical therapy (PT) is considered a useful treatment for OA, although evidence is qualitative. The purpose of this study was to quantitatively measure the effects of a 3-month PT program ( n = 40; 20 men and 20 women) with knee OA. Muscle function and functional assessment parameters were measured. All data were analyzed by repeated measures analysis of variance ( p
A double crossover study was designed and carried out on 39 patients to test the efficacy of valgus bracing using a GII brace in patients with medial gonarthrosis. Two brace designs were studied-one with a medial and one with a lateral hinge. The double crossover technique involved evaluating each patient under conditions of no brace, brace in neutral, and brace in valgus, each for a period of 6 weeks. Pain and function were recorded by subjects on diary forms daily and at the end of each week. Standing posterior-anterior radiographs were done on all patients under conditions of weight bearing, nonweight bearing, without brace, and with brace in valgus. Statistical analysis using repeated measures analysis of variance showed statistically significant pain relief compared to baseline with both a lateral hinge in valgus (p = 0.02) and a medial hinge in valgus (p < 0.0001). No significant change in function was found and no significant radiographic evidence of change in femoral-tibial angle or joint space alteration was demonstrated. Seventy-four percent of patients purchased their brace at the end of the study. Follow-up at an average 20 months after the study showed 58% of the patients with a lateral hinge and 93% of the patients with a medial hinge were still using their braces as the principal form of therapy. Valgus bracing using a GII brace, especially with a medial hinge, can be a useful treatment modality for reducing pain in the patient with medial gonarthrosis to replace or delay surgery.
(C) Lippincott-Raven Publishers.
A group of 120 patients with rheumatoid arthritis or osteoarthritis volunteered to be subjects for this study of aerobic versus nonaerobic exercise. Patients were stratified by diagnosis and randomized into an exercise program of aerobic walking, aerobic aquatics, or non-aerobic range of motion (controls). The retention rate for the 12-week program was 83%. Exercise tolerance, disease-related measures, and self-reported health status were assessed. The aquatics and walking exercise groups showed significant improvement over the control group in aerobic capacity, 50-foot walking time, depression, anxiety, and physical activity after the 12-week exercise program. There were no significant between-group differences in the change scores for flexibility, number of clinically active joints, duration of morning stiffness, or grip strength. Our findings document the feasibility and efficacy of conditioning exercise for people who have rheumatoid arthritis or osteoarthritis.
In the study presented, knee joint proprioception of 17 patients with primary degenerative joint disease of the knee joint
was evaluated. As a control group, the proprioception of 30 healthy volunteers with clinical and anamnestically inconspicuous
knee joints was examined. We tested the proprioceptive capability of the subjects with an angle reproduction test. Additionally,
all knee joints were measured with and without an elastic knee bandage. The study showed significantly more deterioration
in knee joint proprioception in patients with gonarthrosis than in the control group. Even the proprioception of the contralateral,
healthy knee joint was worse than the results of the control group. However, after using an elastic knee bandage, significant
improvement in the proprioceptive abilities of the injured knee joint was documented.
1. The treatment of osteoarthritis is currently purely symptomatic. To enable rational therapy, careful clinical assessment is necessary to identify the origin of symptoms. Often, effective therapy can result from a biomechanical approach such as surgery, orthotics, physiotherapy and dieting. If drugs are required, there is little evidence that the current over-reliance on non-steroidal anti-inflammatory drugs (NSAIDs) is justified. Full dose regular paracetamol should be the first line of analgesic therapy. In the majority of patients, simple analgesics are probably as effective as NSAIDs. If NSAIDs are used it is necessary to review regularly their use and to be aware of potential toxicity. 2. Many alternative strategies of pain management such as topical preparations, intra-articular steroid injections, acupuncture, radiosynovectomy, transcutaneous nerve stimulation and anti-depressants, may be effective but their precise place in the armamentarium is not yet fully established. 3. The realisation that osteoarthritis is not a passive 'wear and tear' phenomenon but an active process that may be potentially modified, has led to interest in 'chondroprotective' agents, which may beneficially affect the osteoarthritic process. To date there are no convincing data available that such agents are, in fact, chondroprotective in humans.
Osteoarthritis, the most common rheumatic disease, presents the clinician with a major therapeutic and management task. The chronic and progressive course of the disease is punctuated by pain, declining function and escalating disability. This article attempts to deal with the pharmacological therapeutic options available to use in the management of osteoarthritis. Other non-pharmacological therapeutic modalities are also briefly discussed, including patient education, joint protection, physiotherapy, occupational therapy and surgery. Drug therapy as discussed focuses on the control of pain and inflammation. For this intermittently painful condition analgesic drugs assume a very important role. Non-steroidal anti-inflammatory drugs (NSAIDs) have combined analgesic and anti-inflammatory properties which are particularly useful in many patients who manifest inflammation in addition to pain. While systemic steroids have no role in the treatment of osteoarthritis, intra-articular steroid injections may be of benefit. In trying to slow the degenerative process chondroprotective agents such as glycosaminoglycan may also assume increasing importance in the future. Choosing one drug over another must be done after consideration of many factors including the therapeutic and toxicity profile of the drugs involved, their pharmacology and dose regimen, the patient profile, cost and the desired effect.
The optimal short-term, symptomatic therapy for osteoarthritis of the knee has not been fully determined. Accordingly, we compared the efficacy of a nonsteroidal antiinflammatory drug, ibuprofen, given in either an antiinflammatory dose (high dose) or an analgesic dose (low dose), with that of acetaminophen, a pure analgesic.
In a randomized, double-blind trial, 184 patients with chronic knee pain due to osteoarthritis were given either 2400 or 1200 mg of ibuprofen per day or 4000 mg of acetaminophen per day. They were evaluated after a washout period of three to seven days before the beginning of the study, and again after four weeks of treatment. The major measures of outcome included scores on the pain and disability scales of the Stanford Health Assessment Questionnaire (range of possible scores, 0 to 3), scores on the visual-analogue scales for pain at rest and pain while walking, the time needed to walk 50 ft (15 m), and the physician's global assessment of the patient's arthritis.
Seventy-eight percent of the patients completed four weeks of therapy. No significant differences were noted among the three treatment groups with respect to failure to complete the trial because of noncompliance or adverse events. All three groups had improvement in all major outcome variables, and the groups did not differ significantly in the magnitude of improvement in most variables. The mean improvement (change) in the scores on the pain scale of the Health Assessment Questionnaire was 0.33 with acetaminophen (95 percent confidence interval, 0.14 to 0.52), 0.30 with the low dose of ibuprofen (95 percent confidence interval, 0.09 to 0.51), and 0.35 with the high dose of ibuprofen (95 percent confidence interval, 0.13 to 0.57). Side effects were minor and similar in all three groups.
In short-term, symptomatic treatment of osteoarthritis of the knee, the efficacy of acetaminophen was similar to that of ibuprofen, whether the latter was administered in an analgesic or an antiinflammatory dose.
The applicability of a signal measurement strategy was compared with a traditional method of measuring outcome in osteoarthritis. The signal method detected statistically significant alterations in health status with small sample sizes and with a relative efficiency close to or at unity. The prevalence of deterioration in nonsignal items was low. Signal methods of measurement may provide an alternative approach to outcome measurement in osteoarthritis clinical trials.
We identified all residents of Rochester, Minnesota, who sought medical assistance for the first time in 1985 because of symptomatic osteoarthritis of the hip or knee that was unrelated to a specific disease. Of these residents, 98 (59 women and 39 men) had 122 symptomatic joints (95 knees and 27 hips), for age- and sex-adjusted incidence rates of 205 new patients and 255 newly affected joints per 100,000 person-years. The incidence of osteoarthritis of the hip was greater in women than in men, whereas the sex ratio for occurrence of osteoarthritis of the knee approached unity. Rates at both sites increased steadily with aging in men but plateaued after the menopause in women; similar patterns were seen whether or not grade 1 disease was included. Projected nationally, these first population-based data indicate that as many as approximately half a million new symptomatic cases of idiopathic osteoarthritis of the knee and hip may arise annually in the white population of the United States. With increasing longevity, osteoarthritis may exact an even greater toll in the future.
Superoxide dismutase (orgotein for injection) has been used in managing osteoarthritis for more than seven years in Europe; however, well-controlled studies to establish an optimum dosage regimen have not been conducted. In this study, three orgotein dose/regimens were compared with placebo in terms of efficacy, safety, and duration of effect in patients with active osteoarthritis of the knee.
A total of 139 patients with osteoarthritis of the knee were enrolled in the study. Nonsteroidal anti-inflammatory agents were withdrawn to induce a flare of disease activity. Patients were then randomly assigned to receive one intra-articular injection of either placebo or orgotein (8 mg to 32 mg) each week for three weeks. Both investigators and patients evaluated disease activity and adverse experiences at a series of follow-up visits for three months.
Orgotein was effective in reducing symptoms of osteoarthritis for up to three months after treatment; 16 mg given twice was the most effective and most best-tolerated regimen. Discomfort at the injection site was drug related, although this effect also occurred occasionally after injection of placebo.
The long-lasting effects of intra-articular superoxide dismutase contribute to a favorable risk-benefit ratio and support the importance of the free-radical anion, superoxide (O2-), in the biochemical pathology of osteoarthritis.
Current methods of clinical assessment in osteoarthritis show a high degree of variability. By contrast, patients with rheumatoid arthritis may be evaluated using a number of standardised and validated indices. One hundred patients with primary osteoarthritis of the hip and knee were interviewed in order to determine the dimensionality of their discomfort and disability and to define the clinical importance of each component item. The symptomatology of osteoarthritis was captured by five pain, one stiffness, twenty-two physical, eight social and eleven emotional items. In spite of a high degree of variability in the frequency of involvement of the individual items, their clinical importance was similar both within as well as across dimensions. Further studies are indicated to determine the reliability, validity and responsiveness of each of the items identified as a prelude to developing a standardized method of assessing patients with osteoarthritis of the hip and knee.
Data from the US Health and Nutrition Examination Survey (HANES I) of 1971-1975 confirm the high prevalence of musculoskeletal impairments among United States adults. Musculoskeletal impairments tend to be more prevalent among older persons, and persons with less education and with lower annual family incomes. Prevalence rates are slightly higher in females than in males, while Whites and non-Whites are affected with almost equal frequency. Among persons reporting a history of musculoskeletal symptoms, those who have some disability tend to be older, non-White, of lower education and income, and widowed, separated, or divorced. Persons with multiple parts of the body involved, or reporting that their symptoms are due to accident or injury are also especially likely to report disability. Taken as a whole, the data suggest that medical, social, and economic factors all play a role in determining whether a person with musculoskeletal impairment goes on to develop disability related to his or her impairment.
Outcome measures for clinical trials to be valid and reliable should also be responsive to change. There are currently no standardised methods of measuring the outcome in osteoarthritis clinical trials. A review of 63 trials of nonsteroidal anti-inflammatory drugs revealed a large degree of variability in the items, instruments and scales employed. The implications of this variability are discussed and methods proposed for rationalising outcome measurement in this area of clinical research.
Joint proprioception in the human knee has been studied using two previously described tests. Threshold of detection of slow, constant, passive motion and ability to reproduce angles to which the knee was passively placed were accurately measured. A group of postoperative total knee arthroplasty (TKA) patients were examined. All patients also had documented articular disease in the unoperated knee. Results were compared to age-matched controls. In addition, a young control group was studied for comparison to both groups. A significant difference was seen between the young control group and the older control group in both tests performed. Age-matched controls and the postoperative patients demonstrated an even greater difference. There was, however, no difference between the operated and unoperated knee among the TKA patients. It is concluded that joint proprioception declines to some degree with normal aging. A more marked decline is associated with degenerative joint disease. Total joint replacement, however, did not lead to a further decrease in sensation.
To evaluate the cost-effectiveness of telephone intervention for patients with osteoarthritis.
Randomized, controlled trial.
The intervention did not significantly increase health care costs. The annual costs for a 1-unit improvement in physical functioning and in pain, as measured by the Arthritis Impact Measurement Scales, were $70.86 and $31.00, respectively.
Telephone contact is a potentially cost-effective intervention in osteoarthritis.
Elastic bandages are often used to treat musculoskeletal disorders, even though there is little scientific evidence currently to support this generalized practice. We tested the hypothesis that elastic bandages improve proprioception of the bandaged joint during their use, and that this benefit was more than temporary. The uninjured human knee was used as a model. Fifty-four volunteers (54 knees), aged 22 to 40 years, were asked to identify a prior set joint angle as their knee was passively extended. Each knee was tested without the elastic bandage, immediately after bandage application, after 1 hour of bandage wear, and finally after removal of the bandage. Results showed that elastic bandages significantly improved knee joint proprioception in the uninjured knee during the entire interval of their use (mean decrease in inaccuracy of 1.0 degree, equivalent to 25% improvement, P < 0.05), and that this benefit was lost when the bandage was removed. The magnitude of the improvement, or the potential beneficial effect of the bandage, was inversely related to the participant's inherent knee proprioceptive ability, which was demonstrated in the test group before the initial application of the bandage.
The effect of total hip replacement on the health-related quality of life of patients who have osteoarthrosis was examined as part of a randomized, controlled trial comparing femoral head prostheses that were inserted with or without cement. One hundred and eighty-eight patients were followed for three months: 179 of them, for six months; 156, for one year; and ninety, for two years. The health-related quality of life was assessed with use of the Harris hip score, the Merle d'Aubigné hip score, the Sickness Impact Profile, the Western Ontario and McMaster University (WOMAC) Osteoarthritis Index, the McMaster--Toronto Arthritis (MACTAR) Patient Preference Disability Questionnaire, and the time trade-off technique as a measure of utility. Patients also took the six-minute-walk test. The mean age of the patients in the study was sixty-four years (range, forty to seventy-five years); ninety-seven patients (53 per cent) were men and ninety-four (50 per cent) had a prosthesis inserted with cement. Only three of 188 patients refused to return for quality-of-life assessments. There was significant improvement in all health-related quality-of-life measures and in the six-minute-walk test after the operation (p < 0.01 for all items, except for the work dimension of the Sickness Impact Profile at three months [p = 0.07]). Most of the improvement had occurred by three months postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)
To determine the effects of the Arthritis Self-Management Program 4 years after participation in it.
Valid self-administered instruments were used to measure health status, psychological states, and health service utilization.
Pain had declined a mean of 20% and visits to physicians 40%, while physical disability had increased 9%. Comparison groups did not show similar changes. Estimated 4-year savings were $648 per rheumatoid arthritis patient and $189 per osteoarthritis patient.
Health education in chronic arthritis may add significant and sustained benefits to conventional therapy while reducing costs.
To examine the effects of a knee sleeve type brace on the proprioceptive ability of subjects with normal knees during a dynamic tracking task.
A 2 X 2 Latin square cross over design; in each Latin square, subjects were matched for age and gender.
An institution focused on clinical education.
Twenty subjects with no musculoskeletal or neurological conditions.
Each subject performed a tracking task on a Kin-Com dynamometer. Angle and force data from the Kin-Com and angle data from an electrogoniometer were sampled at 100Hz using a data acquisition program on a PC computer. The subjects were blindfolded and the limb attached to the Kin-Com was moved passively by the dynamometer. Subjects were instructed to follow the movement as closely as possible with the other limb (the tracking limb). Subject performed two trials, one without knee bracing and another that involved the application of a brace to the tracking limb.
The magnitude of the error in tracking was established by taking the difference of the active and passively moving limbs and calculating the root mean square (RMS) of the difference.
The findings showed that there was an improvement of 11% in tracking when subjects wore the knee brace (p < .05).
Alterations in proprioception as a result of bracing may be partly responsible for the improvement in knee injury statistics reported in some studies.
To compare torque-angle characteristics of the knee extensors of women with and without osteoarthritis (OA) of the knee, and to determine the reliability of these measures.
The isometric torque of the knee extensors of both legs was tested on 3 occasions in 17 women with OA of the knee and 17 healthy women. Tests were performed on an isokinetic dynamometer at 3 knee angles (30 degrees, 60 degrees, 90 degrees). The peak torque values were subjected to 4 way analysis of variance (group vs leg vs angle vs time), and intraclass correlation coefficients were calculated.
The reliability coefficients for repeated measures of isometric torque varied from 0.83 to 0.94 in the OA group and from 0.90 to 0.95 in the comparison group. The ANOVA and post hoc analyses revealed that the OA group had significantly (p < 0.05) lower knee extensor torque than the comparison group, and that the more symptomatic OA knee had lower torque than the contralateral limb. The torque was different across the 3 angles, but the torque-angle relationship was the same for both groups.
Isometric torque of the knee extensors can be measured reliably in women with OA of the knee. The torque is lower in women with OA than in women with no knee problems, and the changes are similar across different knee angles.
Variable definitions of outcome have been used in the past to assess the results after total joint replacement surgery. These differ in their approach to the measurement of outcome but all must be valid (they measure what they are designed to measure), reliable (they consistently produce the same score), and responsive (able to detect changes that may occur during a period). Responsiveness is crucial to distinguish those patients who benefit from a procedure from those who do not, and a more responsive test will theoretically be able to identify more subtle changes in patient status. The responsiveness of 6 different scoring systems was compared. The results are based on a cohort of 71 patients undergoing total knee arthroplasty in a 7-month period. Responsiveness was determined by performing a paired t test among each patient's scores at 0, 3, and 6 months. The size of the resulting t value represented the comparative responsiveness of the 6 tests. The highest value achieved was with the Western Ontario and McMaster Universities osteoarthritis index and the Knee Society clinical rating scale. The worst scores were achieved by Short Form-36 and time trade off, a utility method of measurement. If small differences between groups of patients are to be shown, measures of outcome that are more responsive to patient change should be used.
Proprioception was measured in 2 groups of patients after successful knee arthroplasty. Twenty-eight patients had total knee arthroplasty and their results were compared with an age matched group of 10 subjects who had undergone unicondylar knee arthroplasty. The threshold to detection of passive motion was quantified as a measure of proprioception. The degree of preoperative arthritis was objectively classified according to Resnick. The anterior cruciate ligament and posterior cruciate ligament were present and preserved in all the patients who had undergone unicondylar knee arthroplasty. The anterior cruciate ligament was sacrificed and posterior cruciate ligament retained in 15 of the patients who had total knee arthroplasty and the anterior cruciate ligament and posterior cruciate ligament were sacrificed in 13 of the patients who had total knee arthroplasties. There was no difference in threshold to detection of passive motion among any of the 3 groups. Maintaining the anterior cruciate ligament and posterior cruciate ligament did not impart improved proprioception in unicondylar knee arthroplasty nor did maintaining the posterior cruciate ligament impart improved proprioception in total knee arthroplasty.
To investigate the clinical efficacy of the Generation II (G II) knee brace, a newly developed knee orthosis, on patients experiencing severe medial compartment osteoarthritis (OA) of the knee.
Case series.
A national medical and pharmaceutical hospital in Japan.
Twenty primary OA subjects (excluding those with secondary OA), all older than 55 years of age and experiencing only knee joint problems, were selected according to their ability to walk more than 500 meters independent of support. These patients had arthritis in both knees and no less than one half of normal joint space remaining as revealed by roentgenogram studies. The more severely affected side was selected for bracing.
For 12 months, each patient wore a G II knee brace on the affected knee on a daily basis, removing it only at night. To evaluate the effects of G II OA brace alone, additional use of new oral drugs or any other treatment was prohibited from 1 month before application of the G II OA brace and throughout the trial period.
Clinical efficacy was evaluated using the Japan Orthopaedic Association's knee scoring system. X-ray evaluation was performed with patients standing on one leg. A dynamometer was used to evaluate isokinetic quadriceps muscle strength. The center of gravity was measured using an X-Y recording. Clinical evaluation was performed every 2 months thereafter. Final evaluation was at 12 months.
Nineteen of the 20 patients answered that they experienced significant pain relief. Knee pain scores on walking increased from 18.0 to 21.5 and on ascending and descending stairs increased from 12.8 to 15.8. The femorotibial angle decreased in 12 of the patients, and the mean angle decreased from 185.1 degrees before application to 183.7 degrees with the brace on at the final observation period. In addition, isokinetic quadriceps muscle strength increased from an average of 36.8 Nm to 42.8 Nm for all patients. In 17 patients, quadriceps muscle strength increased, while it decreased in 2 and remained the same in 1. Finally, lateral movement of the center of gravity decreased compared with before G II application in all patients.
G II bracing is a beneficial treatment for severe medial OA of the knee.
The purpose of this study was to determine whether a brace designed to unload varus degenerative knees actually alters medial compartment loads by decreasing the adduction moment. Eleven patients who had arthrosis confined to the medial compartment were fitted with a valgus brace and tested before and after brace wear with pain and function scoring instruments and by automated gait analysis. The biomechanical data from these patients were compared with those from 11 healthy control subjects. Scores from an analog pain scale decreased 48% with brace wear, and function with activities of daily living increased 79%. Mean adduction moment without the brace measured 4.0 +/- 0.8% body weight times height versus 3.6 +/- 0.8% body weight times height when wearing the brace (10% decrease). The mean adduction moment for control subjects was 3.5 +/- 0.6% body weight times height. Thus, the mean adduction moment decreased from approximately one standard deviation from the normal mean to a value that is similar to the control value. Nine of 11 patients had a decrease in the adduction moment with the brace, five of 11 patients had a reduction higher than 10%, and decreases in this moment were as high as 32%. This study shows that pain, function, and biomechanical knee loading can be altered by a brace designed to unload the medial compartment of the knee.