Bracing and Orthoses: A Review of Efficacy and Mechanical Effects for Tibiofemoral Osteoarthritis

Management Considerations for Unicompartmental Osteoarthritis in Athletic Populations: A Review of the Literature

Unicompartmental osteoarthritis in the young athlete poses a challenge for both patients and providers. Coronal plane malalignment is frequently a concomitant finding that adds to the complexity of management. Military surgeons are presented unique challenges, in that they must consider optimal joint-preservation methods while returning patients to a high-demand occupational function. Management options range from lifestyle changes to surgical interventions. We present a concise review of the available literature on this subject, with a specific focus on indications and outcomes within the military and young athletic population.

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

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

Comparison of Immediate Effect of New Knee brace and Conventional Three-Points Knee Valgus Brace on Knee Adduction Moment and ROM in Patients with Medial Knee Osteoarthritis

The knee unloader brace can change loading on knee which may be effective in reducing symptoms and progression of disease in people with knee osteoarthritis. The purpose of this study was to evaluate the effect of a new knee brace during walking in a patient with medial compartment knee osteoarthritis. Two brace types were used: new brace and conventional brace. A pneumatic cuff of novel brace was fitted in the bottom of the medical slipper that was connected to the cuff section of the knee through the tube. After the knee brace is deployed, its force can vary in different stages of the gait. During the heel strike, the weight of the cuff is compressed on the floor, causing the air to flow inside it and entering the volume of air into the knee pad. The results of using this pneumatic knee brace compared with conventional knee braces on a patient showed that in both cases, the open and closed palatal pump, the adduction moment and ROM was decreased in the stance phase. But the three-point knee pressure, however, was less effective in reducing the adduction moment but also reduced the knee ROM. Using novel brace can eliminate the patient's need for painful and costly surgery to reduce the symptoms of osteoarthritis.

Efficacy of unloader knee orthosis and lateral wedge insole on static balance in medial knee osteoarthritis

Background

Medial knee osteoarthritis can contribute to pain and stiffness, interfere with balance and limit functional activities of daily living. Unloader knee orthosis or lateral wedged insoles are current conservative approaches used to treat these conditions. The aim of this study was to identify and compare the effects of them on the balance parameters.

Methods

66 subjects with mild to moderate medial knee osteoarthritis were randomly assigned to wear unloader knee brace or full-length 6° lateral wedge insole. Primary outcome balance parameters were stability %, path length and average velocity of center of pressure and mobility score which were investigated by HUMAC® Balance and Tilt system. Secondary outcome measures were knee function score using Knee Injury and Osteoarthritis Outcome Score scale. Assessment was performed at baseline and six months post orthotic intervention period.

Findings

Both orthoses improved all parameters compared to the baseline condition (p < 0.05). Unloader knee orthosis showed a significant improvement in all balance parameters compared to lateral wedged insoles (p < 0.001) except mobility scores (p = 0.527). Except activities of daily living (p = 0.752) and sports and recreational activities (p = 0.437), unloader knee orthosis had a greater effect on the pain (p = 0.002) and symptoms (p < 0.001) sub scales than lateral wedged insoles. However, quality of life sub-scale scores for insoles were more effective than the knee orthosis.

Interpretation

Unloader knee orthosis improved balance and knee function scores more than lateral wedged insole, though both orthoses produced significantly improved results compared to baseline assessment.

Unloader knee brace increases medial compartment joint space during gait in knee osteoarthritis patients

PURPOSE

The purpose of the present study was to investigate the effect of the unloader brace on medial compartment dynamic joint space (DJS) during gait, while simultaneously recording ground reaction force (GRF) in varus knee osteoarthritis (OA) patients using a highly accurate biplane radiography system which allowed continuous measurement of DJS from heel strike through the midstance phase of gait. The hypothesis was that DJS in the medial compartment would be greater with the unloader brace than without the brace during gait.

METHODS

After 2 weeks of daily use of the unloader brace, ten varus knee OA patients (age 52 ± 8 years) walked with and without the brace on an instrumented treadmill, while biplane radiographs of the OA knees were acquired at 100 Hz. Medial compartment DJS was determined from heel strike to terminal stance (0-40% of the gait cycle) using a validated volumetric model-based tracking process that matches subject-specific 3D bone models to the biplane radiographs. The GRF during gait was collected at 1000 Hz. Repeated-measures ANOVA was used to explore differences in medial compartment DJS and GRF between the unbraced and braced conditions. A patient-reported subjective questionnaire related to the brace use was collected at the time of the test.

RESULTS

Medial compartment DJS was significantly greater with the unloader brace than without the brace during gait (P = 0.005). The average difference was 0.3 mm (95% confidence interval 0.1-0.4 mm). No significant difference was observed in terms of vertical GRF between the two conditions. The questionnaire showed participants felt reduced pain when wearing the brace.

CONCLUSION

The unloader brace has the significant effect of increasing medial compartment DJS during gait, which supports the underlying premise that the unloader brace reduces pain by increasing medial joint space during dynamic loading activities.

LEVEL OF EVIDENCE

III.

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

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

Our experience in the application of radiofrequency neuroablation in patients with coxalgia against the background of degenerative osteoarthrosis of the hip joint

The article is concerned with the treatment of coxalgia against the background of degenerative-dystrophic diseases of the hip joint. The author carried out an analysis of foreign studies concerning with the application of radiofrequency neural ablation for the hip joint nerves. Based on the results of our own research, the author has proved that radiofrequency neuroablation of articular nervule of obturator and femoral nerves is an effective treatment of coxalgia pain syndrome against the background of degenerative osteoarthrosis

Long-term effects of lateral wedge orthotics on hip and ankle joint space widths

BACKGROUND

Lateral wedge insoles have been used for the treatment of medial knee osteoarthritis (OA) and have been shown to reduce loading of the medial compartment of the knee. However, as the entire lower extremity acts as a single kinetic chain, altering the biomechanics of the knee may also have significant effects at the ankles or hips. We aimed to evaluate the effects of lateral wedge orthotics on ankle and hip joints, compared to neutral orthotics, by assessing the changes in joint space width (JSW) during 36 months of continuous use.

METHODS

We prospectively enrolled 109 subjects with symptomatic osteoarthritis of the medial knee according to the American College of Rheumatology criteria. The trial was double blind and patients were randomized to either wedged or neutral orthotic shoe inserts. Hip and ankle JSWs were quantified using plain radiographies at baseline and at 36-months follow-up.

FINDINGS

45 patients completed the 36 month study. 31 of those who completed the study were using the lateral wedge versus 14 were using neutral orthotics. 2 patients in the wedge group had missing radiographs and were not included in the JSW analyses. There were no significant differences between the wedge and the neutral orthotics groups in the magnitude of JSW change at either the hip or the ankles at 36 month.

INTERPRETATION

We found no significant adverse effects of the lateral wedges on ankles or hips. (ClinicalTrials.gov NCT00076453).

The 2- and 8-week effects of decompressive brace use in people with medial compartment knee osteoarthritis

BACKGROUND

Knee osteoarthritis is a prevalent disease. Unloading the affected compartment using a brace is a treatment option.

OBJECTIVES

To determine whether a decompressive knee brace alters loading in medial knee osteoarthritis following 2 and 8 weeks of use.

STUDY DESIGN

Within subjects; pre- and post-testing.

METHODS

A total of 15 individuals with medial knee osteoarthritis attended four sessions: baseline, fitting, 2 weeks after fitting (post), and 8 weeks after fitting (final). A gait analysis was performed at baseline (without knee brace), post and final. Knee adduction impulse, first and second peak knee adduction moment, knee motion, and walking velocity were calculated. Participants also recorded hours and steps taken while wearing the brace.

RESULTS

On average, the brace was worn for more than 6 h/day. Through use of repeated-measures analysis of variance, it was determined that the knee adduction impulse and second peak knee adduction moment were reduced (p < 0.05) at post and final compared to baseline (36% and 34% reduction in knee adduction impulse, 26% reduction in second peak knee adduction moment for post and final, respectively). Furthermore, participants walked faster with increased knee motion during stance.

CONCLUSION

The studied decompressive brace was effective in reducing potentially detrimental forces at the knee-knee adduction impulse and second peak knee adduction moment during the stance phase of gait.

CLINICAL RELEVANCE

The data from this study suggest that use of a medial unloading brace can reduce potentially detrimental adduction moments at the knee. Clinicians should use this evidence to advocate for use of this noninvasive treatment for people presenting with medial knee osteoarthritis.

Does knee malalignment predict the efficacy of realignment therapy for patients with knee osteoarthritis?

BACKGROUND

Realignment therapies, including knee braces, foot orthoses and shoes are prescribed to patients with medial knee osteoarthritis (OA) with the goal of unloading the medial tibiofemoral (TF) compartment. It is uncertain whether realignment therapies have different effects in those with knee malalignment. We studied whether the efficacy of realignment therapy for pain and function in persons with medial TF OA is predicted by the severity of the baseline knee malalignment.

METHODS

The baseline characteristics of 48 participants with moderate to severe medial knee OA were collected. Participants' pain and function were measured using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale before and after 12 weeks of realignment therapy using a valgus unloader knee brace plus bilateral neutral foot orthoses and motion control shoes. Anatomical axis (AA) was measured on weight-bearing knee radiographs by a blinded reader and knee malalignment was categorized as either varus malaligned (moderate or severe) or neutral according to the AA angle. We assessed for differences in response to treatment according to alignment category. General linear statistical models were generated to determine which of the measured alignment variables and covariates predicted change in the pain outcome.

RESULTS

Anatomical axis knee alignment was not a significant predictor of pain or function change with active treatment. Baseline WOMAC scores were the best predictor of change in WOMAC (P < 0.01 and P = 0.06 for pain and function, respectively).

CONCLUSIONS

Baseline knee alignment did not predict the efficacy of 12 weeks realignment therapy in participants with medial tibiofemoral OA. [Correction added on 27 August 2015, after first online publication: 'did predict' has been corrected to 'did not predict' in the conclusions of the abstract section.].

Valgus bracing for knee osteoarthritis: a meta-analysis of randomized trials

OBJECTIVE

To evaluate the effects of valgus knee bracing on pain and function, and compliance and complications, in patients with medial knee osteoarthritis (OA).

METHODS

A meta-analysis of randomized controlled trials that compared changes in patient-reported pain and/or function in patients with medial knee OA was performed. Seven databases were searched from their inception to January 2014. Two reviewers independently determined study eligibility, rated risk of bias, and extracted data. Pooled estimates and 95% confidence intervals (95% CIs) for standardized mean differences (SMDs) for the improvement in pain (and function) were calculated. Event rates (proportions) were calculated for studies that reported complications.

RESULTS

Six studies were included in the meta-analysis. Overall, there was a statistically significant difference favoring the valgus brace group for improvement in pain (SMD 0.33 [95% CI 0.13, 0.52], P = 0.001) and function (SMD 0.22 [95% CI 0.02, 0.41], P = 0.03). When compared to a control group that did not use an orthosis, the effect size was moderate for pain (SMD 0.56 [95% CI 0.03, 1.09], P = 0.04) and function (SMD 0.48 [95% CI 0.02, 0.95], P = 0.04). When compared to a control group that used a control orthosis, only a small, statistically significant effect for pain remained (SMD 0.33 [95% CI 0.08, 0.58], P = 0.01). Instructions for brace use varied considerably and compliance ranged from 45% to 100%. Up to 25% of patients reported minor complications with brace use.

CONCLUSION

Meta-analysis of randomized trials suggests valgus bracing for medial knee OA results in small-to-moderate improvements in pain. Effect sizes vary based on study design and warrant future research.

Clinical effectiveness and safety of a distraction-rotation knee brace for medial knee osteoarthritis

OBJECTIVE

Evaluation of the clinical effectiveness and safety of a new custom-made valgus knee brace (OdrA) in medial knee osteoarthritis (OA) in terms of pain and secondary symptoms.

METHODS

Open-label prospective study of patients with symptomatic medial knee OA with clinical evaluation at 6 and 52 weeks (W6, W52). We systematically assessed pain on a visual analog scale (VAS), Knee injury and Osteoarthritis Outcome Score (KOOS), spatio-temporal gait variables, use of nonsteroidal anti-inflammatory drugs (NSAIDs) and analgesic-sparing effects of the brace and tolerance. Mean scores were compared at baseline, W6 and W52 and the effect size (ES) and 95% confidence intervals (95% CIs) were calculated.

RESULTS

We included 20 patients with knee OA (mean age 64.2±10.2 years, mean body mass index 27.2±5.4 kg/m2). VAS pain and KOOS were improved at W6 and W52: pain (ES=0.9 at 1 year), amelioration of other symptoms (ES=0.4), and function in activities of daily living (ES=1.1), sports and leisure (ES=1.5), quality of life (ES=0.9) and gait speed (ES=0.41). In total, 76% of patients showed clinical improvement at 1 year. Analgesic and NSAIDs consumption was significantly decreased at W6 and W52. One serious adverse effect noted was lower-limb varices, and observance was deemed satisfactory at 1 year.

CONCLUSION

This new unloader brace appeared to have good effect on medial knee OA, with an acceptable safety profile and good patient compliance.

Biomechanical effects of valgus knee bracing: a systematic review and meta-analysis

To review and synthesize the biomechanical effects of valgus knee bracing for patients with medial knee osteoarthritis (OA). Electronic databases were searched from their inception to May 2014. Two reviewers independently determined study eligibility, rated study quality and extracted data. Where possible, data were combined into meta-analyses and pooled estimates with 95% confidence intervals (CI) for standardized mean differences (SMD) were calculated. Thirty studies were included with 478 subjects tested while using a valgus knee brace. Various biomechanical methods suggested valgus braces can decrease direct measures of medial knee compressive force, indirect measures representing the mediolateral distribution of load across the knee, quadriceps/hamstring and quadriceps/gastrocnemius co-contraction ratios, and increase medial joint space during gait. Meta-analysis from 17 studies suggested a statistically significant decrease in the external knee adduction moment (KAM) during walking, with a moderate-to-high effect size (SMD = 0.61; 95% CI: 0.39, 0.83; P < 0.001). Meta-regression identified a near-significant association for the KAM effect size and duration of brace use only (β, -0.01; 95% CI: -0.03, 0.0001; P = 0.06); with longer durations of brace use associated with smaller treatment effects. Minor complications were commonly reported during brace use and included slipping, discomfort and poor fit, blisters and skin irritation. Systematic review and meta-analysis suggests valgus knee braces can alter knee joint loads through a combination of mechanisms, with moderate-to-high effect sizes in biomechanical outcomes.

An algorithm recommendation for the management of knee osteoarthritis in Europe and internationally: a report from a task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO)

OBJECTIVES

Existing practice guidelines for osteoarthritis (OA) analyze the evidence behind each proposed treatment but do not prioritize the interventions in a given sequence. The objective was to develop a treatment algorithm recommendation that is easier to interpret for the prescribing physician based on the available evidence and that is applicable in Europe and internationally. The knee was used as the model OA joint.

METHODS

ESCEO assembled a task force of 13 international experts (rheumatologists, clinical epidemiologists, and clinical scientists). Existing guidelines were reviewed; all interventions listed and recent evidence were retrieved using established databases. A first schematic flow chart with treatment prioritization was discussed in a 1-day meeting and shaped to the treatment algorithm. Fine-tuning occurred by electronic communication and three consultation rounds until consensus.

RESULTS

Basic principles consist of the need for a combined pharmacological and non-pharmacological treatment with a core set of initial measures, including information access/education, weight loss if overweight, and an appropriate exercise program. Four multimodal steps are then established. Step 1 consists of background therapy, either non-pharmacological (referral to a physical therapist for re-alignment treatment if needed and sequential introduction of further physical interventions initially and at any time thereafter) or pharmacological. The latter consists of chronic Symptomatic Slow-Acting Drugs for OA (e.g., prescription glucosamine sulfate and/or chondroitin sulfate) with paracetamol at-need; topical NSAIDs are added in the still symptomatic patient. Step 2 consists of the advanced pharmacological management in the persistent symptomatic patient and is centered on the use of oral COX-2 selective or non-selective NSAIDs, chosen based on concomitant risk factors, with intra-articular corticosteroids or hyaluronate for further symptom relief if insufficient. In Step 3, the last pharmacological attempts before surgery are represented by weak opioids and other central analgesics. Finally, Step 4 consists of end-stage disease management and surgery, with classical opioids as a difficult-to-manage alternative when surgery is contraindicated.

CONCLUSIONS

The proposed treatment algorithm may represent a new framework for the development of future guidelines for the management of OA, more easily accessible to physicians.

Malalignment: a possible target for prevention of incident knee osteoarthritis in overweight and obese women

OBJECTIVES

The present study aims to investigate the associations between malalignment and incident knee OA after 2.5 years in a high-risk group of 333 middle-aged overweight women (BMI ≥ 27 kg/m(2)) free of clinical and radiological knee OA at baseline.

METHODS

The primary outcome measure was the incidence of knee OA, defined as the incidence of radiographic knee OA (Kellgren and Lawrence grade ≥2), clinical knee OA (ACR criteria) or medial or lateral joint space narrowing (≥1.0 mm). Using generalized estimating equations, associations between valgus and varus alignment (compared with neutrally aligned knees) and the primary outcome measure and all its items separately were studied.

RESULTS

Neither varus- nor valgus-aligned knees had a significantly increased risk for incident knee OA according to the primary outcome measure. A significantly increased risk for the development of radiographic knee OA was found for varus-aligned knees [odds ratio (OR) 3.3, 95% CI 1.5, 7.3]. Valgus-aligned knees showed a borderline increased OR (2.8, 95% CI 1.0, 8.0) for the development of radiographic knee OA. No statistically significant effects were found for varus and valgus alignment on the incidence of clinical knee OA or medial or lateral joint space narrowing.

CONCLUSION

Since this study was performed in a true target population, current data suggest that malalignment might be a target for the prevention of radiographic knee OA in overweight and obese women.