Ben R. Metcalf

Lateral wedges in knee osteoarthritis: What are their immediate clinical and biomechanical effects and can these predict a three‐month clinical outcome?

OBJECTIVE To assess immediate effects of laterally wedged insoles on walking pain, external knee adduction moment, and static alignment, and whether these immediate effects together with age, body mass index, and disease severity predict clinical outcome after 3 months of wearing insoles in medial knee osteoarthritis. METHODS Forty volunteers (mean age 64.7 years, 16 men) were tested in random order with and without a pair of 5 degrees full-length lateral wedges. Immediate changes in static alignment were measured via radiographic mechanical axis and changes in adduction moment via 3-dimensional gait analysis. After 3 months of treatment with insoles, changes in pain and physical functioning were assessed via the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and patient-perceived global change scores. RESULTS Reductions in the adduction moment occurred with insoles (first peak mean [95% confidence intervals (95% CI)] -0.22 [-0.28, -0.15] Nm/body weight x height %), accompanied by a reduction in walking pain of approximately 24% (mean [95% CI] -1.0 [-4.0, 2.0]). Insoles had no mean effect on static alignment. Mean improvement in WOMAC pain (P = 0.004) and physical functioning (mean [95% CI] -6 [-11, -1]) was observed at 3 months, with 25 (69%) and 26 (72%) of 36 individuals reporting global improvement in pain and functioning, respectively. Regression analyses demonstrated that disease severity, baseline functioning, and magnitude of immediate change in walking pain and the first peak adduction moment with insoles were predictive of clinical outcome at 3 months. CONCLUSION Lateral wedges immediately reduced knee adduction moment and walking pain but had no effect on static alignment. Although some parameters predicted clinical outcome, these explained only one-third of the variance, suggesting that other unknown factors are also important.

Relationship of knee joint proprioception to pain and disability in individuals with knee osteoarthritis

Proprioception plays an integral role in neuromotor control of the knee joint and deficits in knee joint proprioception are well documented in individuals with knee osteoarthritis (OA). However, the functional relevance of these deficits is not clear. This crosssectional study evaluated the relationship between knee joint proprioception and pain and disability in a large cohort of individuals with knee OA. Two hundred and twenty participants (145 F, 75 M) with symptomatic knee OA were recruited from the community. Five non‐weight bearing active tests with ipsilateral limb matching responses were performed at 20° and 40° flexion to measure knee joint position sense. Pain and disability were assessed by self‐reported questionnaires and objective measures of balance and gait. Results showed little association between knee joint position sense variables and measures of pain and disability (r values <0.24, most p > 0.05). When comparing participants with the worst and best joint position sense, no significant differences in pain and disability could be found (p > 0.05). While our study design does not allow causality to be established, these results suggest that deficits in joint position sense may be due to factors other than pain and that deficits are not large enough to impact upon disability.

Acupuncture for Chronic Knee Pain: A Randomized Clinical Trial

IMPORTANCE There is debate about benefits of acupuncture for knee pain. OBJECTIVE To determine the efficacy of laser and needle acupuncture for chronic knee pain. DESIGN, SETTING, AND PARTICIPANTS Zelen-design clinical trial (randomization occurred before informed consent), in Victoria, Australia (February 2010-December 2012). Community volunteers (282 patients aged ≥50 years with chronic knee pain) were treated by family physician acupuncturists. INTERVENTIONS No acupuncture (control group, n = 71) and needle (n = 70), laser (n = 71), and sham laser (n = 70) acupuncture. Treatments were delivered for 12 weeks. Participants and acupuncturists were blinded to laser and sham laser acupuncture. Control participants were unaware of the trial. MAIN OUTCOMES AND MEASURES Primary outcomes were average knee pain (numeric rating scale, 0 [no pain] to 10 [worst pain possible]; minimal clinically important difference [MCID], 1.8 units) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index, 0 [no difficulty] to 68 [extreme difficulty]; MCID, 6 units) at 12 weeks. Secondary outcomes included other pain and function measures, quality of life, global change, and 1-year follow-up. Analyses were by intention-to-treat using multiple imputation for missing outcome data. RESULTS At 12 weeks and 1 year, 26 (9%) and 50 (18%) participants were lost to follow-up, respectively. Analyses showed neither needle nor laser acupuncture significantly improved pain (mean difference; -0.4 units; 95% CI, -1.2 to 0.4, and -0.1; 95% CI, -0.9 to 0.7, respectively) or function (-1.7; 95% CI, -6.1 to 2.6, and 0.5; 95% CI, -3.4 to 4.4, respectively) compared with sham at 12 weeks. Compared with control, needle and laser acupuncture resulted in modest improvements in pain (-1.1; 95% CI, -1.8 to -0.4, and -0.8; 95% CI, -1.5 to -0.1, respectively) at 12 weeks, but not at 1 year. Needle acupuncture resulted in modest improvement in function compared with control at 12 weeks (-3.9; 95% CI, -7.7 to -0.2) but was not significantly different from sham (-1.7; 95% CI, -6.1 to 2.6) and was not maintained at 1 year. There were no differences for most secondary outcomes and no serious adverse events. CONCLUSIONS AND RELEVANCE In patients older than 50 years with moderate or severe chronic knee pain, neither laser nor needle acupuncture conferred benefit over sham for pain or function. Our findings do not support acupuncture for these patients. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12609001001280.

Reducing joint loading in medial knee osteoarthritis: Shoes and canes

OBJECTIVE Increased medial knee loading is associated with a much higher risk of disease progression in knee osteoarthritis (OA). Interventions that can reduce medial knee joint load have the potential to slow disease progression over time. We evaluated the effects of shoes and a cane on knee load in people with knee OA. METHODS Forty people with medial knee OA underwent 3-dimensional gait analysis to measure their peak knee adduction moment, an indicator of medial knee joint load. Results when walking in bare feet were compared with those obtained when walking in their own usual shoes. Twenty participants also underwent testing using a cane, and results were compared with walking unaided. RESULTS Compared with barefoot, walking in shoes was associated with a significant increase in the peak knee adduction moment (mean +/- SD N x m/BW x H% 3.49 +/- 0.84 versus 3.77 +/- 0.90; P < 0.001), although there was considerable individual variation. The use of a cane resulted in a 10% decrease in the knee adduction moment (mean +/- SD N x m/BW x H% 3.76 +/- 0.95 versus 3.38 +/- 0.68; P = 0.001). CONCLUSION Wearing shoes increases medial knee joint load compared with walking barefoot. Given the variable response to shoes observed, further research is required to ascertain which shoe types might be optimal for those with knee OA. The use of a cane significantly reduces medial knee loading and has the potential to reduce the risk of disease progression in knee OA.

Effect of Physical Therapy on Pain and Function in Patients With Hip Osteoarthritis: A Randomized Clinical Trial

IMPORTANCE There is limited evidence supporting use of physical therapy for hip osteoarthritis. OBJECTIVE To determine efficacy of physical therapy on pain and physical function in patients with hip osteoarthritis. DESIGN, SETTING, AND PARTICIPANTS Randomized, placebo-controlled, participant- and assessor-blinded trial involving 102 community volunteers with hip pain levels of 40 or higher on a visual analog scale of 100 mm (range, 0-100 mm; 100 indicates worst pain possible) and hip osteoarthritis confirmed by radiograph. Forty-nine patients in the active group and 53 in the sham group underwent 12 weeks of intervention and 24 weeks of follow-up (May 2010-February 2013) INTERVENTIONS: Participants attended 10 treatment sessions over 12 weeks. Active treatment included education and advice, manual therapy, home exercise, and gait aid if appropriate. Sham treatment included inactive ultrasound and inert gel. For 24 weeks after treatment, the active group continued unsupervised home exercise while the sham group self-applied gel 3 times weekly. MAIN OUTCOMES AND MEASURES Primary outcomes were average pain (0 mm, no pain; 100 mm, worst pain possible) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index, 0 no difficulty to 68 extreme difficulty) at week 13. Secondary outcomes were these measures at week 36 and impairments, physical performance, global change, psychological status, and quality of life at weeks 13 and 36. RESULTS Ninety-six patients (94%) completed week 13 measurements and 83 (81%) completed week 36 measurements. The between-group differences for improvements in pain were not significant. For the active group, the baseline mean (SD) visual analog scale score was 58.8 mm (13.3) and the week-13 score was 40.1 mm (24.6); for the sham group, the baseline score was 58.0 mm (11.6) and the week-13 score was 35.2 mm (21.4). The mean difference was 6.9 mm favoring sham treatment (95% CI, -3.9 to 17.7). The function scores were not significantly different between groups. The baseline mean (SD) physical function score for the active group was 32.3 (9.2) and the week-13 score was 27.5 (12.9) units, whereas the baseline score for the sham treatment group was 32.4 (8.4) units and the week-13 score was 26.4 (11.3) units, for a mean difference of 1.4 units favoring sham (95% CI, -3.8 to 6.5) at week 13. There were no between-group differences in secondary outcomes (except greater week-13 improvement in the balance step test in the active group). Nineteen of 46 patients (41%) in the active group reported 26 mild adverse effects and 7 of 49 (14%) in the sham group reported 9 mild adverse events (P = .003). CONCLUSIONS AND RELEVANCE Among adults with painful hip osteoarthritis, physical therapy did not result in greater improvement in pain or function compared with sham treatment, raising questions about its value for these patients. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12610000439044.

Dynamic knee loading is related to cartilage defects and tibial plateau bone area in medial knee osteoarthritis

OBJECTIVE To evaluate the relationship between dynamic mechanical loading, as indicated by external knee adduction moment (KAM) measures during walking, and measures of articular cartilage morphology and subchondral bone size in people with medial knee osteoarthritis (OA). DESIGN 180 individuals with radiographic medial tibiofemoral OA participated. Peak KAM and KAM angular impulse were measured by walking gait analysis. Tibial cartilage volume and plateau bone area, and tibiofemoral cartilage defects were determined from magnetic resonance imaging using validated methods. RESULTS Both peak KAM (coefficient=0.42, 95% confidence interval (CI) 0.04-0.79, P=0.03) and KAM impulse (coefficient=1.79, 95% CI 0.80-2.78, P<0.001) were positively associated with the severity of medial tibiofemoral cartilage defects. KAM impulse was also associated with the prevalence of medial tibiofemoral cartilage defects (odds ratio 4.78, 95% CI 1.10-20.76, P=0.04). Peak KAM (B=0.05, 95% CI 0.01-0.09, P=0.02) and KAM impulse (B=0.16, 95% CI 0.06-0.25, P=0.002) were positively associated with medial:lateral tibial plateau bone area, and KAM impulse was also associated with medial tibial plateau bone area (B=133.7, 95% CI 4.0-263.3, P=0.04). There was no significant association between KAM measures and tibial cartilage volume. CONCLUSION Peak KAM and KAM impulse are associated with cartilage defects and subchondral bone area in patients with medial knee OA, suggesting that increased mechanical loading may play a role in the pathological changes in articular cartilage and subchondral bone that occur with medial knee OA.

Clinical pilates versus general exercise for chronic low back pain: randomized trial.

PURPOSE This single-assessor-blinded randomized controlled trial aimed to compare the efficacy of physiotherapy-delivered clinical Pilates and general exercise for chronic low back pain. METHODS Eighty-seven community volunteers with low back pain for ≥3 months and age 18-70 were randomized to either the Pilates (n = 44) or general exercise (n = 43) group. The primary outcome was pain/disability measured with the Quebec scale. Secondary outcomes included pain on a numeric rating scale, Patient-Specific Functional Scale, Pain Self-efficacy Questionnaire, quality of life, and global perceived effect of treatment. All participants attended 60-min exercise sessions twice weekly for 6 wk supervised by a physiotherapist and performed daily home exercises that were continued during the follow-up. Participants from the clinical Pilates group received an individualized direction-specific exercise program prescribed by the physiotherapist after a clinical examination. The general exercise group received a generic set of exercises that were multidirectional and nonspecific. Outcomes were assessed after 6 wk (primary time point) and at 12 and 24 wk. Differences in mean change were compared between groups using ANCOVA adjusted for baseline values of the outcome. RESULTS Eighty-three participants (96%) completed the 6-wk intervention and 60 (69%) completed the 24-wk follow-up. At 6 wk, no difference was found between groups for change in the Quebec scale (3.5, 95% confidence interval = -7.3 to 0.3, P = 0.07); both groups showed significant improvements. Similar results were found at the 12- and 24-wk follow-up and for the secondary outcome measures. CONCLUSIONS An individualized clinical Pilates program produced similar beneficial effects on self-reported disability, pain, function and health-related quality of life as a general exercise program in community volunteers with chronic low back pain.

A physiotherapist-delivered, combined exercise and pain coping skills training intervention for individuals with knee osteoarthritis: a pilot study.

BACKGROUND Osteoarthritis (OA) of the knee is associated with a number of physical and psychological impairments. Unfortunately, very few treatment strategies are capable of addressing both types of impairments concurrently. We performed a pilot, randomized controlled, proof of principle trial investigating the feasibility and effects of an intervention combining physical exercise and pain coping skills training (PCST). METHODS Twenty patients with a clinical and radiographical diagnosis of tibiofemoral OA were randomized to receive either 10 weeks of physiotherapist supervised exercises (lower limb strengthening and walking) combined with non-directive counseling (NDC) or the same exercise program delivered concurrently with PCST. Primary outcomes included self-reported pain and pain coping, while secondary outcomes included self efficacy and self-reported physical function. RESULTS Ten participants were randomized to each group and both groups exhibited significant improvements in isometric knee strength, self-reported knee pain and physical function, self efficacy for control of pain management and other arthritis symptoms. Only those in the exercise + PCST group reported statistically significant improvements in pain control coping and rational thinking. No between-group differences existed in any outcome (0.07 < p < 0.98). Based on our findings, 63 participants per group would be needed for future large-scale studies using similar outcome measures and design. CONCLUSIONS Our study showed that an intervention that combines exercise and PCST within the same treatment session and delivered by specially-trained physiotherapists is feasible and can improve both physical and psychological outcomes in individuals with knee OA. LEVEL OF EVIDENCE Level II Clinical Trials Registry number: ACTRN12609000623291.

Neuromuscular Versus Quadriceps Strengthening Exercise in Patients With Medial Knee Osteoarthritis and Varus Malalignment: A Randomized Controlled Trial†

To compare the effects of neuromuscular exercise (NEXA) and quadriceps strengthening (QS) on the knee adduction moment (an indicator of mediolateral distribution of knee load), pain, and physical function in patients with medial knee joint osteoarthritis (OA) and varus malalignment.

Quadriceps strength is not related to gait impact loading in knee osteoarthritis

Joint loading has been implicated in the pathogenesis of knee osteoarthritis (OA). While compartment-specific measures such as the knee adduction moment have received much attention in the literature, less is known about other measures of dynamic loading in this patient population. This cross-sectional study assessed strength and walking patterns of 204 individuals with radiographically confirmed medial tibiofemoral OA and varus malalignment. Pearson product moment correlations and regression analyses were used to determine the bivariate and multivariate relationships amongst measures of impact loading (rate of loading and heelstrike transient occurrence) with demographic, clinical (in particular, radiographic disease severity, lower limb alignment, and self-reported pain and function), and biomechanical variables (maximum voluntary isometric quadriceps strength and gait kinematics). While maximum voluntary isometric quadriceps strength was significantly correlated with rate of loading (r>0.27) when walking at a freely chosen speed, multiple regression analyses indicated that rate of loading was primarily dictated by walking speed (p<0.001), and the effect of quadriceps strength was insignificant when accounting for all other included variables. Individuals who exhibited a heelstrike transient in their vertical ground reaction force profile were significantly more varus malaligned and were more likely to demonstrate severe radiographic degeneration than those who did not exhibit heelstrike transients. These results demonstrate higher impact loading during walking in those with knee OA with faster self-selected walking speeds, though the relationship with quadriceps strength is less clear. Importantly a potential association between disease characteristics, such as malalignment and disease severity, and higher impact loading was also observed.