Benedicte Vanwanseele

Strength Training for Treatment of Osteoarthritis of the Knee: A Systematic Review

OBJECTIVE To assess the effectiveness of isolated resistance training on arthritis symptoms, physical performance, and psychological function in people with knee osteoarthritis. METHODS A comprehensive systematic database search for randomized controlled trials was performed. Two reviewers independently assessed studies for potential inclusion. Study quality indicators, arthritis symptoms, muscle strength, functional performance, and psychological outcomes were extracted. The relative effect sizes (ES) were calculated with 95% confidence intervals. RESULTS Eighteen studies enrolling 2,832 subjects were reviewed; the mean cohort age range was 55-74 years. In general, the quality of the reviewed literature was moderately robust; on average, 8 out of 12 quality criteria were accounted for in the reviewed literature. Self-reported measures of pain, physical function, and performance, along with muscle strength (mean 17.4%), maximal gait speed and chair stand time, and balance improved significantly following resistance training in 56-100% of studies where they were measured. Limitations included lack of data available for ES calculations and lack of adverse event and compliance reporting, particularly with regard to the actual training intensity versus the prescribed training intensity. CONCLUSION Resistance training improved muscle strength and self-reported measures of pain and physical function in over 50-75% of this cohort; 50-100% of the studies reported a significant improvement in all but 1 performance-based physical function measure (walk time). The effects of resistance training on health-related quality of life and depression are yet to be confirmed. More research needs to be conducted to establish dose-response relationships and the effect of resistance training on long-term disability, disease pathology, and progression.

Lower limb muscle strengthening does not change frontal plane moments in women with knee osteoarthritis: A randomized controlled trial

BACKGROUND Osteoarthritis is a common musculo-skeletal problem accompanied with muscle weakness. Muscle weakness may be readily improved by resistance training. Greater muscle strength has been associated with a lower knee joint loading rate. METHODS We conducted a single-blind randomized controlled trial of 54 female patients with osteoarthritis in at least one knee, according to the American College of Rheumatology clinical criteria. Patients were randomized into a 6-month high intensity progressive resistance training or a sham-exercise program. The primary outcomes were first peak knee and hip adduction moment measured using three-dimensional gait analysis at self-selected habitual and maximal speeds. Secondary outcomes were sagittal plane knee and hip moments, peak muscle strength, gait speed, and self-reported knee osteoarthritis symptoms measured by the Western Ontario and McMaster Osteoarthritis Index (WOMAC). FINDINGS Six months of high intensity resistance training did not change the first peak knee or hip adduction moment at either habitual or maximum walking speeds (P>0.413) compared to the sham-exercise. However, the second peak hip adduction moment (P=0.025) and WOMAC pain score (P<0.001) were reduced significantly in both groups over time, but there was no group effect. The changes in the second peak hip adduction moment were inversely related to the changes in the WOMAC pain score (r=-0.394, P=0.009). INTERPRETATIONS Muscle strength training in women with osteoarthritis, while effective for reducing osteoarthritis symptoms, appeared to operate through mechanisms other than improved knee or hip joint loading, as paradoxically, improved symptoms were related to decreases of hip adduction moment in late stance.

The relationship between knee adduction moment and cartilage and meniscus morphology in women with osteoarthritis

OBJECTIVE The aim of this cross-sectional study is to investigate the relationship between knee adduction moment and knee adduction angular impulse and meniscus, cartilage and bone morphology in women with knee osteoarthritis (OA). METHOD Forty-five women aged >40 years with OA in at least one knee, according to American College of Rheumatology clinical criteria were studied. The knee joint loading was assessed by three-dimensional motion analysis system during gait. Three Tesla magnetic resonance imaging (MRI) with a coronal T2-weighted spin echo sequence was used for evaluating meniscus pathology, and a coronal T1-weighted gradient echo sequence for quantifying cartilage morphology and bone surface size. Cartilage thickness, denuded area and subchondral area in the femorotibial joint was measured using custom software. RESULTS A higher peak knee adduction moment was observed in participants with medial compared to those with lateral tears (2.92+/-1.06 vs -0.46+/-1.7, P<0.001). Participants with a higher knee adduction moment displayed a larger medial meniscus extrusion (r=0.532, P<0.001) and a lower medial meniscus height (r=-0.395, P=0.010). The inverse relationship was observed for the lateral meniscus. A higher knee adduction moment was also associated with a higher ratio of the medial to lateral tibial subchondral bone area (r=0.270, P=0.035). By contrast, cartilage thickness and denuded areas in the femur and tibia were not related to the knee adduction moment. Similar results were found for the relationship between knee adduction angular impulse and meniscus, cartilage and bone morphology. CONCLUSIONS Dynamic knee joint loading is significantly related to meniscus pathology and bone size, but not to cartilage thickness in women with OA.

Dynamic alignment and its association with knee adduction moment in medial knee osteoarthritis

Lower limb dynamic alignment represents the limb position during functional loading conditions and obtains valuable information throughout the gait cycle rather than a single instant in time. This study aims to determine whether dynamic alignment is altered in medial knee osteoarthritis (OA) and how dynamic alignment is related to knee adduction moment (KAM). Community-dwelling women (n=17) with medial OA in at least one knee, according to the American College of Rheumatology criteria and 17 body mass index-matched women without OA were recruited. A three-dimensional motion analysis system was used to collect the gait data at self-selected habitual and maximal speeds. Clinical evaluation of lower extremities, physical function, pain, habitual level of physical activity, quality of life and physical self-efficacy were assessed. Shank adduction angle and shank mean angular velocity were significantly greater in the OA group compared to the controls from heel strike to 30% stance. KAM was not different between the groups (p=0.542). Dynamic alignment variables were the best predictors of KAM. Health-related quality of life, habitual level of physical activity, lower extremity muscle strength and balance performance were impaired in the OA group compared to the controls. The importance of variables that contribute to dynamic alignment and the contribution of limb alignment to KAM were highlighted in this study. Detection of postural changes such as altered dynamic alignment in early stages of OA will lead to the institution of joint-protective measures including changes in footwear, orthotics, gait re-training, use of assistive devices to reduce weight-bearing loads, strengthening and balance enhancing exercises, better analgesia, or cartilage-preserving pharmacotherapy.

Resistive Exercise for Arthritic Cartilage Health (REACH): A randomized double-blind, sham-exercise controlled trial

BackgroundThis article provides the rationale and methodology, of the first randomised controlled trial to our knowledge designed to assess the efficacy of progressive resistance training on cartilage morphology in women with knee osteoarthritis.Development and progression of osteoarthritis is multifactorial, with obesity, quadriceps weakness, joint malalignment, and abnormal mechanical joint forces particularly relevant to this study. Progressive resistance training has been reported to improve pain and disability in osteoarthritic cohorts. However, the disease-modifying potential of progressive resistance training for the articular cartilage degeneration characteristic of osteoarthritis is unknown. Our aim was to investigate the effect of high intensity progressive resistance training on articular cartilage degeneration in women with knee osteoarthritis.MethodsOur cohort consisted of women over 40 years of age with primary knee osteoarthritis, according to the American College of Rheumatology clinical criteria. Primary outcome was blinded measurement of cartilage morphology via magnetic resonance imaging scan of the tibiofemoral joint. Secondary outcomes included walking endurance, balance, muscle strength, endurance, power, and velocity, body composition, pain, disability, depressive symptoms, and quality of life.Participants were randomized into a supervised progressive resistance training or sham-exercise group. The progressive resistance training group trained muscles around the hip and knee at 80% of their peak strength and progressed 3% per session, 3 days per week for 6 months. The sham-exercise group completed all exercises except hip adduction, but without added resistance or progression. Outcomes were repeated at 3 and 6 months, except for the magnetic resonance imaging scan, which was only repeated at 6 months.DiscussionOur results will provide an evaluation of the disease-modifying potential of progressive resistance training for osteoarthritis.Trial RegistrationANZCTR Reference No. 12605000116628

Progressive resistance training and dynamic alignment in osteoarthritis: A single-blind randomised controlled trial.

BACKGROUND we hypothesised that high intensity progressive resistance training would improve lower limb dynamic alignment and function (lower knee adduction moment, increased muscle strength, and fewer knee osteoarthritis symptoms). METHODS women (n=54) with osteoarthritis in at least one knee were randomised into a 6-month resistance training or a sham-exercise program. The primary outcomes were dynamic shank and knee adduction angles and knee adduction moment of the most symptomatic knee measured with quantitative gait analysis. Secondary outcomes were muscle strength, gait speed, and osteoarthritis symptoms. FINDINGS dynamic alignment and knee adduction moment did not change over time or between groups. Muscle strength improved in both groups over time, but significantly more in the resistance training group (P=0.002). By contrast, gait velocity and pain improved over time (P ≤ 0.009) in both groups. Improvements in shank adduction angle were related to improvements in self-reported disability (r=0.381, P=0.015), but not to changes in muscle strength, gait velocity, or pain (all P>0.05). INTERPRETATIONS although muscle strength improved significantly more in the PRT group, the hypothesised reduction in knee adduction moment, shank and knee adduction angles were not evident after either exercise modality. However, improvements in disability and shank adduction angle were significantly directly related. Initial alignment should be used to stratify this population into separate groups when designing future trials and alternative modes of training investigated to potentially enhance beneficial alterations in knee alignment.

Individual selection of gait retraining strategies is essential to optimally reduce medial knee load during gait

BACKGROUND The progression of medial knee osteoarthritis seems closely related to a high external knee adduction moment, which could be reduced through gait retraining. We aimed to determine the retraining strategy that reduces this knee moment most effective during gait, and to determine if the same strategy is the most effective for everyone. METHODS Thirty-seven healthy participants underwent 3D gait analysis. After normal walking was recorded, participants received verbal instructions on four gait strategies (Trunk Lean, Medial Thrust, Reduced Vertical Acceleration, Toe Out). Knee adduction moment and strategy-specific kinematics were calculated for all conditions. FINDINGS The overall knee adduction moment peak was reduced by Medial Thrust (-0.08Nm/Bw·Ht) and Trunk Lean (-0.07Nm/Bw·Ht), while impulse was reduced by 0.03Nms/Bw·Ht in both conditions. Toeing out reduced late stance peak and impulse significantly but overall peak was not affected. Reducing vertical acceleration at initial contact did not reduce the overall peak. Strategy-specific kinematics (trunk lean angle, knee adduction angle, first peak of the vertical ground reaction force, foot progression angle) showed that multiple parameters were affected by all conditions. Medial Thrust was the most effective strategy in 43% of the participants, while Trunk Lean reduced external knee adduction moment most in 49%. With similar kinematics, the reduction of the knee adduction moment peak and impulse was significantly different between these groups. INTERPRETATION Although Trunk Lean and Medial Thrust reduced the external knee adduction moment overall, individual selection of gait retraining strategy seems vital to optimally reduce dynamic knee load during gait.

Effect of thong style flip-flops on children's barefoot walking and jogging kinematics.

BackgroundThong style flip-flops are a popular form of footwear for children. Health professionals relate the wearing of thongs to foot pathology and deformity despite the lack of quantitative evidence to support or refute the benefits or disadvantages of children wearing thongs. The purpose of this study was to compare the effect of thong footwear on children’s barefoot three dimensional foot kinematics during walking and jogging.MethodsThirteen healthy children (age 10.3 ± 1.6 SD years) were recruited from the metropolitan area of Sydney Australia following a national press release. Kinematic data were recorded at 200 Hz using a 14 camera motion analysis system (Cortex, Motion Analysis Corporation, Santa Rosa, USA) and simultaneous ground reaction force were measured using a force platform (Model 9281B, Kistler, Winterthur, Switzerland). A three-segment foot model was used to describe three dimensional ankle, midfoot and one dimensional hallux kinematics during the stance sub-phases of contact, midstance and propulsion.ResultsThongs resulted in increased ankle dorsiflexion during contact (by 10.9°, p; = 0.005 walk and by 8.1°, p; = 0.005 jog); increased midfoot plantarflexion during midstance (by 5.0°, p; = 0.037 jog) and propulsion (by 6.7°, p; = 0.044 walk and by 5.4°, p;= 0.020 jog); increased midfoot inversion during contact (by 3.8°, p;= 0.042 jog) and reduced hallux dorsiflexion during walking 10% prior to heel strike (by 6.5°, p; = 0.005) at heel strike (by 4.9°, p; = 0.031) and 10% post toe-off (by 10.7°, p; = 0.001).ConclusionsAnkle dorsiflexion during the contact phase of walking and jogging, combined with reduced hallux dorsiflexion during walking, suggests a mechanism to retain the thong during weight acceptance. Greater midfoot plantarflexion throughout midstance while walking and throughout midstance and propulsion while jogging may indicate a gripping action to sustain the thong during stance. While these compensations exist, the overall findings suggest that foot motion whilst wearing thongs may be more replicable of barefoot motion than originally thought.

The effect of external ankle support on knee and ankle joint movement and loading in netball players

OBJECTIVES External ankle support has been successfully used to prevent ankle sprains. However, some recent studies have indicated that reducing ankle range of motion can place larger loads on the knee. The aim of this study was to investigate the effect of external ankle support (braces and high-top shoes) on the ankle and knee joint loading during a netball specific landing task. DESIGN A repeated measure design. METHODS High performance netball players with no previously diagnosed severe ankle or knee injury (n=11) were recruited from NSW Institute of Sport netball programme. The kinematic and kinetic data were collected simultaneously using a 3-D Motion Analysis System and one Kistler force plate to measure ground reaction forces. Players performed a single leg landing whilst receiving a pass while wearing a standard netball shoe, the same shoe with a lace-up brace and a high-top shoe. RESULTS Only the brace condition significantly reduced the ankle range of motion in the frontal plane (in/eversion) by 3.95 ± 3.74 degrees compared to the standard condition. No changes were found for the knee joint loading in the brace condition. The high-top shoes acted to increase the peak knee internal rotation moment by 15%. Both the brace and high-top conditions brought about increases in the peak ankle plantar flexion moment during the landing phase. CONCLUSIONS Lace-up braces can be used by netball players to restrict ankle range of motion during a single leg landing while receiving a pass without increasing the load on the knee joint.

Wireless Tri-Axial Trunk Accelerometry Detects Deviations in Dynamic Center of Mass Motion Due to Running-Induced Fatigue

Small wireless trunk accelerometers have become a popular approach to unobtrusively quantify human locomotion and provide insights into both gait rehabilitation and sports performance. However, limited evidence exists as to which trunk accelerometry measures are suitable for the purpose of detecting movement compensations while running, and specifically in response to fatigue. The aim of this study was therefore to detect deviations in the dynamic center of mass (CoM) motion due to running-induced fatigue using tri-axial trunk accelerometry. Twenty runners aged 18–25 years completed an indoor treadmill running protocol to volitional exhaustion at speeds equivalent to their 3.2 km time trial performance. The following dependent measures were extracted from tri-axial trunk accelerations of 20 running steps before and after the treadmill fatigue protocol: the tri-axial ratio of acceleration root mean square (RMS) to the resultant vector RMS, step and stride regularity (autocorrelation procedure), and sample entropy. Running-induced fatigue increased mediolateral and anteroposterior ratios of acceleration RMS (p < .05), decreased the anteroposterior step regularity (p < .05), and increased the anteroposterior sample entropy (p < .05) of trunk accelerometry patterns. Our findings indicate that treadmill running-induced fatigue might reveal itself in a greater contribution of variability in horizontal plane trunk accelerations, with anteroposterior trunk accelerations that are less regular from step-to-step and are less predictable. It appears that trunk accelerometry parameters can be used to detect deviations in dynamic CoM motion induced by treadmill running fatigue, yet it is unknown how robust or generalizable these parameters are to outdoor running environments.