Look at a biomechanical intervention

14 April of 2008

We are going to look at a biomechanical intervention first for his knee, and we can consider three different things. An OA knee brace, sometimes called an unloader brace. It is designed specifically for knee OA. We can look at a compression sleeve with a patellar support, since he does seem to have some tracking abnormalities. We can also look at a medial heel wedge or part of an insole that goes inside your shoe. This is what a knee unloader brace looks like. It can be designed for either medial or lateral compartment osteoarthritis and is designed to change biomechanically the joint. This is an example of the knee compression sleeve. They cost around $30 to $40. You can often buy them off the counter. This is essentially a soft brace with probably a polypropylene ring that helps capture the patella and not let it go just where it wants to go. So what is the evidence on that?

Well, in a randomized control trial of a fairly large number of people where they actually compared the unloader brace that you saw to the knee compression sleeve, they found similar improvements and no significant difference within group or between groups on walking and stairs. In another study reported in 2006 they had a treatment group only, much smaller, but they evaluated improved pain and walking in this group but no significant change in pain or gait parameters or stairs, or squatting. In a case series of 20 people, again no control, people reported improved pain and observed improvements in gait. However, since our fellow is on the farm, does a lot of work outside and is around equipment, external devices on bodies sometimes are not safe and we need to consider that. They are also fairly expensive and cumbersome to put on. So we’ve decided to try a wedged insole for him. The evidence on that is in a study that used a treated and non-treated group, again a fairly large group of people. People did have improved pain and walking time in stage I-III of knee osteoarthritis, although they didn’t find similar or significant improvements in late-stage disease. In another study here, also with only a treated group, they found decreased pain and decreased lateral thrust biomechanically at the knee when they did a medial insole.

Let me show you what that looks like. You see on the left the untreated foot, and I hope you can see the lines there that are showing calcaneal valgus. And you can see on the right the effect it has on the foot and therefore on the knee, and when you put a very slight wedge medially – and this can stick inside of his boot, won’t be a problem, it can stay there, he doesn’t have to take on or off or remember to wear it. We are planning to use initial clinic visits with him to reduce the knee contracture and to activate and get his VMO going again. Now that he has less effusion that should work better, and also to instruct him in lower extremity strengthening and range of motion exercises and also aerobic exercise routines that he can use inside the house. Here’s just an example of what you might see in clinic if you walked in while he was there. This is using E-STEM for quadriceps reeducation, particularly to activate the VMO and to put him in a position where he actively can work against and reduce the knee flexion contracture. Knee flexion contracture get by us very easily, particularly in people who have heavy legs, and even a 10 degree knee flexion contracture increases significantly the amount of energy that people have to expend just to walk around on level ground. So it’s an important thing to pay attention to. We are going to use for him, in clinic visits, to instruct him in a home program and we are using the model that was reported as successful by Michael Hurley and colleagues last year. In this study they had 89 patients with ACR criteria of knee OA and put them on an exercise regimen that they supervised in clinic two times a week for five weeks. About 30 minutes. That’s well within the guidelines of almost all managed care organizations for knee pain, although this was done in Great Britain. Then they were on a home program for six months. The results they found were significant improvements, at both five weeks and six months, of muscle function. Proprioception extremely important here, function and self-reported disability. You have a copy of that protocol and a more complete citation in your handouts. Maybe I should say here, we did max out on how many pages we could give you in the syllabus.

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