ABSTRACT

BACKGROUND: Patients suffering from medial compartment and Lateral compartment knee osteoarthritis may be successfully treated with offloading knee braces and Salford insoles by reducing their pain score and improving their efficiency.

OBJECTIVE: This Case Study was undertaken to find out whether the provision of an offloading knee brace, either external knee adducting moment, or external knee abducting moment, and/or the provision of Salford offloading insoles, made a difference to their pain score and the speed in which they walked.

There are a number of patients who attend orthotic clinics who are considered either unsuitable or too high a risk for a Total Knee Replacement. Both health and/or age factors can prevent their being selected for surgery. Therefore, providing physiotherapy or changing the biomechanics of the knee using a knee brace and orthotic in a shoe may be the only option

It may seem obvious that providing an orthotic brace to offload the medial or lateral compartment, the brace would do what we expect it to do, that is to reduce

the load, add support and reduce pain. However, using outcome measurements to gain data, we can ascertain that the provision of a knee brace given to a patient is the correct treatment plan to take, not only in reducing the pain score, but making the patient more efficient.

The knee adduction/ abduction moment during gait is the Primary determinant of medial/lateral load distribution. Medial loads placed on the joint during walking have been related to the progression of knee osteoarthritis. It is known that 2.5 times greater loads are taken through the medial compartment than through the lateral compartment. Or during normal gait approximately 60-80% of the load across the knee joint is transmitted to the medial compartment (Prodromos et al

1985). Therefore, there are a larger percentage of patients with medial compartment osteoarthritis than lateral compartment osteoarthritis. This trial was no exception to that rule (see Distribution of affected limb and compartment diagram 1 ).

Osteoarthritis is the most common type of arthritis and is often associated with disability. Osteoarthritis is the result of 2

Off loading knee braces and Salford insoles

Off loading knee braces and Salford insoles can be used as a conservative treatment in reducing knee pain and increasing gait efficiency for patients with knee osteoarthritis.

available.

Pain will have an effect on the efficiency of the gait pattern. If the efficiency of gait is improved the metres per second travelled will be increased, i.e. more distance in less time. The study was undertaken to see if pain scores could be reduced and the metres per second increased by the use of a knee brace and orthotic insert in the shoe.

METHOD: Simple routine assessment changes in clinic were undertaken. Questions on pain score, mobility, quadriceps angle and a timed up and go trial were noted. The appropriate knee brace was then fitted and tuned according to the patients requirements.

RESULTS: The comparison of the pain score and the changes in the metres/second from no orthotic intervention to those with orthotic intervention was then noted. A 3 month trial was undertaken ( n =50 : 27 male and 23 female ), results show that with intervention of a knee brace the pain score decreased on average 2 on the pain score. However, some patients by 8 on the pain score. The addition of a Salford insole decreased the pain score by 3, compared with no intervention. 25% of patients in the trial reported of 100% pain relief with combined knee brace and Salford insoles.

CONCLUSION: From the results gained from the trial, it was found that the provision of orthotic intervention generally improved both the pain and speed of the patient with osteoarthritis of the knee. The best intervention would be both knee brace and Salford insole.

major factors; those that increase regional load across articular cartilage and those that affect the material properties and the remodelling process of articular cartilage and therefore its ability to withstand load. Walking speed decreases with age, however, patients with knee pathologies walk at a slower speed than patients with healthy knees. From other case studies it is known that 64% of patients who attend with osteoarthritis of a knee also have osteoarthritis of the contralateral knee. (The Journal of Rheumatology ).

Osteoarthritis is the most common form of arthritis, and the knee joint is the most commonly affected joint. “Wear and tear “or “worn-out knees” can be described as painful and debilitating and have a massive impact on function and patients activities and daily living. There are numerous factors associated with the osteoarthritic knee, such as age, weight, muscle weakness and/or previous injury.

Not all patients want to wear a knee brace; in fact there are a percentage of patients that would rather go straight to surgery, although there are also a percentage of patients that wish to avoid surgery at all cost. The surgical option may not be appropriate for many individuals, such as the younger population, so wearing an orthosis to reduce the excessive compartmental load and increase the individuals independence may well be the better option and obtained by the use of the correct knee brace and or offloading insole.

The patients seen in the case study were of a wide variety of age, all with osteoarthritis of the knee, either medial compartment or lateral compartment degeneration, and/or patella femoral OA, and were provided with 2 different types of knee brace, depending on the compartment affected and/or a Salford offloading insole into the shoe. The case study was undertaken to see if the pain and speed of a patient with osteoarthritis of the knee could be

improved by the use of an offloading knee brace and/or a Salford offloading insole.

CASE

The data collected was taken over a 3 month period, with the patients being sent to the orthotic clinic, from the Orthopaedic Consultants at Stepping Hill Hospital. The trial involved 50 random patients all with osteoarthritis of the knee, 27 Male subjects and 23 Female subjects were assessed. The age varied from 32 years old to 92 years old. Information given were MRI reports and x-ray results. At the time of consultation with the Orthotist, the knee was examined for range of motion, stability, Q angle, and knee apprehension test.

A simple format sheet was filled in regarding age, occupation, weight and height. From the data collected on weight and height the BMI was ascertained. The findings showed that most of the patients were in the categories overweight to severely obese. Weight is a critical factor in patients with osteoarthritis of the knee. Gravity is a constant of 9.806 meters per second squared, and

it is known that when walking the weight =mass x acceleration due to gravity. W=mg. As gravity acts on mass , it is known that compression forces of 4 to 5 times body weight acts through the skeletal frame when walking. (Functional Anatomy of the foot and Ankle. Jeff Balazsy, M.D. Orthopaedic Physical Therapy secrets. Hanley&Belfus.)

Walking speed decreases with age, however patients with knee pathologies walk at a slower speed than patients with healthy knees. From other case studies, it is known that 64% of patients who attend with osteoarthritis of a knee also have osteoarthritis of the contralateral knee. (The Journal of Rheumatology ).

From the Q angle, the knee alignment was taken and determined if it was aligned or mal-aligned. The normal value for the Q angle being 13 to 18 degrees, with men tending to be in the lower range.

It was decided to undertake a Timed up and Go (TUG) time trial. This was decided on as it incorporated movements which would influence the osteoarthritic knee, such as sitting to stand, standing to sit, a distance travelled and a turn. The patient was asked to turn the same way each time and to walk at their normal walking speed.

The Timed up and Go involved the patient sitting to stand, walking 3 metres, turning around a cone placed 3 metres from the chair, walking back the 3 metres and sitting back down. This was timed and repeated 3 times. The mean result was taken and logged and converted to metres per second.

A pain score was also taken with 0 being no pain and 10 being the worse pain. Patients were asked the distance they could walk. The pain score was logged for distance, at rest and in bed (night time pain ).

The TUG was taken with the patient wearing no brace 3 times and the mean time was recorded. The TUG was again taken with the patient wearing the brace 3 times and the mean time recorded. The force provided through the knee was altered accordingly to achieve the best mean score of m/s. The time was then taken with a Salford insole again 3 times, and the mean time recorded.

For the case study it was decided to use 2 styles of knee bracing. One is a pushing brace; The Freestyle Breg OA brace. The other was the Unloader Brace from Ossur, which is a pulling brace. It was decided that the Freestyle brace would be used for patients with medial compartment OA changes, where the dial would be placed on the lateral side of the knee joint, and

a determined size of force be used by turning the dial on the joint. The size of the force being determined by the weight of the patient. This brace would provide an external knee adducting moment.

FEATURE

	30
	25
	20
	15
	10
	5
	0
		Bilateral Lat Bilat Med Left Lateral Left Medial Right Lateral Right Medial
	fig 1: Distribution of affected limb compartment
	20
							Female			Male
	15

10

5

0

Genu VarumAlignedGenu Valgum

fig 2: Q angle difference between male and female patients

			Female				Male
			parameters				parameters
	Genu Varum		14 degrees or less		9		12 degrees or less	4
	Aligned		15 to 18 degrees		9		13 to 15 degrees	16
	Genu Valgum		19 degrees or more		5		16 degrees or more	7
	fig 3: Q angle parameters
	Score		BMI				Number of patients
	less than 18.5		underweight			0
18.5 - 24.9			healthy			12
25 - 29.9			overweight			17
30+			obese			15
35+			severe obesity			7
40+			morbid obesity			0
	fig 4: Categories by BMI
	Age range					Mean time in seconds
20 - 29							8.57 seconds
30 - 39							8.56 seconds
40 - 49							8.86 seconds
50 - 59							9.90 seconds
60 - 69							8.10 seconds
70 - 79							9.20 seconds
80 - 99							11.3 seconds

fig 5: Timed Up and Go mean times by age range

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The Ossur unloader brace was used for lateral compartment OA changes. This brace is a pulling rather than pushing style of brace where the joint for this occasion is on the lateral side, and the strapping system pulls the knee to the mid line. This brace was ideal for the valgus knee. With the brace having only straps on the medial aspect it reduces the possibility that the brace could rub/ clip into the opposite leg. This knee brace will provide an external knee abducting moment.

The Salford insole was used either with lateral or medial postings. These alter the force vector that travels through the knee, either to bring the knee medially or the knee laterally.

The treatment plan for the study was to demonstrate that the pain in the knee was hopefully reduced by wearing the knee brace not only when walking but when standing/sitting and turning. The TUG became a tool for information. The patient sometimes did not feel a pain reduction; though felt the knee was more stable/easier to move, during the movement zones within the TUG.

The expected outcome of the trial was to gather relevant factual data that could be used to inform the patient of their improvement with the orthosis. Being able not only to get a reduction in the pain score, but to improve the speed of gait would encourage orthotic wear. This information being used to state that improved distances could be obtained with less pain in the knee.

RESULTS

The full results of the study are at the back of the report. 23 female and 27 male patients were seen in the 3 month period and undertook the trial.

It is generally recognised that the Q angle between males and females are different due to the width of the pelvis in the female. The breadth of the pelvis and close proximity of the knee creates a valgus angulation to the femur. The direction of pull of the quadriceps is along the shaft of the femur and that of the patellar tendon is almost vertical. This difference between the pull is known as the Q angle. The normal values are 13.5 +/- 4.5 degrees in healthy subjects between 18 and 35 years of age, The Q angle is 4.6 degrees greater than that of men.

In this trial we used the Q angle of 13-15 degrees for men and 15 to 18 degrees for women. If the Q angle was outside these parameters then the knee was considered malaligned.

The mean times produced for the Timed Up and Go obtained by the 50 participants in relation to their age shows that 30 of the participants were above average for their age and 20 were average or below average for their age.

The pain scale is the most commonly used scale where a person relates their pain on a scale of 0 to 10. Zero means no pain and 10 mean the worst possible pain.

Grading scales for the radiographic osteoarthritis classification systems. The table shows that with intervention, the pain score decreased. With the intervention of an offloading knee brace, appropriately adjusted fitted and loaded for the individual’s needs, on average the pain score decreased by 2 points. However, for some participants the pain score decreased by 8 points.

With the addition of a functional foot orthosis specific for the patient’s diagnosis the average pain score decreased by 3 points when compared to no intervention.

25% of participants from the trial reported a score of zero when the combination of both Knee offloading brace and shoe orthotic was provided.

The conclusive findings of the trial are shown in the table below:

DISCUSSION

There have been many occasions when a patient has arrived in the Orthotic Clinic to be assessed for an offloading knee brace, and the initial discussion from the patient has been “What does a knee brace look like?” “Does it have to be that long? Can it just cover the knee joint only”. For this group of patients it can be difficult to provide a brace and justify its effect without any backup data. There are also a group of patients who do not want the knee brace and wish to go straight to the operating table, as they have had knee pain for so long and do not believe the brace will work. There are also patients who do not want a knee operation at any cost. These are the patients who are open for using a brace, but still need the backup data.

This report is independent and was undertaken with no specific grant or from any funding agency in the public, commercial or not for profit sectors. The Knee braces used were the two current OA braces that were being used within the clinic. The information gained was purely to ascertain if the offloading Knee braces did make a difference to the speed of the patient with osteoarthritic knees. The patients metres per second in general was improved within the 6 metres TUG from average 0.59 m/s without the brace, to 0.62 m/s with the brace and 0.65 m/s with the brace and Salford insole Their pain score was decreased by a score of 2 when wearing a knee brace, and 3 with the knee brace and Salford insole combination.

It became good practice to incorporate the assessment and the TUG as part of a normal assessment appointment, as providing the data whilst the patient was in the clinic, became a decisive factor.

Generally the pain score was reduced, and generally the metres per second was improved, however, in some cases the knee brace was not provided, and in other cases the Salford insoles were not

GradeCharacteristics

0No JSN or reactive changes

1Doubtful JSN, possible osteophytic lipping

2Definite osteophytes, possible JSN

3Moderate osteophytes, definite JSN, some sclerosis, possible bone end deformity

4Large osteophytes, marked JSN, severe sclerosis, definite bone ends deformity

fig 6: Kellgren-Lawrence scale

Participants	Average	Average	Speed
	speed m/s	pain score	m/s
Without intervention	10.94 s	5/10 (4.8)	0.59 ms
With brace	10.29 s	3/10 (2.6)	0.62 ms
With brace and Salford	9.7 s	2/10 (1.9)	0.65 ms

fig 7

FEATURE

provided.

A small percentage of patients in the trial had no change in pain, or had any improvement in their speed with the knee brace. These patients were not provided with the knee brace due to the lack

of improvement. The information gained from the trial became an important tool for the Orthotist as a positive cost implication and a saving of money for the Trust.

Some patients preferred to have the knee brace and not the Salford insoles, even though their pain score was lower with both. Ladies footwear in some cases did not accommodate the bulk of the Salford insole, and so they preferred to wear the knee brace which could be hidden under clothing, and not have to change their style of shoes. Again a positive cost implication for the Trust.

CONCLUSION

Provision of OA knee braced Salford insoles to patients with osteoarthritis of the knee is a positive pathway undertake when it comes to their treatment plan. The findings were very encouraging. Overall the pain scores were reduced. In many cases pain was completely reduced, though over the total of the 50 patients the pain score was reduced to 2/10 with just the brace and 3/10 with the combination of brace and Salford insoles.

The metres per second from the timed up and go also improved. Over the 50 patients participating the time that was improved to do the timed up and go test was 0.65 seconds with the brace and 1.2 seconds with the brace and Salford insole combination. The speed improvement was 0.03 m/s with the brace and 0.06 m/s with brace and Salford insoles combined.

The findings are now to be given back to the consultant who will review the patients in the study after a 9 month period of wearing the orthosis and take new standing images of the knee to see if the valgus/varus angle has been improved.

Michael Carter

Orthotist

REFERENCES

1Richard K. Jones, Graham J. Chapman, Laura Forsythe, Matthew J. Parkes, David T. Felson : The Relationship Between Reductions in Knee Loading and Immediate Pain Response While Wearing Lateral Wedged Insoles in Knee Osteoarthritis. 6 June 2014 Wiley Online Library.

2A Relationship Between Gait and Clinical Changes Following High Tibial

Osteotomy, Prodromos et al 1985.

3Leena Sharma, Debra E. Hurwitz, Eugene J-M .A Thonar, Jefffrey

A. Sum, Mary Ellen Lenz, Dorothy D. Dunlop, Thomas J.Schnitzer, Gretchen Kirwan-Mellis, Thomas P. Andriacchi. Knee Adduction Moment, Serum Hyaluronan Level, and Disease Severity in Medial Tibiofemoral

Osteoarthritis.

4Richard K. Jones, Graham J.Chapman, Andrew H. Findlow, Laura Forsythe, Matthew J.Parkes, Jawad Sultan, David T Felson. A New Approach to Prevention of Knee Osteoarthritis: Reducing Medial Load in the Contralateral Knee. The Journal of Rheumatology .

5G.Peat, R. McCarney, P. Croft. Knee Pain and Osteoarthritis in Older

Adults: A Review of Community Burden and Current Use of Primary Care Health.

6Jefffrey D. Placczek, David A.Boyce. Orthopaedic Physical Therapy

Secrets 2001 Hanley & Belfus.

7http://geriatrictoolkit.missouri.edu/tug/Bohannon-TUG-Ref- JGPT2006-2. pdf http://journals.sagepub.com/doi/abs/ 10.1177/2150131916659282

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