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Biomechanical and clinical outcomes with shock absorbing insoles in patients with knee osteoarthritis… Turpin, Kevin; Cooney, Thea; MacKenzie, Megan; Apps, Amy 2011-08

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Kevin Turpin, Thea Cooney,  Megan MacKenzie, Amy Apps with supervision from Dr. Michael Hunt   Biomechanical and clinical outcomes with shock absorbing insoles in patients with knee osteoarthritis: Immediate effects and changes following one month of wear Agenda: 1) Introduction to OA 2) Previous interventions 3) Study Rationale  4) Methods 5) Results 6) Discussion 7) Conclusions/Future considerations Osteoarthritis Facts: - degenerative joint disease affecting hands and weight bearing joints - knee most commonly affected 1  - affecting 1 in 10 Canadians 2 - no cure for OA  1. Oliveria (1985), 2. Arthritis Society (2011) Characteristics of OA: - degradation of articular       cartilage, menisci &       subchondral bone  - progressive  - joint pain, stiffness,     localized swelling  -?physical function   OA and Walking:  - walking implicated in progression of OA due to repetitive nature3,4  - higher loads in medial compartment cause ? breakdown of articular cartilage and more severe disease5,6 3. Miyazaki et al (2002), 4. Andriacchi & Mundermann (2006), 5. Creaby et al (2010), 6. Radin (1971) How is load measured? - knee adduction moment (KAM)       indirect measure of medial tibiofemoral loading7,8  -KAM= ground reaction force (GRF) x lever arm9 -  Increased KAM at stance      changes in joint structure and more severe disease10,11 7. Andriacchi (1994), 8. Schipplein & Andriacchi (1991), 9. Hunt et al (2006), 10. Baliunas et al (2002), 11. Sharma et al (1998)     Valgus bracing: improves pain, function12,13 and reduces KAM14,15, but expensive and cumbersome16  Previous Interventions: 12. Draganich et al, 2006, 13. Brouwer et al, 2006, 14. Pollo et al, 2002, 15. Self et al, 2000, 16. Krohn, 2005, 17. Erhart et al (2010) Variable stiffness footwear: uses varying material properties to make shoe stiffer on lateral side17    Lateral wedged insoles: unload medial compartment by shifting load laterally18; can be off the shelf or custom made19,20 18. Baker et al, 2007, 19. Zhang et al, 2008, 20. Gelis et al, 2005  High tibial osteotomy: redistributes weight bearing forces, reduces pain, improves function21,22  21. Birmingham et al, 2009, 22. Marti et al, 2001 Rationale:  A) Shock Absorbing Insoles:   ? inexpensive ? no known contraindications  ?    impact forces and loading rates in healthy runners and military populations ? never been tried before in this population   B) it is proposed that by    the rate of tibial acceleration and magnitude of loading at foot strike during gait, the load transmitted to knee will be reduced23  23.Nigg et al, 1988   Purpose: To examine the effectiveness of SAIs in: 1) the immediate reduction of knee joint load  2) the reduction in knee joint load, pain, and dysfunction after one month of wear             * in individuals with knee OA *  Ethics? Ethical approval was obtained from the Institutional Clinical Research Ethics Board and all participants provided written informed consent  Research Design:  Pre-post design with participants exposed to  2 conditions: - normal footwear   - SAIs with a one month follow-up  Inclusion Criteria:      radiographic evidence of tibio-femoral OA      varus malalignment     knee pain during walking > 3/10 most days of the previous month     grade ? 2 knee OA based on Kellgren and Lawrence criteria by an independent radiologist                Exclusion Criteria:     knee injury, surgery or corticosteroid use         within 6 months (oral use= 1 month)   MSK or neurological condition affecting lower limb  function    ankle/foot pathology that precludes the use of  insoles   current use of foot orthotics    primary footwear unable to accommodate an insole   walk with a gait aid   inflammatory arthritic condition      Recruitment strategy:  Participants were recruited from the community via advertisements in local papers   Participants: - 16 in total (10 F, 6 M) - mean age: 66.9 years - mean BMI: 27.7  - mean lower limb alignment of: 178.0? -10 participants had mild OA , 2 had moderate, 4 had    severe  - all had OA in medial compartment - 14 returned for follow-up testing  Procedure: -baseline and follow-up testing over one month -measured gait, physical function and pain  -participants given 2 pairs of insoles to take home -completion of daily log Insole:   -3/4 length Spenco? insoles -non-customized, triple density gel -heel thickness of 8.35mm and forefoot thickness 4.31mm   Gait Analysis: -3 dimensional gait analysis -2 synchronized force platforms -modified Helen Hayes 22-marker set  -walk at self-selected speed Outcome Measures:  1) Primary:  ? KAM1, KAM2, KAMp ? KAM impulse ? peak vertical tibial acceleration  2) Secondary:  ? walking pain ? WOMAC ? timed stair climb   Statistics: -biomechanical: 2  factor repeated measures ANOVA -clinical: paired t-test  Results: 1) Biomechanical: no significant   in knee joint loading were observed*  2) Pain and Function: significant differences found for all measures after one month   - average pain during walking  - WOMAC pain   - WOMAC total   - time to ascend 12 stairs  * One exception Discussion: 1)   improvements in joint pain & function found; unlikely due to changes in the loading environment 2)  SAIs may not have a protective role against disease progression     3)   SAIs effective in    impact forces and loading rates using tibial accelerometry; not found in this study (findings may be due to relatively smaller GRF?s that occur during walking)      Discussion cont?  4)  Improvements in pain and function found: WHY?  - Treatment effect for pain? - Placebo? -     Reflection of natural history of disease?    Discussion Cont? Furthermore? -these findings highlight the disconnect between measures of pain and function and objective measures of knee joint loading as quantified indirectly using 3-D motion analysis  Limitations:   A) KAM is not a direct measure of knee joint loading B) 16 individuals: possible that much smaller    in joint load may have gone undetected C)   no control group Future Considerations: - more research is required to:  - optimize the clinical benefits of SAIs      - improve uptake of this treatment        strategy      Conclusions: 1) SAIs can significantly improve measures of knee joint pain and physical dysfunction after 1 month of wear 2) evidence for the role of SAIs in the clinical self     management of the disease 3)   SAIs represent an intervention that is inexpensive, non-invasive and has minimal side effects  References: 1) Oliveria SA, Felson DT, Reed JI, Cirillo PA, Walker AM.Incidence of symptomatic hand, hip, and knee osteoarthritisamong patients in a health maintenance organization. ArthritisRheum 1995;38:1134?41.  2) The Arthritis Society. Types of Arthritis- Osteoarthritis: How common is osteoarthritis? Retrieved on June 8, 2011 from  3) Miyazaki T, Wada M, Kawahara H, Sato M, Baba H, Shimada S. Dynamicload at baseline can predict radiographic disease progression in medialcompartment knee osteoarthritis. Ann Rheum Dis 2002;61:617-22.3) Andriacchi T, Mundermann A. The role of ambulatory mechanics in theinitiation and progression of knee osteoarthritis. Curr Opin Rheumatol2006;18:514-8. 4) Andriacchi T, Mundermann A. The role of ambulatory mechanics in the initiation and progression of knee osteoarthritis. Curr Opin Rheumatol 2006;18:514-8. 5) Creaby MW, Wang Y, Bennell KL, Hinman RS, Metcalf BR, Bowles KA et al. Dynamic knee loading is related to cartilage defects and tibial plateau bone areain medial knee osteoarthritis. Osteoarthritis Cartilage 2010;18:1380-5. 6)  Radin E, Paul I. Response of joints to impact loading. I. In vitro wear. Arth Rheum 1971;14:356-62.      7) Andriacchi T. Dynamics of knee malalignment. Orthop Clin N Am 1994;25:395-403. 8) Schipplein O, Andriacchi T. Interaction between active and passive knee stabilizers during level walking. J Orthop Res 1991;9:113-9. 9) Hunt MA, Birmingham TB, Giffin JR, Jenkyn TR. Associations among knee adduction moment, frontal plane ground reaction force, and lever arm duringwalking in patients with knee osteoarthritis. J Biomech 2006;39:2213-20. 10) Baliunas A, Hurwitz D, Ryals A, Karrar A, Case J, Block J et al. Increased knee joint loads during walking are present in subjects with knee osteoarthritis.Osteoarthritis Cartilage 2002;10:573-9. 11) Sharma L, Hurwitz D, Thonar E, Sum J, Lenz M, Dunlop D et al. Knee adduction moment, serum hyaluronan level, and disease severity in medial tibiofemoralosteoarthritis. Arthritis Rheum 1998;41:1233-40.  12) Draganich L, Reider B, Rimington T, Piotrowski G, Mallik K, Nasson S. The effectiveness of self-adjustable custom and off-the-shelf bracing in the treatment of varus gonarthrosis. J Bone Joint Surg 2006;88A:2645-52.    13) Brouwer R, van Raaij T, Verhaar J, Coene L, Bierma-Zeinstra S. Brace treatment for osteoarthritis of the knee: a prospective randomized multi-centre trial. Osteoarthritis Cartilage 2006;14:777-83. 14) Pollo F, Otis 1 J, Backus S, Warren R, Wickiewicz T. Reduction of medial compartment loads with valgus bracing of the osteoarthritic knee. Am J Sports Med 2002;30:414-21.  15) Self BP, Greenwald RM, Pflaster DS. Biomechanical analysis of valgus bracing for the osteoarthritic knee. Arthr Care Res 2000;13:191-7. 16) Krohn K. Footwear alterations and bracing as treatments for knee osteoarthritis. Curr Opin Rheumatol 2005;17:653-6. 17) Erhart JC, Mundermann A, Elspas B, Giori NJ, Andriacchi TP. Changes in knee adduction moment, pain, and functionality with a variable-stiffness walking shoe after 6 months J Orthop Res 2010;28:873-9. 18) Baker K, Goggins J, Xie H, Szumowski K, LaValley M, Hunter DJ et al. A randomized cross-over trial of a wedged insole for treatment of knee osteoarthritis. Arthr Rheum 2007;56:1198-203.       19) Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage 2008;16:137-62. 20) Gelis A, Coudeyre E, Aboukrat P, Cros P, Herisson C, Pelissier J. Feet insoles and knee osteoarthritis: evaluation of biomechanical and clinical effects from a literature review. Annales de Readaptation et de Medicine Physique 2005;48:682-9. 21) Birmingham TB, Giffin JR, Chesworth BM, Bryant DM, Litchfield RB, Willits K et al. Medial opening wedge high tibial osteotomy: a prospective cohort study of gait, radiographic, and patient-reported outcomes. Arthritis Rheum 2009;61:648-57. 22) Marti RK, Verhagen R, Kerkhoffs G, Moojen TM. Proximal tibial varus osteotomy: indications, technique, and five to twenty-one-year results. J Bone Joint Surg 2001;83A:164-70.  23) Nigg BM, Herzog W, Read LJ. Effect of viscoelastic shoe insoles on vertical impact forces in heel?toe running. Am J Sports Med 1988;16:70-8.         


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