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Design of patient-specific gait modifications for knee osteoarthritis rehabilitation.

ABSTRACT: Abstract-Gait modification is a nonsurgical approach for reducing the external knee adduction torque in patients with knee osteoarthritis (OA). The magnitude of the first adduction torque peak in particular is strongly associated with knee OA progression. While toeing out has been shown to reduce the second peak, no clinically realistic gait modifications have been identified that effectively reduce both peaks simultaneously. This study predicts novel patient-specific gait modifications that achieve this goal without changing the foot path. The modified gait motion was designed for a single patient with knee OA using dynamic optimization of a patient-specific, full-body gait model. The cost function minimized the knee adduction torque subject to constraints limiting how much the new gait motion could deviate from the patient's normal gait motion. The optimizations predicted a "medial-thrust" gait pattern that reduced the first adduction torque peak between 32% and 54% and the second peak between 34% and 56%. The new motion involved three synergistic kinematic changes: slightly decreased pelvis obliquity, slightly increased leg flexion, and slightly increased pelvis axial rotation. After gait retraining, the patient achieved adduction torque reductions of 39% to 50% in the first peak and 37% to 55% in the second one. These reductions are comparable to those reported after high tibial osteotomy surgery. The associated kinematic changes were consistent with the predictions except for pelvis obliquity, which showed little change. This study demonstrates that it is feasible to design novel patient-specific gait modifications with potential clinical benefit using dynamic optimization of patient-specific, full-body gait models. Further investigation is needed to assess the extent to which similar gait modifications may be effective for other patients with knee OA.

SUBMITTER: Fregly BJ

PROVIDER: S-EPMC2040055 | biostudies-literature | 2007 Sep

REPOSITORIES: biostudies-literature

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Design of patient-specific gait modifications for knee osteoarthritis rehabilitation.

Fregly Benjamin J BJ Reinbolt Jeffrey A JA Rooney Kelly L KL Mitchell Kim H KH Chmielewski Terese L TL

IEEE transactions on bio-medical engineering 20070901 9

Abstract-Gait modification is a nonsurgical approach for reducing the external knee adduction torque in patients with knee osteoarthritis (OA). The magnitude of the first adduction torque peak in particular is strongly associated with knee OA progression. While toeing out has been shown to reduce the second peak, no clinically realistic gait modifications have been identified that effectively reduce both peaks simultaneously. This study predicts novel patient-specific gait modifications that ach ...[more]

PMID: 17867361

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Project description:BACKGROUND:Total knee arthroplasty using patient-specific instrumentation (TKA-PSI), which are disposable cutting block guides generated to fit each patient's 3-dimensional knee anatomy, has been developed to treat patients with end-stage osteoarthritis of the knee. Surrogate markers such as radiographic malalignment have been well investigated, however, patient-important outcomes are not well examined to elucidate the efficacy of TKA-PSI. The aim of this review is to determine if TKA-PSI improves patient-reported outcome measures (PROM), surgery time, blood loss, transfusion and complications (e.g. surgical site infection, deep venous thrombosis, and revision TKA). METHODS:We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and ongoing clinical trials. For PROMs, surgery time, blood loss, and transfusion rate, we included randomized controlled trials (RCT) comparing TKA-PSI and standard TKA to treat osteoarthritis of the knee. For complications, we also included non-randomized comparative studies (non-RCT). RESULTS:This review includes 38 studies, 24 of which were RCT and 14 of which were non-RCT. These included a total of 3487 patients. The predominant population in the included studies highly reflected the general population, with 62% being female, aged over 60 and having end-stage osteoarthritis of the knee. TKA-PSI did not improve PROMs as compared to standard TKA for less than 1-year (mean difference 0.48, 95% confidence interval (CI) -1.92-0.97 in the Oxford knee score, mean 3-month follow-up) and for 1-year or more (mean difference 0.25, 95%CI -?4.39-4.89 in the WOMAC score, mean 29-month follow-up). TKA-PSI did not reduce surgery time (mean difference?-?3.09?min, 95%CI -6.73-0.55). TKA-PSI decreased blood loss with a small effect size corresponding to a 0.4?g/dl hemoglobin decrease (95%CI 0.18-0.88), but did not decrease transfusion rate (risk difference?-?0.04, 95%CI -0.09-0.01). TKA-PSI did not reduce complication rates (risk difference 0.00, 95%CI -?0.01-0.01 in the composite outcome). CONCLUSIONS:TKA-PSI does not improve patient-reported outcome measures, surgery time, and complication rates as compared to standard TKA. TKA-PSI decreases blood loss with a small effect, which is not enough to reduce transfusion rate.

Project description:BackgroundExercise-induced pain flares represent a significant barrier for individuals with knee osteoarthritis to meet physical activity recommendations. There is a need to understand factors that contribute to pain flares and the potential for the motor system to adapt and reduce joint loading should a flare occur. The study aim was to examine the impact of a bout of exercise on self-reported pain, walking mechanics and muscle co-contraction for participants with knee osteoarthritis.MethodsThirty-six adults (17 healthy older and 19 knee osteoarthritis) participated in this study. Self-reported pain, joint mechanics and muscle co-activation during gait at two self-selected speeds were collected before and after a 20-min preferred pace treadmill walk (20MTW).ResultsEight of nineteen osteoarthritis participants had a clinically significant pain flare response to the 20MTW. At baseline the participants that did not experience a pain flare had smaller knee flexion and total reaction moments compared to both the participants with pain flares (p = 0.02; p = 0.05) and controls (p < 0.001; p < 0.001). In addition, the 2nd peak knee adduction (p = 0.01) and internal rotation (p = 0.001) moments were smaller in the no flares as compared to controls. The pain flare participants differed from controls with smaller knee internal rotation moments (p = 0.03), but greater relative hamstrings (vs. quadriceps) and medial (vs. lateral) muscle activation (p = 0.04, p = 0.04) compared to both controls and no flare participants (p = 0.04, p = 0.007). Following the 20MTW there were greater decreases in the 1st and 2nd peak knee adduction (p = 0.03; p = 0.02), and internal rotation (p = 0.002) moments for the pain flare as compared to the no flare group. In addition, for the pain flare as compared to controls, greater decreases in the knee flexion (p = 0.03) and internal rotation (p = 0.005) moments were found.ConclusionsIndividuals who adapt their gait to reduce knee joint loads may be less susceptible to exercise-induced pain flares. This highlights a potential role of gait biomechanics in short-term osteoarthritis pain fluctuations. The results also suggest that despite the chronic nature of osteoarthritis pain, the motor system's ability to respond to nociceptive stimuli remains intact.

Project description:Muscle strengthening exercises have been shown to improve pain and function in adults with mild-to-moderate knee osteoarthritis, but individual response rates can vary greatly. Predicting individuals who respond and those who do not is important in developing a more efficient and effective model of care for knee osteoarthritis (OA). Therefore, the purpose of this study was to use pre-intervention gait kinematics and patient-reported outcome measures to predict post-intervention response to a 6-week hip strengthening exercise intervention in patients with mild-to-moderate knee OA.Thirty-nine patients with mild-to-moderate knee osteoarthritis completed a 6-week hip-strengthening program and were subgrouped as Non-Responders, Low-Responders, or High-Responders following the intervention based on their change in Knee injury Osteoarthritis Outcome Score (KOOS). Predictors of responder subgroups were retrospectively determined from baseline patient-reported outcome measures and kinematic gait parameters in a discriminant analysis of principal components. A 3-4 year follow-up on 16 of the patients with knee OA was also done to examine long-term changes in these parameters.A unique combination of patient-reported outcome measures and kinematic factors was able to successfully subgroup patients with knee osteoarthritis with a cross-validated classification accuracy of 85.4%. Lower patient-reported function in daily living (ADL) scores and hip frontal plane kinematics during the loading response were most important in classifying High-Responders from other sub-groups, while a combination of hip, knee, ankle kinematics were used to classify Non-Responders from Low-Responders.Patient-reported outcome measures and objective biomechanical gait data can be an effective method of predicting individual treatment success to an exercise intervention. Measuring gait kinematics, along with patient-reported outcome measures in a clinical setting can be useful in helping make evidence-based decisions regarding optimal treatment for patients with knee OA.

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Design of patient-specific gait modifications for knee osteoarthritis rehabilitation.

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Design of patient-specific gait modifications for knee osteoarthritis rehabilitation.

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