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Scientific Articles   |    
A Mechanical Theory for the Effectiveness of Bracing for Medial Compartment Osteoarthritis of the Knee
Dan K. Ramsey, PhD1; Kristin Briem, PT, MHSc2; Michael J. Axe, MD2; Lynn Snyder-Mackler, ScD, PT, SCS2
1 Department of Exercise and Nutrition Science, University at Buffalo, State University of New York, 214 Kimball Tower, South Campus, Buffalo, NY 14214-8028. E-mail address: dkramsey@buffalo.edu
2 Department of Physical Therapy, 309 McKinly Laboratory, University of Delaware, Newark, DE 19716
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the National Center for Research Resources and the National Institutes of Health (P20RR016458, T32HD007490, R01HD037985, and R01AR048212). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated. Braces ordered from the manufacturer by the Physical Therapy Clinic were paid for with the grants that funded this study.
The contents of the article are the sole responsibility of the authors and do not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
Investigation performed at the Department of Physical Therapy, Graduate Program in Biomechanics and Movement Science, and Center for Biomedical Engineering Research, University of Delaware, Newark, Delaware

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Nov 01;89(11):2398-2407. doi: 10.2106/JBJS.F.01136
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Abstract

Background: Evidence that knee braces used for the treatment of osteoarthritis mediate pain relief and improve function by unloading the joint (increasing the joint separation) remains inconclusive. Alternatively, valgus-producing braces may mediate pain relief by mechanically stabilizing the joint and reducing muscle cocontractions and joint compression. In this study, therefore, we sought to examine the degree to which so-called unloader braces control knee instability and influence muscle cocontractions during gait.

Methods: Sixteen subjects with radiographic evidence of knee malalignment and medial compartment osteoarthritis were recruited and fitted with a custom Generation II Unloader brace. Gait analysis was performed without use of the brace and with the brace in neutral alignment and in 4° of valgus alignment. A two-week washout period separated the brace conditions. Muscle cocontraction indices were derived for agonist and antagonist muscle pairings. Pain, instability, and functional status were obtained with use of self-reported questionnaires, and the results were compared.

Results: The scores for pain, function, and stability were worst when the knee was unsupported (the baseline and washout conditions). At baseline, nine of the sixteen patients reported knee instability and five of the nine complained that it affected their activities of daily living. Poor knee stability was found to be correlated with low ratings for the activities of daily living, quality of life, and global knee function and with increased pain and symptoms. Knee function and stability scored best with the brace in the neutral setting compared with the brace in the valgus setting. The cocontraction of the vastus lateralis-lateral hamstrings was significantly reduced from baseline in both the neutral (p = 0.014) and valgus conditions (p = 0.023), and the cocontraction of the vastus medialis-medial hamstrings was significantly reduced with the valgus setting (p = 0.068), as a result of bracing. Patients with greater varus alignment had greater decreases in vastus lateralis-lateral hamstring muscle cocontraction.

Conclusions: When knees with medial compartment osteoarthritis are braced, neutral alignment performs as well as or better than valgus alignment in reducing pain, disability, muscle cocontraction, and knee adduction excursions. Pain relief may result from diminished muscle cocontractions rather than from so-called medial compartment unloading.

Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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