Is increased joint loading detrimental to obese patients with knee osteoarthritis? A secondary data analysis from a randomized trial. Occupational physical loading tasks and knee osteoarthritis: a review of the evidence. Intermittent treatment of knee osteoarthritis with oral chondroitin sulfate: a one-year, randomized, double-blind, multicenter study versus placebo. Effects of specialized footwear on joint loads in osteoarthritis of the knee. OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis. Effects of a modified shoe on knee load in people with and those without knee osteoarthritis. Medial arch supports do not significantly alter the knee adduction moment in people with knee osteoarthritis. The effect of instruction in analgesic use compared with neuromuscular exercise on knee-joint load in patients with knee osteoarthritis: a randomized, single-blind, controlled trial. The effects of hip muscle strengthening on knee load, pain, and function in people with knee osteoarthritis: a protocol for a randomised, single-blind controlled trial Higher dynamic medial knee load predicts greater cartilage loss over 12 months in medial knee osteoarthritis Glucosamine sulfate reduces osteoarthritis progression in postmenopausal women with knee osteoarthritis: evidence from two 3-year studies EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT) The knee adduction moment during gait in subjects with knee osteoarthritis is more closely correlated with static alignment than radiographic disease severity, toe out angle and pain. Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Knee adduction moment, serum hyaluronan level, and disease severity in medial tibiofemoral osteoarthritis. Is there an evidence-based efficacy for the use of foot orthotics in knee and hip osteoarthritis? Elaboration of French clinical practice guidelines. The Bristol 'OA500 study': progression and impact of the disease after 8 years. Biomechanical and clinical outcomes with shock-absorbing insoles in patients with knee osteoarthritis: immediate effects and changes after 1 month of wear. Knee pain and joint loading in subjects with osteoarthritis of the knee. OARSI/OMERACT Initiative to Define States of Severity and Indication for Joint Replacement in Hip and Knee Osteoarthritis. An OMERACT 10 Special Interest Group Comparison of neuromuscular and quadriceps strengthening exercise in the treatment of varus malaligned knees with medial knee osteoarthritis: a randomised controlled trial protocol Nonrandom evolution of end-stage osteoarthritis of the lower limbs. Correlation between radiographic severity of knee osteoarthritis and future disease progression. Results from a 3-year prospective, placebo-controlled study evaluating the effect of glucosamine sulfate.
OBJECTIVE To investigate whether increased knee joint loading due to improved ambulatory function and walking speed following weight loss achieved over 16 weeks accelerates symptomatic and structural disease progression over a subsequent 1 year weight maintenance period in an obese population with knee osteoarthritis ( OA ) . METHODS Data from a prospect i ve study of weight loss in obese patients with knee OA ( the CARtilage in obese knee OsteoarThritis ( CAROT ) study ) were used to determine changes in knee joint compressive loadings ( model estimated ) during walking after a successful 16 week weight loss intervention . The participants were divided into ' Unloaders ' ( participants that reduced joint loads ) and ' Loaders ' ( participants that increased joint loads ) . The primary symptomatic outcome was changes in knee symptoms , measured with the Knee injury and Osteoarthritis Outcome Score ( KOOS ) question naire , during a subsequent 52 weeks weight maintenance period . The primary structural outcome was changes in tibiofemoral cartilage loss assessed semi-quantitatively ( Boston Leeds Knee Osteoarthritis Score ( BLOKS ) from MRI after the 52 weight maintenance period . RESULTS 157 participants ( 82 % of the CAROT cohort ) with medial and /or lateral knee OA were classified as Unloaders ( n = 100 ) or Loaders ( n = 57 ) . The groups showed similar significant changes in symptoms ( group difference : -2.4 KOOS points [ 95 % CI -6.8:1.9 ] ) and cartilage loss ( group difference : -0.06 BLOKS points [ 95 % CI -0.22:0.11 ) after 1 year , with no statistically significant differences between Loaders and Unloaders . CONCLUSION For obese patients undergoing a significant weight loss , increased knee joint loading for 1 year was not associated with accelerated symptomatic and structural disease progression compared to a similar weight loss group that had reduced ambulatory compressive knee joint loads . CLINICAL TRIALSGOV NCT00655941 UNLABELLED Purpose : To perform a systematic review with best evidence synthesis examining the literature on the relationship between occupational loading tasks and  knee osteoarthritis ( OA ) . METHODS Two data bases were search ed to identify articles published between 1946 and April , 2011 . Eligible studies were those that ( 1 ) included adults reporting on their employment history ; ( 2 ) measured individuals ' exposure to work-related activities with heavy loading in the knee joint ; and ( 3 ) identified presence of knee OA ( determined by X-ray ) , cartilage defects associated with knee OA ( identified by magnetic resonance imaging ) , or joint replacement surgery . RESULTS A total of 32 articles from 31 studies met the inclusion criteria . We found moderate evidence that combined heavy lifting and kneeling is a risk factor for knee OA , with odds ratios ( OR ) varying from 1.8 to 7.9 , and limited evidence for heavy lifting ( OR=1.4 - 7.3 ) , kneeling ( OR=1.5 - 6.9 ) , stair climbing ( OR=1.6 - 5.1 ) , and occupational groups ( OR=1.4 - 4.7 ) as risk factors . When examined by sex , moderate level evidence of knee OA was found in men ; however , the evidence in women was limited . CONCLUSIONS Further high- quality prospect i ve studies are warranted to provide further evidence on the role of occupational loading tasks in knee OA , particularly in women OBJECTIVE To investigate the efficacy and tolerability of a 3-month duration , twice a-year , intermittent treatment with oral chondroitin sulfate ( CS ) in knee osteoarthritis ( OA ) patients . DESIGN A total of 120 patients with symptomatic knee OA were r and omized into two groups receiving either 800 mg CS or placebo ( PBO ) per day for two periods of 3 months during 1 year . Primary efficacy outcome was Lequesne 's algo-functional index ( AFI ) ; secondary outcome parameters included VAS , walking time , global judgment , and paracetamol consumption . Radiological progression was assessed by automatic measurement of medial femoro-tibial joint space width on weight-bearing X-rays of both knees . Clinical and biological tolerability was assessed . RESULTS One hundred and ten of 120 patients were included in the ITT analysis .  AFI decreased significantly by 36 % in the CS group after 1 year as compared to 23 % in the PBO group . Similar results were found for the secondary outcomes parameters . Radiological progression at month 12 showed significantly decreased joint space width in the PBO group with no change in the CS group . Tolerability was good with only minor adverse events identically observed in both groups . CONCLUSION This study provides evidence s that oral CS decreased pain and improved knee function . The 3-month intermittent administration of 800mg/day of oral CS twice a year does support the prolonged effect known with symptom-modifying agents for OA . The inhibitory effect of CS on the radiological progression of the medial femoro-tibial joint space narrowing could suggest further evidence of its structure-modifying properties in knee OA OBJECTIVE Elevated dynamic joint loads have been associated with the severity and progression of osteoarthritis ( OA ) of the knee . This study compared the effects of a specialized shoe ( the mobility shoe ) design ed to lower dynamic loads at the knee with self-chosen conventional walking shoes and with a commercially available walking shoe as a control . METHODS Subjects with knee OA were evaluated in 2 groups . Group A ( n = 28 ) underwent gait analyses with both their self-chosen walking shoes and the mobility shoes .  Group B ( n = 20 ) underwent gait analyses with a control shoe and the mobility shoe .  Frontal plane knee loads were compared between the different footwear conditions . RESULTS Group A demonstrated an 8 % reduction in the peak external knee adduction moment with the mobility shoe compared with self-chosen walking shoes ( mean + /- SD 49 + /- 0.80 versus 2.71 + /- 0.84 % BW x H ; P < 0.05 ) . Group B demonstrated a 12 % reduction in the peak external knee adduction moment with the mobility shoe compared with the control shoe ( mean + /- SD 2.66 + /- 0.69 versus 3.07 + /- 0.75 % BW x H ; P < 0.05 ) . CONCLUSION Specialized footwear can effectively reduce joint loads in subjects with knee OA , compared with self-chosen shoes and control walking shoes . Footwear may represent a therapeutic target for the treatment of knee OA . The types of shoes worn by subjects with knee OA should be evaluated more closely in terms of their effects on the disease OBJECTIVES To recommend a consensus-derived set of performance-based tests of physical function for use in people diagnosed with hip or knee osteoarthritis ( OA ) or following joint replacement . METHODS An international , multidisciplinary expert advisory group was established to guide the study . Potential tests for consideration in the recommended set were identified via a survey of selected experts and through a systematic review of the measurement properties for performance-based tests . A multi-phase , consensus-based approach was used to prioritize and select performance-based tests by applying decision analysis methodology ( 1000Minds software ) via online decision surveys . The recommended tests were chosen based on available measurement-property evidence , feasibility of the tests , scoring methods and expert consensus . RESULTS Consensus incorporated the opinions of 138 experienced clinicians and research ers from 16 countries . The five tests recommended by the advisory group and endorsed by Osteoarthritis Research Society International ( OARSI ) were the  30-s chair-st and test , 40 m fast-paced walk test , a stair-climb test , timed up- and -go test and 6-min walk test . The first three were recommended as the minimal core set of performance-based tests for hip or knee OA . CONCLUSION The OARSI recommended set of performance-based tests of physical function represents the tests of typical activities relevant to individuals diagnosed with hip or knee OA and following joint replacements . These tests are complementary to patient-reported measures and are recommended as prospect i ve outcome measures in future OA research and to assist decision-making in clinical practice . Further research should be directed to exp and ing the measurement-property evidence of the recommended tests OBJECTIVE To evaluate the effects of a modified shoe that incorporates both lateral wedging and a variable-stiffness sole on knee joint loading in 3 population s : individuals with symptomatic and radiographic knee osteoarthritis ( OA ) , asymptomatic overweight individuals , and asymptomatic healthy weight individuals . METHODS Ninety participants ( 30 per group ) underwent a 3-dimensional gait analysis  across 3 test conditions : modified shoes , st and ard control shoes , and barefoot . For each condition , the first peak knee adduction moment ( KAM ) and knee flexion moment ( KFM ) ( both expressed as Nm/[body weight × height]% ) as well as the KAM impulse ( expressed as Nm.s/[body weight × height]% ) were determined . RESULTS The modified shoes significantly reduced the peak KAM as compared to the control shoes in both the OA ( P = 0.002 ) and the overweight ( P = 0.03 ) groups . In the OA group , there was no significant difference in peak KAM when walking in the modified shoe as compared to walking barefoot . In the overweight and the healthy weight groups , the peak KAM when walking in the modified shoe was significantly higher than that when walking barefoot ( P < 0.001 ) . Irrespective of group , the KAM impulse was significantly reduced when walking in the modified shoe as compared to the control shoe ( P < 0.001 ) and was significantly higher during both shoe conditions as compared to walking barefoot ( P < 0.001 ) . There was no change in the KFM between walking conditions for any group . CONCLUSION The findings illustrate that a shoe incorporating both a lateral wedge and a variable-stiffness sole can significantly reduce medial knee joint load . Further research examining the effects of these shoes on pain , function , and structural changes in the joint is warranted OBJECTIVE This study aim ed to evaluate the immediate effects of medial arch supports on indices of medial knee joint load ( the peak external knee adduction moment ( KAM ) and knee adduction angular ( KAA ) impulse ) and knee pain during walking in people with medial knee osteoarthritis ( OA ) . DESIGN Twenty-one people with medial compartment OA underwent gait analysis in st and ardised athletic shoes wearing ( 1 ) no medial arch supports and ( 2 ) prefabricated medial arch supports  , in r and om order . Outcomes were the first and second peaks in the external KAM , the KAA impulse and severity of knee pain during testing . Outcomes were compared across conditions using paired t tests ( gait data ) and Wilcoxon Signed Ranks test ( pain data ) . RESULTS There were no significant changes in either first or second peak KAM , or in the KAA impulse , with the addition of medial arch supports ( all P > 0.05 ) . Considerable individual variation in response to the arch supports was observed across participants . There was no immediate change in knee pain during walking when medial arch supports were worn ( P = 0.56 ) . CONCLUSIONS This study showed no mean change in any of the measured indices of medial knee load with medial arch supports . No immediate changes in knee pain were evident OBJECTIVE To investigate the effect of a neuro-muscular exercise ( NEMEX ) therapy program compared with instructions in optimized analgesics and anti-inflammatory drug use ( PHARMA ) , on measures of knee-joint load in people with mild to moderate knee osteoarthritis ( OA ) . We hypothesized that knee joint loading during walking would be reduced by NEMEX and potentially increased by PHARMA . DESIGN Single-blind , r and omized controlled trial ( RCT ) comparing NEMEX therapy twice a week with PHARMA . Participants with mild-to-moderate medial tibiofemoral knee OA were r and omly allocated ( 1:1 ) to one of two 8-week treatments . Primary outcome was change in knee load during walking ( Knee Index , a composite score from all three planes based on 3D movement analysis ) after 8 weeks of intervention . Secondary outcomes were frontal plane peak knee adduction moment ( KAM ) , Knee Injury and Osteoarthritis Outcome Scores ( KOOS ) and functional performance tests . RESULTS Ninety three participants ( 57 % women , 58 ± 8 years with a body mass index [ BMI ] of 27 ± 4 kg/m2 ( mean ± st and ard deviation [ SD ] ) ) were r and omized to NEMEX group ( n = 47 ) or PHARMA ( n = 46 ) ; data from 44 ( 94 % ) and 41 ( 89 % ) participants respectively , were available at follow-up . 49 % of the participants in NEMEX and only 7 % in PHARMA demonstrated good compliance . We found no difference in the primary outcome as evaluated by the Knee Index -0.07 [ -0.17 ; 0.04 ] Nm/%BW HT . Secondary outcomes largely supported this finding . CONCLUSIONS We found no difference in the primary outcome ; knee joint load change during walking from a NEMEX program vs information on the recommended use of analgesics and anti-inflammatory drugs . Clinical Trials.gov Identifier : NCT01638962 ( July 3 , 2012 ) . Ethical Committee : S-20110153 Background Lower limb strengthening exercises are an important component of the treatment for knee osteoarthritis ( OA ) . Strengthening the hip abductor and adductor muscles may influence joint loading and /or OA-related symptoms , but no study has evaluated these hypotheses directly . The aim of this r and omised , single-blind controlled trial is to determine whether hip abductor and adductor muscle strengthening can reduce knee load and improve pain and physical function in people with medial compartment knee OA . Methods / Design 88 participants with painful , radiographically confirmed medial compartment knee OA and varus alignment will be recruited from the community and r and omly allocated to a hip strengthening or control group using concealed allocation stratified by disease severity . The hip strengthening group will perform 6 exercises to strengthen the hip abductor and adductor muscles at home 5 times per week for 12 weeks . They will consult with a physiotherapist on 7 occasions to be taught the exercises and progress exercise resistance . The control group will be requested to continue with their usual care . Blinded follow up assessment will be conducted at 12 weeks after r and omisation . The primary outcome measure is the change in the peak external knee adduction moment measured during walking . Question naires will assess changes in pain and physical function as well as overall perceived rating of change . An intention-to-treat analysis will be performed using linear regression modelling and adjusting for baseline outcome values and other demographic characteristics . Discussion Results from this trial will contribute to the evidence regarding the effect of hip strengthening on knee loads and symptoms in people with medial compartment knee OA . If shown to reduce the knee adduction moment , hip strengthening has the potential to slow disease progression . Trial Registration Australia New Zeal and Clinical Trials Registry Objective Mechanical factors , in particular increased medial knee joint load , are believed to be important in the structural progression of knee osteoarthritis . This study evaluated the relationship of medial knee load during walking to indices of structural disease progression , measured on MRI , in people with medial knee osteoarthritis . Methods A longitudinal cohort design utilising a subset of participants ( n=144 , 72 % ) enrolled in a r and omised controlled trial of lateral wedge insoles was employed .  Medial knee load parameters including the peak knee adduction moment ( KAM ) and the KAM impulse  were measured at baseline using three-dimensional gait analysis during walking . MRI at baseline and at 12 months was used to assess structural indices . Multiple regression with adjustment for covariates assessed the relationship between medial knee load parameters and the annual change in medial tibial cartilage volume . Binary logistic regression was used for the dichotomous variables of progression of medial tibiofemoral cartilage defects and bone marrow lesions ( BML ) . Results A higher KAM impulse , but not peak KAM , at baseline was independently associated with greater loss of medial tibial cartilage volume over 12 months ( β=29.9 , 95 % CI 6.3 to 53.5 , p=0.01 ) . No significant relationships were seen between medial knee load parameters and the progression of medial tibiofemoral cartilage defects or BML . Conclusion This study suggests knee loading , in particular the KAM impulse , may be a risk factor for loss of medial tibial cartilage volume . As knee load is modifiable , load-modifying treatments may potentially slow disease progression Objective To investigate the effect of glucosamine sulfate on long-term symptoms and structure progression in postmenopausal women with knee osteoarthritis ( OA ) . Design This study consisted of a preplanned combination of two three-year , r and omized , placebo-controlled , prospect i ve , independent studies evaluating the effect of glucosamine sulfate on symptoms and structure modification in OA and post-hoc analysis of the results obtained in postmenopausal women with knee OA .  Minimal joint space width was assessed at baseline and after 3 years from st and ing anteroposterior knee radiographs . Symptoms were scored by the algo-functional WOMAC index at baseline and after 3 years . All primary statistical analyses were performed in intention-to-treat , comparing joint space width and WOMAC changes between groups by ANOVA . Results Of 414 participants r and omized in the two studies , 319 were postmenopausal women . At baseline , glucosamine sulfate and placebo groups were comparable for demographic and disease characteristics , both in the general population and in the postmenopausal women subset . After 3 years , postmenopausal participants in the glucosamine sulfate group showed no joint space narrowing [ joint space change of + 0.003 mm ( 95 % CI , −0.09 to 0.11 ) ] , whereas participants in the placebo group experienced a narrowing of −0.33 mm ( 95 % CI , −0.44 to −0.22 ; P < 0.0001 between the two groups ) . Percent changes after 3 years in the WOMAC index showed an improvement in the glucosamine sulfate group [ −14.1 % ( 95 % , −22.2 to −5.9 ) ] and a trend for worsening in the placebo group ( 5.4 % ( 95 % CI , −4.9 to 15.7 ) ( P = 0.003 between the two groups ) . Conclusion This analysis , focusing on a large cohort of postmenopausal women , demonstrated for the first time that a pharmacological intervention for OA has a disease-modifying effect in this particular population , the most frequently affected by knee OA BACKGROUND Osteoarthritis ( OA ) is the most common joint disease encountered throughout Europe . A task force for the EULAR St and ing Committee for Clinical Trials met in 1998 to determine the method ological and logistical approach required for the development of evidence based guidelines for treatment of knee OA . The guidelines were restricted to cover all currently available treatments for knee OA diagnosed either clinical ly and /or radiographically affecting any compartment of the knee . METHODS The first stage was the selection of treatment modalities to be considered . The second stage comprised a search of the electronic data bases Medline and Embase using a combination of subject headings and keywords . All European language publications in the form of systematic review s , meta-analyses , r and omised controlled trials , controlled trials , and observational studies were included . During stage three all the relevant studies were quality scored . The summary statistics for vali date d outcome measures , when available , were recorded and , where practical , the numbers needed to treat and the effect size for each treatment were calculated . In the fourth stage key clinical propositions were determined by expert consensus employing a Delphi approach . The final stage ranked these propositions according to the available evidence . A second set of propositions relating to a future research agenda was determined by expert consensus using a Delphi approach . RESULTS Over 2400 English language publications and 400 non-English language publications were identified . Seven hundred and forty four studies presented outcome data of the effects of specific treatments on knee OA . Quantitative analysis of treatment effect was possible in only 61 studies . Recommendations for the management of knee OA based on currently available data and expert opinion are presented . Proposals for a future research agenda are highlighted . CONCLUSIONS These are the first clinical guidelines on knee OA to combine an evidence based approach and a consensus approach across a wide range of treatment modalities . It is apparent that certain clinical propositions are supported by substantial research based evidence , while others are not . There is thus an urgent need for future well design ed trials to consider key clinical questions This study tested whether the peak external knee adduction moments during walking in subjects with knee osteoarthritis ( OA ) were correlated with the mechanical axis of the leg , radiographic measures of OA severity , toe out angle or clinical assessment s of pain , stiffness or function .  Gait analysis was performed on 62 subjects with knee OA and 49 asymptomatic control subjects ( normal subjects ) . The subjects with OA walked with a greater than normal peak adduction moment during early stance ( p = 0.027 ) . In the OA group , the mechanical axis was the best single predictor of the peak adduction moment during both early and late stance ( R = 0.74 , p < 0.001 ) . The radiographic measures of OA severity in the medial compartment were also predictive of both peak adduction moments ( R = 0.43 to 0.48 , p < 0.001 ) along with the sum of the WOMAC subscales ( R = -0.33 to -0.31 , p < 0.017 ) . The toe out angle was predictive of the peak adduction moment only during late stance ( R = -0.45 , p < 0.001 ) . Once mechanical axis was accounted for , other factors only increased the ability to predict the peak knee adduction moments by 10 18 % . While the mechanical axis was indicative of the peak adduction moments , it only accounted for about 50 % of its variation , emphasizing the need for a dynamic evaluation of the knee joint loading environment . Underst and ing which clinical measures of OA are most closely associated with the dynamic knee joint loads may ultimately result in a better underst and ing of the disease process and the development of therapeutic interventions OBJECTIVE To evaluate the safety and efficacy of long-term intraarticular ( IA ) steroid injections for  knee pain related to osteoarthritis ( OA ) . METHODS In a r and omized , double-blind trial , 68 patients with OA of the knee received IA injections of triamcinolone acetonide 40 mg ( 34 patients ) or saline ( 34 patients ) into the study knee every 3 months for up to 2 years . The primary outcome variable was radiologic progression of joint space narrowing of the injected knee after 2 years . Measurements of minimum joint space width were performed by an automated computerized method on st and ardized fluoroscopically guided radiographs taken with the patient st and ing and with the knee in a semiflexed position . The clinical efficacy measure of primary interest was the pain subscale from the Western Ontario and McMaster Universities OA Index ( WOMAC ) . Efficacy measures of secondary interest were the total score on the WOMAC , physician 's global assessment , patient 's global assessment , patient 's assessment of pain , range of motion ( ROM ) of the affected knee , and 50-foot walking time . Clinical symptoms were assessed just before each injection . RESULTS At the 1-year and 2-year followup evaluations , no difference was noted between the two treatment groups with respect to loss of joint space over time . The steroid-injected knees showed a trend toward greater symptom improvement , especially at 1 year , for the WOMAC pain subscale , night pain , and ROM values ( P = 0.05 ) compared with the saline-injected knees . Using area under the curve analyses , knee pain and stiffness were significantly improved throughout the 2-year study by repeated injections of triamcinolone acetonide , but not saline ( P < 0.05 ) . CONCLUSION Our findings support the long-term safety of IA steroid injections for patients with symptomatic knee OA . No deleterious effects of the long-term administration of IA steroids on the anatomical structure of the knee were noted . Moreover , long-term treatment of knee OA with repeated steroid injections appears to be clinical ly effective for the relief of symptoms of the disease OBJECTIVE The adduction moment at the knee during gait is the primary determinant of medial-to-lateral load distribution . If the adduction moment contributes to progression of osteoarthritis ( OA ) , then patients with advanced medial tibiofemoral OA should have higher adduction moments . The present study was undertaken to investigate the hypothesis that the adduction moment normalized for weight and height is associated with medial tibiofemoral OA disease severity after controlling for age , sex , and pain level , and to examine the correlation of serum hyaluronan ( HA ) level with disease severity and with the adduction moment in a subset of patients . METHODS Fifty-four patients with medial tibiofemoral OA underwent gait analysis and radiographic evaluation .  Disease severity was assessed using the Kellgren-Lawrence ( K-L ) grade and medial joint space width . In a subset of 23 patients with available sera , HA was quantified by s and wich enzyme-linked immunosorbent assay . Pearson correlations , a r and om effects model , and multivariate regression models were used . RESULTS The  adduction moment  correlated with the K-L grade in the left and right knees ( r = 0.68 and r = 0.60 , respectively ) , and with joint space width in the left and right knees ( r = -0.45 and r = -0.47 , respectively ) . The relationship persisted after controlling for age , sex , and severity of pain . The partial correlation between K-L grade and adduction moment was 0.71 in the left knees and 0.61 in the right knees . For every 1.0-unit increase in adduction moment , there was a 0.63-mm decrease in joint space width . In the subset of patients in whom serum HA levels were measured , HA levels correlated with medial joint space width ( r = -0.55 ) , but not with the adduction moment . CONCLUSION There is a significant relationship between the  adduction moment and OA disease severity . Serum HA levels correlate with joint space width but not with the adduction moment . Longitudinal studies will be necessary to determine the contribution of the adduction moment , and its contribution in conjunction with metabolic markers , to progression of medial tibiofemoral OA OBJECTIVE To develop clinical practice guidelines for the use of foot orthotics ( FO ) in the treatment of knee and hip osteoarthritis . METHOD The SOFMER ( French Physical Medicine and Rehabilitation Society ) methodology , associating a systematic review of the literature , input from every day clinical practice and external review by a multidisciplinary expert committee , was used . The selected analysis criteria were  pain , disability , medications used and X-ray evolution of osteoarthritis .  The recommendations are classified according to the level of proof in Grade A , B or C according to the French National Agency for Health Accreditation and Evaluation ( NAHAE ) . RESULTS In medial knee osteoarthritis , foot pronation orthotics -- when there are no contraindications -- can be proposed for their symptomatic impact , especially in the decrease of NSAIDs consumption ( Grade B ) . To this day , there is no evidence of a structural or functional impact on osteoarthritis ( Grade B ) . Outside of this specific clinical framework , there is no vali date d indication for prescribing foot orthotics in the treatment of knee or hip OA ( Grade C ) . CONCLUSION It is necessary to have further r and omized controlled trials to better define the indication of Foot orthotics ( severity of knee OA , genu varum ) , test the efficacy of other orthoses such as cushioning FO . The long-term side effects , mainly on the external femorotibial compartment could also be assessed . A medical and economical assessment of FO prescriptions is also quite necessary OBJECTIVE To study the natural history of peripheral joint osteoarthritis ( OA ) and assess its impact over eight years in a prospect i ve study of 500 patients . METHODS 500 consecutive patients with peripheral joint OA were recruited from a hospital-based rheumatology clinic . All were invited for review 3 and 8 years after entry . Joint sites involved , pain severity , change in index joints , global change in the condition , use of medication , surgery and walking aids were all recorded at each visit , and after eight years disability was assessed by the  health assessment question naire ( HAQ ) and  anxiety and depression by the Hospital anxiety and depression scale ( HAD ) . RESULTS At eight-year review , 349 patients were seen : 90 % of those remaining alive . Outcome was heterogeneous . Sixty patients ( 17.2 % ) reported worsening in all three subjective parameters ( pain , index joint and global change ) compared with 22 ( 6.3 % ) who improved in all three parameters . Using this definition of worsening or improvement , strong baseline predictors of clinical outcome did not emerge . For further description , the group was split according to the index joint sites involved at entry to the study , there being 111 with knee OA alone , 87 with h and and knee OA , 72 with h and disease alone , and 29 with hip disease alone . Forty-four percent of those with lone h and disease at entry had acquired significant knee or hip OA 8 years later . The mean HAQ and HAD scores at 8 years were high , especially in those with knee disease , indicating significant disability as a result of the disease . Those with knee or knee and h and disease had the worst outcome in all parameters recorded . The data showed a general decrease in use of NSAIDs over the eight years , but an increase in utilization of analgesics , surgery ( especially for hip disease ) and walking aids . CONCLUSIONS Patients with peripheral joint OA of sufficient severity to lead to hospital referral have a heterogeneous , but generally bad outcome over 8 years , the disease result ing in high levels of physical disability , anxiety and depression , with a high level of utilization of healthcare re sources , including joint replacement , drugs and walking aids . The results were consistent with previous suggestions that peripheral joint OA in older people is characterized by the slow acquisition of new joint sites . Progression and outcome may depend on a complex set of psychosocial factors , as well as biological ones OBJECTIVES To examine the effectiveness of shock-absorbing insoles in the immediate reduction of knee joint load , as well as reductions in knee joint load , pain , and dysfunction after 1 month of wear , in individuals with knee osteoarthritis ( OA ) . DESIGN Pre-post design with participants exposed to 2 conditions ( normal footwear , shock-absorbing insoles ) with a 1-month follow-up . SETTING University laboratory for testing and general community for intervention . PARTICIPANTS Community-dwelling individuals ( N=16 ; 6 men , 10 women ) with medial compartment knee OA . INTERVENTION Participants were provided with sulcus length shock-absorbing insoles to be inserted into their everyday shoes . MAIN OUTCOME MEASURES Primary outcome measures included the peak , early stance peak , and late stance peak external knee adduction moment ( KAM ) ; the KAM impulse ( positive area under the KAM curve ) ; and peak tibial vertical acceleration . Secondary outcomes included walking pain , the Western Ontario and McMaster Universities Osteoarthritis Index pain subscale and total score , and a timed stair climb task . RESULTS There was a significant reduction in the late stance peak KAM with shock-absorbing insoles ( P=.03 ) during follow-up compared with the baseline test session . No other immediate or longitudinal significant changes ( P>.05 ) in the other KAM parameters or peak tibial acceleration after use of a shock-absorbing insole were observed . However , significant improvements in all measures of pain and function ( P<.05 ) were observed . CONCLUSIONS Shock-absorbing insoles produced significant reductions in self-reported knee joint pain and physical dysfunction with 1 month of wear in patients with knee OA despite no consistent changes in knee joint load . Further research using r and omized controlled trials , with larger sample sizes and explorations into long-term use of shock-absorbing insoles and their effect on disease progression , is warranted Although treatments for osteoarthritis of the knee are often directed at relieving pain , pain may cause patients to alter how they perform activities to decrease the loads on the joints . The knee-adduction moment is a major determinant of the load distribution between the medial and lateral plateaus . Therefore , the interrelationship between pain and the external knee-adduction moment during walking may be especially important for underst and ing mechanical factors related to the progression of medial tibiofemoral osteoarthritis . Fifty-three subjects with symptomatic radiographic evidence of osteoarthritis of the knee were studied . These subjects were a subset of those enrolled in a double-blind study in which  gait analysis and radiographic and clinical evaluations were performed after a 2-week washout of anti-inflammatory and analgesic treatment . The subjects then took a nonsteroidal anti-inflammatory drug , acetaminophen , or placebo for 2 weeks , and the gait and clinical evaluations were repeated . The change in the peak external adduction moment between the two evaluations was inversely correlated with the change in pain ( R = 0.48 , p < 0.001 ) and was significantly different between those whose pain increased ( n = 7 ) , decreased ( n = 18 ) , or remained unchanged ( n = 28 ) ( p = 0.009 ) . Those with increased pain had a significant decrease in the peak external adduction ( p = 0.005 ) and flexion moments ( p = 0.023 ) . In contrast , the subjects with decreased pain tended to have an increase in the peak external adduction moment ( p = 0.095 ) and had a significant increase in the peak external extension moment ( p = 0.017 ) . The subjects whose pain was unchanged had no significant change in the peak external adduction ( p = 0.757 ) , flexion ( p = 0.234 ) , or extension ( p = 0.465 ) moments . Thus , decreases in pain among patients with medial tibiofemoral osteoarthritis were related to increased loading of the degenerative portion of the joints . Additional long-term prospect i ve studies are needed to determine whether increased loading during walking actually results in accelerated progression of the disease Objective . To define pain and physical function cutpoints that would , coupled with structural severity , define a surrogate measure of “ need for joint replacement surgery , ” for use as an outcome measure for potential structure-modifying interventions for osteoarthritis ( OA ) . Methods . New scores were developed for pain and physical function in knee and hip OA . A cross-sectional international study in 1909 patients was conducted to define data -driven cutpoints corresponding to the orthopedic surgeons ’ indication for joint replacement . A post hoc analysis of 8 r and omized clinical trials ( 1379 patients ) evaluated the prevalence and validity of cutpoints , among patients with symptomatic hip/knee OA . Results . In the international cross-sectional study , there was substantial overlap in symptom levels between patients with and patients without indication for joint replacement ; indeed , it was not possible to determine cutpoints for pain and function defining this indication . The post hoc analysis of trial data showed that the prevalence of cases that combined radiological progression , high level of pain , and high degree of function impairment was low ( 2%–12 % ) . The most discriminatory cutpoint to define an indication for joint replacement was found to be [ pain ( 0–100 ) + physical function ( 0–100 ) > 80 ] . Conclusion . These results do not support a specific level of pain or function that defines an indication for joint replacement . However , a tentative cutpoint for pain and physical function levels is proposed for further evaluation . Potentially , this symptom level , coupled with radiographic progression , could be used to define “ nonresponders ” to disease-modifying drugs in OA clinical trials Background Osteoarthritis of the knee involving predominantly the medial tibiofemoral compartment is common in older people , giving rise to pain and loss of function . Many people experience progressive worsening of the disease over time , particularly those with varus malalignment and increased medial knee joint load . Therefore , interventions that can reduce excessive medial knee loading may be beneficial in reducing the risk of structural progression . Traditional quadriceps strengthening can improve pain and function in people with knee osteoarthritis but does not appear to reduce medial knee load . A neuromuscular exercise program , emphasising optimal alignment of the trunk and lower limb joints relative to one another , as well as quality of movement performance , while dynamically and functionally strengthening the lower limb muscles , may be able to reduce medial knee load . Such a program may also be superior to traditional quadriceps strengthening with respect to improved pain and physical function because of the functional and dynamic nature . This r and omised controlled trial will investigate the effect of a neuromuscular exercise program on medial knee joint loading , pain and function in individuals with medial knee joint osteoarthritis . We hypothesise that the neuromuscular program will reduce medial knee load as well as pain and functional limitations to a greater extent than a traditional quadriceps strengthening program . Methods / Design 100 people with medial knee pain , radiographic medial compartment osteoarthritis and varus malalignment will be recruited and r and omly allocated to one of two 12-week exercise programs : quadriceps strengthening or neuromuscular exercise . Each program will involve 14 supervised exercise sessions with a physiotherapist plus four unsupervised sessions per week at home . The primary outcomes are medial knee load during walking ( the peak external knee adduction moment from 3D gait analysis ) , pain , and self-reported physical function measured at baseline and immediately following the program . Secondary outcomes include the external knee adduction moment angular impulse , electromyographic muscle activation patterns , knee and hip muscle strength , balance , functional ability , and quality -of-life . Discussion The findings will help determine whether neuromuscular exercise is superior to traditional quadriceps strengthening regarding effects on knee load , pain and physical function in people with medial knee osteoarthritis and varus malalignment . Trial Registration Australian New Zeal and Clinical Trials Registry reference : OBJECTIVE Patients with unilateral hip or knee replacements for end-stage osteoarthritis ( OA ) are at high risk for future progression of OA in other joints of the lower extremities , often requiring additional joint replacements . Although the risks of future surgery in the contralateral cognate joints ( i.e. , contralateral hip replacement after an initial hip replacement ) have been evaluated , the evolution of end-stage hip OA to OA involving the knee joints , and vice versa ( i.e. , noncognate progression ) has not been investigated . Because characterization of OA progression in noncognate joints may shed light on the pathogenesis of multijoint OA , we investigated the pattern of evolution of end-stage lower extremity OA in a large , clinical cohort . METHODS Total joint replacement ( TJR ) was selected as a marker of end-stage OA , and a data base comprising all lower extremity TJRs performed at a large referral center between 1981 and 2001 was accessed . Of the 5,894 patients identified , 486 patients with idiopathic OA who underwent hip replacement and 414 who underwent initial knee replacement  were analyzed to determine the relative likelihood of subsequent TJRs .  Patients with the systemic inflammatory arthropathy , rheumatoid arthritis ( RA ) , were evaluated as a control population because RA progression is not considered to be a primarily mechanically mediated process . RESULTS The contralateral cognate joint was the most common second joint to undergo replacement in both the OA and the RA groups . However , in OA patients for whom the second TJR was in a noncognate joint , that joint was > 2-fold more likely to be on the contralateral limb than on the ipsilateral limb ( hip to knee P < 0.001 ; knee to hip P = 0.013 ) . In contrast , among the RA cohort , the evolution was r and om and no laterality for noncognate TJR was observed at either the hip or the knee ( P = 0.782 ) . CONCLUSION This characterization of end-stage lower extremity OA demonstrates that the disease evolves nonr and omly ; after 1 joint is replaced , the contralateral limb is significantly more likely to show progression of OA than is the ipsilateral limb . Thus , OA in 1 weight-bearing joint appears to influence the evolution of OA in other joints . The absence of such laterality in RA suggests that OA progression may be mediated by extrinsic factors such as altered joint loading OBJECTIVE To investigate the relationship between baseline radiographic severity of knee osteoarthritis ( OA ) and the importance of long-term joint space narrowing . DESIGN Sub- analysis from a three-year r and omized , placebo-controlled , prospect i ve study , of 212 patients with knee OA , recruited in an osteoarthritic outpatient clinic and having been part of a study evaluating the effect of glucosamine sulfate on symptom and structure modification in knee OA . MATERIAL AND METHODS Measurements of mean joint space width ( JSW ) , assessed by a computer-assisted method , were performed at baseline and after 3 years , on weightbearing anteroposterior knee radiographs . RESULTS In the placebo group , baseline JSW was significantly and negatively correlated with the joint space narrowing observed after 3 years ( r=-0.34 , P=0.003 ) . In the lowest quartile of baseline mean JSW ( < 4.5 mm ) , the JSW increased after 3 years by ( mean ( S.D. ) ) 3.8 % ( 23.8 ) in the placebo group and 6.2 % ( 17.5 ) in the glucosamine sulfate group . The difference between the two groups in these patients with the most severe OA at baseline was not statistically significant ( P=0.70 ) . In the highest quartile of baseline mean JSW ( > 6.2 mm ) , a joint space narrowing of 14.9 % ( 17.9 ) occurred in the placebo group after 3 years while patients from the glucosamine sulfate group only experienced a narrowing of 6.0 % ( 15.1 ) . Patients with the most severe OA at baseline had a RR of 0.42 ( 0.17 - 1.01 ) to experience a 0.5 mm joint space narrowing over 3 years , compared to those with the less affected joint . In patients with mild OA , i.e. in the highest quartile of baseline mean JSW , glucosamine sulfate use was associated with a trend ( P=0.10 ) towards a significant reduction in joint space narrowing . CONCLUSION These results suggest that patients with the less severe radiographic knee OA will experience , over 3 years , the most dramatic disease progression in terms of joint space narrowing . Such patients may be particularly responsive to structure-modifying drugs
There is very limited and low- quality evidence to support for a causal link between knee joint loading during walking and structural progression of knee OA .
OBJECTIVE We performed a systematic review , meta- analysis and assessed the evidence supporting a causal link between knee joint loading during walking and structural knee osteoarthritis ( OA ) progression .