- Email: [email protected]
Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis
+
MODEL
Journal of Bodywork & Movement Therapies (2013) xx, 1e7
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/jbmt
COMPARATIVE STUDY
Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis Khosro Khademi-Kalantari, PhD, PT a, Somayeh Mahmoodi Aghdam, MSc, PT a,*, Alireza Akbarzadeh Baghban, PhD b, Mehdi Rezayi, PhD a, Abbas Rahimi, PhD, PT a, Sedighesadat Naimee, PhD, PT a a
Department of Physiotherapy, Faculty of Rehabilitation, Shahid Beheshti University of Medical Sciences, Damavand Ave, Opposite to Bou Ali Hospital, Tehran, Iran b Department of Basic Sciences, Faculty of Rehabilitation, Shahid Beheshti University of Medical Sciences, Iran Received 19 September 2013; received in revised form 29 November 2013; accepted 3 December 2013
KEYWORDS Knee; Osteoarthritis; Distraction; Pain; Function
Summary Purpose: The aim of this study was to evaluate the clinical results of non surgical knee distraction in patients with severe knee osteoarthritis. Method: forty female patients with severe knee osteoarthritis were randomly divided in two groups. A standard physiotherapy treatment was applied to both groups and in one group it was accompanied with 20 min knee joint distraction. The patients were treated for 10 sessions. Clinical examination consisted of functional examination, completion of a quality of life questionnaire, pain scale, and assessment of joint mobility and joint edema. Result: The standard physiotherapy treatment accompanied by knee distraction resulted in significantly higher improvement in pain (P Z 0.004), functional ability (P Z 0.02), quality of life (P Z 0.002) and knee flexion range of motion (p Z 0.02) compared to the standard physiotherapy treatment alone post treatment and after 1 month follow up. Conclusion: Adding knee distraction to standard physiotherapy treatment can result in further improvement in pain relief, increased functional ability and better quality of life in patients with severe knee osteoarthritis. ª 2013 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ98 21 77561411; fax: þ98 21 77561406. E-mail address: [email protected] (S. Mahmoodi Aghdam). 1360-8592/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jbmt.2013.12.001
Please cite this article in press as: Khademi-Kalantari, K., et al., Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.001
+
MODEL
2
K. Khademi-Kalantari et al.
Introduction
Materials and method
Osteoarthritis (OA) is known as a degenerative joint disease, characterized by joint pain and stiffness. These clinical symptoms are the result of cartilage damage, changes in the subchondral bone, and bony outgrowth at the joint margins (Michael et al., 2010). Normal synovial joints can survive loading during normal activities for a lifetime without developing OA. When the mechanical demand exceeds the tolerance of the joint (cartilage, bone or ligaments) however, it could lead to development and progression of osteoarthritis. The association between physically demanding occupations (Felson, 2004, 2005; Rossignol et al., 2005), severe sport activities (Buckwalter and Martin, 2004), obesity (Felson, 2004; Holmberg et al., 2005) and osteoarthritis suggests that intense joint loading is associated with early onset and progression of joint degeneration. There is also reported association between joint injury and later development of osteoarthritis. Damage to joint articular structures such as menisci, ligaments, and capsules can lead to permanent joint instability and/or incongruity of the articular surface, causing increased contact pressure on articular surfaces. This increased stress can initiate or accelerate joint degeneration (Buckwalter and Martin, 2004). The impact of lower limb alignment during gait has also been suggested to have an important role in the development and progression of OA (Krohn, 2005). In general, mechanical factors, specifically in the weight-bearing and large joints such as knee, are involved in the actual initiation of the joint damage in OA (Andriacchi et al., 2004). If over loading has a major impact on development and progression of OA, then unloading may be able to, at least, slow down its progression. There are numerous examples that show different unloading techniques, including weight loss (Christensen et al., 2005; Messier et al., 2005), wedged insole and unloader knee brace (Krohn, 2005), surgical osteotomy (Annette et al., 2005; Bo ¨rjesson et al., 2005; Hoell et al., 2005; Ito et al., 2004, 2005; Tang and Henderson, 2005) and surgical joint distraction (Chiodo and McGarvey, 2004; Westacott et al., 1997) are able to improve pain, stiffness, physical symptoms and slowing down structural damage. Measures that may decrease the intensity and frequency of impact and torsional loading of joints during sports also have been reported to prevent joint injury and development and progression of osteoarthritis (Buckwalter and Martin, 2004). More importantly, it has been demonstrated that the proper joint loading could result in constructive alterations in cartilage composition and biomechanical properties of the joint. This observation supports the concept that OA joints are possibly able to show positive adaptation to unloading (Herzog et al., 2003). Although knee distraction is one of the mobilization techniques applied by physiotherapists for reduction of pain and dysfunction (Donatelli and Wooden, 2001; Kisner and Colby, 2002), the effect of non surgical short term knee distraction on the improvement of pain and functional ability of these patients has not been investigated previously.
Participants Forty female patients with severe knee osteoarthritis who met the inclusion criteria were selected by non-random sampling method from patients referring to 17 Shahrivar clinic, Tehran, Iran, over 9 months period of time. Orthopedist referred patients to physiotherapy based on inclusion criteria. The criteria for selection of subjects included: symptomatic KellgreneLawrence grade 3 or 4 knee OA, skeletally mature, age 65 years and capacity to walk with or without using ambulatory aids. Excluded from the study were patients who met any of the following criteria: history of inflammatory arthritis, previous history of knee surgery, metabolic or endocrine disease, the presence of other symptomatic joints in lower extremity, current history of alcohol or drug abuse, having injection in the knee or taking new medication for osteoarthritis within the previous 30 days. The study was approved by the local institution ethics committee and written, witnessed consent was obtained from all patients.
Methodological study To evaluate repeatability of clinical variables, the knee range of motion (ROM) and 6 min walking test (6 MWT) were repeated twice in 6 patients with one week interval.
Main study procedure Patients were randomly assigned to one of these groups: the standard physiotherapy treatment (control group n Z 20) and standard physiotherapy treatment accompanied by knee distraction (experimental group n Z 20). Standard physiotherapy treatment included: 2 hot packs to anterior and posterior of the knee for 20 min, 10 min continuous 1 MHz ultrasound (5 min anterior and 5 min posterior to the knee) at an intensity of 1 W/cm2 and conventional TENS (frequency: 100 HZ, pulse Duration: 50 ms) for 30 min. Exercises for strengthening of quadriceps, gluteals and gastrosoleus muscles were also included in the treatment procedure. Standard physiotherapy treatment was provided for all patients. For patients in the experimental group, besides receiving standard physiotherapy treatment, joint distraction was also integrated. To distract the knee joint, a special greave was designed and built. Sustained traction was applied in supine position for 20 min while the knee was placed in 30 flexion by the use of a platform under the lower thigh to induce a counter pressure (Picture 1). The correct knee angle was checked for each patient by a goniometer. The amount of traction was set to the perceptional threshold of the patients in each session. In the other words, the lowest load that patients start feeling distraction was used for distraction. Patients received a total of 10 treatment sessions, 5 sessions weekly for 2 weeks. Dependent variables consisted of a pain visual analog scale (VAS), a 6 min walk test (6 MWT), the KOOS (knee injury and osteoarthritis outcome
Please cite this article in press as: Khademi-Kalantari, K., et al., Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.001
+
MODEL
Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis
Picture 1
Showing how the knee joint is distracted.
score) questionnaire; range of motion (ROM) and edema. Previous studies have used these parameters as an outcome measure so this study used them. All of the patients were assessed at baseline, at the 10th treatment (post treatment) and at a one month follow-up. This study was one side blinded. All of the patient examinations were performed by one therapist who was aware of patient’s grouping, but patients were not aware of the assortment. The 6-min walk is a test where the subject walks for 6 min on level ground, and the distance covered in 6 min is measured. The test was conducted on a premeasured 20 m, unobstructed, uncarpeted, point to point track. The goal of the test was to have subjects adopt a self-selected walking speed such that at the end of 6 min, they felt that they could not have walked any farther. Standardized encouragement “You are doing well, keep up the good work” was provided at 60-s intervals (Focht et al., 2005; Stratford et al., 2006). The KOOS is a subjective questionnaire that evaluates five subscales of disease including pain, symptoms, daily activity, sport and pleasure and quality of life. A Score of 0 represents severe situation and score of 100 represents normality. Reliability and validity of the Persian version of this questionnaire has been shown previously (Salavati et al., 2008). Knee ROM was assessed by goniometry and edema was measured by use of a measuring tape at the level of joint line and 10 cm above and below this.
3
reliability and Data normality was also evaluated using the ShapiroeWilk test. A 2 3 repeated measures analysis of variance (ANOVA) test was used to determine the main effects and interactions of within and between subjects’ factors for all the dependent variables. The within-subjects factor for repeated measures ANOVA was time (baseline, 10th session and one month follow up), the between-subjects factor was group (control and experimental) and covariate factors were age and BMI. Statistical significance in changes over time was determined using the paired samples T-test (the data at baseline, post treatment and follow-up served as a pair). Multiple Regression was also used to evaluate the correlation between variables.
Results All the forty female patients (control group average age: 61.20 8.6, average BMI: 32.25 5.6; experimental group average age: 61.25 6.8, average BMI: 30.79 6.1) who enrolled in the study completed the treatment program and the follow up evaluation. In each group, 18 patients had bilateral and 2 patients had unilateral knee OA and patients were matched based on age and BMI (P > 0.05). Although independent sample t-tests revealed no statistically significance difference between the two groups at the baseline, the relative variables with respect to the baseline measurement (the percentage of changes in each variable) were used for statistical analysis. In the other words, for each variable, the amount of variable obtained in 10th and follow up session was subtracted from the amount of variable in the first session and divided on it and this amount of variable was included in data analysis. Table 1 shows mean values with SE for all the dependent variables at baseline, after 10 sessions and follow up and Table 2 shows mean relative values with SE and 95% confidence interval for some of the dependent variables.
Methodological study The ICC of 6 MWT, ROM and edema had values ranged from .93 to .99 that represent very good reliability of variables.
Statistical analysis 6 MWT Data analysis was carried out using SPSS software, Version 17 and a priori significance level was set at .05. Intraclass Correlation Coefficient (ICC) was used to evaluate the data
Table 1
The repeated measures ANOVA showed that the main effect of group was statistically significant for 6 MWT, (P Z 0.02),
Mean SE of variables at the base line, post treatment and follow up.
Variable
Base line
Post treatment
Experimental VAS 6 MWT (m) Knee flex (degree) Knee ext (degree) Knee joint edema (cm) Above knee edema (cm) Below knee edema (cm)
64.1 304.15 120.6 4.56 41.58 48.17 38.33
4.8 22.2 3.2 .74 .61 .95 .71
Control 68 320.60 124.4 5.47 43.47 49.81 39.78
Experimental 3.4 15.7 2 .58 .80 .93 .73
19.50 343.90 128.92 4.06 41.51 48.32 38.17
4.1 20.8 1.8 .71 .61 .96 .71
Follow up Control 47.15 317.40 123.58 5.39 43.46 49.62 39.69
Experimental 6.6 15.7 1.7 .66 .79 .90 .72
33.69 336.28 127.93 4.52 41.38 48.33 38.28
4.5 21.6 1.5 .93 .78 1.1 .88
Control 58.15 323.10 124.57 5.96 42.34 49.11 38.75
6.1 16.5 1.9 .76 .88 1.1 .84
Please cite this article in press as: Khademi-Kalantari, K., et al., Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.001
+
MODEL
4
K. Khademi-Kalantari et al. Table 2
Mean relative values SE and 95% confidence interval of variables.
Variables
6 MWT
10.1 relative
6 MWT
f.1 relative
VAS
10.1 relative
VAS
f.1 relative
KOOS.Symptoms
10.1 relative
KOOS.Symptoms
f.1 relative
KOOS.pain
10.1 relative
KOOS.pain
f.1 relative
KOOS.Activity
10.1 relative
KOOS.Activity
f.1 relative
KOOS.Sport & recreation
10.1 relative
KOOS.Sport & recreation
f.1 relative
KOOS.Quality of life
10.1 relative
KOOS.Quality of life
f.1 relative
Control experimental Control experimental Control experimental Control experimental Control experimental Control experimental Control experimental Control experimental Control experimental Control experimental Control experimental Control experimental Control experimental Control experimental
Mean
Std. error
.0001 .171 .013 .150 .328 .703 .157 .454 .249 .677 .122 .576 .189 .605 .176 .558 .146 .558 .153 .525 .377 2.58 1.29 2.03 .281 1.10 .153 1.31
.296 .044 .025 .064 .096 .057 .093 .062 .118 .190 .133 .183 .078 .116 .084 .151 .060 .095 .076 .131 .636 1.04 1.16 .465 .145 .376 .132 .436
95%Confidence interval for mean Upper bound
Lower bound
.062 .078 .040 .014 .529 .824 .353 .584 .001 .279 .159 .179 .024 .362 .003 .230 .019 .359 .008 .241 1.17 .172 1.56 .937 .024 .317 .126 .367
.061 .264 .066 .285 .126 .583 .037 .324 .496 1.07 .404 .972 .354 .849 .355 .886 .274 .757 .316 .809 1.93 5.00 4.14 3.13 .586 1.89 .434 2.25
in 10th sessionthe amount of variable in first session ðbaselineÞ 10:1 relativeZthe amount of variable the amount of variable in first sessionðbaselineÞ in follow up sessionthe amount of variable in first session ðbaselineÞ f:1 relativeZthe amount of variablethe amount of variable in first session ðbaselineÞ
meaning that patients in the experimental group walked a longer distance (between group average difference in 10th and follow up session respectively: 26, 13) in 6 min compared to the control group. The main effect of time and the interaction of group and time were not significant for 6 MWT Fig. 1. The pair wise comparison across the evaluation times showed that the walking distance in experimental group in the 10th and follow up sessions were significantly higher than the control group (p Z 0.001). In the experimental group, the walking distance in the 10th session and follow up session compared to the baseline (p Z 0.0001 and p Z 0.01 respectively) were also significantly higher, however in control group no significant differences was observed. Multiple Regression analysis showed that only the group factor has significant correlation to the walking distance in 6 MWT (p Z 0.01). Age and BMI have shown no significant correlation.
patients in the experimental group reported statistically better pain relief (between group average difference in 10th and follow up session respectively: 28, 25) and both groups of patients reported significant reduction of pain over time (the control group average difference in 10th and
VAS The main effect of group and time were statistically significant for VAS (P Z 0.004 and p Z 0.05); meaning that
Figure 1 Mean distances walked at baseline, post treatment and follow up for the control and experimental groups.
Please cite this article in press as: Khademi-Kalantari, K., et al., Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.001
+
MODEL
Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis
5
edema. The main effect of time and the interaction of time and group were also not significant for knee flexion/ extension and edema. The experimental group showed statistically significant knee flexion ROM only in post treatment compared to the control group (p Z 0.01). In follow up sessions the knee flexion ROM in both groups was not statistically different.
Discussion
Figure 2 Mean VAS pain scores as recorded at baseline, post treatment and follow up for the control and experimental groups.
follow up session respectively: 21, 10; the experimental group average difference in 10th and follow up session respectively: 45, 31). The interaction of group and time was non-significant Fig. 2. In the experimental group the pain relief was significant from the baseline to follow up evaluations (p Z 0.0001). In the control group the pain score was lower compared to the baseline (p Z 0.04) but was raised to non significant levels in follow up.
KOOS For the KOOS questionnaire, the main effect of group was statistically significant for all of its subscales (P < 0.05) except for the sport/recreational subscale. In the other words, pain, symptoms, activity and quality of life showed statistically significant improvement in the experimental group although the sport and recreation ability of the patients was not statistically different between two groups. The main effect of time and group time interaction was not significant for any of the subscales of KOOS (P > 0.05). Table 3 shows the mean values with SE for all subscales of the KOOS questionnaire at baseline, at the 10th session and follow up. Multiple Regression showed that only the group factor has a statistically significant effect on KOOS global score (P Z 0.001) whereas age, weight and BMI had no effect.
ROM and edema The main effect of group was only statistically significant for knee flexion (P Z 0.02) but not for knee extension and Table 3
Incorporating joint distraction into standard physiotherapy treatment leads to additional improvement in pain and functional ability in patients with severe knee osteoarthritis. Given the relatively homogenous groups at the outset, the clinical improvements obtained can be attributed to the effect of joint distraction. Although OA etiology is probably multifactorial (Aspden, 2008), it is now generally accepted that OA onset and progression are mediated largely through biomechanical forces acting across the joint (Waller et al., 2011). Microfractures within the subchondral cortical endplate caused by aberrant loading results in sclerotic bone thickening with concomitant loss of inherent shock-absorbing capacity, facilitating cartilage degradation (Burr and Radin, 2003; Lindsey et al., 2004). Just as aberrant joint loading has been suggested as the cause of OA, the idea has been put forward that, conversely, unloading the joint will reverse the structural damage (Waller et al., 2011). These structural changes are mainly reported for surgically applied joint distraction and it is unlikely that 10 sessions of 20 min joint distraction could result in significant structural improvements. However, the achieved pain relief and improved functional ability in patients with severe knee OA in the present experiment, post treatment and after a 1 month follow up, are indeed of clinical significance. We applied distraction at 30 knee flexion. It has been suggested that at this position the knee ligaments and capsule are at their least tension and the distractive force can induce maximum joint separation and unloading effect (Perry and Burnfield, 1993). Therefore we postulated that the clinical outcomes observed in this experiment can be attributed mainly to decreased intra-articular pressure. Pain in knee OA is correlated with the compressive loading of the joint surfaces. During loading, compression of cartilage forces fluid into the bone through the damaged subchondral plate (van Dijk et al., 2010). The hydraulic conductance of osteochondral tissue has been shown to be higher in OA (Hwang et al., 2008) and therefore an increase in hydraulic conductance might be responsible for joint pain. Conversely any decrease in this hydraulic
Mean SE of all subscales of KOOS at the base line, post treatment and follow up.
Subscales of KOOS
Base line Experimental
Symptoms Pain Activity Sport and recreation Quality of life
49.11 45.97 45.66 7 22.19
4.7 3.5 3.5 2.4 2.3
Post treatment Control 49.64 45.14 47.65 7 29.06
Experimental 3.9 3.5 3.2 3.1 2.8
72.68 69.44 68.23 21 38.12
4.8 4.1 4.4 5.1 3.4
Follow up Control 56.07 52.08 53.90 10.50 34.69
Experimental 3.8 4.4 4.2 3 4
68.37 67.06 68.28 22.50 43.30
4.2 4.8 5.6 5.3 5.4
Control 56.09 52.61 54.67 11.18 30.51
4.3 5.2 4.8 3.6 3.4
Please cite this article in press as: Khademi-Kalantari, K., et al., Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.001
+
MODEL
6 conductance could lead to pain relief. It is likely that the pain relief resulted from joint distraction in the present experiment could be the result of the decreased interior joint pressure. OA subjects couldn’t distribute load equally between medial and lateral compartments. They walk with greater absolute load over the medial compartment and maintain this higher proportion of loading distribution over the medial compartment (Kumar et al., 2012). Also studies have shown people with knee OA walk with greater muscle cocontraction that has been thought to be associated with increased loading (Hubley-Kozey et al., 2009). We speculate that reduction of pain and improvement of functional ability in this study is due to the reduction of muscle cocontraction and consequently transient reduction of excessive loading. Joint distraction is also a good stimulus for mechanoreceptors that are located in knee structures such as the joint capsule and ligaments. It is probable that pain was modulated by stretching of these receptors (Ploegmakers et al., 2005) and the recruitment of ascending and descending pain inhibitory pathways. Improving a patient’s ability to walk is important as it helps in maintaining independence to carry out activities of daily living. Walking ability is impaired in patients with OA of the knee because of pain and stiffness in the joint (Stratford et al., 2006), instability in the joint, and weak quadriceps muscles (Schmitt and Rudolph, 2007). The six minute walk test is suggested as one of the most responsive measures to detecting deterioration and improvement in the knee physical performance (Kreibich et al., 1996; Parent and Moffet, 2002). The minimum important difference (i.e. improvement) in the distance walked in a 6 MWT has traditionally been estimated as 54 m for patients with lung disease (Redelmeier et al., 1997). A distance of 35 m (95% confidence limits 30e42 m) or about 10% increase has also been identified as representing an important effect in COPD patients (Puhan et al., 2008). Considering the reported difference of walking distance between healthy and OA patients (about 100 m)(Kervio et al., 2003) and the suggested minimum important difference, the average of 40 m improvement (more than 10%) in this study can be considered a valuable clinical improvement. Although the clinical improvement observed in this study cannot be attributed to structural changes due to the short term and intermittent characteristic of the applied unloading distraction, there is a possibility that integration of this distraction with other non surgical off-loading techniques, such as insole wedges or knee braces, could result in some structural normalisation in the knee OA. We also used unloading distraction force at the perception threshold that was about 10% of body weight in each patient. It is plausible that a higher unloading force could result in better clinical outcomes. Further research is needed to establish these hypotheses.
Declaration of interest This study is derived from a MSc thesis in physiotherapy and was funded by Shahid Beheshti University of medical Sciences. This project has been registered in Iranian Registry of Clinical Trials (Reg no: N 201111214738IRCT).
K. Khademi-Kalantari et al.
Acknowledgments We thank of authorities of 17 Shahrivar clinic and patients referring to this center.
References Andriacchi, T.P., Mu ¨ndermann, A., Smith, R.L., et al., 2004. A framework for the in vivo pathomechanics of osteoarthritis at the knee. Ann. Biomed. Eng. 32, 447e457. Annette, W., Toksvig-Larsen, S., Roos, E.M., 2005. A 2-year prospective study of patient-relevant outcomes in patients operated on for knee osteoarthritis with tibial osteotomy. BMC Musculoskelet. Disord. 6, 18. Aspden, R., 2008. Osteoarthritis: a problem of growth not decay? Rheumatology 47, 1452e1460. Bo ¨rjesson, M., Weidenhielm, L., Mattsson, E., Olsson, E., 2005. Gait and clinical measurements in patients with knee osteoarthritis after surgery: a prospective 5-year follow-up study. Knee 12, 121e127. Buckwalter, J.A., Martin, J.A., 2004. Sports and osteoarthritis. Curr. Opin. Rheumatol. 16, 634e639. Burr, D.B., Radin, E.L., 2003. Microfractures and microcracks in subchondral bone: are they relevant to osteoarthrosis? Rheum. Dis. Clin. North Am. 29, 675e685. Chiodo, C.P., McGarvey, W., 2004. Joint distraction for the treatment of ankle osteoarthritis. Foot Ankle Clin. 9, 541e553. Christensen, R., Astrup, A., Bliddal, H., 2005. Weight loss: the treatment of choice for knee osteoarthritis? A randomized trial. Osteoarthr. Cartil. 13, 20e27. Donatelli, R., Wooden, M.J., 2001. Orthopaedic Physical Therapy. Churchill Livingstone, USA. Felson, D.T., 2004. Obesity and vocational and avocational overload of the joint as risk factors for osteoarthritis. J. Rheumatol. Suppl., 2e5. Felson, D.T., 2005. Relation of obesity and of vocational and avocational risk factors to osteoarthritis. J. Rheumatol. 32, 1133e1135. Focht, B.C., Rejeski, W.J., Ambrosius, W.T., Katula, J.A., Messier, S.P., 2005. Exercise, self-efficacy, and mobility performance in overweight and obese older adults with knee osteoarthritis. Arthr. Care Res. 53, 659e665. Herzog, W., Clark, A., Wu, J., 2003. Resultant and local loading in models of joint disease. Arthr. Care Res. 49, 239e247. Hoell, S., Suttmoeller, J., Stoll, V., Fuchs, S., Gosheger, G., 2005. The high tibial osteotomy, open versus closed wedge, a comparison of methods in 108 patients. Arch. Orthop. Trauma Surg. 125, 638e643. Holmberg, S., Thelin, A., Thelin, N., 2005. Knee osteoarthritis and body mass index: a population-based case-control study. Scand. J. Rheumatol. 34, 59e64. Hubley-Kozey, C.L., Hill, N.A., Rutherford, D.J., Dunbar, M.J., Stanish, W.D., 2009. Co-activation differences in lower limb muscles between asymptomatic controls and those with varying degrees of knee osteoarthritis during walking. Clin. Biomech. 24, 407e414. Hwang, J., Bae, W.C., Shieu, W., et al., 2008. Increased hydraulic conductance of human articular cartilage and subchondral bone plate with progression of osteoarthritis. Arthrit. Rheum. 58, 3831e3842. Ito, H., Matsuno, T., Minami, A., 2004. Chiari pelvic osteotomy for advanced osteoarthritis in patients with hip dysplasia. J. Bone Joint Surg. 86, 1439e1445. Ito, H., Matsuno, T., Minami, A., 2005. Intertrochanteric varus osteotomy for osteoarthritis in patients with hip dysplasia: 6 to 28 years follow up. Clin. Orthop. Relat. Res. 433, 124e128.
Please cite this article in press as: Khademi-Kalantari, K., et al., Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.001
+
MODEL
Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis Kervio, G., Carre, F., Ville, N.S., 2003. Reliability and intensity of the six-minute walk test in healthy elderly subjects. Med. Sci. Sports Exerc. 35, 169e174. Kisner, C., Colby, L.A., 2002. Therapeutic Exercise. Biblis M, USA. Kreibich, D., Vaz, M., Bourne, R., et al., 1996. What is the best way of assessing outcome after total knee replacement? Clin. Orthopaed. Relat. Res. 331, 221e225. Krohn, K., 2005. Footwear alterations and bracing as treatments for knee osteoarthritis. Curr. Opin. Rheumatol. 17, 653e656. Kumar, D., Manal, K.T., Rudolph, K.S., 2012. Knee joint loading during gait in healthy controls and individuals with knee osteoarthritis. Osteoarthr. Cartil. 21, 298e305. Lindsey, C., Narasimhan, A., Adolfo, J., et al., 2004. Magnetic resonance evaluation of the interrelationship between articular cartilage and trabecular bone of the osteoarthritic knee. Osteoarthr. Cartil. 12, 86e96. Messier, S.P., Gutekunst, D.J., Davis, C., DeVita, P., 2005. Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthrit. Rheum. 52, 2026e2032. Michael, J.W.-P., Schlu ¨ter-Brust, K.U., Eysel, P., 2010. The epidemiology, etiology, diagnosis, and treatment of osteoarthritis of the knee. Deuts. Arzteblatt Int. 107, 152. Parent, E., Moffet, H., 2002. Comparative responsiveness of locomotor tests and questionnaires used to follow early recovery after total knee arthroplasty. Arch. Phys. Med. Rehabil. 83, 70e80. Perry, J., Burnfield, J.M., 1993. Gait Analysis: Normal and Pathological Function. Slack, USA. Ploegmakers, J., Van Roermund, P., Van Melkebeek, J., et al., 2005. Prolonged clinical benefit from joint distraction in the treatment of ankle osteoarthritis. Osteoarthr. Cartilage 13, 582e588.
7
Puhan, M.A., Mador, M., Held, U., et al., 2008. Interpretation of treatment changes in 6-minute walk distance in patients with COPD. Eur. Respir. J. 32, 637e643. Redelmeier, D.A., Bayoumi, A.M., Goldstein, R.S., Guyatt, G.H., 1997. Interpreting small differences in functional status: the six minute walk test in chronic lung disease patients. Am. J. Respir. Crit. Care Med. 155, 1278e1282. Rossignol, M., Leclerc, A., Allaert, F., et al., 2005. Primary osteoarthritis of hip, knee, and hand in relation to occupational exposure. Occup. Environ. Med. 62, 772e777. Salavati, M., Mazaheri, M., Negahban, H., et al., 2008. Validation of a persian-version of knee injury and osteoarthritis outcome score (KOOS) in Iranians with knee injuries. Osteoarthr. Cartilage 16, 1178e1182. Schmitt, L.C., Rudolph, K.S., 2007. Influences on knee movement strategies during walking in persons with medial knee osteoarthritis. Arthr. Care Res. 57, 1018e1026. Stratford, P.W., Kennedy, D.M., Woodhouse, L.J., 2006. Performance measures provide assessments of pain and function in people with advanced osteoarthritis of the hip or knee. Phys. Ther. 86, 1489e1496. Tang, W.C., Henderson, I.J., 2005. High tibial osteotomy: long term survival analysis and patients’ perspective. Knee 12, 410e413. van Dijk, C.N., Reilingh, M.L., Zengerink, M., van Bergen, C., 2010. The natural history of osteochondral lesions in the ankle. Instr. Course Lect. 59, 375. Waller, C., Hayes, D., Block, J.E., London, N.J., 2011. Unload it: the key to the treatment of knee osteoarthritis. Knee Surg. Sports Traumatol. Arthrosc. 19, 1823e1829. Westacott, C.I., Webb, G.R., Warnock, M.G., Sims, J.V., Elson, C.J., 1997. Alteration of cartilage metabolism by cells from osteoarthritic bone. Arthrit. Rheum. 40, 1282e1291.
Please cite this article in press as: Khademi-Kalantari, K., et al., Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.001
MODEL
Journal of Bodywork & Movement Therapies (2013) xx, 1e7
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/jbmt
COMPARATIVE STUDY
Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis Khosro Khademi-Kalantari, PhD, PT a, Somayeh Mahmoodi Aghdam, MSc, PT a,*, Alireza Akbarzadeh Baghban, PhD b, Mehdi Rezayi, PhD a, Abbas Rahimi, PhD, PT a, Sedighesadat Naimee, PhD, PT a a
Department of Physiotherapy, Faculty of Rehabilitation, Shahid Beheshti University of Medical Sciences, Damavand Ave, Opposite to Bou Ali Hospital, Tehran, Iran b Department of Basic Sciences, Faculty of Rehabilitation, Shahid Beheshti University of Medical Sciences, Iran Received 19 September 2013; received in revised form 29 November 2013; accepted 3 December 2013
KEYWORDS Knee; Osteoarthritis; Distraction; Pain; Function
Summary Purpose: The aim of this study was to evaluate the clinical results of non surgical knee distraction in patients with severe knee osteoarthritis. Method: forty female patients with severe knee osteoarthritis were randomly divided in two groups. A standard physiotherapy treatment was applied to both groups and in one group it was accompanied with 20 min knee joint distraction. The patients were treated for 10 sessions. Clinical examination consisted of functional examination, completion of a quality of life questionnaire, pain scale, and assessment of joint mobility and joint edema. Result: The standard physiotherapy treatment accompanied by knee distraction resulted in significantly higher improvement in pain (P Z 0.004), functional ability (P Z 0.02), quality of life (P Z 0.002) and knee flexion range of motion (p Z 0.02) compared to the standard physiotherapy treatment alone post treatment and after 1 month follow up. Conclusion: Adding knee distraction to standard physiotherapy treatment can result in further improvement in pain relief, increased functional ability and better quality of life in patients with severe knee osteoarthritis. ª 2013 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ98 21 77561411; fax: þ98 21 77561406. E-mail address: [email protected] (S. Mahmoodi Aghdam). 1360-8592/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jbmt.2013.12.001
Please cite this article in press as: Khademi-Kalantari, K., et al., Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.001
+
MODEL
2
K. Khademi-Kalantari et al.
Introduction
Materials and method
Osteoarthritis (OA) is known as a degenerative joint disease, characterized by joint pain and stiffness. These clinical symptoms are the result of cartilage damage, changes in the subchondral bone, and bony outgrowth at the joint margins (Michael et al., 2010). Normal synovial joints can survive loading during normal activities for a lifetime without developing OA. When the mechanical demand exceeds the tolerance of the joint (cartilage, bone or ligaments) however, it could lead to development and progression of osteoarthritis. The association between physically demanding occupations (Felson, 2004, 2005; Rossignol et al., 2005), severe sport activities (Buckwalter and Martin, 2004), obesity (Felson, 2004; Holmberg et al., 2005) and osteoarthritis suggests that intense joint loading is associated with early onset and progression of joint degeneration. There is also reported association between joint injury and later development of osteoarthritis. Damage to joint articular structures such as menisci, ligaments, and capsules can lead to permanent joint instability and/or incongruity of the articular surface, causing increased contact pressure on articular surfaces. This increased stress can initiate or accelerate joint degeneration (Buckwalter and Martin, 2004). The impact of lower limb alignment during gait has also been suggested to have an important role in the development and progression of OA (Krohn, 2005). In general, mechanical factors, specifically in the weight-bearing and large joints such as knee, are involved in the actual initiation of the joint damage in OA (Andriacchi et al., 2004). If over loading has a major impact on development and progression of OA, then unloading may be able to, at least, slow down its progression. There are numerous examples that show different unloading techniques, including weight loss (Christensen et al., 2005; Messier et al., 2005), wedged insole and unloader knee brace (Krohn, 2005), surgical osteotomy (Annette et al., 2005; Bo ¨rjesson et al., 2005; Hoell et al., 2005; Ito et al., 2004, 2005; Tang and Henderson, 2005) and surgical joint distraction (Chiodo and McGarvey, 2004; Westacott et al., 1997) are able to improve pain, stiffness, physical symptoms and slowing down structural damage. Measures that may decrease the intensity and frequency of impact and torsional loading of joints during sports also have been reported to prevent joint injury and development and progression of osteoarthritis (Buckwalter and Martin, 2004). More importantly, it has been demonstrated that the proper joint loading could result in constructive alterations in cartilage composition and biomechanical properties of the joint. This observation supports the concept that OA joints are possibly able to show positive adaptation to unloading (Herzog et al., 2003). Although knee distraction is one of the mobilization techniques applied by physiotherapists for reduction of pain and dysfunction (Donatelli and Wooden, 2001; Kisner and Colby, 2002), the effect of non surgical short term knee distraction on the improvement of pain and functional ability of these patients has not been investigated previously.
Participants Forty female patients with severe knee osteoarthritis who met the inclusion criteria were selected by non-random sampling method from patients referring to 17 Shahrivar clinic, Tehran, Iran, over 9 months period of time. Orthopedist referred patients to physiotherapy based on inclusion criteria. The criteria for selection of subjects included: symptomatic KellgreneLawrence grade 3 or 4 knee OA, skeletally mature, age 65 years and capacity to walk with or without using ambulatory aids. Excluded from the study were patients who met any of the following criteria: history of inflammatory arthritis, previous history of knee surgery, metabolic or endocrine disease, the presence of other symptomatic joints in lower extremity, current history of alcohol or drug abuse, having injection in the knee or taking new medication for osteoarthritis within the previous 30 days. The study was approved by the local institution ethics committee and written, witnessed consent was obtained from all patients.
Methodological study To evaluate repeatability of clinical variables, the knee range of motion (ROM) and 6 min walking test (6 MWT) were repeated twice in 6 patients with one week interval.
Main study procedure Patients were randomly assigned to one of these groups: the standard physiotherapy treatment (control group n Z 20) and standard physiotherapy treatment accompanied by knee distraction (experimental group n Z 20). Standard physiotherapy treatment included: 2 hot packs to anterior and posterior of the knee for 20 min, 10 min continuous 1 MHz ultrasound (5 min anterior and 5 min posterior to the knee) at an intensity of 1 W/cm2 and conventional TENS (frequency: 100 HZ, pulse Duration: 50 ms) for 30 min. Exercises for strengthening of quadriceps, gluteals and gastrosoleus muscles were also included in the treatment procedure. Standard physiotherapy treatment was provided for all patients. For patients in the experimental group, besides receiving standard physiotherapy treatment, joint distraction was also integrated. To distract the knee joint, a special greave was designed and built. Sustained traction was applied in supine position for 20 min while the knee was placed in 30 flexion by the use of a platform under the lower thigh to induce a counter pressure (Picture 1). The correct knee angle was checked for each patient by a goniometer. The amount of traction was set to the perceptional threshold of the patients in each session. In the other words, the lowest load that patients start feeling distraction was used for distraction. Patients received a total of 10 treatment sessions, 5 sessions weekly for 2 weeks. Dependent variables consisted of a pain visual analog scale (VAS), a 6 min walk test (6 MWT), the KOOS (knee injury and osteoarthritis outcome
Please cite this article in press as: Khademi-Kalantari, K., et al., Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.001
+
MODEL
Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis
Picture 1
Showing how the knee joint is distracted.
score) questionnaire; range of motion (ROM) and edema. Previous studies have used these parameters as an outcome measure so this study used them. All of the patients were assessed at baseline, at the 10th treatment (post treatment) and at a one month follow-up. This study was one side blinded. All of the patient examinations were performed by one therapist who was aware of patient’s grouping, but patients were not aware of the assortment. The 6-min walk is a test where the subject walks for 6 min on level ground, and the distance covered in 6 min is measured. The test was conducted on a premeasured 20 m, unobstructed, uncarpeted, point to point track. The goal of the test was to have subjects adopt a self-selected walking speed such that at the end of 6 min, they felt that they could not have walked any farther. Standardized encouragement “You are doing well, keep up the good work” was provided at 60-s intervals (Focht et al., 2005; Stratford et al., 2006). The KOOS is a subjective questionnaire that evaluates five subscales of disease including pain, symptoms, daily activity, sport and pleasure and quality of life. A Score of 0 represents severe situation and score of 100 represents normality. Reliability and validity of the Persian version of this questionnaire has been shown previously (Salavati et al., 2008). Knee ROM was assessed by goniometry and edema was measured by use of a measuring tape at the level of joint line and 10 cm above and below this.
3
reliability and Data normality was also evaluated using the ShapiroeWilk test. A 2 3 repeated measures analysis of variance (ANOVA) test was used to determine the main effects and interactions of within and between subjects’ factors for all the dependent variables. The within-subjects factor for repeated measures ANOVA was time (baseline, 10th session and one month follow up), the between-subjects factor was group (control and experimental) and covariate factors were age and BMI. Statistical significance in changes over time was determined using the paired samples T-test (the data at baseline, post treatment and follow-up served as a pair). Multiple Regression was also used to evaluate the correlation between variables.
Results All the forty female patients (control group average age: 61.20 8.6, average BMI: 32.25 5.6; experimental group average age: 61.25 6.8, average BMI: 30.79 6.1) who enrolled in the study completed the treatment program and the follow up evaluation. In each group, 18 patients had bilateral and 2 patients had unilateral knee OA and patients were matched based on age and BMI (P > 0.05). Although independent sample t-tests revealed no statistically significance difference between the two groups at the baseline, the relative variables with respect to the baseline measurement (the percentage of changes in each variable) were used for statistical analysis. In the other words, for each variable, the amount of variable obtained in 10th and follow up session was subtracted from the amount of variable in the first session and divided on it and this amount of variable was included in data analysis. Table 1 shows mean values with SE for all the dependent variables at baseline, after 10 sessions and follow up and Table 2 shows mean relative values with SE and 95% confidence interval for some of the dependent variables.
Methodological study The ICC of 6 MWT, ROM and edema had values ranged from .93 to .99 that represent very good reliability of variables.
Statistical analysis 6 MWT Data analysis was carried out using SPSS software, Version 17 and a priori significance level was set at .05. Intraclass Correlation Coefficient (ICC) was used to evaluate the data
Table 1
The repeated measures ANOVA showed that the main effect of group was statistically significant for 6 MWT, (P Z 0.02),
Mean SE of variables at the base line, post treatment and follow up.
Variable
Base line
Post treatment
Experimental VAS 6 MWT (m) Knee flex (degree) Knee ext (degree) Knee joint edema (cm) Above knee edema (cm) Below knee edema (cm)
64.1 304.15 120.6 4.56 41.58 48.17 38.33
4.8 22.2 3.2 .74 .61 .95 .71
Control 68 320.60 124.4 5.47 43.47 49.81 39.78
Experimental 3.4 15.7 2 .58 .80 .93 .73
19.50 343.90 128.92 4.06 41.51 48.32 38.17
4.1 20.8 1.8 .71 .61 .96 .71
Follow up Control 47.15 317.40 123.58 5.39 43.46 49.62 39.69
Experimental 6.6 15.7 1.7 .66 .79 .90 .72
33.69 336.28 127.93 4.52 41.38 48.33 38.28
4.5 21.6 1.5 .93 .78 1.1 .88
Control 58.15 323.10 124.57 5.96 42.34 49.11 38.75
6.1 16.5 1.9 .76 .88 1.1 .84
Please cite this article in press as: Khademi-Kalantari, K., et al., Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.001
+
MODEL
4
K. Khademi-Kalantari et al. Table 2
Mean relative values SE and 95% confidence interval of variables.
Variables
6 MWT
10.1 relative
6 MWT
f.1 relative
VAS
10.1 relative
VAS
f.1 relative
KOOS.Symptoms
10.1 relative
KOOS.Symptoms
f.1 relative
KOOS.pain
10.1 relative
KOOS.pain
f.1 relative
KOOS.Activity
10.1 relative
KOOS.Activity
f.1 relative
KOOS.Sport & recreation
10.1 relative
KOOS.Sport & recreation
f.1 relative
KOOS.Quality of life
10.1 relative
KOOS.Quality of life
f.1 relative
Control experimental Control experimental Control experimental Control experimental Control experimental Control experimental Control experimental Control experimental Control experimental Control experimental Control experimental Control experimental Control experimental Control experimental
Mean
Std. error
.0001 .171 .013 .150 .328 .703 .157 .454 .249 .677 .122 .576 .189 .605 .176 .558 .146 .558 .153 .525 .377 2.58 1.29 2.03 .281 1.10 .153 1.31
.296 .044 .025 .064 .096 .057 .093 .062 .118 .190 .133 .183 .078 .116 .084 .151 .060 .095 .076 .131 .636 1.04 1.16 .465 .145 .376 .132 .436
95%Confidence interval for mean Upper bound
Lower bound
.062 .078 .040 .014 .529 .824 .353 .584 .001 .279 .159 .179 .024 .362 .003 .230 .019 .359 .008 .241 1.17 .172 1.56 .937 .024 .317 .126 .367
.061 .264 .066 .285 .126 .583 .037 .324 .496 1.07 .404 .972 .354 .849 .355 .886 .274 .757 .316 .809 1.93 5.00 4.14 3.13 .586 1.89 .434 2.25
in 10th sessionthe amount of variable in first session ðbaselineÞ 10:1 relativeZthe amount of variable the amount of variable in first sessionðbaselineÞ in follow up sessionthe amount of variable in first session ðbaselineÞ f:1 relativeZthe amount of variablethe amount of variable in first session ðbaselineÞ
meaning that patients in the experimental group walked a longer distance (between group average difference in 10th and follow up session respectively: 26, 13) in 6 min compared to the control group. The main effect of time and the interaction of group and time were not significant for 6 MWT Fig. 1. The pair wise comparison across the evaluation times showed that the walking distance in experimental group in the 10th and follow up sessions were significantly higher than the control group (p Z 0.001). In the experimental group, the walking distance in the 10th session and follow up session compared to the baseline (p Z 0.0001 and p Z 0.01 respectively) were also significantly higher, however in control group no significant differences was observed. Multiple Regression analysis showed that only the group factor has significant correlation to the walking distance in 6 MWT (p Z 0.01). Age and BMI have shown no significant correlation.
patients in the experimental group reported statistically better pain relief (between group average difference in 10th and follow up session respectively: 28, 25) and both groups of patients reported significant reduction of pain over time (the control group average difference in 10th and
VAS The main effect of group and time were statistically significant for VAS (P Z 0.004 and p Z 0.05); meaning that
Figure 1 Mean distances walked at baseline, post treatment and follow up for the control and experimental groups.
Please cite this article in press as: Khademi-Kalantari, K., et al., Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.001
+
MODEL
Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis
5
edema. The main effect of time and the interaction of time and group were also not significant for knee flexion/ extension and edema. The experimental group showed statistically significant knee flexion ROM only in post treatment compared to the control group (p Z 0.01). In follow up sessions the knee flexion ROM in both groups was not statistically different.
Discussion
Figure 2 Mean VAS pain scores as recorded at baseline, post treatment and follow up for the control and experimental groups.
follow up session respectively: 21, 10; the experimental group average difference in 10th and follow up session respectively: 45, 31). The interaction of group and time was non-significant Fig. 2. In the experimental group the pain relief was significant from the baseline to follow up evaluations (p Z 0.0001). In the control group the pain score was lower compared to the baseline (p Z 0.04) but was raised to non significant levels in follow up.
KOOS For the KOOS questionnaire, the main effect of group was statistically significant for all of its subscales (P < 0.05) except for the sport/recreational subscale. In the other words, pain, symptoms, activity and quality of life showed statistically significant improvement in the experimental group although the sport and recreation ability of the patients was not statistically different between two groups. The main effect of time and group time interaction was not significant for any of the subscales of KOOS (P > 0.05). Table 3 shows the mean values with SE for all subscales of the KOOS questionnaire at baseline, at the 10th session and follow up. Multiple Regression showed that only the group factor has a statistically significant effect on KOOS global score (P Z 0.001) whereas age, weight and BMI had no effect.
ROM and edema The main effect of group was only statistically significant for knee flexion (P Z 0.02) but not for knee extension and Table 3
Incorporating joint distraction into standard physiotherapy treatment leads to additional improvement in pain and functional ability in patients with severe knee osteoarthritis. Given the relatively homogenous groups at the outset, the clinical improvements obtained can be attributed to the effect of joint distraction. Although OA etiology is probably multifactorial (Aspden, 2008), it is now generally accepted that OA onset and progression are mediated largely through biomechanical forces acting across the joint (Waller et al., 2011). Microfractures within the subchondral cortical endplate caused by aberrant loading results in sclerotic bone thickening with concomitant loss of inherent shock-absorbing capacity, facilitating cartilage degradation (Burr and Radin, 2003; Lindsey et al., 2004). Just as aberrant joint loading has been suggested as the cause of OA, the idea has been put forward that, conversely, unloading the joint will reverse the structural damage (Waller et al., 2011). These structural changes are mainly reported for surgically applied joint distraction and it is unlikely that 10 sessions of 20 min joint distraction could result in significant structural improvements. However, the achieved pain relief and improved functional ability in patients with severe knee OA in the present experiment, post treatment and after a 1 month follow up, are indeed of clinical significance. We applied distraction at 30 knee flexion. It has been suggested that at this position the knee ligaments and capsule are at their least tension and the distractive force can induce maximum joint separation and unloading effect (Perry and Burnfield, 1993). Therefore we postulated that the clinical outcomes observed in this experiment can be attributed mainly to decreased intra-articular pressure. Pain in knee OA is correlated with the compressive loading of the joint surfaces. During loading, compression of cartilage forces fluid into the bone through the damaged subchondral plate (van Dijk et al., 2010). The hydraulic conductance of osteochondral tissue has been shown to be higher in OA (Hwang et al., 2008) and therefore an increase in hydraulic conductance might be responsible for joint pain. Conversely any decrease in this hydraulic
Mean SE of all subscales of KOOS at the base line, post treatment and follow up.
Subscales of KOOS
Base line Experimental
Symptoms Pain Activity Sport and recreation Quality of life
49.11 45.97 45.66 7 22.19
4.7 3.5 3.5 2.4 2.3
Post treatment Control 49.64 45.14 47.65 7 29.06
Experimental 3.9 3.5 3.2 3.1 2.8
72.68 69.44 68.23 21 38.12
4.8 4.1 4.4 5.1 3.4
Follow up Control 56.07 52.08 53.90 10.50 34.69
Experimental 3.8 4.4 4.2 3 4
68.37 67.06 68.28 22.50 43.30
4.2 4.8 5.6 5.3 5.4
Control 56.09 52.61 54.67 11.18 30.51
4.3 5.2 4.8 3.6 3.4
Please cite this article in press as: Khademi-Kalantari, K., et al., Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.001
+
MODEL
6 conductance could lead to pain relief. It is likely that the pain relief resulted from joint distraction in the present experiment could be the result of the decreased interior joint pressure. OA subjects couldn’t distribute load equally between medial and lateral compartments. They walk with greater absolute load over the medial compartment and maintain this higher proportion of loading distribution over the medial compartment (Kumar et al., 2012). Also studies have shown people with knee OA walk with greater muscle cocontraction that has been thought to be associated with increased loading (Hubley-Kozey et al., 2009). We speculate that reduction of pain and improvement of functional ability in this study is due to the reduction of muscle cocontraction and consequently transient reduction of excessive loading. Joint distraction is also a good stimulus for mechanoreceptors that are located in knee structures such as the joint capsule and ligaments. It is probable that pain was modulated by stretching of these receptors (Ploegmakers et al., 2005) and the recruitment of ascending and descending pain inhibitory pathways. Improving a patient’s ability to walk is important as it helps in maintaining independence to carry out activities of daily living. Walking ability is impaired in patients with OA of the knee because of pain and stiffness in the joint (Stratford et al., 2006), instability in the joint, and weak quadriceps muscles (Schmitt and Rudolph, 2007). The six minute walk test is suggested as one of the most responsive measures to detecting deterioration and improvement in the knee physical performance (Kreibich et al., 1996; Parent and Moffet, 2002). The minimum important difference (i.e. improvement) in the distance walked in a 6 MWT has traditionally been estimated as 54 m for patients with lung disease (Redelmeier et al., 1997). A distance of 35 m (95% confidence limits 30e42 m) or about 10% increase has also been identified as representing an important effect in COPD patients (Puhan et al., 2008). Considering the reported difference of walking distance between healthy and OA patients (about 100 m)(Kervio et al., 2003) and the suggested minimum important difference, the average of 40 m improvement (more than 10%) in this study can be considered a valuable clinical improvement. Although the clinical improvement observed in this study cannot be attributed to structural changes due to the short term and intermittent characteristic of the applied unloading distraction, there is a possibility that integration of this distraction with other non surgical off-loading techniques, such as insole wedges or knee braces, could result in some structural normalisation in the knee OA. We also used unloading distraction force at the perception threshold that was about 10% of body weight in each patient. It is plausible that a higher unloading force could result in better clinical outcomes. Further research is needed to establish these hypotheses.
Declaration of interest This study is derived from a MSc thesis in physiotherapy and was funded by Shahid Beheshti University of medical Sciences. This project has been registered in Iranian Registry of Clinical Trials (Reg no: N 201111214738IRCT).
K. Khademi-Kalantari et al.
Acknowledgments We thank of authorities of 17 Shahrivar clinic and patients referring to this center.
References Andriacchi, T.P., Mu ¨ndermann, A., Smith, R.L., et al., 2004. A framework for the in vivo pathomechanics of osteoarthritis at the knee. Ann. Biomed. Eng. 32, 447e457. Annette, W., Toksvig-Larsen, S., Roos, E.M., 2005. A 2-year prospective study of patient-relevant outcomes in patients operated on for knee osteoarthritis with tibial osteotomy. BMC Musculoskelet. Disord. 6, 18. Aspden, R., 2008. Osteoarthritis: a problem of growth not decay? Rheumatology 47, 1452e1460. Bo ¨rjesson, M., Weidenhielm, L., Mattsson, E., Olsson, E., 2005. Gait and clinical measurements in patients with knee osteoarthritis after surgery: a prospective 5-year follow-up study. Knee 12, 121e127. Buckwalter, J.A., Martin, J.A., 2004. Sports and osteoarthritis. Curr. Opin. Rheumatol. 16, 634e639. Burr, D.B., Radin, E.L., 2003. Microfractures and microcracks in subchondral bone: are they relevant to osteoarthrosis? Rheum. Dis. Clin. North Am. 29, 675e685. Chiodo, C.P., McGarvey, W., 2004. Joint distraction for the treatment of ankle osteoarthritis. Foot Ankle Clin. 9, 541e553. Christensen, R., Astrup, A., Bliddal, H., 2005. Weight loss: the treatment of choice for knee osteoarthritis? A randomized trial. Osteoarthr. Cartil. 13, 20e27. Donatelli, R., Wooden, M.J., 2001. Orthopaedic Physical Therapy. Churchill Livingstone, USA. Felson, D.T., 2004. Obesity and vocational and avocational overload of the joint as risk factors for osteoarthritis. J. Rheumatol. Suppl., 2e5. Felson, D.T., 2005. Relation of obesity and of vocational and avocational risk factors to osteoarthritis. J. Rheumatol. 32, 1133e1135. Focht, B.C., Rejeski, W.J., Ambrosius, W.T., Katula, J.A., Messier, S.P., 2005. Exercise, self-efficacy, and mobility performance in overweight and obese older adults with knee osteoarthritis. Arthr. Care Res. 53, 659e665. Herzog, W., Clark, A., Wu, J., 2003. Resultant and local loading in models of joint disease. Arthr. Care Res. 49, 239e247. Hoell, S., Suttmoeller, J., Stoll, V., Fuchs, S., Gosheger, G., 2005. The high tibial osteotomy, open versus closed wedge, a comparison of methods in 108 patients. Arch. Orthop. Trauma Surg. 125, 638e643. Holmberg, S., Thelin, A., Thelin, N., 2005. Knee osteoarthritis and body mass index: a population-based case-control study. Scand. J. Rheumatol. 34, 59e64. Hubley-Kozey, C.L., Hill, N.A., Rutherford, D.J., Dunbar, M.J., Stanish, W.D., 2009. Co-activation differences in lower limb muscles between asymptomatic controls and those with varying degrees of knee osteoarthritis during walking. Clin. Biomech. 24, 407e414. Hwang, J., Bae, W.C., Shieu, W., et al., 2008. Increased hydraulic conductance of human articular cartilage and subchondral bone plate with progression of osteoarthritis. Arthrit. Rheum. 58, 3831e3842. Ito, H., Matsuno, T., Minami, A., 2004. Chiari pelvic osteotomy for advanced osteoarthritis in patients with hip dysplasia. J. Bone Joint Surg. 86, 1439e1445. Ito, H., Matsuno, T., Minami, A., 2005. Intertrochanteric varus osteotomy for osteoarthritis in patients with hip dysplasia: 6 to 28 years follow up. Clin. Orthop. Relat. Res. 433, 124e128.
Please cite this article in press as: Khademi-Kalantari, K., et al., Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.001
+
MODEL
Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis Kervio, G., Carre, F., Ville, N.S., 2003. Reliability and intensity of the six-minute walk test in healthy elderly subjects. Med. Sci. Sports Exerc. 35, 169e174. Kisner, C., Colby, L.A., 2002. Therapeutic Exercise. Biblis M, USA. Kreibich, D., Vaz, M., Bourne, R., et al., 1996. What is the best way of assessing outcome after total knee replacement? Clin. Orthopaed. Relat. Res. 331, 221e225. Krohn, K., 2005. Footwear alterations and bracing as treatments for knee osteoarthritis. Curr. Opin. Rheumatol. 17, 653e656. Kumar, D., Manal, K.T., Rudolph, K.S., 2012. Knee joint loading during gait in healthy controls and individuals with knee osteoarthritis. Osteoarthr. Cartil. 21, 298e305. Lindsey, C., Narasimhan, A., Adolfo, J., et al., 2004. Magnetic resonance evaluation of the interrelationship between articular cartilage and trabecular bone of the osteoarthritic knee. Osteoarthr. Cartil. 12, 86e96. Messier, S.P., Gutekunst, D.J., Davis, C., DeVita, P., 2005. Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthrit. Rheum. 52, 2026e2032. Michael, J.W.-P., Schlu ¨ter-Brust, K.U., Eysel, P., 2010. The epidemiology, etiology, diagnosis, and treatment of osteoarthritis of the knee. Deuts. Arzteblatt Int. 107, 152. Parent, E., Moffet, H., 2002. Comparative responsiveness of locomotor tests and questionnaires used to follow early recovery after total knee arthroplasty. Arch. Phys. Med. Rehabil. 83, 70e80. Perry, J., Burnfield, J.M., 1993. Gait Analysis: Normal and Pathological Function. Slack, USA. Ploegmakers, J., Van Roermund, P., Van Melkebeek, J., et al., 2005. Prolonged clinical benefit from joint distraction in the treatment of ankle osteoarthritis. Osteoarthr. Cartilage 13, 582e588.
7
Puhan, M.A., Mador, M., Held, U., et al., 2008. Interpretation of treatment changes in 6-minute walk distance in patients with COPD. Eur. Respir. J. 32, 637e643. Redelmeier, D.A., Bayoumi, A.M., Goldstein, R.S., Guyatt, G.H., 1997. Interpreting small differences in functional status: the six minute walk test in chronic lung disease patients. Am. J. Respir. Crit. Care Med. 155, 1278e1282. Rossignol, M., Leclerc, A., Allaert, F., et al., 2005. Primary osteoarthritis of hip, knee, and hand in relation to occupational exposure. Occup. Environ. Med. 62, 772e777. Salavati, M., Mazaheri, M., Negahban, H., et al., 2008. Validation of a persian-version of knee injury and osteoarthritis outcome score (KOOS) in Iranians with knee injuries. Osteoarthr. Cartilage 16, 1178e1182. Schmitt, L.C., Rudolph, K.S., 2007. Influences on knee movement strategies during walking in persons with medial knee osteoarthritis. Arthr. Care Res. 57, 1018e1026. Stratford, P.W., Kennedy, D.M., Woodhouse, L.J., 2006. Performance measures provide assessments of pain and function in people with advanced osteoarthritis of the hip or knee. Phys. Ther. 86, 1489e1496. Tang, W.C., Henderson, I.J., 2005. High tibial osteotomy: long term survival analysis and patients’ perspective. Knee 12, 410e413. van Dijk, C.N., Reilingh, M.L., Zengerink, M., van Bergen, C., 2010. The natural history of osteochondral lesions in the ankle. Instr. Course Lect. 59, 375. Waller, C., Hayes, D., Block, J.E., London, N.J., 2011. Unload it: the key to the treatment of knee osteoarthritis. Knee Surg. Sports Traumatol. Arthrosc. 19, 1823e1829. Westacott, C.I., Webb, G.R., Warnock, M.G., Sims, J.V., Elson, C.J., 1997. Alteration of cartilage metabolism by cells from osteoarthritic bone. Arthrit. Rheum. 40, 1282e1291.
Please cite this article in press as: Khademi-Kalantari, K., et al., Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.001