Effect of real-time biofeedback on peak knee adduction moment in patients with medial knee osteoarthritis: Is direct feedback effective?

      Highlights

      • With direct feedback on knee adduction moment alone, patients were unable to significantly reduce the knee adduction moment.
      • When provided with specific instructions and direct feedback, significant reductions were found.
      • Reductions in knee adduction moment were maintained after removal of the feedback.

      Abstract

      Background

      Gait modifications can reduce the knee adduction moment, a representation of knee loading. Reduced loading may help to slow progression of medial knee osteoarthritis. We aimed to investigate the response of patients with medial knee osteoarthritis to direct feedback on the knee adduction moment as a method for modifying the gait pattern, before and after training with specific gait modifications.

      Methods

      Forty patients with medial knee osteoarthritis underwent 3D gait analysis on an instrumented-treadmill, while receiving real-time feedback on the peak knee adduction moment. Patients were trained with three different modifications; toe-in, wider steps and medial thrust gait. The response to real-time feedback on the knee adduction moment was measured before and after training. To evaluate the short term retention effect, we measured the changes without feedback. We also evaluated the effects on the knee flexion moment and at the hip and ankle joints.

      Findings

      With direct feedback on the knee adduction moment, patients were initially unable to reduce the knee adduction moment. After training with specific modifications, peak knee adduction moment was reduced by 14% in response to direct feedback. Without feedback a 9% reduction in peak knee adduction moment was maintained. Hip moments were not increased with modified gait, but small increases in ankle adduction moment and knee flexion moment were observed.

      Interpretation

      Real-time biofeedback directly on the knee adduction moment is a promising option for encouraging gait modifications to reduce knee loading, however only when combined with specific instructions on how to modify the gait.

      Keywords

      To read this article in full you will need to make a payment
      Subscribe to Clinical Biomechanics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Aresti N.
        • Kassam J.
        • Nicholas N.
        • Achan P.
        Hip osteoarthritis.
        BMJ. 2016; 354: 1-10
        • Bellamy N.
        • Buchanan W.W.
        A preliminary evaluation of the dimensionality and clinical importance of pain and disability in osteoarthritis of the hip and knee.
        Clin. Rheumatol. 1986; 5: 231-241
        • Bennell K.L.
        • Bowles K.A.
        • Wang Y.
        • Cicuttini F.
        • Davies-Tuck M.
        • Hinman R.S.
        Higher dynamic medial knee load predicts greater cartilage loss over 12 months in medial knee osteoarthritis.
        Ann. Rheum. Dis. 2011; 70: 1770-1774
        • Bhatnagar T.
        • Jenkyn T.R.
        Internal kinetic changes in the knee due to high tibial osteotomy are well-correlated with change in external adduction moment: an osteoarthritic knee model.
        J. Biomech. 2010; 43: 2261-2266
        • van den Bogert A.J.
        • Geijtenbeek T.
        • Even-Zohar O.
        • Steenbrink F.
        • Hardin E.C.
        A real-time system for biomechanical analysis of human movement and muscle function.
        Med. Biol. Eng. Comput. 2013; 51: 1069-1077
        • Cappozzo A.
        • Catani F.
        • Croce U.D.
        • Leardini A.
        Position and orientation in space of bones during movement: anatomical frame definition and determination.
        Clin. Biomech. 1995; 10: 171-178
        • Chang A.H.
        • Moisio K.C.
        • Chmiel J.S.
        • Eckstein F.
        • Guermazi A.
        • Prasad P.V.
        • Zhang Y.
        • Almagor O.
        • Belisle L.
        • Hayes K.
        • Sharma L.
        External knee adduction and flexion moments during gait and medial tibiofemoral disease progression in knee osteoarthritis.
        Osteoarthr. Cartil. 2015; 23: 1099-1106
        • Creaby M.W.
        It's not all about the knee adduction moment: the role of the knee flexion moment in medial knee joint loading.
        Osteoarthr. Cartil. 2015; 23: 1038-1040
        • Favre J.
        • Erhart-Hledik J.C.
        • Chehab E.F.
        • Andriacchi T.P.
        A general scheme to reduce the knee adduction moment by modifying a combination of gait variables.
        J. Orthop. Res. 2016; 34: 1547-1556
        • Fregly B.J.
        • Reinbolt J.A.
        • Chmielewski T.L.
        Evaluation of a patient-specific cost function to predict the influence of foot path on the knee adduction torque during gait.
        Comput. Methods Biomech. Biomed. Eng. 2008; 11: 63-71
        • Gerbrands T.A.
        • Pisters M.F.
        • Theeven P.J.R.
        • Verschueren S.
        • Vanwanseele B.
        Lateral trunk lean and medializing the knee as gait strategies for knee osteoarthritis.
        Gait Posture. 2017; 51: 247-253
        • Gerbrands T.A.
        • Pisters M.F.
        • Vanwanseele B.
        Individual selection of gait retraining strategies is essential to optimally reduce medial knee load during gait.
        Clin. Biomech. 2014; 29: 828-834
        • Hunt M.A.
        • Simic M.
        • Hinman R.S.
        • Bennell K.L.
        • Wrigley T.V.
        Feasibility of a gait retraining strategy for reducing knee joint loading: increased trunk lean guided by real-time biofeedback.
        J. Biomech. 2011; 44: 943-947
        • Hunt M.A.
        • Takacs J.
        Effects of a 10-week toe-out gait modification intervention in people with medial knee osteoarthritis: a pilot, feasibility study.
        Osteoarthr. Cartil. 2014; 22: 904-911
        • Lindenfeld T.N.
        • Hewett T.E.
        • Andriacchi T.P.
        Joint loading with valgus bracing in patients with varus gonarthrosis.
        Clin. Orthop. Relat. Res. 1997; : 290-297
        • Manal K.
        • Gardinier E.
        • Buchanan T.S.
        • Snyder-Mackler L.
        A more informed evaluation of medial compartment loading: the combined use of the knee adduction and flexor moments.
        Osteoarthr. Cartil. 2015; 23: 1107-1111
        • Miyazaki T.
        • Wada M.
        • Kawahara H.
        • Sato M.
        • Baba H.
        • Shimada S.
        Dynamic load at baseline can predict radiographic disease progression in medial compartment knee osteoarthritis.
        Ann. Rheum. Dis. 2002; 61: 617-622
        • Morgenroth D.C.
        • Medverd J.R.
        • Seyedali M.
        • Czerniecki J.M.
        The relationship between knee joint loading rate during walking and degenerative changes on magnetic resonance imaging.
        Clin. Biomech. (Bristol, Avon). 2014; 29: 664-670
        • van den Noort J.C.
        • Steenbrink F.
        • Roeles S.
        • Harlaar J.
        Real-time visual feedback for gait retraining: toward application in knee osteoarthritis.
        Med. Biol. Eng. Comput. 2015; 53: 275-286
        • Nuesch C.
        • Laffer D.
        • Netzer C.
        • Pagenstert G.
        • Mundermann A.
        Effect of gait retraining for reducing ambulatory knee load on trunk biomechanics and trunk muscle activity.
        Gait Posture. 2016; 47: 24-30
        • Pollo F.E.
        • Otis J.C.
        • Backus S.I.
        • Warren R.F.
        • Wickiewicz T.L.
        Reduction of medial compartment loads with valgus bracing of the osteoarthritic knee.
        Am. J. Sports Med. 2002; 30: 414-421
        • Reeves N.D.
        • Bowling F.L.
        Conservative biomechanical strategies for knee osteoarthritis.
        Nat. Rev. Rheumatol. 2011; 7: 113-122
        • Richards R.
        • van den Noort J.C.
        • Dekker J.
        • Harlaar J.
        Gait retraining with real-time biofeedback to reduce knee adduction moment: systematic review of effects and methods used.
        Arch. Phys. Med. Rehabil. 2017; 98: 137-150
        • Riley P.O.
        • Paolini G.
        • Della C.U.
        • Paylo K.W.
        • Kerrigan D.C.
        A kinematic and kinetic comparison of overground and treadmill walking in healthy subjects.
        Gait Posture. 2007; 26: 17-24
        • Shull P.B.
        • Shultz R.
        • Silder A.
        • Dragoo J.L.
        • Besier T.F.
        • Cutkosky M.R.
        • Delp S.L.
        Toe-in gait reduces the first peak knee adduction moment in patients with medial compartment knee osteoarthritis.
        J. Biomech. 2013; 46: 122-128
        • Shull P.B.
        • Silder A.
        • Shultz R.
        • Dragoo J.L.
        • Besier T.F.
        • Delp S.L.
        • Cutkosky M.R.
        Six-week gait retraining program reduces knee adduction moment, reduces pain, and improves function for individuals with medial compartment knee osteoarthritis.
        J. Orthop. Res. 2013; 31: 1020-1025
        • Simic M.
        • Hinman R.S.
        • Wrigley T.V.
        • Bennell K.L.
        • Hunt M.A.
        Gait modification strategies for altering medial knee joint load: a systematic review.
        Arthritis Care Res. 2011; 63: 405-426
        • Toriyama M.
        • Deie M.
        • Shimada N.
        • Otani T.
        • Shidahara H.
        • Maejima H.
        • Moriyama H.
        • Shibuya H.
        • Okuhara A.
        • Ochi M.
        Effects of unloading bracing on knee and hip joints for patients with medial compartment knee osteoarthritis.
        Clin. Biomech. 2011; 26: 497-503
        • Walter J.P.
        • D'Lima D.D.
        • Colwell Jr., C.W.
        • Fregly B.J.
        Decreased knee adduction moment does not guarantee decreased medial contact force during gait.
        J. Orthop. Res. 2010; 28: 1348-1354
        • Wheeler J.W.
        • Shull P.B.
        • Besier T.F.
        Real-time knee adduction moment feedback for gait retraining through visual and tactile displays.
        J. Biomech. Eng. 2011; 133041007
        • Wulf G.
        Attentional focus and motor learning: a review of 15 years.
        in: International Review of Sport and Exercise Psychology. Routledge, 2013: 77-104
        • Wulf G.
        • Su J.
        An external focus of attention enhances golf shot accuracy in beginners and experts.
        Res. Q. Exerc. Sport. 2007; 78: 384-389
        • Zhao D.
        • Banks S.A.
        • Mitchell K.H.
        • D'Lima D.D.
        • Colwell C.W.
        • Fregly B.J.
        Correlation between the knee adduction torque and medial contact force for a variety of gait patterns.
        J. Orthop. Res. 2007; 25: 789-797