Trajectories of perceived exertion and pain over a 12-week neuromuscular exercise program in patients with knee osteoarthritis.

BACKGROUND: Exercise programs rely on the overload principle, yet patients with knee osteoarthritis (OA) may not adequately progress exercises due to fear of exacerbating symptoms. OBJECTIVE: To describe trajectories for perceived exertion and exercise-induced knee pain during a neuromuscular exercise program for patients with knee OA. DESIGN: Participants with knee OA completed a 12-week neuromuscular exercise program consisting of weekly supervised sessions plus home exercises. During each supervised session, the Borg's rating of perceived exertion (RPE; 6 = no exertion, 20 = maximal exertion) and knee pain (pre, post, max) using Numeric Rating Scales (NRS; 0 = no pain, 10 = worst imaginable pain) were completed. Mean changes in RPE and pain from weeks 1-12 were calculated. Mixed effects regression was used to investigate trajectories over time (weeks) for RPE, and maximum pain (pre-to-max) and pain-change (pre-to-post) during exercise. RESULTS: 56 patients (95%) completed the program. From week 1-12, RPE increased by 2.6 (95%CI, 1.7 to 3.5), from 'somewhat hard' to 'very hard', while max pain decreased by 1.0 NRS (95%CI, 0.5 to 1.3) and pain-change decreased by 0.9 NRS (95%CI, 0.4 to 1.3). Linear mixed effects regression showed a quadratic increase for RPE over time until between weeks 9 and 10, then RPE plateaued. Maximum pain decreased linearly over time. Pain-change showed a quadratic decrease over time until approximately week 9, then pain-change plateaued. CONCLUSIONS: In patients with knee OA participating in a 12-week neuromuscular exercise program, perceived exertion during exercise progressed from 'somewhat hard' to 'very hard' at 9 weeks, while exercise-induced knee pain decreased. Patients were able to work harder while experiencing decreases rather than increases in pain.

Biomechanical effects of valgus knee bracing: a systematic review and meta-analysis.

To review and synthesize the biomechanical effects of valgus knee bracing for patients with medial knee osteoarthritis (OA). Electronic databases were searched from their inception to May 2014. Two reviewers independently determined study eligibility, rated study quality and extracted data. Where possible, data were combined into meta-analyses and pooled estimates with 95% confidence intervals (CI) for standardized mean differences (SMD) were calculated. Thirty studies were included with 478 subjects tested while using a valgus knee brace. Various biomechanical methods suggested valgus braces can decrease direct measures of medial knee compressive force, indirect measures representing the mediolateral distribution of load across the knee, quadriceps/hamstring and quadriceps/gastrocnemius co-contraction ratios, and increase medial joint space during gait. Meta-analysis from 17 studies suggested a statistically significant decrease in the external knee adduction moment (KAM) during walking, with a moderate-to-high effect size (SMD = 0.61; 95% CI: 0.39, 0.83; P < 0.001). Meta-regression identified a near-significant association for the KAM effect size and duration of brace use only (ß, -0.01; 95% CI: -0.03, 0.0001; P = 0.06); with longer durations of brace use associated with smaller treatment effects. Minor complications were commonly reported during brace use and included slipping, discomfort and poor fit, blisters and skin irritation. Systematic review and meta-analysis suggests valgus knee braces can alter knee joint loads through a combination of mechanisms, with moderate-to-high effect sizes in biomechanical outcomes.

Osteoarthritis year in review 2014: mechanics--basic and clinical studies in osteoarthritis.

The purpose of this review was to highlight recent research in mechanics and osteoarthritis (OA) by summarizing results from selected studies spanning basic and clinical research methods. Databases were searched from January 2013 through to March 2014. Working in pairs, reviewers selected 67 studies categorized into four themes--mechanobiology, ambulatory mechanics, biomechanical interventions and mechanical risk factors. Novel developments in mechanobiology included the identification of cell signaling pathways that mediated cellular responses to loading of articular cartilage. Studies in ambulatory mechanics included an increased focus on instrumented knee implants and progress in computational models, both emphasizing the importance of muscular contributions to load. Several proposed biomechanical interventions (e.g., shoe insoles and knee braces) produced variable changes in external knee joint moments during walking, while meta-analysis of randomized clinical trials did not support the use of lateral wedge insoles for decreasing pain. Results from high quality randomized trials suggested diet with or without exercise decreased indicators of knee joint load during walking, whereas similar effects from exercise alone were not detected with the measures used. Data from longitudinal cohorts suggested mechanical alignment was a risk factor for incidence and progression of OA, with the mechanism involving damage to the meniscus. In combination, the basic and clinical studies highlight the importance of considering multiple contributors to joint loading that can evoke both protective and damaging responses. Although challenges clearly exist, future studies should strive to integrate basic and clinical research methods to gain a greater understanding of the interactions among mechanical factors in OA and to develop improved preventive and therapeutic strategies.

Alignment, body mass and their interaction on dynamic knee joint load in patients with knee osteoarthritis.

OBJECTIVE: To examine the interaction and relative contributions of frontal plane alignment and body mass on dynamic knee joint loading in patients with knee osteoarthritis (OA). METHODS: We completed three-dimensional gait analyses and hip-to-ankle standing anteroposterior radiographs on 487 patients with knee OA referred to a tertiary care center specializing in orthopaedics. RESULTS: Using sequential (hierarchical) linear regression, the interaction term (mechanical axis anglexmass) contributed significantly (P<0.001) to a model (total adjusted R(2)=0.70) predicting the external knee adduction moment, that included mechanical axis angle (R(2)=0.37) and mass (R(2)=0.06) while controlling for age, sex, height, Kellgren and Lawrence grade, pain score during walking, gait speed, toe out angle and trunk lean (R(2)=0.25). When the sample was split into tertiles for mass, mechanical axis angle accounted for 32-54% of explained variance in knee adduction moment. In the tertile with greatest mass, results suggest a 3.2 N m increase in knee load for every 1 degrees increase in varus alignment. When split into tertiles for mechanical axis angle, mass accounted for 6-10% of explained variance in the knee adduction moment. In the tertile with the most varus alignment, results suggest a 0.4 N m increase in knee load for every 1 kg increase in mass. CONCLUSION: Our findings describe the interaction between alignment and body mass on dynamic knee joint loading, with the association between alignment and load highest in patients with the highest mass. Our findings also emphasize the role of malalignment on knee load at all levels of mass, and have implications for better understanding risk factors and intervention strategies for knee OA.

Lead as surface bolus for high-energy photon and electron therapy.

Dose distributions were evaluated under thin sheet lead used as surface bolus for 4- and 10-MV photons and 6- and 9-MeV electrons using a parallel-plate ion chamber and film. A narrow, significantly low dose region (-17%) was noted for 4-MV photons, whereas a 6% increase in dose was present for 10-MV photons. The dose was elevated 15%-22% near the surface of electron fields with lead bolus, but depth dose relationships were similar to soft-tissue-equivalent (STE) bolus. Investigation of partial-field bolus (2-cm-diam circle) documented reduced doses due to lack of lateral electron equilibrium for 10-MV photons, which was less evident using lead, and large edge effects (up to 30%) for electrons using either lead or STE bolus. Dose distributions on sloped surfaces with electron fields were similar for lead and STE; both require thickness adjustment to achieve a desired effective thickness normal to the surface. Lead bolus has been used successfully in clinical practice for photons.

A surface bolus material for high-energy photon and electron therapy.

The authors describe a useful bolus material for therapy with high-energy photons and electrons (greater than 1 MeV). Qualities evaluated included flexibility, transparency, tissue equivalence (re radiation interactions), stability at high doses, durability, lack of toxicity, ease in cleaning, low flammability, and cost. Using a parallel-plate ionization chamber and 60Co, 4-, and 10-MV photons as well as 6- and 18-MeV electrons, maximum deviation from water-equivalent values was approximately 2 mm for 6-MeV electrons. The material comes in large sheets of precise thickness (+/- 0.5 mm) which can be cut and layered to form more complex shapes.

Quality assurance of electron-beam energy using an aluminum wedge.

An aluminum wedge was designed to facilitate evaluation of the constancy of high-energy electron teletherapy beams (6-18 MeV). Ready-packed film was exposed with the wedge on top, and optical density distribution was recorded with a scanning densitometer. Energy-dependent statistics were obtained using the practical-range extrapolation method. The procedure takes approximately 15 minutes and requires less than one minute of therapy machine time. Repeated daily measurements on a medical linear accelerator at 12 MeV showed a variation of +/- 0.37 MeV (3 sigma). This technique has proved useful for prompt machine evaluation following malfunctions and has been incorporated into routine quality assurance testing.

Systematic patient-dose errors for 4- and 10-MeV microwave linear accelerators associated with rectangular collimator settings.

Systematic patient-dose errors relating to standard equivalent-square approximations and movable collimator-exchange effect were evaluated for rectangular fields of photon beams from 4- and 10-MeV microwave electron accelerators (Varian Clinac 4 and Clinac 18). Errors approached 2.5% at nominal treatment depths for highly elongated rectangular fields. The collimator-exchange effect should be considered when (a) evaluating ionization-chamber stem effect, (b) specifying relative output factors for rectangular fields, and (c) evaluating equivalent-square-field algorithms.

The mysterious wall around exposure.

The quantity, exposure, and its associated unit, the roentgen, have been employed for approximately 50 years for the practical measurement of x- and gamma-ray source "output." Practical exposure-measuring devices must be provided with a wall of critical thickness and composition. Confusion arises since the wall is not mentioned in the definition of "exposure." This mystery can be dispelled by the fact that exposure never is measured in the manner in which it is defined.