The use of braces or insoles in combination with nonbiomechanical treatments appear to deliver the greatest pain relief for patients with medial tibiofemoral osteoarthritis, although the evidence supporting these interventions has a high degree of uncertainty, according findings from a large meta-analysis of randomized, controlled trials presented at the OARSI 2021 World Congress.
Thinkstock/Zinkevych
“It’s been highlighted for several years now that due to the high rate of joint replacement, we need to promote more effective nonsurgical treatments,” Ans van Ginckel, PhD, of Ghent (Belgium) University, told the conference.
However, guidelines on the use of biomechanical treatments for knee OA pain vary widely, and there are few studies that compare the effectiveness of different interventions.
To address this, Dr. van Ginckel and colleagues conducted a network meta-analysis of 27 randomized, controlled trials – involving a total of 2,413 participants – of biomechanical treatments for knee OA pain. The treatments included were valgus braces, combined brace treatment (with added nonbiomechanical treatment), lateral or medial wedged insoles, combined insole treatment (with added nonbiomechanical treatment), contralateral cane use, gait retraining, and modified shoes.
“These treatments are mainly based on the premise that people with knee osteoarthritis likely experience a higher external knee adduction moment during walking, compared to healthy people,” Dr. van Ginckel told the conference, which is sponsored by the Osteoarthritis Research Society International. “This has been associated to some extent with disease onset, severity, and progression.”
When compared to nonbiomechanical controls, walking sticks and canes were the only intervention that showed a benefit in reducing pain, although the authors described the data supporting this as “high risk.”
When all the treatments were ranked according to the degree of pain relief seen in studies, combined insole and/or combined brace treatments showed the greatest degree of benefit.
However, Dr. van Ginckel said the evidence supporting even these treatments was of low to very low certainty, there was significant variation in the control treatments used in the studies, and the confidence intervals were wide. This also reflected the multifactorial nature of pain in knee OA, she said.
“A plausible explanation is the partial role in the biomechanics of the pathogenesis of pain and the multifactorial nature of pain,” she said.
Prof. Rik Lories
Commenting on the study, Rik Lories, MD, PhD, head of the division of rheumatology at University Hospitals Leuven (Belgium) and of the department of development and regeneration at Catholic University Leuven, said the findings of the analysis show how difficult it is to study biomechanical interventions for knee OA.
“It was a smart approach to try to get some more information about a wide array of studies that have been performed, being selective with regards to what to include,” Dr. Lories said. “It’s still a big challenge in terms of how do you control for confounders.”
Dr. Lories said that he took a positive view of the findings, suggesting that these interventions are unlikely to cause harm, and are therefore “not a road to avoid” in helping to reduce knee OA pain. But he also argued that the analysis pointed to a clear need for better studies of biomechanical interventions for knee OA. “I think that’s an important message that somehow the field has to improve the quality of their trials,” he said in an interview, although he acknowledged that such trials may be difficult to run and get funding for.
Dr. van Ginckel was supported by an EU Horizon 2020 fellowship, and a coauthor was supported by the Australian National Health and Medical Research Council. No conflicts of interest were declared.