Changes in knee moments with contralateral versus ipsilateral cane usage in females with knee osteoarthritis
Introduction
Osteoarthritis (OA) is the world’s most prevalent rheumatic disease (March and Schwarz, 1994), and the knee is the most often-affected weight-bearing joint. According to Morrison (1970), the joint force transmitted through the knee during walking is in the range of 2–4 times body weight. Furthermore, Schipplein and Andriacchi (1991) found that the medial compartment of the knee can experience up to 2.5 times the load seen by the lateral compartment. Subjects with healthy knees typically demonstrate knee joint loading both medial and lateral compartments, with the former bearing more than 70% of the total joint load (Morrison, 1970, Schipplein and Andriacchi, 1991, Kettelkamp and Chao, 1972). On the other hand, virtually all of the load is transmitted through the medial compartment in individuals with OA (Harrington, 1983). Thus, alleviating excessive medial compartment loading in subject with OA should be a goal of any intervention. Although the pathogenesis of osteoarthritis is still controversial, it is possible that (a) increased compressive loading of the joint and (b) decreased congruity of the joint surfaces may acerbate the osteoarthritic changes, giving rise to pain and deformity at the knee (Gerber and Hicks, 1984). As such, different interventions have been used including surgical (Leon et al., 2001) and non-surgical (Maly et al., 2002).
Hurwitz et al., 1998, Hurwitz et al., 1999, Hurwitz et al., 2000 studied the relationship between knee loading, pain and osteoarthritis of the knee, commenting that interventions which targeted the reduction of pain as a means of reducing discomfort for persons with OA of the knee, may in fact be exposing these persons to higher risk of damage from OA in that the protective nature of knee pain is also removed. They also found that the peak external knee adduction moment is a good indicator of not just the total knee load but its medial–lateral distribution as well. Reductions in pain were associated with increased peak knee external adduction moments as well as increased peak knee external extension moments.
The use of a cane differs from interventions that have specific analgesic mechanisms as a cane is designed principally to reduce the load at the joint which in turn often results in a reduction in pain. A substantially high proportion (40%) of patients with hip and knee OA own a cane (Van der Esch et al., 2003). The use of a contralateral walking cane to reduce joint loading in patients with hip OA is well supported in the literature (cf., Blount, 1956, Mulley, 1988). The cane-generated external moment acts in the same rotary direction as the moment naturally produced by the contralateral hip abductor, thereby lowering the hip abductor moment needed (Neumann, 1998). The reduction in this moment also reduces the hip joint forces. The question of contralateral versus ipsilateral use of a cane to unload the knee joint in patients with knee OA has not been fully explored. Unlike the hip, the knee lacks a muscle group analogous to the hip abductors, and the magnitude of frontal plane moments at the knee during stance is relatively minor compared with sagittal plane moments (Morrison, 1970, Harrington, 1983). As a result, the rationale for the most efficacious use of a cane for subjects with knee OA may not be the same as for the hip.
There are very few studies of cane usage in persons with OA of the knee. Murray et al. (1969) showed that the total cane–floor contact periods of the subjects coincided closely with the total weight-bearing period on the affected side, which appeared to reduce the weight-bearing stress on the affected extremity. However, no concurrent measurement of the knee joint moments or forces during the gait cycle was made. Edwards (1986) investigated cane usage and found greater mean knee joint motion and reduced forefoot forces (foot contact force) with ipsilateral cane use. With contralateral cane use, 75% of the subjects showed greater mean stride length and cadence. However, ground reaction force was examined in this study instead of individual joint moments. Vargo et al. (1992) examined cane use in static postures by 10 healthy subjects using electromyography (EMG). Hip abductor EMG was the lowest when maximal weight was placed through a contralateral cane and highest when maximal weight was supported on the ipsilateral side. However, there was no statistically significant difference in muscle activity of the quadriceps, medial hamstrings, lateral hamstrings and gastrocnemius in contralateral versus ipsilateral cane use. In fact, contralateral cane use resulted in over twice the medial hamstrings muscle activity compared to ipsilateral usage at maximum effort and at the 20% body weight, which may have been associated with increased loading of the knee joint. Even though the data suggested that the forces generated by muscular activity around the knee were not uniformly diminished by holding a cane in the contralateral hand, such statically determined results have limited ability to predict muscle activity during a dynamic activity such as walking. A more recent study by Mendelson et al. (1998) employed in-vivo strain measuring techniques on seven healthy subjects. Instead of measuring the strain at the knee joint, the extensometer was externally mounted on the tibial midshaft. Significantly lower tibial strain rate was seen with either ipsilateral or contralateral cane usage, compared with no cane. No significant difference was detected when ipsilateral usage was compared with contralateral usage.
To date, no study has been conducted to evaluate knee joint moments during gait in a population of persons with OA of the knee. In fact, one may well question the use of a cane for persons with knee OA entirely in the absence of solid evidence as to its efficacy. The aim of the present study was to determine the effect on knee joint moments of force with contralateral and ipsilateral cane use during gait in individuals with knee OA. Three walking conditions were investigated: ipsilateral cane use, contralateral cane use and walking without the use of a cane.
An inverse dynamics approach was used to estimate the moment of force at the knee and hip during the three walking conditions. Hurwitz et al. (1998) found that the external adduction moment is a good estimator of the internal medial–lateral loading of the knee. Thus, the calculated internal moments of force will be indicative of the amount and distribution of joint forces experienced by the subjects. Since the effect of cane usage on hip joint kinetics is well documented, a comparison of the changes in the hip abductor moment of force with different uses of the cane to that found in the literature was used as to check the validity of the calculation of knee kinetics.
Section snippets
Ethical approval
The protocol of the study was granted ethical approval by the Hong Kong Polytechnic University Ethics Committee and the Research Ethics Subcommittee of the Queen Mary Hospital, Hong Kong prior to the initiation of the study.
Subjects
Fourteen patients with a diagnosis of OA of the knee satisfying the American College of Rheumatology’s classification criteria for a clinical diagnosis of OA knee (Altman et al., 1986) were convenience sampled from a total population of approximately 80 patients meeting the
Temporal–spatial variables
The temporal–spatial data (cadence, speed and stride length) are presented in the top half of Table 2. Analysis of the data revealed that subjects walked significantly faster in the unaided walking as compared to the two conditions with canes. As well, they had significantly higher cadence in the unaided walking. However, no difference was found in the stride length. Therefore, the faster walking speed is attributable to the higher cadence alone. The relationship between walking speed and knee
Discussion
In patients with knee OA, the pathological changes in the articular cartilage, bone, capsule and surrounding structures frequently result in pain, disability and deformity. In addition, the resulting deformity of the knee (varus or valgus) may cause further cartilage loss, microfractures and bone collapse (Johnson et al., 1980). The use of a cane can decrease the loading on the diseased joint. Patients with varus or valgus knee deformity are currently advised to adopt contralateral placement of
Conclusion
Contralateral cane placement was associated with the lowest peak knee abduction moment and the lowest peak knee flexion moment. In other words, it is concluded that contralateral cane placement is desirable for subjects with OA of the knee. It is suggested that patients with either varus or valgus knee deformity should place the cane opposite to their affected extremity. Due to the inherent variation in the moments between subjects (Winter, 1984) and in the gait of persons with arthritis, a
Acknowledgement
The authors express their gratitude to Professor David A. Winter and Dr Chien Ping for their comments on the study. Our sincere gratitude is extended to Dr Sing Kai Lo for his assistance with the statistical analysis. We also thank the Hong Kong Polytechnic University for its financial support.
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