The Rheumatologist—June 14, 2012
“An orthotic is a device meant to assist a part of the body to achieve functional tasks,” says Howard Hillstrom, PhD, director of the Leon Root, MD, Motion Analysis Laboratory at Hospital for Special Surgery in New York City. “Knee osteoarthritis [KOA] can be treated in many ways, ranging from pharmaceuticals to nutraceuticals, exercise, and surgery, when indicated. Orthotics is a part of our armamentarium and can address pain as well as its root causes.”
Malalignment, high body mass index (BMI), and tissue injury, such as torn ligaments, are the three major reasons for developing KOA and foot problems. Orthotics are designed to address these issues by improving alignment and redistributing joint loads. Based on the concept that lower-extremity structure and function are related, improving structure should help alleviate functional problems.
Do Not Oversell
It is important that physicians and others on the treatment team do not oversell the benefits of using orthotics when talking to their patients.
Dr. Hillstrom notes that there is, as of yet, no literature showing that orthotics can stop progression of knee OA. This is the current “Holy Grail” of osteoarthritis research.
One area where there is agreement is that the proper use of orthotics can be useful in lessening pain.
We have done research showing that bracing and foot orthotics can result in mean pain reductions of 30% or more on visual analog scales,” says Dr. Hillstrom. “That level is greater than what is seen with most analgesics and antiinflammatory medications. Still, the preliminary findings need to be supported by randomized, controlled trials.”
Their use may not be quite as grey when discussing the use of foot orthotics and special shoes.
When making treatment decisions on referring patients for possible orthotic use, talk to the patient about how the appliance will fit in with their lifestyle. The best device in the world won’t work if it sits in the patient’s closet.
Anybody with knee or foot arthritis can potentially benefit from the use of orthoses. Those where there is still some residual flexibility in the joint may have the best response.
“If a clinician can move a joint at least a little bit, that suggests that the joint can still be realigned with the help of a device,” says Dr. Hillstrom. “If somebody’s knee or foot is literally stiff, frozen like the Tin Man from the Wizard of Oz, then they might not be a good candidate. The orthotics need to be able to nudge the joint into an improved position of alignment.”
Rheumatologists should assess their patient’s response to the orthotic at every visit. In addition to an assessment of joint mobility and tenderness, ask about what causes them pain and if there have been any changes since the last visit.
There are a number of scales available. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) measures five items for pain, two for stiffness, and 17 for functional limitation and is one of the more widely used measuring tools. The Knee injury and Osteoarthritis Outcome Score (KOOS) looks at pain, other symptoms, functioning in activities of daily living, function in sports and recreation, and knee-related quality of life.
The experts interviewed here emphasized that, when possible, it is best to talk about pain after the knees and feet have been stressed. Ask the patient to do something specific, such as walking up and down a half flight of steps first.
“Have them perturb the system by doing a task and then immediately afterward ask them about their pain intensity,” says Dr. Hillstrom. “There is not a lot of pain involved with watching football on the couch. What is much more interesting is if they complain about their knee killing them following dancing for two hours at someone’s wedding.”
Monitoring the fit and use of orthotics can be undertaken during the office visit. If the knee brace is too tight, there can be a concern about compromising circulation or throwing off a blood clot.
It is also possible that a previously well-fitted orthotic may become too loose. For example, the patient who had a high BMI can now get up and walk around more. They are soon 25 pounds lighter and need to have their brace adjusted.
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