TIP OF THE MONTH: June/July 2014
Use of Unloader Braces for Knee Osteoarthritis
First-Place Winning Article, 2014 Paper of the Year Competition
by Susank K Long, OTC, LAT, MS
Per new Centers for Medicare and Medicaid Services (CMS) guidelines, clinicians now must use a “stepped-care” approach before doing a total knee replacement1. These conservative measures can include physical therapy, anti-inflammatories, injections, weight loss management, and the use of unloader knee braces. Now more than ever the Certified Orthopedic Technologist will be involved in bracing or wedge management of patients with knee osteoarthritis.
The use of unloader braces is becoming a more common non-surgical approach for predominately unicompartmental knee arthritis. The arthritis needs to be in the medial or lateral tibiofemoral joint for the brace to work effectively. Some patients do benefit from bracing even if they have bi-compartmental or tri-compartmental issues. Bracing slightly alters the alignment of the knee so less pressure is put over the arthritic part. Anyone can use a brace. Patient engagement is important and the patient must be willing to wear the brace for it to work.
Our facility many times starts the patient in heel wedges before they progress to an unloader brace. If a patient has medial compartment osteoarthritis, lateral wedges in their shoes change their knee biomechanics by reducing varus torque. Wedging shifts the load from the medial compartment of the knee. We use medial wedges for the opposite effect with people with lateral compartment degenerative joint disease. Medial wedging reduces the valgus torque of the knee. A pair of wedges costs approximately $15.00 whereas an unloader brace can cost over $2000.00. Patient education is highly important when using wedges as the Certified Orthopaedic Technologist needs to emphasize proper placement in the shoes, especially when the patient is using them in different shoes. Patients have been known to reverse the wedges in their shoes, which creates more knee pain. For some people, wedges are enough and they do not want or need an unloader brace.
The next step for a patient is an unloader knee brace. Unloader braces either push or pull the patient’s knee depending on how they are designed. The idea is to reduce the force placed on their arthritic knee. Some braces are static with the load being constant while others are more dynamic and are loaded from heel strike to toe off. Unloader braces can work effectively if the patient is compliant in wearing them. Compliance, many times, is problematic for patients. This is why it’s important for the Certified Orthopedic Technologist to educate the patient about the importance of using the brace properly. At our facility, many of our patients do well with both a knee brace and heel wedges used together.
When picking a brace you need to think about body type, level of mobility, and the unloading needs of a patient. An active patient may only want unloading during their daily exercise. A semi-active patient my need load throughout the day and for exercise. A sedentary patient may have completely different needs. There are pros and cons to all unloader braces, but no brace will work if the patient doesn’t wear it. It’s highly important that the certified orthopaedic technologist makes sure the patient understands how to apply the brace correctly and that the brace fits well to the patient’s body structure. Having samples of the braces in your facility so patients can see them and understand the expectations of wearing them can help.
For the Certified Orthopaedic Technologist, fitting of the brace can be complex. It is much easier to fit a lean 6-foot person than a 5-foot overweight person. Patients with very large or fatty quadriceps and very skinny legs don’t fit well in unloader braces. Braces should not be used for patients at risk of deep vein thrombosis. You also have to be aware of insurance considerations and decide if you want to do custom or non-custom braces. Medicare does not cover custom braces. In order for satisfactory patient engagement the brace must fit well and the patient must be provided the proper education on how to apply the brace correctly. The Certified Orthopaedic Technologist must be willing to spend enough time with the patient to make sure the patient fully understands how to apply the brace so that patient compliance is higher. Proper patient education and proper fitting of the brace initially can help with patient compliance and higher patient satisfaction rates. Talk through the process with the patient and have the patient reproduce the fitting before they leave the clinic.
Subjectively, patients report positive outcomes with unloader braces. Many times they can return to all or some of their previous recreational activities with reduced pain. Many can lose weight because they are more active which in effect helps lessen the force on their knees and decreases their pain. Others are able to return to work with decreased or no pain throughout the day.
Studies are controversial on the topic of bracing. There are a variety of studies that show per subjective report that patients feel they get improvement with knee bracing or wedging. Karen K. Briggs, MPH, Director of Clinical Research at the Steadman Philippon Research Institute in Vail, Colorado, presented a paper at the March 2010 Annual Meeting of the American Academy of Orthopedic Surgeons (AAOS) stating patients reported subjective improvement with pain and disability and decreased use of anti-inflammatories while using unloader braces. She also noted the participants continued to wear the brace after the study was finished. “It is our opinion that the low drop-out rate is due to patient education and proper fittings of the brace initially”.2
Objectively, studies are expensive and many times funded by the brace companies, which can lead to ethical concerns. Objectively, it is hard to tell if unloader braces slow disease progression. It can be questionable if the unloader brace is actually unloading the varus/valgus torques or if the patient’s muscles are just working differently when wearing the brace. More objective studies are needed in this area, especially for the long-term results.
It’s an exciting time to be a Certified Orthopaedic Technologist, so use your skills and resources to provide your patients with great fitting unloader braces to help improve patient outcomes. The value of a certified orthopaedic technologist who can properly measure for and fit an unloader brace and educate patients is great not only to the patient but also to physicians and the organization you work for.
About The Author:
Susan Long, OTC, LAT, MS, is a Certified Athletic Trainer and Orthopaedic Technologist at the University of Wisconsin Hospitals and Clinics, where she has worked at for four years. She has a BA from Luther College, MS from Illinois State University and she became an OTC in 2012.