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Living FRIendly Summaries of the Body of Evidence using Epistemonikos (FRISBEE)
Medwave 2020;20(1):e7759 doi: 10.5867/medwave.2020.01.7759
Contralateral canes for knee osteoarthritis
Francesca Moller, Luis Ortiz - Muñoz, Sebastián Irarrázaval
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Key Words: knee osteoarthritis, cane, Epistemonikos, GRADE

Abstract

Introduction
Knee osteoarthritis is a relevant health problem given its high prevalence and associated disability. Within the non-pharmacological management alternatives, the use of canes has been proposed, however, there is no consensus in the literature regarding its indication.

Methods
We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach.

Results and conclusions
We identified three systematic reviews including four studies overall, of which one was randomized trials. We conclude that the use of a contralateral cane in patients with knee osteoarthritis probably reduces pain. In addition, it could slightly increase function, but the certainty of the evidence is low.


 
Problem

Osteoarthritis is a relevant health problem, with hip and knee osteoarthritis the eleventh leading cause of global disability, the thirty-eighth in years of life adjusted for disability[1] and an important reason for consultation in both primary and specialist care. Conservative management is the first line of treatment and its main objective is pain control. This includes the use of drugs, patient education, weight loss in patients with obesity, kinesiotherapy and the use of technical aids such as the cane, among others. The cane is used with the aim of reducing the biomechanical load that is exerted on the hip and knee. However, there is no consensus in the literature about its effect or its indication.

Methods

We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others, to identify systematic reviews and their included primary studies. We extracted data from the identified reviews and reanalyzed data from primary studies included in those reviews. With this information, we generated a structured summary denominated FRISBEE (Friendly Summary of Body of Evidence using Epistemonikos) using a pre-established format, which includes key messages, a summary of the body of evidence (presented as an evidence matrix in Epistemonikos), meta-analysis of the total of studies when it is possible, a summary of findings table following the GRADE approach and a table of other considerations for decision-making. 

Key messages

  • The use of a contralateral cane in patients with knee osteoarthritis probably reduces pain (certainty of moderate evidence).

  • It is not possible to establish clearly if the use of contralateral cane increases walking speed, because the certainty of the existing evidence has been evaluated as very low.

  • The use of a contralateral cane could slightly increase the function (certainty of the low evidence).

About the body of evidence for this question

What is the evidence

See evidence matrix in Epistemonikos later

We found three systematic reviews[2],[3],[4], which included four primary studies[5],[6],[7],[8] of which one corresponds to a randomized trial[7].

All the studies reported interesting outcomes, for which reason this table and the summary, in general, are based on these.

What types of patients were included*

All the studies[5],[6],[7],[8] included adult patients with a diagnosis of knee osteoarthritis, based on the American College of Rheumatology criteria, all of which presented symptoms (pain).

The average age ranged from 53.6 to 65 years.

76.5% of the patients were women.

What types of interventions were included*

One study[5] evaluated the use of a contralateral walking pole, one trial[7] analyzed the use of a wooden cane with a contralateral T-shaped handle, the other two studies[6],[8] used contralateral cane not specifying the type.

Three studies[5],[6], [8] compared the same patients without the use of canes, while one trial[7] compared a control group with knee osteoarthritis. 

What types of outcomes were measured

Of the multiple outcomes measured by the trials, the systematic reviews presented in a grouped manner the following: pain, function, quality of life, walking speed, moment of adduction of the knee and vertical reaction force to the ground.

The average follow-up of the trials was one month (range between 0 and 2 months).

* Information about primary studies is not extracted directly from primary studies but from identified systematic reviews, unless otherwise stated. 

Summary of findings

The information on the effects of the use of canes in knee osteoarthritis is based on two studies, one observational[5] and one randomized[7], which included 98 patients.

The randomized trial[7] measured pain and function outcomes (64 patients), while the observational study[5] measured the walking speed outcome (34 patients).

The summary of the results is as follows:

  • The use of contralateral cane in patients with knee osteoarthritis probably decreases the pain (certainty of the evidence is moderate).

  • It is not possible to establish clearly if contralateral cane use increases walking speed, because the certainty of the existing evidence has been evaluated as very low.

  • The use of a contralateral cane could slightly increase function (certainty of the evidence is low).

Follow the link to access the interactive version of this table (Interactive Summary of Findings – iSoF)


Other considerations for decision-making

To whom this evidence does and does not apply 

  • The evidence contained in this summary is applicable to adult patients with symptomatic knee osteoarthritis.
  • It is not applicable to patients with acute or chronic knee pain from another cause, or to patients with symptomatic osteoarthritis of other joints.
About the outcomes included in this summary 
  • The outcomes included in the results summary table are those considered critical for decision making by the authors of this summary.
  • Although some systematic reviews considered peak knee adduction moment as a relevant outcome and some clinicians might think in the same way, these outcomes are now known as surrogate outcomes[10]. The report of these outcomes is made when there is an absence of information on clinically relevant outcomes, since the use of surrogate outcomes in decision making entails a risk of incorrect decisions. However, the authors of this summary decided to analyze it, obtaining a certainty of the very low evidence, since the outcome presented limitations due to the risk of bias, imprecision, and inconsistency.
Balance between benefits and risks, and certainty of the evidence 
  • Among the benefits of cane use, it is highlighted that it probably decreases the pain (moderate certainty) and could have a slight effect on function (low certainty).
  • In turn, the adverse effects of cane use have not been systematically evaluated, and although there are theories showing kinetic and kinematic changes in other joints of the lower extremities, the clinical implications of these changes are not defined.
  • Due to the absence of the measurement of adverse effects, it is difficult to make an adequate risk/benefit balance.
Resource considerations 
  • No studies were found that evaluated the cost-benefit of this intervention. However, it is a low-cost and widely available technical aid. 
What would patients and their doctors think about this intervention 
  • Faced with the available evidence, it is expected to find variability in the decision of the different patients and physicians. Although there may be pain reduction and there are clinical guidelines that recommend its use, there is uncertainty about the adverse effects, so its indication should be individualized and supervised.
  • One study[9] evaluated the factors that influence the use of a cane in patients with osteoarthritis of the knee. This study, which uses a behavioral change approach, found that older people, with a higher body mass index, a longer duration of knee pain and more intense pain when walking, tend to prefer using the cane.
  • It could be considered as an option in patients in whom other therapeutic options are not being considered, or as a complement to other therapeutic options with greater evidence.
Differences between this summary and others sources
  • The revised systematic reviews do not make specific recommendations regarding the use of canes due to the limited available evidence, which is consistent with the results obtained.
  • The International Society for the Study of Osteoarthritis (OARSI)[11] recommends the use of a cane in patients with osteoarthritis of the knee, without osteoarthritis in other joints based on the results of the mentioned randomized trial[5]. The American Academy of Orthopedic Surgery (AAOS) does not refer to the use of canes[12].
Could this evidence change in the future?
  • The probability that the conclusions of this summary will change in the future varies depending on each outcome, with the probability of walking speed and adverse effects being high. On the other hand, the probability that the results change is less in function and pain.
  • We identified an ongoing systematic review in International Prospective Register of Systematic Registries (PROSPERO) that assesses changes in maximum moment of adduction of the knee from interventions that modify gait, including the use of a cane[13].
  • We identified two randomized trials underway in the International Clinical Trials Registry Platform of the World Health Organization, one that evaluates maximum vertical force in patients with osteoarthritis of the knee[14] and another in relation to pain and function with the use of walking sticks[15].
How we conducted this summary

Using automated and collaborative means, we compiled all the relevant evidence for the question of interest and we present it as a matrix of evidence.


Follow the link to access the interactive version: Canes for knee osteoarthritis

Notes

The upper portion of the matrix of evidence will display a warning of “new evidence” if new systematic reviews are published after the publication of this summary. Even though the project considers the periodical update of these summaries, users are invited to comment in Medwaveor to contact the authors through email if they find new evidence and the summary should be updated earlier.  

After creating an account in Epistemonikos, users will be able to save the matrixes and to receive automated notifications any time new evidence potentially relevant for the question appears. 

This article is part of the Epistemonikos Evidence Synthesis project. It is elaborated with a pre-established methodology, following rigorous methodological standards and internal peer review process. Each of these articles corresponds to a summary, denominated FRISBEE (Friendly Summary of Body of Evidence using Epistemonikos), whose main objective is to synthesize the body of evidence for a specific question, with a friendly format to clinical professionals. Its main resources are based on the evidence matrix of Epistemonikos and analysis of results using GRADE methodology. Further details of the methods for developing this FRISBEE are described here (http://dx.doi.org/10.5867/medwave.2014.06.5997)

Epistemonikos foundation is a non-for-profit organization aiming to bring information closer to health decision-makers with technology. Its main development is Epistemonikos database (www.epistemonikos.org).

Potential conflicts of interest 
The authors do not have relevant interests to declare.

Follow the link to access the interactive version: Canes for knee osteoarthritis
Licencia Creative Commons Esta obra de Medwave está bajo una licencia Creative Commons Atribución-NoComercial 3.0 Unported. Esta licencia permite el uso, distribución y reproducción del artículo en cualquier medio, siempre y cuando se otorgue el crédito correspondiente al autor del artículo y al medio en que se publica, en este caso, Medwave.

 

Introducción
La artrosis de rodilla es un problema de salud relevante dada su alta prevalencia y discapacidad asociada. Dentro de las alternativas de manejo no farmacológico se ha planteado el uso de bastones, sin embargo no existe consenso en la literatura respecto a su indicación.

Métodos
Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios, realizamos un metanálisis, preparamos tablas de resumen de los resultados utilizando el método GRADE.

Resultados y conclusiones
Identificamos tres revisiones sistemáticas que en conjunto incluyeron cuatro estudios primarios, de los cuales, uno es ensayo aleatorizado. Concluimos que el uso de bastón contralateral en pacientes con artrosis de rodilla probablemente disminuye el dolor. Además, podría aumentar levemente la funcionalidad, pero la certeza de la evidencia es baja.

Authors: Francesca Moller[1,2], Luis Ortiz - Muñoz[2,3], Sebastián Irarrázaval[2,4]

Affiliation:
[1] Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
[2] Proyecto Epistemonikos, Santiago, Chile
[3] Centro Evidencia UC, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
[4] Departamento de Ortopedia y Traumatología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile

E-mail: sirarraz@med.puc.cl

Author address:
[1] Centro Evidencia UC
Pontificia Universidad Católica de Chile
Diagonal Paraguay 476
Santiago
Chile

Citation: Moller F, Ortiz - Muñoz L, Irarrázaval S. Contralateral canes for knee osteoarthritis. Medwave 2020;20(1):e7759 doi: 10.5867/medwave.2020.01.7759

Submission date: 11/3/2019

Acceptance date: 17/5/2019

Publication date: 16/1/2020

Origin: This article is a product of the Evidence Synthesis Project of Epistemonikos Fundation, in collaboration with Medwave for its publication

Type of review: Non-blinded peer review by members of the methodological team of Epistemonikos Evidence Synthesis Project

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  1. Cross M, Smith E, Hoy D, Nolte S, Ackerman I, Fransen M, et al. The global burden of hip and knee osteoarthritis: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014 Jul;73(7):1323-30. | CrossRef | PubMed |
  2. Baghaei Roodsari R, Esteki A, Aminian G, Ebrahimi I, Mousavi ME, Majdoleslami B, et al. The effect of orthotic devices on knee adduction moment, pain and function in medial compartment knee osteoarthritis: a literature review. Disabil Rehabil Assist Technol. 2017 Jul;12(5):441-449. | CrossRef | PubMed |
  3. Newberry SJ, FitzGerald J, SooHoo NF, Booth M, Marks J, Motala A, et al. Treatment of Osteoarthritis of the Knee: An Update Review. Rockville (MD): Agency for Healthcare Research and Quality (US); 2017 May. [on line] | PubMed | Link |
  4. Simic M, Hinman RS, Wrigley TV, Bennell KL, Hunt MA. Gait modification strategies for altering medial knee joint load: a systematic review. Arthritis Care Res (Hoboken). 2011 Mar;63(3):405-26. | CrossRef | PubMed |
  5. Bechard DJ, Birmingham TB, Zecevic AA, Jones IC, Leitch KM, Giffin JR, et al. The effect of walking poles on the knee adduction moment in patients with varus gonarthrosis. Osteoarthritis Cartilage. 2012 Dec;20(12):1500-6. | CrossRef | PubMed |
  6. Chan GN, Smith AW, Kirtley C, Tsang WW. Changes in knee moments with contralateral versus ipsilateral cane usage in females with knee osteoarthritis. Clin Biomech (Bristol, Avon). 2005 May;20(4):396-404. | PubMed |
  7. Jones A, Silva PG, Silva AC, Colucci M, Tuffanin A, Jardim JR, et al. Impact of cane use on pain, function, general health and energy expenditure during gait in patients with knee osteoarthritis: a randomised controlled trial. Ann Rheum Dis. 2012 Feb;71(2):172-9. | CrossRef | PubMed |
  8. Kemp G, Crossley KM, Wrigley TV, Metcalf BR, Hinman RS. Reducing joint loading in medial knee osteoarthritis: shoes and canes. Arthritis Rheum. 2008 May 15;59(5):609-14. | CrossRef | PubMed |
  9. Hart J, Hinman RS, van Ginckel A, Hall M, Nelligan R, Bennell KL. Factors Influencing Cane Use for the Management of Knee Osteoarthritis: A Cross-Sectional Survey. Arthritis Care Res (Hoboken). 2018 Oct;70(10):1455-1460. | CrossRef | PubMed |
  10. Guyatt GH, Oxman AD, Kunz R, Atkins D, Brozek J, Vist G, et al. GRADE guidelines: 2. Framing the question and deciding on important outcomes. J Clin Epidemiol. 2011 Apr;64(4):395-400. | CrossRef | PubMed |
  11. McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014 Mar;22(3):363-88. | CrossRef | PubMed |
  12. Brown GA. AAOS clinical practice guideline: treatment of osteoarthritis of the knee: evidence-based guideline, 2nd edition. J Am Acad Orthop Surg. 2013 Sep;21(9):577-9. | CrossRef | PubMed |
  13. Bowd J, Biggs P, Whatling G, Holt C. Do gait style and gait retraining have the potential to reduce medial compartmental loading in individuals with knee osteoarthritis whilst not adversely affecting the hip and ankle joints? Protocol for a systematic review. PROSPERO 2018 CRD42018085738 [on line] | Link |
  14. Fang M. Walking Aids in the Management of Knee Osteoarthritis. ClinicalTrials.gox. [on line] | Link |
  15. Jones A. Effectiveness of Cane in Osteoarthritis (OA) Patients. ClinicalTrials.gox. [on line] | Link |
Cross M, Smith E, Hoy D, Nolte S, Ackerman I, Fransen M, et al. The global burden of hip and knee osteoarthritis: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014 Jul;73(7):1323-30. | CrossRef | PubMed |

Baghaei Roodsari R, Esteki A, Aminian G, Ebrahimi I, Mousavi ME, Majdoleslami B, et al. The effect of orthotic devices on knee adduction moment, pain and function in medial compartment knee osteoarthritis: a literature review. Disabil Rehabil Assist Technol. 2017 Jul;12(5):441-449. | CrossRef | PubMed |

Newberry SJ, FitzGerald J, SooHoo NF, Booth M, Marks J, Motala A, et al. Treatment of Osteoarthritis of the Knee: An Update Review. Rockville (MD): Agency for Healthcare Research and Quality (US); 2017 May. [on line] | PubMed | Link |

Simic M, Hinman RS, Wrigley TV, Bennell KL, Hunt MA. Gait modification strategies for altering medial knee joint load: a systematic review. Arthritis Care Res (Hoboken). 2011 Mar;63(3):405-26. | CrossRef | PubMed |

Bechard DJ, Birmingham TB, Zecevic AA, Jones IC, Leitch KM, Giffin JR, et al. The effect of walking poles on the knee adduction moment in patients with varus gonarthrosis. Osteoarthritis Cartilage. 2012 Dec;20(12):1500-6. | CrossRef | PubMed |

Chan GN, Smith AW, Kirtley C, Tsang WW. Changes in knee moments with contralateral versus ipsilateral cane usage in females with knee osteoarthritis. Clin Biomech (Bristol, Avon). 2005 May;20(4):396-404. | PubMed |

Jones A, Silva PG, Silva AC, Colucci M, Tuffanin A, Jardim JR, et al. Impact of cane use on pain, function, general health and energy expenditure during gait in patients with knee osteoarthritis: a randomised controlled trial. Ann Rheum Dis. 2012 Feb;71(2):172-9. | CrossRef | PubMed |

Kemp G, Crossley KM, Wrigley TV, Metcalf BR, Hinman RS. Reducing joint loading in medial knee osteoarthritis: shoes and canes. Arthritis Rheum. 2008 May 15;59(5):609-14. | CrossRef | PubMed |

Hart J, Hinman RS, van Ginckel A, Hall M, Nelligan R, Bennell KL. Factors Influencing Cane Use for the Management of Knee Osteoarthritis: A Cross-Sectional Survey. Arthritis Care Res (Hoboken). 2018 Oct;70(10):1455-1460. | CrossRef | PubMed |

Guyatt GH, Oxman AD, Kunz R, Atkins D, Brozek J, Vist G, et al. GRADE guidelines: 2. Framing the question and deciding on important outcomes. J Clin Epidemiol. 2011 Apr;64(4):395-400. | CrossRef | PubMed |

McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014 Mar;22(3):363-88. | CrossRef | PubMed |

Brown GA. AAOS clinical practice guideline: treatment of osteoarthritis of the knee: evidence-based guideline, 2nd edition. J Am Acad Orthop Surg. 2013 Sep;21(9):577-9. | CrossRef | PubMed |

Bowd J, Biggs P, Whatling G, Holt C. Do gait style and gait retraining have the potential to reduce medial compartmental loading in individuals with knee osteoarthritis whilst not adversely affecting the hip and ankle joints? Protocol for a systematic review. PROSPERO 2018 CRD42018085738 [on line] | Link |

Fang M. Walking Aids in the Management of Knee Osteoarthritis. ClinicalTrials.gox. [on line] | Link |

Jones A. Effectiveness of Cane in Osteoarthritis (OA) Patients. ClinicalTrials.gox. [on line] | Link |