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The Future of Knee Bracing
Standards of Care
The REHABILITATOR™ System of Knee Bracing
Statistics
• 10% of the population over 60 has knee OA that impairs function
• TKR procedures are projected to grow 673% from now to 2030 to 3.8 million surgeries a year
• Increases from aging population and higher incidence of knee OA in both older and younger patients
Trends in Reimbursement for TKR
Requirement by insurers including Medicare that the physician document conservative management of Knee OA prior to approval for TKR
Standard of Care for the conservative management of knee OA prior to TKR should include use of OA REHABILITATOR™ therapy (the most clinically significant therapy to delay the progression of knee OA available)
Knee OA Standards of Care
• Use of NSAIDs
• Injections
• Exercise
• Unloading Knee Braces
Standard of Care
• “there is a need to develop alternative, efficacious, nonpharmacological, and nonsurgical treatment approaches that are capable of ameliorating the symptoms of knee OA.”
– Journal of Biomechanical Engineering, Pneumatic Osteoarthritis Knee Brace, April 2009
Unloader LimitationsEffective for pain relief during
use only
May reduce leg strength over time
No carry over benefit unbraced
w/no rehabilitation benefits, can not provide a stand alone “Standard of Care” alternative
What is a REHABILITATOR™?• A REHABILITATOR™ is an innovative patented knee brace
that dynamically corrects gait to realize significant rehabilitative benefits after several weeks of use.
• Uses pneumatic air to unload, protect and support the knee joint.
• Uses an extension swing assist to correct gait during use.• Has clinically proven “carry over”; patients demonstrate
UNBRACED significant gait improvements, reduction in pain, and gains in leg strength after 90 days of use.
Unloading Pneumatic Lever• The three-point leverage is achieved using a novel
pneumatic leverage system that, when pressurized evokes a valgus correction (for varus OA), which reduces excessive medial compartment loading.
• “pneumatic soft materials can counterbalance the negative influence of the adduction moment and thus alleviate its negative influence on the progression of OA. The brace is capable of unloading 90 – 100% of the excessive adduction moment.”
– Journal of Biomechanical Engineering, Pneumatic Osteoarthritis Knee Brace, April 2009
New Clinical Research
Recent clinical research has identified a consistent abnormal gait that deteriorates as OA worsens
“Abnormal OA Gait” is strongly linked to OA progressionAbnormal OA Gait reduces pain, but significantly
increases the wear and tear on the impacted joint compartment (joint biomechanics change)
The affected knee loses quadriceps strength over time because of diminished use with altered gait biomechanics, decreasing dynamic support of the affected knee compartment
Quadriceps strength 98 OA patients to Swedish and Fearon data on 79 Normal patients
Male OA Male normal Female OA Female normal
0
10
20
30
40
50
60
70
Series1
(Force/BW)*100
Diminished Quad Strength Impact• Significant reduction of quad strength reduces the
knee compartment dynamic support (joint space balance)
• Increased knee adduction moment w/ gait• Altered ankle / foot biomechanics (lateral loading of
ankle w/ varus OA) further reducing quad strength over time
• Increased torque in the knee joint w/ ambulation over time
• Diminished functional capabilities over time
New Standard of Care for the Conservative Management of Knee OA
• Gait rehabilitating dynamic knee bracing that in 90 days will increase quad strength by 46%, hamstring strength by 29%
• Improves gait biomechanics UNBRACED w/ improved knee extension, walking speed, total ROM in gait, foot placement, and reduced abnormal knee movements.
• Significantly reduces knee pain UNBRACED • Reduces knee adduction moment 48% compared to
14% from 90 days of exercise
Prospective randomized study to assess effect of OA REHABILITATOR™
in Kellegren Lawrence 3, 4 patientsN= 57OA REHABILITATOR™ = 27Control = 30Dropped out study , Brace = 5, Control = 7
Patients wore brace for 3 hours or more
Gait and Strength, scores and functional tests at initial visit and at 90 days UNBRACED.
Improvement in 90 days of Brace use Gait parameter
Walking speed 12%
Knee extension 6 degrees (-1-22)
Total ROM in Gait 12 degrees (7-33)
Foot placement 1.7 cms (-0.9 to 6 cms)
Loading response Knee flexion 9 degrees (-4 to 11)
Reduced abnormal knee moments 11/22
All Gait studies performed without brace to test retained effect of the brace
Gait improvement after 90 days of OA REHABILITATOR™
Reduction in Adduction Moment
Pre Brace
After 3 months of brace use
Bhave 2013
Biodex Isokinetic Dynamometer
• Testing at 60 degrees• Lever arm same
length• 5 REPS each side• Average Peak torque
in FT/LB• For comparison (Force/BW)*100
Strength comparison OA REHABILITATOR™vs. control
Condition Percentage change
OA REHABILITATOR™ Quadriceps strength
+46% (10.5% - 136%)
OA REHABILITATOR™ Hamstring strength
+29% (-2% -80%)
Control Quadriceps strength -10.1% (-50% - 48%)
Control Hamstrings strength -0.5% (-43% - 48%)
All strength studies performed without brace to test retained effect of the brace
Strengthening Brace
24.00
25.00
26.00
27.00
28.00
29.00
30.00
31.00
32.00
0.0
5.0
10.0
15.0
20.0
25.0
30.0
1 2
OA REHABILITATOR vs. control
Visit 1 90 days
Improvement in quadriceps strength in braced group
vs. loss of strength in control group at 90 days
Bracecontrol
Force/BW*100
Improvement in hamstring strength in braced group vs.
loss of strength in control group at 90 days
Visit 1 90 days
Bracecontrol
Force/BW*100
% change in quadriceps strength in braced patients vs. control
-20
-10
0
10
20
30
40
50
60
70
Cel
l Mea
n
%diff.ext.brace %diff.ext.ct
Cell Bar ChartError Bars: ± 1 Standard Error(s)
OA REHABILITATOR™
Control
Force/BW*100
% quad Strength change
Result
OA REHABILITATOR™
+ 46%
Control -10.1%
0
5
10
15
20
25
30
35
40
Cel
l Mea
n
pre.ext.brace post.ext.brace
Cell Bar ChartError Bars: ± 1 Standard Deviation(s)
0
5
10
15
20
25
30
Cel
l Mea
n
pre.f lex.brace post.f lex.brace
Cell Bar ChartError Bars: ± 1 Standard Deviation(s)
Pre Brace Post Brace
Post Brace
Pre Brace
Improvement in quadriceps and hamstring strength with 90 days of OA REHABILITATOR™ use
Quadriceps
Hamstrings
Force/BW*100
P=0.001
P=0.011
% change in hamstring strength in braced patients vs. control
-8
-6
-4
-2
0
2
4
6
8
Cel
l Mea
n
dif f .f lex.brace %.diff.f lex.ct
Cell Bar ChartError Bars: ± 1 Standard Error(s)
OA REHABILITATOR™ Control
Force/BW*100
% hams Strength change
Result
OA REHABILITATOR™
+ 29%
Control -0.5%
Improvement in thigh strength in braced group vs.
loss of strength in control group at 90 days
-8
-6
-4
-2
0
2
4
6
8
10
Cel
l Mea
n
diff.
ext.b
race
diff.
flex.
brac
e
diff.
ext.c
t
diff.
flex.
ct
Cell Bar ChartError Bars: ± 1 Standard Error(s)
Force/BW*100
OA REHABILITATOR™
Control
Quadriceps Hamstrings
HamstringsQuadriceps
Weaker muscles showed greater gain in strength
Conversion to TKA
• Brace = 2• Control = 5
Social factors also influenced these decisions
Bhave 2013
Pre Brace
• LEFS =34• Pain score 5/10• Single limb stance time = 9• Celebrex = BID• Injection every 3 moths• Walking limited to 2 city blocks at a time
Bhave 2013
Bhave 2013
Post Brace (1 year out)
• LEFS =54• Pain score 2/10• Single limb stance time = 19• Celebrex STOPPED• Injection only 1 in last one year• Walking up to I.5 miles
Bhave 2013
Wearing schedule 3 to 4 hours per day
Conclusion – Knee OA Rehabilitation
Gait retraining effects retained without the braceQuad and hams strengtheningImproved foot position w/ gaitReduced rate of TKA in brace groupReduced VAS pain scoresReduced TUG time Significantly delays the progression of knee OA
Bhave 2013
Potential useOsteoarthritis Knee varus or valgusPrehabilitationRehabilitationReduced rate of TKA
Potential prehabiltation market to grow 673% by 2030
Potential worldwide market potential of 60 Million units *(rehabilitation)
Bhave 2013
PrehabilitationRehabilitating the affected leg prior to a TKR to significantly
improve patient outcomes.
Use the OA REHABILITATOR™ 6 – 12 weeks prior to TKR surgery
Strengthen hamstring and quads and normalize gait biomechanics prior to surgery
Accelerates recovery and reduces risks of chronic post TKR issues
Prehabilitation
• Estimated number of TKA’s currently is over 600,000 per year
• Growth in TKA’s projected at 673% by 2030
• Projected TKA’s to 3.48 million procedures by 2030
• Currently approximately 10% of Medicare expenditure is for TKA’s
OA REHABILITATOR™ Summary
• Why simply unload the OA knee when you can rehabilitate and delay the progression of knee OA
• Significant opportunity to redefine the Knee OA Standard of Care to include a rehabilitative bracing option.
• New treatment for the prehabilitation prior to TKA to significantly improve patient outcomes and minimize TKA chronic post operative issues
• Significant growth in TKA’s from now to 2030 provide a bracing prehabilitation opportunity