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Original Investigation
May 12, 2020

Effect of Biomechanical Footwear on Knee Pain in People With Knee Osteoarthritis: The BIOTOK Randomized Clinical Trial

Author Affiliations
  • 1Institute for Social and Preventive Medicine, University of Bern, Bern, Switzerland
  • 2Department of Rheumatology, Immunology, and Allergology, Bern University Hospital, Bern, Switzerland
  • 3Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, England
  • 4NIHR Manchester Musculoskeletal Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, England
  • 5Clinical Epidemiology Unit, Boston University, Boston, Massachusetts
  • 6Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
  • 7Department of Chiropractic Medicine, Faculty of Medicine, University of Zurich and Balgrist University Hospital, Zurich, Switzerland
  • 8Clinical Trials Unit, University of Bern, Bern, Switzerland
  • 9Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
  • 10Department for Diagnostic, Interventional, and Pediatric Radiology, Bern University Hospital, Bern, Switzerland
  • 11Centre for Health Sciences Research, School of Health Sciences, University of Salford Manchester, Manchester, England
JAMA. 2020;323(18):1802-1812. doi:10.1001/jama.2020.3565
Key Points

Question  Is an individualized biomechanical footwear therapy effective for reducing knee pain in people with knee osteoarthritis?

Findings  In this randomized clinical trial that included 220 participants with knee pain due to knee osteoarthritis, treatment with an individualized biomechanical footwear therapy compared with control footwear resulted in a lower Western Ontario and McMaster Universities Osteoarthritis Index pain subscore (range, 0-10) after 24 weeks of follow-up (1.3 vs 2.6, respectively), a difference that was statistically significant.

Meaning  Although use of biomechanical footwear compared with control footwear resulted in an improvement in knee pain at 24 weeks of follow-up that was statistically significant, the difference was of uncertain clinical importance, and further research is needed to assess long-term efficacy and safety.

Abstract

Importance  Individually calibrated biomechanical footwear therapy may improve pain and physical function in people with symptomatic knee osteoarthritis, but the benefits of this therapy are unclear.

Objective  To assess the effect of a biomechanical footwear therapy vs control footwear over 24 weeks of follow-up.

Design, Setting, and Participants  Randomized clinical trial conducted at a Swiss university hospital. Participants (N = 220) with symptomatic, radiologically confirmed knee osteoarthritis were recruited between April 20, 2015, and January 10, 2017. The last participant visit occurred on August 15, 2017.

Interventions  Participants were randomized to biomechanical footwear involving shoes with individually adjustable external convex pods attached to the outsole (n = 111) or to control footwear (n = 109) that had visible outsole pods that were not adjustable and did not create a convex walking surface.

Main Outcomes and Measures  The primary outcome was knee pain at 24 weeks of follow-up assessed with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscore standardized to range from 0 (no symptoms) to 10 (extreme symptoms). The secondary outcomes included WOMAC physical function and stiffness subscores and the WOMAC global score, all ranging from 0 (no symptoms) to 10 (extreme symptoms) at 24 weeks of follow-up, and serious adverse events.

Results  Among the 220 randomized participants (mean age, 65.2 years [SD, 9.3 years]; 104 women [47.3%]), 219 received the allocated treatment and 213 (96.8%) completed follow-up. At 24 weeks of follow-up, the mean standardized WOMAC pain subscore improved from 4.3 to 1.3 in the biomechanical footwear group and from 4.0 to 2.6 in the control footwear group (between-group difference in scores at 24 weeks of follow-up, −1.3 [95% CI, −1.8 to −0.9]; P < .001). The results were consistent for WOMAC physical function subscore (between-group difference, −1.1 [95% CI, −1.5 to −0.7]), WOMAC stiffness subscore (between-group difference, −1.4 [95% CI, −1.9 to −0.9]), and WOMAC global score (between-group difference, −1.2 [95% CI, −1.6 to −0.8]) at 24 weeks of follow-up. Three serious adverse events occurred in the biomechanical footwear group compared with 9 in the control footwear group (2.7% vs 8.3%, respectively); none were related to treatment.

Conclusions and Relevance  Among participants with knee pain from osteoarthritis, use of biomechanical footwear compared with control footwear resulted in an improvement in pain at 24 weeks of follow-up that was statistically significant but of uncertain clinical importance. Further research would be needed to assess long-term efficacy and safety, as well as replication, before reaching conclusions about the clinical value of this device.

Trial Registration  ClinicalTrials.gov Identifier: NCT02363712

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