***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective Mechanical factors , in particular increased medial knee joint load , are believed to be important in the structural progression of knee osteoarthritis . This study evaluated the relationship of medial knee load during walking to indices of structural disease progression , measured on MRI , in people with medial knee osteoarthritis . Methods A longitudinal cohort design utilising a subset of participants ( n=144 , 72 % ) enrolled in a r and omised controlled trial of lateral wedge insoles was employed .  Medial knee load parameters including the peak knee adduction moment ( KAM ) and the KAM impulse  were measured at baseline using three-dimensional gait analysis during walking . MRI at baseline and at 12 months was used to assess structural indices . Multiple regression with adjustment for covariates assessed the relationship between medial knee load parameters and the annual change in medial tibial cartilage volume . Binary logistic regression was used for the dichotomous variables of progression of medial tibiofemoral cartilage defects and bone marrow lesions ( BML ) . Results A higher KAM impulse , but not peak KAM , at baseline was independently associated with greater loss of medial tibial cartilage volume over 12 months ( β=29.9 , 95 % CI 6.3 to 53.5 , p=0.01 ) . No significant relationships were seen between medial knee load parameters and the progression of medial tibiofemoral cartilage defects or BML . Conclusion This study suggests knee loading , in particular the KAM impulse , may be a risk factor for loss of medial tibial cartilage volume . As knee load is modifiable , load-modifying treatments may potentially slow disease progression Background There is controversial evidence regarding whether foot orthoses or knee braces improve pain and function or correct malalignment in selected patients with osteoarthritis ( OA ) of the medial knee compartment . However , insoles are safe and less costly than knee bracing if they relieve pain or improve function . Questions / purpose sWe therefore asked whether laterally wedged insoles or valgus braces would reduce pain , enhance functional scores , and correct varus malalignment comparable to knee braces . Patients and Methods We prospect ively enrolled 91 patients with symptomatic medial compartmental knee OA and r and omized to treatment with either a  10-mm laterally wedged insole  ( index group , n = 45 ) or a valgus brace ( control group , n = 46 ) . All patients were assessed at 6 months . The primary outcome measure was pain severity as measured on a visual analog scale . Secondary outcome measures were knee function score using WOMAC and correction of varus alignment on AP whole-leg radiographs taken with the patient in the st and ing position . Additionally , we compared the percentage of responders according to the OMERACT-OARSI criteria for both groups . Results We observed no differences in pain or WOMAC scores between the two groups . Neither device achieved correction of knee varus malalignment in the frontal plane . According to the OMERACT-OARSI criteria , 17 % of our patients responded to the allocated intervention . Patients in the insole group complied better with their intervention . Although subgroup analysis results should be translated into practice cautiously , we observed a slightly higher percentage of responders for the insole compared with bracing for patients with mild medial OA . Conclusions Our data suggest a laterally wedged insole may be an alternative to valgus bracing for noninvasively treating symptoms of medial knee OA.Level of Evidence Level I , therapeutic study . See the Guidelines for Authors for a complete description of level of evidence We examined if a subject-specific amount of lateral wedge added to a foot orthosis could alter knee mechanics to potentially reduce the progression of knee osteoarthritis in patients with medial knee osteoarthritis . Twenty individuals with medial knee osteoarthritis ( > /=2 Kellgren Lawrence grade ) were prescribed a custom laterally wedged foot orthotic device . The prescribed wedge amount was the minimal wedge amount that provided the maximum amount of pain reduction during a lateral step-down test . Following an accommodation period , all subjects returned to the laboratory for a gait analysis . Knee mechanics were collected as the subjects walked at an intentional walking speed . Walking in the laterally wedged orthotic device significantly reduced the peak adduction moment during early stance ( p < 0.01 ) compared to the nonwedged device . Similarly , the wedged orthotic device significantly reduced the knee adduction excursion from heel strike to peak adduction ( p < 0.01 ) compared to the nonwedged device . No differences in the peak adduction moment during propulsion or peak adduction during stance were observed between the orthotic conditions . A subject-specific laterally wedged orthotic device was able to reduce the peak knee adduction moment during early stance , which is thought to be associated with the progression of knee osteoarthritis . Previous studies on this device have reported issues associated with foot discomfort when using wedge amounts > 7 degrees ; however , no such issues were reported in this study . Therefore , providing a custom laterally wedged orthotic device may potentially increase compliance while still potentially reducing disease progression OBJECTIVE To compare the effectiveness of transcutaneous electrical nerve stimulation ( TENS ) , interferential currents ( IFCs ) , and shortwave diathermy ( SWD ) against each other and sham intervention with exercise training and education as a multimodal package . DESIGN A double-blind , r and omized , controlled , multicenter trial . SETTING Departments of physical medicine and rehabilitation in 4 centers . PARTICIPANTS Patients ( N=203 ) with knee osteoarthritis ( OA ) . INTERVENTIONS The patients were r and omized by the principal center into the following 6 treatment groups : TENS sham , TENS , IFCs sham , IFCs , SWD sham , and SWD . All interventions were applied 5 times a week for 3 weeks . In addition , exercises and an education program were given . The exercises were carried out as part of a home-based training program after 3 weeks ' supervised group exercise . MAIN OUTCOME MEASURES Primary outcome was a visual analog scale ( 0 - 100 mm ) to assess knee pain . Other outcome measures were time to walk a distance of 15 m , range of motion , Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) , Nottingham Health Profile , and paracetamol intake ( in grams ) . RESULTS We found a significant decrease in all assessment parameters ( P<.05 ) , without a significant difference among the groups except WOMAC stiffness score and range of motion . However , the intake of paracetamol was significantly lower in each treatment group when compared with the sham groups at 3 months ( P<.05 ) . Also , the patients in the IFCs group used a lower amount of paracetamol  at 6 months ( P<.05 ) in comparison with the IFCs sham group . CONCLUSIONS Although all groups showed significant improvements , we can suggest that the use of physical therapy agents in knee OA provided additional benefits in improving pain because paracetamol intake was significantly higher in the patients who were treated with 3 sham interventions in addition to exercise and education Background : Knee joint osteoarthritis ( OA ) is one of the most incapacitating diseases affecting older population , which is associated with pain and functional limitation . Various kinds of conservative treatment have been used to decrease knee pain and to improve the quality of life of the subjects suffering from this disease . There are discrepancies in the clinical effects reported for the use of lateral wedge insole in spite of being used as one of the first conservative mechanical treatments for patients with medial compartments of knee OA . Methods : A total of 36 subjects with medial knee compartment OA were recruited in this research project . Subjects were r and omized into two groups to receive 3- and 7-mm lateral wedge insoles based on the date of birth of the participants . Some parameters such as severity of knee pain , Tibiofemoral angle ( TFA ) , severity of OA , and quality of life were selected in this research project . Results : The use of both 3-mm and 7-mm lateral wedge insole improves the quality of life and decreases knee joint pain . However , the effect of 7 mm lateral wedge insole was more than that of 3 mm . Conclusion : Using lateral wedge insole is a simple , inexpensive therapy for decreasing pain and improving quality of life ; however , most research must be carried out to find the effects of lateral wedge on severity of knee joint OA and aligning TFA Background The present study tests whether a combined treatment of acupuncture and transcutaneous electrical nerve stimulation ( TENS ) is more effective than acupuncture or TENS alone for treating knee osteoarthritis ( OA ) . Methods Thirty-two patients with knee OA were r and omly allocated to four groups . The acupuncture group ( ACP ) received only acupuncture treatment at selected acupoints for knee pain ; the TENS group ( TENS ) received only TENS treatment at pain areas ; the acupuncture and TENS group ( A&T ) received both acupuncture and TENS treatments ; the control group ( CT ) received topical poultice ( only when necessary ) . Each group received specific weekly treatment five times during the study . Outcome measures were pain intensity in a visual analogue scale ( VAS ) and knee function in terms of the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) . Results The ACP , TENS and A&T groups reported lower VAS and WOMAC scores than the control group . Significant reduction in pain intensity ( P = 0.039 ) and significant improvement in knee function ( P = 0.008 ) were shown in the A&T group . Conclusion Combined acupuncture and TENS treatment was effective in pain relief and knee function improvement for the sample d patients suffering from knee OA Pneumatic unloader bracing with extension assists have been proposed as a non-operative modality that may delay the need for knee surgery by reducing pain and improving function . This prospect i ve , r and omized trial evaluated 52 patients who had knee osteoarthritis for changes in : ( 1 ) muscle strength ; ( 2 ) objective functional improvements ; ( 3 ) ; subjective functional improvements ; ( 4 ) pain ; ( 5 ) quality of life ; and ( 6 ) conversion to total knee arthroplasty ( TKA ) compared to st and ard of care . Patient outcomes were evaluated at a minimum 3 months . Braced patient 's demonstrated significant improvements in muscle strength , several functional tests , and patient reported outcomes when compared to the matched cohort . These results are encouraging and suggest that this device may represent a promising alternative to st and ard treatment methods for knee osteoarthritis The aim of this study was to evaluate the effects of electrical stimulation program on pain , disability , and quadriceps strength in the patients with knee osteoarthritis . Fifty women diagnosed as knee osteoarthritis were r and omized into two groups as electrical stimulation and biofeedback-assisted isometric exercises . Both of the programs were performed 5 days a week , for a duration of 4 weeks . Outcome measures for pain were visual analogue scale pain score and Western Ontario McMaster osteoarthritis index ( WOMAC ) pain score . Disability and stiffness were assessed with WOMAC physical function and stiffness score . One repetition maximum ( RM ) and 10 RM were used for measuring quadriceps strength . In addition , 50 m walking time and 10 steps stairs climbing up-down time were evaluated . Both groups showed significant improvements in pain , physical function , and stiffness scores after the therapy . There were statistically significant improvements in 50 m walking time and 10 steps stairs climbing up-down time and 1 RM and 10 RM values indicating the improvement in muscle strength . In addition , there were no significant differences between the groups after the therapy . We conclude that electrical stimulation treatment was as effective as exercise in knee osteoarthritis and electrical stimulation treatment can be suggested especially for the patients who have difficulty in or contraindications to perform an exercise program This study tested the effectiveness of episodic transcutaneous electrical nerve stimulation ( TENS ) as a supplement to pharmacologic analgesia on pain with movement and at rest after abdominal surgery and evaluated whether its use during walking and vital capacity maneuvers enhances performance of these activities . TENS , with a modulated frequency , intensity as high as the subject could tolerate , and electrodes placed on either side and parallel to the incision , was compared to placebo TENS and pharmacologic analgesia alone ( control ) by using a crossover design . Self-report of pain intensity , walking function , and vital capacity were assessed on 33 subjects .  TENS result ed in significantly less pain than the control during both walking ( P < .5 ) and vital capacity activities ( P < .1 ) and significantly less pain than placebo TENS during vital capacity ( P < .01 ) . TENS also produced significantly better gait speeds than the control ( P < .05 ) and greater gait distances ( P < .01 ) than the control and placebo TENS .  Vital capacity and pain intensity at rest were not significantly different among the 3 treatments . These results suggest TENS reduces pain intensity during walking and deep breathing and increases walking function postoperatively when used as a supplement to pharmacologic analgesia . The lack of effect on pain at rest supports the hypothesis that TENS works through reducing hyperalgesia The purpose of the study was to examine the clinical efficacy of individually prescribed laterally wedged orthoses and walking shoes in the treatment of medial knee osteoarthritis using a prospect i ve , single-blind , block-r and omized controlled design . Sixty-six subjects ( 29 males , 37 females , mean age 62.4 years , mean BMI 33.0 kg/m(2 ) ) were  block-r and omized to a lateral wedge ( treatment ) or neutral ( control ) orthotic group . Both groups were issued a 
    Output:
    
Overall , all four non-operative modalities of treatment were found to have a significant effect on the reduction of pain in OA of the knee .
This study shows that non-operative physical modalities of treatment are of benefit when treating OA of the knee .