Uncovering the treatment effects for the conservative management of the knee
Submitting InstitutionUniversity of Central Lancashire
Unit of AssessmentSport and Exercise Sciences, Leisure and Tourism
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Clinical Sciences
Summary of the impact
The key driver for this research is to provide clinicians with robust
tools that they can use to evaluate, treat and therefore improve the
clinical outcome in their patients. Our research has assisted the
development of the evidence base of many clinical treatments and
assessment tools. This has led to the design and development of new
rehabilitation products and medical devices in partnership with both large
companies and small to medium sized enterprises. The core impact of this
work has been improvements in patient care and quality of life by
improving the efficacy and effectiveness in these areas with a particular
focus on the advancement of conservative management and lower limb
Since 2004 Professor Jim Richards and Professor James Selfe have
contributed to the clinical understanding of movement control and the
effect of treatments of unstable and painful knee joints. This work has
shown the biomechanical and clinical effectiveness of several different
conservative and surgical managements and the efficacy of rehabilitation
devices and led to the development of new outcome measures.
Within knee osteoarthritis the most common treatments are surgical to
realign the knee; from 2005 onwards research at the University of Central
Lancashire has shown that the amount of physical correction possible with
knee bracing is similar to that of some surgery procedures with similar
associated reductions in pain and improvements in function. In addition
our work on patellofemoral pain was the first to determine the
biomechanical effects on the three dimensional movement and control of the
knee when using taping and bracing in 2008. This work highlighted
improvements in the knee control, and in collaboration with colleagues at
the University of Manchester (Dr Mike Callaghan & Prof Jackie Oldham)
we have established that patellofemoral patients demonstrate clinically
important proprioceptive deficits (2008), therefore identifying the
possible proprioception and mechano-reception mechanism through which
these treatments work. This work has changed clinical practice with the
assessment and treatment of proprioception now routine in these patients.
In 2011 clinical studies, derived from these early "proof of principle"
studies, further explored the improvements in control and mapped to these
improvements in self-reported pain and function in patellofemoral pain
Biomechanical and clinical data were collected to determine the
mechanical efficacy and clinical effectiveness on a range of products for
a range of musculoskeletal problems including Knee Osteoarthritis,
Patellofemoral Pain and lower limb rehabilitation. One example of this
came from our research on the exploration of the biomechanics of squatting
tasks and their implications for lower limb rehabilitation. Single-limb
squats on a decline angle have been suggested as a rehabilitative
intervention to target the knee extensors, however very little empirical
research exists documenting the optimum angle of decline. Our work
explored the use of squatting using decline boards and aimed to determine
the optimum angle and the most effective regimen. Our paper, published in
the Journal of Athletic Training (Richards et al, 2008), was the first to
determine the biomechanics of such exercises, and suggests the optimum
angles for different rehabilitation purposes. This work led to the
development of a new rehabilitation device, the "Rehab Angel", which
allows the decline angle to be adjusted based on our findings. This device
is now commercially available and is being used in many rehabilitation
centres and professional sports clubs in a variety of knee and other lower
Our research has also supported the development and product testing of
many new devices that aim to reduce pain and improve function. This has
assisted large companies from the USA through to small/medium-sized
enterprises (SMEs) in the UK. Between 2007 and 2009 20 UK SMEs were
assisted in product testing and development. This led to 20 new jobs being
created and an increase in sales of £750k and £1.1 m sales safeguarded
over this time period when audited by the European Regional Development
Agency. This work led to several new products making it to market that
have shown successful application in the clinical management of
References to the research
1. Jones RK, Nester CJ, Richards JD, Kim WY, Johnson DS, Jari S, Laxton
P, Tyson SF (2013). A comparison of the biomechanical effects of valgus
knee braces and lateral wedged insoles in patients with knee
osteoarthritis. Gait Posture,37(3):368-72.
2. Selfe J, Thewlis D, Hill S, Whitaker J, Sutton C, Richards J, (2011).
A Clinical Study of the Biomechanics of Step Descent Using Different
Treatment Modalities for Patellofemoral Pain. Gait &
3. Selfe J, Richards J, Thewlis D, Kilmurray S (2008). The biomechanics
of step descent under different treatment modalities used in
patellofemoral pain. Gait & Posture,27(2):258-263.
4. Callaghan M, Selfe J Henry A, Oldham J (2008) Effects of patellar
taping on knee joint proprioception in patients with patellofemoral pain
syndrome. Manual Therapy,13:192-199.
5. Richards J, Thewlis D, Selfe J, Cunningham A, Hayes C (2008). The
biomechanics of single limb squats at different decline angles. Journal of
6. Richards J, Sanchez-Ballester J, Jones RK, Darke N (2005). A
comparison of the effectiveness of two knee braces in the treatment of
subjects with medial compartment osteoarthritis of the knee during
walking. Journal of Bone and Joint Surgery,87-B(7):937-939.
Selected research grant support
• Richards J and Selfe J. ERDF (European Regional Development Fund),
£156,000. Biomechanical Testing Facilities in the North West. This project
supported independent product testing for 20 Small/Medium Enterprises,
• Richards J and Selfe J. R&D funded by DJO global, £119,000.
Independent research of products in the management of musculoskeletal
problems and the development of new devices to reduce pain and improve
• Richards J and Selfe J. TrustTECH (NHS Innovation) Pathfinder funding,
£25,000. Testing of a new lower cost rehabilitation device, 2010.
• Richards J and Selfe J. TSB, Knowledge Transfer Partnership, £126,000.
To introduce advanced biomechanics technologies to evaluate new designs of
sports footwear and protective equipment used in sports leading to
sustainable production of new products, 2011.
• Richards J and Selfe J. PhD studentship for 3 years DELSYS Inc.,
£53,000. The advanced use of electromyography in the assessment of
musculoskeletal conditions, 2011.
• Selfe J, Callaghan M, Witwrouw E, Richards J, Dey M, Sutton C,
Baltzopoulos B, Stokes M, Dixon J, Martin D, Polman R, Masters R, Hogarth
R, Ritchie E, Arden N, Turner D. Arthritis Research UK (ARUK), £30,000.
Targeted Intervention in Patellofemoral Pain Syndrome (TIPPS). Explores
proximal, distal or local factors in Patellofemoral Pain Syndrome, 2011.
• Richards J, Selfe J, Chohan A. (Rophi Ltd.) Commercial funding for
independent research, £30,000. To determine the effectiveness of a cushion
designed to reduce back pain over standard clinical care, 2012.
• Richards J, Selfe J, Chohan A. SPARK Ventures £58,000. To determine the
effectiveness of a passive gravity assisted spinal traction device, 2013.
Details of the impact
The team's research into Osteoarthritis was first reported in a paper
published in The Knee in 2004 that led to subsequent development
of "proofs of concepts" through to our current work. This led to the
development of new methods of movement analysis and biomechanical
modelling techniques that we are now using in our current work. With a
mission to improve the quality of life of patients treated by Allied
Health Professionals, our work pursues this goal by performing basic and
applied research, and by developing new techniques in the assessment of
musculoskeletal and neurological conditions. The team also advises medical
staff on methods of conservative management of knee pain through invited
talks to clinical groups internationally.
The applied clinical nature of the work is firmly rooted in the every-day
world of clinical practice. Although some of the tools used in this
research are very advanced and only available in specialist research units
the focus has always to be to produce results that are clinically useful.
When considering clinical utility the aim is to provide clinicians with
evidence about patient management or new tools to assist in patient
management. By helping to optimise clinical practice the health and
well-being of patients attending for conservative management of
musculoskeletal conditions is improved.
The findings of the research team suggest that there are many benefits in
terms of joint stability and control that had gone previously undetected
which had led many clinicians to doubt the therapeutic benefit of some
conservative management. The research team at the University of Central
Lancashire has now developed a program of work to systematically assess
the effectiveness of different levels of conservative and surgical
management. The effect of surgical management of knee osteoarthritis using
total knee arthroplasty was initially tested by Dr Dominic Thewlis (a
former PhD student and now a senior lecturer of University of South
Australia). This has now been followed up by considering a spectrum of
conservative and surgical managements to give comparative guidance of what
biomechanical and clinical outcomes clinicians could expect.
Dissemination of these research findings has been to academic and
professional conferences but often, more importantly, through specific CPD
activities which are particularly effective at influencing clinical
practice. Some of this research has been translated into other languages
including Persian, Flemish and Chinese, and is cited by other
international research groups. It appears that a wide international
audience of clinicians and academics have been influenced.
From this research evidence base key members of staff have delivered
expert advice to clinical groups in Europe (1995 onwards), USA (2007
onwards), China (2010 onwards) and South East Asia (2011 onwards), South
America (2012 onwards), and receive invitations to speak at conferences
worldwide on a regular basis. This has included over 150 invited talks to
clinical groups, professional sports clubs, commercial companies, academic
groups in over 20 different countries between 2008 and 2013. This
dissemination has helped the acceptance of conservative treatment before
surgical management in Europe and the US and is now being used throughout
China and South East Asia, which has improved the clinical options of
Allied Health Professionals and Orthopaedic Surgeons. This has led to more
than 1,000 patients worldwide now receiving conservative management for
Knee Osteoarthritis and Patellofemoral pain since 2010 as a direct result
of this work who would not of otherwise been treated conservatively
(source DJO Global inc.). Since 2007 the research team have been directly
involved in prototype development and testing of new knee braces and other
conservative managements for many companies including DJO Inc., Vista
California, USA with the focus being on maximising patient benefits.
The reach of our work can be further evidenced by the authoring of
relevant books and being invited to contribute book chapters including;
Clinical Case Studies in Physiotherapy (2008), Biomechanics in Clinic and
Research (2008), Biomechanics in Clinic and Research: Chinese edition
(2011) and the new edition of Whittles Gait Analysis (2012), Tidy's
Physiotherapy 13th, 14th and 15th editions (2006 -
2012) and Mercer's Textbook of Orthopaedics and Trauma (2012). As a result
of these academic contributions patients with complex musculoskeletal and
neurological disorders are regularly referred from around the UK by GPs,
Orthopaedic surgeons and Allied Health Professions for advanced
biomechanical assessments to assist clinical decision making in their
Sources to corroborate the impact
CONTACT 1: Crystal Chan, Sales and Marketing Manager, DJO (DJO
CONTACT 2: Darren Marcangelo, Commercial Director, Harrison Spinks
CONTACT 3: Martin Levermore, Chief Executive, MDTi (UK).
CONTACT 4: Simon Skirrow, Former Vice-President, Adidas.
CONTACT 5: Nicola Maffulli, Professor of Trauma and Orthopaedics
& Consultant Orthopaedic Surgeon, Queen Mary University London.
6. Supporting a UK Success Story: The impact of university
research and sport development. Rehabilitation Equipment. Second
Impact Report, Universities UK (UUK).
7. ERDF North West Of England Objective 2 Programme 2000-2006:
APP Project Ref No 1.4-16. 17 UK SMEs were assisted in product testing and
development 20 new jobs created and an increase in sales of £750k and £1.1
m sales safeguarded. Neil Clatworthy, Northwest Universities European Unit
Ltd, Albert House, 17 Bloom Street, Manchester. firstname.lastname@example.org
8. Chartered Society of Physiotherapy Citation (2008).
Reproduced in full in Frontline, The Chartered Society of Physiotherapy
Magazine (2009) 4 February Vol. 15 No 3 p14-15
9. Development of consensus document: 1st International
Patellofemoral Research Retreat, Baltimore, USA. (Davies I &
Powers C Patellofemoral Pain: Proximal, Distal, and Local Factors,
JOSPT;40(3): A1-A48. doi:10.2519/jospt.2010.0302)
10. Further development of consensus document: 2nd
International Patellofemoral Research Retreat, Ghent, Belgium.
(Powers C et al, 2012 Patellofemoral Pain: Proximal, Distal, and Local
Factors, JOSPT; 42(6): A1-A20. doi:10.2519/jospt.2012.0301).