تقویت راه رفتن با توانبخشی در کودکان با زانوی خمیده: آزمایش کنترل شده تصادفی Rehabilitation improves walking kinematics in children with a knee varus: Randomized controlled trial

1. Introduction Knee osteoarthritis (OA) is one of the most common and important diseases affecting about 10% of the adult population [1]. The distribution of tibiofemoral compressive forces between the medial and lateral compartments could be affected by frontal plane joint position and affect degeneration of biological knee joint tissues [2]. Laboratory and cadaver studies have demonstrated increased medial stresses in knee varus alignment [3], which may result in accelerated articular cartilage degeneration. Therefore, selecting a suitable treatment strategy for individuals with knee malalignment should be a priority. The treatment of varus malalignment of the knee is likely to benefit from an increased understanding of the biomechanical risk factors associated with knee injuries. In total, 13% of children with age 11 years showed knee varus deformity that needed treatment to prevent secondary deformity in adulthood [4]. Previous studies have investigated biomechanical changes during walking in children with genu varus (without knee OA) as compared with healthy controls [5,6]. Varus alignment of the knee in healthy children is associated with abnormally increased internal foot placement and increased internal knee rotation during the stance phase of walking [5]. Bias of muscle activation to knee external rotators and lateral knee joint muscles may decrease knee joint 35 internal rotation [7] and therefore reduce medial knee joint load. 36 However, this was not evaluated from a scientific standpoint. Kean et al. [3] argued that change in quadriceps strength (12-week quadriceps strengthening program) did not predict the change in peak vertical ground reaction force or average rate of loading (changes in quadriceps strength explained 3% of the variance in the change in maximum rate of loading) in individuals with medial knee OA and varus alignment. Another study reported that a quadriceps strengthening protocol had no significant effect on knee adduction moment, considered a main risk factor for OA [8]. However, we have a dearth of information regarding the impact of corrective exercise programs on joint kinematics of the lower extremities in children with genu varus. Further study is 8 needed to assess the effects of different scientific training protocols on biomechanical variables of walking in these children. Although childhood is the appropriate time to implement 51therapeutic interventions such as corrective protocols, unfortu nately, mosttraining programs do notfeature the proper treatment guidelines for children [9]. Among various corrective exercise programs, the corrective exercise continuum (CEC) programming strategy is considered a popular and effective therapy modifying the anatomical alignment of the extremities [9]. The CEC includes 4 primary phases [9] with the aim of releasing tension of overactive neuromyofascial tissues (via self-myofascial release [SMR] tech niques) [10–12], increasing the extensibility of neuromyofascial tissues [13,14], reeducating or increasing the activation of underactive tissues (by isolated strengthening exercises and positional isometric techniques) [9], and finally retraining the