Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Maimonides Inservice

717 views

Published on

  • Be the first to comment

Maimonides Inservice

  1. 1. Open and Closed Kinetic Chain Exercises used in Various Joint Injuries Christina Machado, SPT NYIT Class of 2017
  2. 2. Objectives • Understand the importance of tissue healing • Understand the differences between OKC/CKC • Current evidence that addresses the two forms of exercises (LE/UE) • General Rehab ‘protocols’ • Warning signs to take a step back • Conclusion
  3. 3. RESPECT Tissue Healing • Inflammatory Response Phase (1-6 days) – Tx: Modalities to reduce circulation, pain, enzyme activity rate and TherEx that do NOT stress the injured area – Goal: Prevent disruption of new tissue • Fibroplastic Repair Phase (3-20 days) – Tx: Modalities to increase circulation, enzyme activity rate, collagen deposition and TherEx to improve neuromuscular control – Goal: Prevent muscle atrophy & joint deterioration of injured area • Maturation-Remodeling Phase (Day 9- 2 years) – Tx: Modalities to modulate balance of collagen deposition/resorption to improve collagen alignment and TherEx that is sport/functional specific – Goal: optimize tissue function to return to PLOF • PMH is VITAL: contraindications/precautions to the modalities Haff G and Triplett T. Essentials of Strength and Conditioning. 4th ed. 2015. Cameron M. Physical Agents in Rehabilitation: From Research to Practice. 4th ed.
  4. 4. Definitions OPEN KINETIC CHAIN • Exercise that uses of a combination of successively arranged joints, which terminal joint is FREE to move • Allows for greater concentration on isolated joint/muscle movement • Ex: seated knee extension CLOSED KINETIC CHAIN • Exercise, which the terminal joint meets considerable resistance that prohibits or restrains free ROM as the distal joint is STATIONARY • Ex: squat/push-up
  5. 5. Advantages & Disadvantages Ellenbecker TS, Davies GJ. Closed kinetic chain exercises. A comprehensive guide to multiple-joint exercises. J Chiropr Med 2002;1(4):200.
  6. 6. Common LE Injuries – I. Post Operative Procedure – II. Overuse/Arthritis/Tendinopathy Injuries • Hip – THA – OA • Knee – TKA – ACL Reconstruction/Repair – Mensicus Injury – MCL Tear – Patellofemoral syndrome • Ankle – Achilles rupture – Fracture
  7. 7. HIP I: THA & OA THA • Surgeon precautions to prevent dislocation • WB status • Progressive strength focusing on abductor mm strength • Gait training • CKC • OKC OA • Decrease pain • Maybe offer AD • CKC • OKC Goal: restore ambulation & ADLs Assess leg length discrepancies
  8. 8. Hip II: ITB Syndrome • Weak muscles in the trunk and hip • Hip flexor tightness and glut medius weakness • Tightness of piriformis • CKC • OKC
  9. 9. Knee I: TKA • Mobilization, static strength, dynamic strength, and stabilization – Patella mobility, knee extension ROM, quad strength • Goals for D/C – 120 degrees knee flexion – QI 70% – Reciprocal stair negotiation – Unlimited walking distance • CKC • OKC
  10. 10. Knee II: ACL Reconstruction/Repair • Weeks 1-3 – Normalized gait/stair negotiation by week 2-3 – A/PROM 0-90 degrees by week 1 – Quad set with superior glide – Effusion control – CKC 0-60 degrees • Weeks 3-8 – Full knee ROM – QI of 80% – OKC: Start 90-45 degrees • Weeks 9- 12 – CKC: Full range squat – OKC: 90-10 degrees – Initiate running program • Week 13+ – Plyometric training – Agility progression Focus on Quad strength early*
  11. 11. Types of Grafts
  12. 12. Knee III: Meniscus Repair • Goal: Minimize stress – WB limitation (based on surgeon) – 0-90 degrees x 4 weeks – No loaded flexion or isolated hamstrings until weeks 4-6 – CKC then OKC • Time frame variables: – Size of tear, location of tear, tissue quality, activity level, specific procedure
  13. 13. Knee IV: MCL Tear/Repair • Depends on the grade of the tear • Acute Management: Adams D, Logerstedt DS, Hunter-Giordano A, Axe MJ, Snyder-Mackler L. Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression. JOSPT. 2012;42(7):601-614. Which of these exercises are appropriate at the early stages of MCL Rehab?
  14. 14. Knee IV: MCL Tear/Repair • Restorative to Advanced Phase: – Continue to address the kinetic chain and NM control – Exercise progression: sagittal plane  frontal plane – Leg press/partial squats – Balance/Perturbation • If you implement side stepping… – Plyos/Agility training
  15. 15. Knee V: Patellofemoral Syndrome • Patellar instability – Bracing/Taping – Dynamic stability of kinetic chain • Soft tissue lesions – Limit painful activities – Restore biomechanics • Overuse syndromes – Decrease tendon compression with rest – Progressive quad/patella loading • CKC OKC
  16. 16. “I have pain right here!”
  17. 17. Ankle I: Achilles Rupture • Early AROM but NO Achilles stretching! • Progressive tendon loading • Heel raise progression by week 8 • DF within 5 degrees of CL side • *Proprioceptive deficits may persist up to 6 months * Weber AJSM 2003
  18. 18. Ankle II: Fracture • Ottowa Ankle and Foot Rules • NWB for 4 weeks to allow for wound healing & WBAT after 4 weeks • ROM early even with brace/cast to restore DF • Incline walking by 1% • PF strength is a good predictor of stair climbing/walking • Risk of OA • CKC • OKC? Weber AJSM 2003
  19. 19. Common UE Injuries • I. Post Operative Procedure • II. Overuse/Tendinopathy • Shoulder – RTC tear – RTC tendinopathy – Labral tear • Elbow – Medial/Lateral epicondylitis • Wrist/Hand – Fracture
  20. 20. Shoulder I: RTC Repair • Mostly supraspinatus repair • Size of tear impacts treatment • Weeks 0-6 weeks – Pt education (lifting, sleeping, pain control. raising arm 90 – PROM shoulder in scap plane, AROM elbow wrist/hand – CKC • Weeks 6-8 – Progress full ROM, hor AD, extension, IR – Emphasize scapulohumeral rhythm – Nueromuscular control – CKC • Weeks 8-16 – Normalize strength and endurance – Functional activities – CKC, OKC • Weeks 16- 6 months – Return to sport/work – Injury prevention education – CKC, OKC Subscapularis: No AROM IR >4 wks No IR strengthening >6wks
  21. 21. Treatment of Non-traumatic RC tears • “Results suggest that at one-year follow-up, operative treatment is no better than conservative treatment with regard to non-traumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this [RTC tear] condition” Kukkonen J1, et al. Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. Bone Joint J. 2014 Jan;96-B(1):75-81. doi: 10.1302/0301-620X.96B1.32168
  22. 22. Shoulder II: RTC Tendinopathy • Reactivity Stage – Decrease pain/reactivity – Rest – Submax isometrics (45 sec) – Scapulohumeral rhythm – Restore posterior shoulder ROM – CKC, OKC • Degeneration Stage – Progressive RTC loading – CKC, OKC
  23. 23. Elbow I: Medial/Lateral Epicondylitis • Rehab: pain management with anti-inflammatory med, ultrasound, phonophoresis, iontophoresis, laser, E-stim • Cyriax: cross friction tissue massage • Mill’s manipulation • Ther-Ex: static stretching ECRB (30-45 sec. hold, 3x, 30 sec. rest) then eccentric strengthening with NO weight. Once patient has minor discomfort/pain, add free weights based on pt’s 10RM. • CKC, OKC • What above above and below the elbow in terms of ther-ex? Viswas R. Comparison of Effectiveness of Supervised Exercise Program and Cyriax Physiotherapy in Patient with Tennis Elbow. 2012.
  24. 24. Wrist/Hand I: Fracture • Management plan: – modalities, splinting, tissue mobilizations • OKC, CKC • *Burning in cast • Hand specialist
  25. 25. General UE Protocol
  26. 26. Core/Trunk Stability • McKenzie Method • Correcting lateral shift • Yoga, Pilates
  27. 27. The Tricky Neck • STRETCH –Levator scapula –Upper trapezius –Chin tucks
  28. 28. How to Judge if We are Doing Too Much?
  29. 29. Conclusion • Respect the tissue healing process – Too much, too soon= no bueno • Assess patient status each day • Treat the symptoms not just the diagnoses • Isometrics  Isotonics  Plyometrics – Every patient is different • Be as functional and sport-specific as possible • Remember we are one kinetic chain
  30. 30. References • Haff G and Triplett T. Essentials of Strength and Conditioning. 4th ed. 2015. • Cameron M. Physical Agents in Rehabilitation: From Research to Practice. 4th ed. • Ellenbecker TS, Davies GJ. Closed kinetic chain exercises. A comprehensive guide to multiple-joint exercises. J Chiropr Med 2002;1(4):200. • http://www.running-physio.com. Accessed November 26, 2016. • Zhang F, Wang J, Wang F. Comparison of the Clinical Effects of Open and Closed Chain Exercises after Medial Patellofemoral Ligament Reconstruction. Journal of Physical Therapy Science. 2014;26(10):1557-1560. doi:10.1589/jpts.26.1557. • Kukkonen J1, et al. Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. Bone Joint J. 2014 Jan;96-B(1):75-81. doi: 10.1302/0301-620X.96B1.32168 • Viswas R. Comparison of Effectiveness of Supervised Exercise Program and Cyriax Physiotherapy in Patient with Tennis Elbow. 2012. • Hoogvliet, P. ,Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review, (Ann Rehabil Med. 2012 Oct).., geraadpleegd op 2 mei 2014, http://www.ncbi.nlm.nih.gov/pubmed/23709519 • Greenberg, Eric. Common LE/UE Injuries. New York Institute of Technology. Accessed November 2016. • Adams D, Logerstedt DS, Hunter-Giordano A, Axe MJ, Snyder-Mackler L. Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression. JOSPT. 2012;42(7):601-614.

×