1. Open and Closed Kinetic Chain Exercises
used in Various Joint Injuries
Christina Machado, SPT NYIT Class of
2017
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. 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.
5. 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
6. Advantages & Disadvantages
Ellenbecker TS, Davies GJ. Closed kinetic chain exercises. A comprehensive guide
to multiple-joint exercises. J Chiropr Med 2002;1(4):200.
7. 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
8. 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
9. Hip II: ITB Syndrome
• Weak muscles in the trunk and hip
• Hip flexor tightness and glut medius weakness
• Tightness of piriformis
• CKC
• OKC
14. 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
15. 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?
16. 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
20. 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
21. 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
22. Common UE Injuries
• I. Post Operative Procedure
• II. Overuse/Tendinopathy
• Shoulder
– RTC tear
– RTC tendinopathy
– Labral tear
• Elbow
– Medial/Lateral epicondylitis
• Wrist/Hand
– Fracture
23. 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
24. 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
26. 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.
32. 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
33. 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.
Editor's Notes
Stages of Healing
1st Phase: Inflammation: 1-6 days
Cells that remove debris & stop bleeding enter area
Heat, pain, redness, swelling, decrease function
Quicker resoltion of this phase speeds recovery
Physical agents assist in this phase as they reduce circulation, pain, enzyme activity rate, control motion, promote progress to next phase
Cold- decrease histamines and swelling
Compression-
E stim
Laser (no US)
2nd phase: Proliferation: 3-20 days
Collagen is deposited in the damaged area to replace damaged tissue
Myofibroblasts contract to accelerate closure
Epithelial cells migrate to resurface wound
Physical Agents assist in the phase by increasing circulation, enzyme activity rate, collagen deposition, promote progress to next phase
Heat- increase histamines and swelling
E stim
Laster
Mechanical CPM
3rd phase: Maturation: starts within 9 days, lasts up to 2 years
Deposition & resorption of collagen
New tissue changes shape & structure to resemble original for optimal functional recovery
Strength of tissue usually increases while size dectreases
Physical Agents assist by modulating balance of collagen deposition/resorption and improves alignment of new collagen fibers
Heat- superficial & deep
Cold- post exercise (DOMS)
ES- pain control, strengthening
Mechanical- US, CPM, compression
Hydro-WP (whirlpool)
Laser
Shows the importance of the tissue healing process
We must respect what is going on inside since we cannot see it and if we push the treatment, it may backlash
Tendons have the capacity to heal 5-7 weeks
Articular cartilage repair can take up to 2 years to fully heal
Have to assess each patient’s status each day
Now done with the background let’s direct our attention to the main topic
So with this laid out, what are the advantages and disadvantages of the two forms of exercises?
CKC: multiple joints working, so whole body is being activated BUT if someone had an ortho surgery, let’s say ACL, what’s weakest (hamstring and quad) so isnt OKC better to isolate the muscle that is weak? There is actually research now that supports OKC early into rehab post surgery since, not due to hypertrophy of muscles, but basically recruiting the motor units of the muscle. This will help increase lost strength after the trauma from the sx for example.
But let’s consider age difference. What’s better?
Can go both ways
CKC like we said focuses on whole body conditioning in a sense and it’s more FUNCTIONAL (like walking or stair climbing) however, if we wanted to challenge elderly with more weight, it’s been proven that their ability to use free weight exercises or controlling squats may be a little more dentrimental since they are not able to perform the exercises correctly so with that, OKC may be more effective. BUT then if they have OA,OKC will increase those shearing forces, …. Another thing to consider
What about the compressive forces…
No equipment needed for CKC which is a plus
What about athletes that are looking to return to play? BOTH, conjuction
Plyos must be added within the program
I’m not going to say what you should use, it’s based on your disgression based on the patient’s diagnoes and PMH
Now we’re going to jump into common diagnoses we see here (more so ortho related)
I sort of laid out a progression in how to treat these patients, but obviously, every patient is different and presents differently so treatment will be amended
Then I will be asking y’all what is appropriate in terms of OKC and CKC
With total joint replacements, these ppl will return to PLOF fairly well since the joint that was causing them the problem if replaced
Soft tissue and mobs to increase ROM but then what’s next
CKC
OKC
OA: always tricky, don’t want to overload the joint, but primary goal is to decrease their pain and strenghen adjacent joints
Our patients do not stretch enough or at all, keeping muscles as flexible as possible will decrease pain
However, not just stretching, but strengthening the small muscles directly influence stabilization
Stretches in standing and sitting
Standing with leg AB and posteiror leg lifts to isolate the glut med and piriformis
Standing with leg 90 90 ER press leg against the wall
Squat with rotations
OKC: we don’t rly have leg ab/ad machine but those can be used later on
Patella gives the knee a mechanical advantage so it’s important to mob the patella and to teach the patient how to mob the patella
QI is measured with a dynanometer but functional activities such as maintaining squat posiiton for 0-30 seconds can suffice
Quads and hip function
Calf strength, TKE ** to work on that limited knee extension
OKC around > 12 weeks
If these patients have their own gym, leg press would be appropriate
Obviously protocols will vary depending on which graft is used: hamstring vs patella graft, depending on which one is used, exercises must be amended
Autologous BPTB (bone patella bone)
Risk of PFP with resistive exercises
Iso extension in midrange; cautious with deep knee bend
Patellar taping tech
Strengthen gluts and hip
Autologous HS (hamstring)
Graft incorporation by Sharpey Fibers (12 weeks)
No isolated resisted HS 12 weeks
First 6 mo may c/o of autographs feel as if they’re pulling HS but that is scar tissue building
Allograft
Slower progression- may delay by 4 weeks
Increased risk of tearing in younger/active population
ACL Revision
Delay running, hop testing, agility drills, and RTS by 4 weeks
Crutches/immobilizer used for 2 weeks following surgery
Graft Biology
Weakens over first 12 weeks
Called ligamentization; we are making tendons to make them into ligaments
Never be stronger than what you were before hand
Strengthens over the next year
Bony ingrowth around tunnels
Probably never reaches implantation strength
Reconstruction: taking not the native tissue
Repair: same tissue and repairing it
Want to do impairment resolution
Can change the pad closer to knee to dec lever arm; start to inc load to change the pad position, but make the angle the same
Want to restore quad strength early; low resistance at first
Isokinetic: lower speeds have a higher strain on the ACL since there is more force strength
This is just a nice slide to outline the differeneces between the grafts used and how that can impact your treatment
However, follow the surgeon protocol
We are stressed not to use protocols in schools, but to treat the symptoms, but I think a protocol provides a baseline to see how patients are progressing
Leg press
Some of the exercises we used for the hip and knee can be addressed here
Protect against valgus and tibia rotation
Use of brace
Control effusion/swelling
Early and progressive ROM
Early quad activation
Normalize gait
Which is appropriate
Not the middle one since the force of gravity is pushing down the medial aspect of the knee
Side stepping
Toward uninvolved harder
JOSPT 1998
Although, open chain exercise was beneficial for the development of strength and endurance of the knee extensor mechanism following anterior cruciate ligament reconstruction, and could be used effectively in a rehabilitation program21), closed kinetic chain exercise seems to be more effective at improving dynamic balance ability than open kinetic chain exercise within a six-week training period22).
According to the results of electromyographic analysis, one-legged squats and step-ups are effective for muscle rehabilitation after anterior cruciate ligament reconstruction. In addition, closed chain activities might avoid the risk of anterior cruciate ligament graft injury in the rehabilitation process, and closed chain exercises, exercises cost less to implement than open chain exercises with expensive equipment; therefore, the clinical application of closed chain exercise is more convenient23).
The results of this study also indicate that closed chain exercise is better than open chain exercise for both short and long term outcomes, reducing patellofemoral pain, alleviating muscle atrophy and improving knee function.
https://www.youtube.com/watch?v=FcTYXWStIM4
Ball under knee
Sitting ball IR feet
Lunge back with knee straight
Weber AJSM 2003
An ankle x-ray series is only required if
there is any pain in the malleolar zone and any of these findings:
bone tenderness at A OR posterior edge of lateral malleolus
bone tenderness at B OR posterior edge of the medial malleolus
inability to take 4 complete steps both immediately and in ED
A foot x-ray series is only required if
there is any pain in the midfoot zone and any of these findings:
bone tenderness at C OR base of the 5th met
bone tenderness at D OR Navicular
inability to take 4 complete steps both immediately and in ED
RECOMMENDATIONS
Apply the Ottawa Ankle Rules accurately:
palpate the entire distal 6 cm of the fibula and tibia
do not neglect the importance of medial malleolar tenderness
do not use for patients under age 18
FORCE Couples
Check the neck alignment
Serratus anterior protects and stabilizes the scapula
LESS IS MORE. If the patient is not able to raise their arm without pain then do not add resistance
Eccentric control= pain you will have subacromial impingement, gaining pain free ROM is the primary target = manual therapy and stretching
Subscapularis will be tight, so if you get in there and mob A+!
Sideline ER
Wall walks with theraband
Ball stabilzation exercises
Stretching posterior capsule
Rotator Cuff Tendinopathy indicates a problem with your shoulder muscles. It can be caused by an overload of the four muscles located in that region, or an inflammation of one of the tendons. Other causes of a tendinopathy can be found in impingement of the bursa and calcification of the tendons from the rotator cuff muscles.
Posterior capsule: how to tell if its tight
supine IR and hor AD, if the arm does not go past midline than it’s tight, past midline than it is
Sleeper stretch
Eccentric contraction supra and teres minor: side line EER
Internally rotate to get supraspinatus and do cross friction on the tendon, horizontal (referred pain to the biceps): break up scar tissue
polychromatic noncoherent light in managing tennis elbow. They concluded that supervised exercise consisting of static stretching and eccentric strengthening produced the largest effect in reducing pain and improving function
The hypothesized mechanism of Mill's manipulation is the lengthening of scar tissue following the rupture of adhesions due to the manipulation; Mill’s intention was to shift the annular ligament and replace it. Cyriax found out that the annular ligament applies the greatest possible stretching tension to the extensor carpi radialis muscles, that’s why the manipulative procedure should be carried out with a sharp jerk, in order to open the tear in the tendon and relieve tension on the tendon scar by converting a tear.[28
Eccentric strengthening exercise was performed in the seated position with full elbow extension, forearm pronation, and maximum wrist extension. From this position, the patient slowly lowered wrist into flexion for a count of 30, using the contralateral hand to return the wrist to maximum extension.
Viswas R, Ramachandran R, Korde Anantkumar P. Comparison of Effectiveness of Supervised Exercise Program and Cyriax Physiotherapy in Patients with Tennis Elbow (Lateral Epicondylitis): A Randomized Clinical Trial. The Scientific World Journal. 2012;2012:939645. doi:10.1100/2012/939645.
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
Lateral shift dysfunction is on the wall side, side tilt side then you ask them to bring hips towards the wall right before pain
These should be given to all shoulder patients since the neck 8/10 times can contribute to shoulder problems with referred pain or nerve contrapment secondary to tissue inflammation
Patients have one body, why not treat them the best we can
In terms of OKC vs CKC, research has shifted its ways to report that OKC is not as scary as we say it is, but in terms providing functional exercises, CKC is where it’s at and also, patients will be able to do CKC at home which is what we promote: movement and independence
