Transcript The Effectiveness of Open Versus Closed Kinetic Chain

The Effectiveness of Open Versus Closed Kinetic Chain Exercises In Accelerated Rehabilitation
After Anterior Cruciate Ligament Reconstructive Surgery: A Systemic Review
Malak Azab PT
Introduction
Anterior cruciate ligament (ACL) injuries are common in athletes. The mechanism of injury
usually occurs with deceleration of the planted limb’s tibia in relation to the femur combined with
turning around, pivoting, twisting, or changing of direction suddenly (valgus stress at knee joint
combined with sudden rotation). The ACL plays a very important part in establishing the functional
stability of the knee and is considered a primary restraint to the anterior translation of the tibia on
the femur.
During the last 10 years there was a move toward favoring closed kinetic chain exercises (CKC)
over the open kinetic chain (OKC) exercises in the rehabilitation of the ACL for the following
reasons: 1- Decreases the anterior shear forces between tibia and femur; 2- Decrease the
compression forces of the tibiofemoral joint; 3- Increase the hamstrings co contraction; 4- CKC
exercises are involved in most of our daily living activities than OKC exercises; and, 5- Decrease
the complication of patellofemoral joint as chondromalacia, patella maltracking, patella tendenosis,
and pre patellar bursitis .
One of the very important decisions the clinician has to make is to choose which program is more
effective in accelerating the rehabilitation process after an ACL injury. Because of the above
reasons we are trying to investigate the effectiveness of CKC versus OKC exercises after ACL
reconstruction. CKC exercises replicate most of our daily living activities.
A strong quadriceps muscle plays an important role in preventing ACL injury and in accelerating
the rehabilitation following ACL reconstruction by preventing the anterior translation of the tibia.
Due to the confusion regarding which program is more effective following the anterior cruciate
ligament reconstruction (ACLR), it is important to understand the role of quadriceps and hamstring
muscles during daily living activities. During the OKC activities (kicking, swimming, wrestling),
the hamstrings are considered an ACL protector or agonists, and the quadriceps as antagonists.
While as during CKC activities (running, standing, walking, jumping, skiing), the quadriceps plays
the role of ACL supporter or main protagonists of ACL.
Purpose
The purpose of this work was to investigate the effectiveness of OKC compared to CKC in
accelerated rehabilitation after anterior cruciate ligament reconstructive surgery.
Methods
A computerized search of the literature was performed using the following databases:
MEDLINE, CINHAL, COCHRANE and PEDro database. The key words for the search were: ACL
reconstruction, ACL rehabilitation, open kinetic chain, closed kinetic chain, and exercises. Studies
meeting the following criteria were selected for review:
(1) Studies were related to open versus closed kinetic chain exercises and their effect in
accelerated rehabilitation after anterior cruciate ligament reconstructive surgery.
(2) Meta- analysis and randomized controlled trials; and,
(3) Published in a peer reviewed source
Results
Twelve studies were selected according to the mentioned criteria. Five studies investigated the
effect of open kinetic chain and closed kinetic chain exercises on knee function, laxity and level of
pain in the early stage after ACL reconstruction. Two studies compared different types of CKC
exercises in their effect during ACL rehabilitation. Four studies reflect the effect of CKC exercises
in accelerated rehabilitation after ACLR and the functional outcome. One study investigated the
biomechanics of the knee during OKC and CKC exercises.
Table 1 summarizes the literature that indicates the effectiveness of OKC versus
CKC exercises in accelerated rehabilitation after ACL reconstructive surgery.
Citation
Purpose
Subjects
Interventions
Results
Perry et
al., 20051
This study
compared the
effects of
closed and open
knee exercises
on knee laxity
and functions in
patients with
ACLD knees.
64 participants
with knee anterior
Cruciate ligament
deficiency. Their
age was between
18-60 (49 males
and 15 females).
Were randomized
to two groups
CKC group
(n=32); OKC
group (n=32).
The CKC group received
CKC strengthening
exercises for the hip and
knee extension. The OKC
group received OKC knee
strengthening exercises
for the hip and knee
extensor. Strengthening
exercises were
performed: 3 sets of 20
each session until the wk
4 then 3 sets of 6 at wk 6.
The results of this
study showed that
OKC and CKC knee
extensors exercises
have no significant
differences in their
effect on knee laxity
and functions with
patients with ACLD
knees.
Morrissey This study
et al.,
compared the
20022
effect of CKC
and OKC on
the level of
knee pain in the
early stage after
ACL
reconstruction.
Morrissey
et al.,
20003
This study
compared the
effect of OKC
versus CKC on
knee laxity in
the early stage
following
ACLR.
Mikkelsen This study
et al.,
compared CKC
20004
program versus
a combined
program of
CKC and OKC
for quadriceps
hamstring
strength, knee
laxity, and
return to sport
after ACLR.
43 subjects with
ACL
reconstruction
surgery, Their age
between 16-54 (9
females and 34
males) were
randomized to two
treatments groups.
Group C
(CKC training)
(n=21); and Group
O (OKC training)
(n= 22)
36 participants
with ACL
reconstructive
surgery, with a
mean age of 30
were assigned
randomly to two
groups CKC (18
with 6 F and 12
M) OKC (18 with
1 F and 17 M).
Group C received CKC
exercises for hip and knee
extensors muscles. Group
O received resistance for
hip and muscle extensors
group. all participants
received 3 sessions per
wk for 4 wks. Resistance
exercises were 3 sets of
20 RM in each session
with no additional
resistance exercises.
The results showed
that there were no
differences between
the two groups in
muscle performance;
also there was no
significant change in
pain reduction
between CKC and
OKC groups.
CKC group received
CKC resistive exercises
for the knee and hip
extensor. The OKC group
received resistive
exercises for the hip and
knee extensor. Both
groups received physical
therapy 3T X WK X 4
wks and with 3 sets of 20
repetitions in each
session.
The results showed no
statistically significant
differences between
OKC and CKC
training exercises of
knee and hip extensor
in the knee laxity or
anterior tibial
displacements (ATD)
in the early period
following ACLR.
44 participants
with ACL
reconstruction
with ages between
(18- 40) years
were assigned
randomly to two
groups. CKC
group (17 M and 5
F) and CKC
combined with
OKC group (17 M
and 5 F).
1st group received only
CKC quadriceps
exercises. The 2nd group
received the same
quadriceps CKC exercise
as in the 1st group, but
from the 6th wk after the
surgery OKC quadriceps
exercises were added.
The rehabilitation period
was for 6 months.
There were no
significant differences
between both groups
in knee laxity at 6
month. OKC
combined with CKC
showed a significant
improvement in the
concentric and
eccentric strength of
quadriceps at 6 month,
and no difference in
strength of hamstring.
Combined group
returned earlier to
sport than CKC group.
Discussion
This review summarizes the results of twelve studies that investigate the effect of OKC and
CKC exercises on knee function, laxity and pain level, different types of CKC exercises, effect of
CKC exercises in accelerated rehabilitation after ACLR and the functional outcomes, and the
biomechanics of the knee during OKC and CKC exercises.
● Four studies reflect the effect of CKC exercises in accelerated rehabilitation after ACLR and the
functional outcome. It was found that CKC exercises have a very important role in strengthening
the quadriceps muscle, and they may be protecting the ACL grafts.
● Two studies compared different types of CKC exercises in their effect during ACL rehabilitation.
It was found that CKC exercises decrease the anterior shear force so it can be safely used after
ACLR.
● One study investigated the biomechanics of the knee during OKC and CKC exercises. And found
that OKC exercises plays an important role in strengthening rectus femoris while as CKCE plays
an important role in strengthening vasti muscles.
● Five studies investigated the effect of OKC and CKC exercises on knee function, laxity and pain
level after ACLR and found that no differences between both programs.
Conclusion
The review supports that there are no differences between OKC and CKC exercises in their
effect on accelerated rehabilitation after ACLR. It can be concluded that combining OKC and CKC
exercises could be more effective in accelerated rehabilitation.
Recommendation
Further randomized clinical trials are needed to be done to determine the best time to starts these
exercises and to investigate how and when to combine OKC and CKC exercises to accelerate
rehabilitation of ACLR and to provide strong evidence about selective OKC and CKC exercises
that could be used in acceleration rehabilitation after ACLR.
References
1- Perry MC, Morrissey D, Knight PR, McAuliffe TB, King JB: Knee extensors kinetic chain
training in anterior cruciate ligament deficiency. Knee Surg Sports Traumatol Arthro. 2005
Nov;13(8):638-48. Epub 2005 May 5.
2-Morrissey MC, Drechsler WI, Morrissey D, Knight PR, Armstrong PW, McAuliffe TB: Effects
of distally fixated versus no distally fixated leg extensor resistance training on knee pain in the
early period after anterior cruciate ligament reconstruction. Phys Ther. 2002 Jan; 82(1):35-43.
3- Morrissey MC, Hudson ZL, Drechsler WI, Coutts FJ, Knight PR, King JB:
Effects of open versus closed kinetic chain training on knee laxity in the early period after anterior
cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthro. 2000; 8(6):343-8.
4- Mikkelsen C, Werner S, Eriksson E:Closed kinetic chain alone compared to combined open and
closed kinetic chain exercises for quadriceps strengthening after anterior cruciate ligament
reconstruction with respect to return to sports: a prospective matched follow-up study. Knee Surg
Sports Traumatol Arthro. 2000;8(6):337-42.
5- Graham VL, Gehlsen GM, Edwards JA: Electromyographic Evaluation of Closed and Open
Kinetic Chain Knee Rehabilitation Exercises. J Athl Train. 1993 Spring; 28(1):23-30.