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Closed Chain Exercise and Knee Pathologies

Closed Chain Exercise and Knee Pathologies. Gabrielle Wierzbicki Clinical Education II Ithaca College Class of 2012. Closed-Chain vs. Open-Chain Exercise. Closed kinetic chain exercises activate muscles of multiple joints, and do not isolate single specific muscles. Joint Forces.

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Closed Chain Exercise and Knee Pathologies

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  1. Closed Chain Exercise and Knee Pathologies Gabrielle Wierzbicki Clinical Education II Ithaca College Class of 2012

  2. Closed-Chain vs. Open-Chain Exercise

  3. Closed kinetic chain exercises activate muscles of multiple joints, and do not isolate single specific muscles

  4. Joint Forces Adouni M. et al. “Knee Joint Biomechanics in Closed-Kinetic-Chain Exercises” Computer Methods in Biomechanics and Biomedical Engineering. 2009 Dec; Vol. 12 (6), pp 661-670.

  5. Joint Forces Adouni M. et al “Knee Joint Biomechanics in Closed-Kinetic-Chain Exercises”

  6. Ligament Stress Adouni M. et al. “Knee Joint Biomechanics in Closed-Kinetic-Chain Exercises” Computer Methods in Biomechanics and Biomedical Engineering. 2009 Dec; Vol. 12 (6), pp 661-670.

  7. Ligament Stress • Open chain exercises for the hamstrings produce a posterior shearing force and stress the PCL • Increased PCL stress near 90 degrees knee flexion • Open chain exercises for the quads produce an anterior shearing force and stress the ACL • Increased ACL stress near full extension Adouni M. et al. “Knee Joint Biomechanics in Closed-Kinetic-Chain Exercises” Computer Methods in Biomechanics and Biomedical Engineering. 2009 Dec; Vol. 12 (6), pp 661-670.

  8. Closed-Chain vs. Open-Chain Exercise • Isometric contractions in open and closed chain tasks were measured with surface EMG recordings of the quadriceps muscles • Closed-chain knee ext. showed more simultaneous muscle activity of all the quadriceps • Open-chain knee ext. showed contraction of rectus femoris first, and a delay of VMO contraction Stensdotter AK et al. “Quadriceps activation in closed and in open kinetic chain exercise.” Med Sci Sports Exerc. 2003, Dec; Vol. 35 (12), pp. 2043-2047.

  9. Closed-Chain vs. Open-Chain Exercise • VMO activation was 7+/- 13 ms after RF onset and at a smaller amplitude (40 +/- 30% MVC) • Closed kinetic chain exercises produce a more balanced quadriceps activation than open chain • Importance in the stability of the tibiofemoral and patellofemoral jts. Stensdotter AK et al. “Quadriceps activation in closed and in open kinetic chain exercise.” Med Sci Sports Exerc. 2003, Dec; Vol. 35 (12), pp. 2043-2047.

  10. Closed Chain Exercise • Role of external loads on the knee flexor and extensor moments during dynamic squats • Dynamic half-squats were performed, with subjects starting upright, bending knees until thighs were parallel to the floor, and returning to starting position • Subjects held barbells of 8kg, 28kg, 48 kg across the back of the shoulders Rao G. et al “Influence of additional load on the moments of the agonist and antagonist muscle groups at the knee joint during closed chain exercise.” Journal of Electromyography and Kinesiology. 2009; Vol. 19, pp 459-466.

  11. Closed Chain Exercise • Higher loads significantly increased the knee net jt moment • Net knee jt moment increased 7.8% between 8 and 28 kg, and 8.3% between 28 and 48 kg Rao G. et al “Influence of additional load on the moments of the agonist and antagonist muscle groups at the knee joint during closed chain exercise.” Journal of Electromyography and Kinesiology. 2009; Vol. 19, pp 459-466.

  12. Closed Chain Exercise • Increased stability from axial compression force due to the antagonist coactivity • Antagonist muscle moments showed no difference in loads between 8 and 28 kg, but a sharp increase for higher loads between 28 and 48 kg • Higher loads provide additional stability to the knee Rao G. et al “Influence of additional load on the moments of the agonist and antagonist muscle groups at the knee joint during closed chain exercise.” Journal of Electromyography and Kinesiology. 2009; Vol. 19, pp 459-466.

  13. Closed Chain Exercise • Agonist-antagonist muscle co-contraction suggests that the combination of the quads and hamstrings contracting together provides joint stabilization to the knee Rao G. et al “Influence of additional load on the moments of the agonist and antagonist muscle groups at the knee joint during closed chain exercise.” Journal of Electromyography and Kinesiology. 2009; Vol. 19, pp 459-466.

  14. Closed Chain Exercise • Increased stability during co-contraction can actively protect the ACL • Minimal translation of the tibia puts less stress on the ligaments of the knee • Co-contraction is highest at 24 degrees for 8kg, 30 degrees for 28kg, and 33 for 48kg • Below 15-22 degrees the hamstrings do not effectively offset the anterior shear force produced by the quads Rao G. et al “Influence of additional load on the moments of the agonist and antagonist muscle groups at the knee joint during closed chain exercise.” Journal of Electromyography and Kinesiology. 2009; Vol. 19, pp 459-466.

  15. Patellofemoral Pain Syndrome • Patellofemoral joint reaction force (PFJRF) is dependent on the magnitude of the quadriceps force and knee flexion angle • Stair ambulation has a PFJRF that is 3 times greater than walking, where squats produce 5 times a greater force than walking • People with PFP were compared to those without knee pain while stair climbing Brechter J. et al “Patellofemoral joint stress during stair ascent and descent in persons with and without patellofemoral pain” Gait and Posture. 2002; Vol 16, pp 115-123.

  16. Patellofemoral Pain Syndrome • No significant differences in knee kinematics were shown for stair ascent or descent Acending Stairs Descending Stairs Brechter J. et al “Patellofemoral joint stress during stair ascent and descent in persons with and without patellofemoral pain” Gait and Posture. 2002; Vol 16, pp 115-123.

  17. Patellofemoral Pain Syndrome • During stair climbing, the PFP group had a lower peak knee extension moment (0.81 vs. 1.16 Nm/kg) (p = 0.04) • During stair descent, the PFP group also had a ↓ knee extension moment, but it was not statistically significant (p = 0.09) Acending Stairs Descending Stairs Brechter J. et al “Patellofemoral joint stress during stair ascent and descent in persons with and without patellofemoral pain” Gait and Posture. 2002; Vol 16, pp 115-123.

  18. Patellofemoral Pain Syndrome • During stair ascent, peak PFJRF was significantly less in the PFP group compared to the control group (p = 0.02) Acending Stairs Descending Stairs Brechter J. et al “Patellofemoral joint stress during stair ascent and descent in persons with and without patellofemoral pain” Gait and Posture. 2002; Vol 16, pp 115-123.

  19. Patellofemoral Pain Syndrome • People with PFP may demonstrate quad avoidance as a compensatory strategy to avoid forces on the PFJ • Reduction in stair climbing cadence and ↓ knee ext. moment in pts to decrease PFJRF • Trunk flexion compensation may also be present, bringing COM anteriorly and reducing moment at knee jt Brechter J. et al “Patellofemoral joint stress during stair ascent and descent in persons with and without patellofemoral pain” Gait and Posture. 2002; Vol 16, pp 115-123.

  20. PFPS Rehabilitation • 60 patients with PFPS were randomly placed into open or closed chain protocol treatment groups • 10 Repitition maximum was determined for each patient and they were instructed to train at 60% • New 60% RM was determined at the end of each week of training • Each group performed 3 sets of 10 reps with 1 minute rest in between sets Witvrouw E. et al. “Open Versus Closed Kinetic Chain Exervises for Patellofemoral Pain: A Prospective, Randomized Study.” Am J Sports Med. 2000; Vol. 28 (5), pp. 687-694.

  21. PFPS Rehabilitation • Open chain protocol • Quad sets in full knee ext • Supine SLR • Short-arc movements from 10 degrees knee flexion to full extension • Leg adduction in sidelying Witvrouw E. et al. “Open Versus Closed Kinetic Chain Exervises for Patellofemoral Pain: A Prospective, Randomized Study.” Am J Sports Med. 2000; Vol. 28 (5), pp. 687-694.

  22. PFPS Rehabilitation • Closed chain protocol • Seated leg press • One-third knee bends (single-leg and bilateral) • Stationary bicycling • Rowing machine • Step-up and step-down exercises • Progressive jumping exercises Witvrouw E. et al. “Open Versus Closed Kinetic Chain Exervises for Patellofemoral Pain: A Prospective, Randomized Study.” Am J Sports Med. 2000; Vol. 28 (5), pp. 687-694.

  23. PFPS Rehabilitation • Both groups were assessed using the unilateral squat test, step test, and triple jump test and rate pain on a 100-mm VAS • Strength was assessed isokinetically using a Cybex dynamometer at speed of 60, 180, and 300 deg/sec Witvrouw E. et al. “Open Versus Closed Kinetic Chain Exervises for Patellofemoral Pain: A Prospective, Randomized Study.” Am J Sports Med. 2000; Vol. 28 (5), pp. 687-694.

  24. PFPS Rehabilitation • Both groups showed significant increases in function after the 5 week treatment period and 3 month follow-up • Both groups had statistically significant improvement in pain, hamstring, and quadriceps strength Witvrouw E. et al. “Open Versus Closed Kinetic Chain Exervises for Patellofemoral Pain: A Prospective, Randomized Study.” Am J Sports Med. 2000; Vol. 28 (5), pp. 687-694.

  25. PFPS Rehabilitation • Both groups had significant differences in reduction of pain, and increased strength of the hamstrings and quadriceps • No significant difference between open and closed chain for unilateral squat, step-up and step-down • Closed chain group had more increase in the triple jump performance

  26. PFPS Rehabilitation • Is specificity of training involved? • Performance of triple-jump test, frequency of locking in the knee joint, experiencing a clicking sensation in the knee joint, pain during the night, and pain during isokinetic testing were significantly better in the closed kinetic chain group Witvrouw E. et al. “Open Versus Closed Kinetic Chain Exervises for Patellofemoral Pain: A Prospective, Randomized Study.” Am J Sports Med. 2000; Vol. 28 (5), pp. 687-694.

  27. Clinical Decision • Open-chain exercises may be more functional for patients • Reason for patients to have PT is to be able to function in their environment • Depends on diagnosis if a specific muscle needs to be strengthened independently • Combination of open and closed chain exercises? • Emphasis on closed chain as the patient progresses?

  28. References Adouni M. et al. “Knee Joint Biomechanics in Closed-Kinetic-Chain Exercises” Computer Methods in Biomechanics and Biomedical Engineering. 2009 Dec; Vol. 12 (6), pp 661-670. Brechter J. et al “Patellofemoral joint stress during stair ascent and descent in persons with and without patellofemoral pain” Gait and Posture. 2002; Vol 16, pp 115-123. Rao G. et al “Influence of additional load on the moments of the agonist and antagonist muscle groups at the knee joint during closed chain exercise.” Journal of Electromyography and Kinesiology. 2009; Vol. 19, pp 459-466. Stensdotter AK et al. “Quadriceps activation in closed and in open kinetic chain exercise.” Med Sci Sports Exerc. 2003, Dec; Vol. 35 (12), pp. 2043-2047. Witvrouw E. et al. “Open Versus Closed Kinetic Chain Exervises for Patellofemoral Pain: A Prospective, Randomized Study.” Am J Sports Med. 2000; Vol. 28 (5), pp. 687-694.

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