Closed kinetic

chain training

Guided by Presented by
Dr.Sandeep singh Saurav Sharma
 INDEX
1. Introduction
2. Characterstics common to CKC training
3. Decieding CKC exercises
4. Basic physiological principles of CKC
training
5. Examination and evaluation
6. Treatment intervention
7. Guidelines for selecting CKC exercises
8. Dosage guidelines
9. Contraindications and precautions
 Introduction
 History
 The kinetic chain concept originated in 1955,when Steindler used
mechanical engineering theories of closed kinematic and link
concepts to describe human kinesiology. in the link concept rigid
overlapping segments are connected in a series by movable
joints. this system allows for predictable movement of one joint
based on the movement of other joints and is considered as close
kinematic chain.
 Applying the concepts to human movement, Steindler observed 2
types of kinetic chain exists depending on loading of terminal
joint
 Open kinetic chain and Closed kinetic chain
 Open kinetic chain in which end segment is free to move.eg hip
flexion of swing limb during walking.

 Closed kinetic chain in which the terminal joints meet considerable

resistance which prohibits or restrains its free motion.eg descending
stairs.

 The use of CKC exercises in rehabilitation began in 1980s, when

physician began looking for safe ways to rehabilitate the quadriceps
mechanism in patients after anterior cruciate ligament
reconstruction.
 During 1960s and 1970s documentation in biomechanics literature
demonstrated an increase in the anterior shear forces during the last
30 degrees of OKC knee extension. Numerous researches thought
that this increase in anterior shear placed a detrimental strain on
healing graft that could compromise the surgical result.
 Using cadaveric experiments, Grood and associates
documented increase in anterior tibial translation with
OKC knee extension and subsequently suggested
exercising in an upright posture to use the forces of
weight bearing to minimize anterior tibial translation.

 Increased joint compressive forces, improved joint

congruency and muscular contraction are enhanced in
weight bearing position.
 Examples
 Performing the CKC activity of sitting results in a predictable pattern
of movement of hip, knee and ankle joints. Hip flexion depends on
the amount of ankle joint dorsiflexion and knee joint flexion.

 OKC activity includes kicking a ball or reaching overhead to retrieve

an object.

 GOAL of CKC exercise

is to use the forces of weight bearing and effect of gravity to
stimulate functional activities, ultimately enabling the patients to
return to their usual environments and perform activities safely.
 Characteristics common to CKC
activities
 Interdependence of joint motion
 Motion occurring proximal and distal to the axis of the joint in a
predictable fashion
 Recruitment of muscle contractions that are predominantly
eccentric, with dynamic muscular stabilization in the form of co
contraction
 Greater joint compressive forces resulting in decreased shearing
 Stabilization afforded by joint congruency
 Normal posture and muscle contractions
 Enhanced proprioception due to increased number of stimulated
mechanoreceptors.
 Characteristics common to CKC
activities
 Independence of joint motion
 Motion occurring distal to the axis of the joint
 Muscle contractions are predominantly
concentric
 Greater distraction and rotatory forces
 Stabilization afforded by outside means
 Activation of mechanoreceptors limited to the
moving joint and surrounding structures
 Alternative classification
 Dillman and associates proposed classification based on
biomechanics of the exercise – the mobility of distal segment
and application of an external load. The researcher referred to
distal segment as boundary. The boundary condition may be
fixed or movable. An external load may or may not be present
at distal segment.
 fixed boundary with an external load(FEL)
correspond to CKC exercises
 Movable boundary with an external load(MEL)
correspond to partially closed system
 Movable boundary no load(MNL)
correspond to OKC exercises
 Deciding CKC exercise for
rehabilitation
 When analysing functional activities ,determining the
type of muscle contractions and joint motions necessary
to complete the task should help guide the decision-
making process about the type of kinetic chain exercise to
prescribe.

 NOTE- All closed chain exercises are not functional.

Similarly all open chain exercises should not be dismissed
because they are non-weight bearing activities.
 Example
Consider a patient who is unable to stand from a
seated position. The patient presents with concentric
quadriceps and hip extensor muscle weakness, mild
knee jiont anterior laxity, moderate tibiofemoral
arthritis and limited ankle dorsiflexion.
Which exercise to be given ???????
 Example

Consider another patient who presents with left arm

hemiplegia and with a subluxated humeral head in glenoid
fossa, poor scapulothoracic rhythm and altered kinesthsia.
Which exercise should be given ??????
 Basic physiological principles of
CKC training
1) Muscular contraction
CKC exercise stimulate muscular contractions, joint
approximation and joint congruency, thereby providing
dynamic stabilization and postural holding around the joint.
Weight bearing activities decrease shear stress and stimulate
co-contraction of hamstring musculature, providing dynamic
stabilization that results in improved postural holding and
additional support for the joint.
2) Biomechanical factors
These contributing to joint stability are accomplished
through the geometry of the joint surfaces, joint
approximation and stimulation of joint receptors. The
geometry of joint surface appears to aid in the decrease
of anterior tibial displacement in the loaded joint.

Wolfs law –remodelling of soft tissue

Collagen fibres organize themselves along lines of
mechanical stress-important in rehabilitating ligamentous
injury. Gradual mechanical stress strengthen injured
tissue and resist reinjury
3) Neurophysiologic factor
Neurophysiologic support for using CKC activities in
rehabilitation is provided by stimulation of proprioceptive
system. The sensory receptor consist of mechanoreceptor and
nociceptors found in muscles, joints, periarticular structures
and skin.

Four major joint receptor, the muscle spindle, the Golgi

tendon organ and cutaneous receptors have been identified as
structures providing sensory input to central nervous system
deformation and loading of soft tissues surrounding a joint
trigger mechanoreceptor that convert mechanical energy to
electrical impulses. The electrical impulses are transmitted to
and integrated by the CNS to produce a motor response.
4) Neural adaptation
It involves changes in the ability of nervous system to recruit
the appropriate muscles to obtain a desired result. In new
exercise program strength gain occurs in few weeks can be
attributed to improved coordination from neural adaptation as
the person becomes more efficient in performing the activity.
5) Specificity of training
A greater increase in strength was measured when the test
activity was similar to the actual training exercise.
This approach involves the use of the specific adaptations to
imposed demands(SAID) principle.
neuromuscular system
apply specific mechanical stress to it
(imposed demands)
specific adaptation in muscle recruitment
pattern(eccentric to control movement followed by
concentric)
 Example
Using 4 inch step to perform stem up exercises to gain the
lower extremity hip and thigh strength needed to improve
functional performance of ascending stairs
6) Stretch-shortening cycle
Involves plyometrics – a method of training neuromuscular
system to increase power by combining speed and strength of
muscle contractions.
done in rehabilitation of athletes after orthopaedic injury
firstly eccentric action stores energy followed by strong
concentric action
so CKC activities like running, jumping, skipping enhance
muscle contractions
7) Influence of motion on the kinetic chain
Influence of foot and ankle biomechanics on entire kinetic
chain is essential to ensure accurate prescription of CKC
exercises
example
1. Subtalar joint- calcaneal eversion and talar plantar
flexion and adduction
2. Lower leg follows talus with internal rotation and superior
and anterior translation of fibular head
3. Flexion with valgus stress at knee
4. Femoral adduction and internal rotation as hip moves into
flexion
5. Pelvis flexes and internally rotates in the phase with limb
6. Lumbar spine extends and counter rotates
Now if excessive subtalar pronation it is coupled with the
frontal plane motions of femoral adduction and increased
valgus stress on knee. Clinical result limb is inefficient during
propulsion.
 Examination and evaluation
CKC training has unique advantage of becoming the test. ; the
test becomes the exercise and consequently the exercise
becomes test
Example
Testing of static balance
Stand on 1 leg for 30 sec
If possible then alter the difficulty level
by altering position and making it difficult to stand
If any problem then this test becomes the patient’s home
exercise programme
Treatment intervention
CKC training is a valuable form of exercise for enhancing
patient’s ability to function in their work, home, or
recreational environments. Rehabilitation of muscular
strength and neuromuscular coordination must take into
account the position and function of entire kinetic chain.

Flexibility, simplicity, and creativity associated with CKC

training affords countless possibilities for exercise to be
included in a home exercise programme
 Guidelines selecting CKC
1) Placement of center of mass
Depending on center of mass of body where it falls muscle
action follows
2) Placement of foot
Influence efficiency of performing CKC like flat foot can cause
patello femoral pain or hinder medial collateral ligament repair
3) Relationship between the proximal and distal segments
Example
Functional CKC activity, the proximal segment is moving on a
more stationary distal segment.
closed chain knee extension – sit to stand
 Dosage guidelines
1) Variables of force, speed, complexity and control of
movement must be considered alone and in combination.
2) It should be performed slowly and in a controlled manner
and then progressed as the healing tissue can tolerate stress
and neuromuscular control improves.
3) Initiation of CKC should be in a single plane and then
progresses to include multiplanes.
 Contraindications and precautions
1) Patient safety -
* So begin sub maximally and progress to functional
goals the patient can tolerate.
* There should be criteria for gradation of exercise.
* Exercise should be easier levels, then repitition to
achieve target.
2) Pain, joint effusion and inability of joint to handle
compressive forces
3) Environmental conditions must be evaluated so the
activities are performed on a flat, hard surface with
proper footwear.
THANK
YOU