Open vs.

Closed Kinetic Chain Exercises for Patellofemoral Pain Syndrome: An Evidence Based Review
Thomas Tsai, DPTc DPT Candidate Spring Symposium 2012

Significance of Patellofemoral Pain Syndrome (PFPS)

Most common cause of knee pain in the outpatient setting. Accounts for 25% - 40% of knee problems in sports medicine centers. 11% of MSK complaints in the office setting caused by anterior knee pain.

(Dixit, 2007) (Bizzini, 2003)

(Dixit, 2007)

Clinical Problem: PFPS

Definition
Peri or retropatellar pain
(Bizzini, 2003)

Cause
Abnormal patellar tracking.
(Bolga, 2011)

Symptoms

(Heintjes, 2009)

Pain with Stairs, Squatting, Sitting

Impairments
quadriceps and hip strength Frontal plane imbalances Posture dysfunctions

Patellofemoral Joint

Role of Patella
Anatomic pulley

Patellofemoral Joint Reaction Forces (PFJRFs)

Posterior force through PFJ Influenced by: Angle of knee flexion Quad contraction Patellar contact area
Levangie and Norkin, 2005

Levangie and Norkin, 2005

Relevance to PT
PFPS results in pain, decreased function, and decreased strength Conservative treatment first line Efficacious, evidence based, appropriate rehab protocal

(Bakhtiray, 2007)

Theoretical Construct
Classically, decreased quad strength Sole risk factor for PFPS Quadriceps

Exercise is effective for PFPS

Short + long term benefits

Tracking

Bolga 2011, Bizzini 2003, Dixit 2005, Herrington 2007, Lankhorst 2012

Theoretical Construct
Open Chain
Quad Isolation Greater PFJRFs Less Functional

VS

Closed Chain
More Functional Co-Contraction

Proprioception Eccentric Activity Decreased PFJRFs

Bahktiary 2007, Fagan 2008 Steine 1996, Steinkamp 1993, Syme 2009, Witrvouw 2000

Gaps in Literature

Clinical studies
Mixed results

Systematic Reviews (Bolga, 2011; Heintjes 2009)

Pain and/or function only

Did not combine effect sizes

Purpose and Primary Question

Purpose
The purpose of this evidence based review is

to compare OKC vs. CKC exercises for patients with PFPS

Foreground Question
Are CKC exercises superior to OKC exercises

for patients with PFPS for ?

1. 2. 3. 4.

Pain Function Knee extensor strength Performance based functional tests (PBFTs)

PICO
Population
Intervention Control Outcomes
Diagnosed with PFPS

Closed Kinetic Chain exercises

Open Kinetic Chain exercises

1) Pain 2) Function 3) Knee Extensor Strength 4) Performance Based Functional Tests

Hypotheses

Null : No significant differences between OKC and CKC exercises in patients in PFPS for all outcomes
Alternative : CKC exercises are statistically superior to OKC exercises for all outcomes

Expected Findings

Expected Findings: 4-5 RCTs, systematic reviews, case studies Expected Answer: CKC exercises are superior to OKC exercises for all outcomes

Methods: Search Procedures

Comparing OKC vs. CKC Inclusion Criteria Adults

English Other diagnoses Prevention

Exclusion Criteria

Methods: Search Procedures

Databases
PubMed CINAHL

Search

Terms

Patellofemoral Anterior knee pain

Cochrane

Database PeDRO JOSPT Recursive Search

Chondromalacia
Open kinetic

chain Closed kinetic chain

Search Results
212 from database search 182 excluded due to irrelevance

30 for further review

26 excluded due to: 1. Not comparing OKC vs. CKC 2. Other knee pathologies 3. Not English 4. Prevention

4 articles selected for inclusion

Confirmed by 2 independent reviewers

List Articles Results

Author Bahktiary et al. Length 3 weeks Study Type* RCT, 1B Total Subjects 32

Herrington et al. 6 weeks

Pilot RCT, 2B

45

Steine et al. Witvrouw et al.

8 weeks 5 weeks

QuasiExperimental, 2B RCT, 1B
*(Jewell 2008)

23 60

Bahktiary et al.
(3 Week Treatment)

Open Chain

Closed Chain

VS
Outcomes Pain: no difference Strength: CKC better Conclusion CKC superior

Herrington et al.
(6 Week Treatment)

Open Chain

Closed Chain

VS
Outcomes Conclusion

Pain: no difference Function: no difference Strength: no difference

OKC and CKC equally effective

Witvrouw et al.
(5 Week Treatment)

Open Chain

Closed Chain

VS
Outcomes
Pain: no difference Function: no difference Strength: CKC better Triple Jump: no difference

Conclusion
CKC a little more effective

(8 Week Treatment)

Steine et al.

Open Chain

Closed Chain

VS
Outcomes
Function: CKC better Strength: CKC better Step Downs: CKC better

Conclusion
CKC superior

Synthesis Across Studies

Outcome Studies Included Measurement Statistically Significant Difference No No No No No No CKC superior CKC superior CKC superior CKC superior No Pain Herrington et al. Bahktiary et al. Witrvouw et al. Herrington et al. Witrvouw et al. Herrington et al. Bahktiary et al. Steine et al. Witrvouw et al. Steine et al. Witrvouw et al. VAS VAS VAS Kujala Scale Kujala Scale Isometric Isometric Isokinetic 180/s Isokinetic 180/s Step downs Triple Jump

Function Knee Extensor Strength

Performance Based Functional Tests

Statistics Used
Extract means and standard deviations Calculate effect sizes and 95% CI Calculate heterogeneity statistic (Q) to determine which model to pool data

Fixed effects model, p value for total

variance > 0.05

Weighting by inverse variance Pool weighted two group effect sizes to obtain a combined effect size and new 95% CI

Results: Pain
Favors OKC Favors CKC

Combined ES and 95% CI: -0.09 (-0.45, 0.27)

Results: Function
Favors OKC Favors CKC

Combined ES and 95% CI: -0.01 (-0.42, 0.40)

Results: Knee Extensor Strength

Favors OKC Favors CKC

Combined ES and 95% CI: 1.15 (0.77, 1.54)

Results: Performance Based Functional Tests

Favors OKC Favors CKC

Combined ES and 95% CI: 0.63 (0.18, 1.08)

Results: Outcomes Summary

Favors OKC Favors CKC

Discussion
Pain
Failed to reject null hypothesis No statistically significant difference

Function

Failed to reject null hypothesis No statistically significant difference

Knee Extensor Strength Performance Based Functional Tests

Reject null hypothesis, accept alternative CKC group statistically superior

Reject null hypothesis, accept alternative CKC group statistically superior

Discussion: Pain
Both groups equal reduction in pain Literature

(Escamilla 1998, Hungerford 1979, Steinkamp 1993)

OKC knee extension = increased joint stress Observational studies may not translate clinically

Other sources of pain

(Powers 2010)

Mechanical Subchondral bone, infrapatellar fat pad Non-mechanical Psychological state Inflammation

Discussion: Function

Both groups equal increases in function

Kujala Scale (ICC = 0.81)

Focuses more on pain than ability

8 of 13 questions have responses regarding pain

Kujala Scale: pain with activity vs. ability to perform function

Discussion: Knee Extensor Strength

Large effect size favoring CKC Witrvouw et al. : 3.85 (2.99, 4.70)

Discrepancy in OKC and CKC protocols

All studies showed positive effect sizes

Greater eccentric muscle activation (Iguchi 2010,
Witrvouw 2000)

Clinical Units:
Isometric peak torque MCID

49.86 Nm

10 Nm (Lin 2009)

Discussion: Performance based Functional Tests

Moderate effect size favoring CKC Specificity of training

(Herrington 2007, Fagan 2008)

Author Steine et al.

CKC Exercise Lateral stepping Step Ups/Downs Single leg squats Jumping

Test Step Downs

Witvrouw et al.

Triple Jump Test

Implications for Clinical Practice

In the short term (3-8 weeks)

Overall, CKC > OKC OKC: Irritable/acute phase Unable to tolerate weight bearing Poor body awareness CKC: Middle/ late phase Functional, activity specific Goal oriented

Harm and Cost

Harm
Increased PFJRFs with OKC knee extensions No patient complaints of pain

Cost
Not addressed

Interventions not cost prohibitive

Cost of PT

Limitations of study
Studies in English Few studies Small sample sizes Varying methodology of outcome measurement Sub-optimal treatment periods No long term follow up

Directions for Future Research

Long term outcomes for OKC vs. CKC

Looking at OKC vs. CKC for different diagnoses

Comparing quad strengthening alone to quad and hip strengthening

Conclusions

OKC and CKC exercises appear to be equally effective for pain reduction and function (Kujala Scale)
CKC exercises are likely superior for knee extensor strength and PBFTs CKC exercises are preferable but OKC exercises may be used with patients unable to tolerate weight bearing

Acknowledgements
Diane D. Allen, PT, PhD Betty Smoot, PT, DPTSc Richard Ritter, PT, DPT, OCS Roger Zhao, MS, DPTc Tin Pham, MS, DPTc UCSF/SFSU DPT Class of 2012

References

Dixit Sameer DJP, Burton Monique, Mines Brandon. Management of Patellofemoral Pain Syndrome. American Family Physician 2007;75:194-202. 2. Herrington Lee A-SA. A Controlled Trial of Weight-Bearing Versus Non-Weight-Bearing Exercises for Patellofemoral Pain. Journal of Orthopaedic & Sports Physical Therapy 2007;37:155-60. 3. Bakhtiary AH, Fatemi E. Open versus closed kinetic chain exercises for patellar chondromalacia. British Journal of Sports Medicine 2008;42:99-102. 4. Levangie PKNCC. Joint Structure & Function: A Comprehensive Analysis. Fourth ed. Philadelphia: F.A. Davis Company; 2005. 5. Bolga Lori A BMC. An Update for the Conservative Management of Patellofemoral Pain Syndrome: A Systematic Review of the Literature from 2000 to 2010. The International Journal of Sports Physical Therapy 2011;6:112-25. 6. Collado Herve FM. Patellofemoral Pain Syndrome. Clinical Sports Medicine 2010:379-98. 7. Heintjes E, Berger MY, Bierma-Zeinstra SM, Bernsen RM, Verhaar JA, Koes BW. Exercise therapy for patellofemoral pain syndrome. Cochrane database of systematic reviews (Online) 2003:CD003472.
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References

Witvrouw E, Danneels L, Van Tiggelen D, Willems TM, Cambier D. Open versus closed kinetic chain exercises in patellofemoral pain: a 5-year prospective randomized study. Am J Sports Med 2004;32:1122-30. 9. Bizzini M, Childs JD, Piva SR, Delitto A. Systematic review of the quality of randomized controlled trials for patellofemoral pain syndrome. The Journal of orthopaedic and sports physical therapy 2003;33:4-20. 10. Lankhorst NE B-ZS, Van Middelkoop M. Risk Factors for Patellofemoral Pain Syndrome: A Systematic Review JOSPT 2012;42:81-95. 11. Fagan V, Delahunt E. Patellofemoral pain syndrome: a review on the associated neuromuscular deficits and current treatment options. Br J Sports Med 2008;42:789-95. 12. Steinkamp LA, Dillingham MF, Markel MD, Hill JA, Kaufman KR. Biomechanical considerations in patellofemoral joint rehabilitation. Am J Sports Med 1993;21:438-44. 13. Steine Henry A; Brosky Tony; Reinking Mark F NJ, Mason Mary Beth. A Comparison of Closed Kinetic Chain and Isokinetic Joint Isolation Exercise in Patients With Patellofemoral Dysfunction. Journal of Orthopaedic & Sports Physical Therapy 1996;24:136-41. 14. Syme G, Rowe P, Martin D, Daly G. Disability in patients with chronic patellofemoral pain syndrome: a randomised controlled trial of VMO selective training versus general quadriceps strengthening. Manual therapy 2009;14:252-63. 15. Witvrouw E, Lysens R, Bellemans J, Peers K, Vanderstraeten G. Open Versus Closed Kinetic Chain Exercises for Patellofemoral Pain. The American Journal of Sports Medicine 2000;28:687-94.
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References

16. Iguchi M, Shields RK. Quadriceps low-frequency fatigue and muscle pain are contraction-type-dependent. Muscle & nerve 2010;42:230-8. 17. Woodall W WJ. A Biomechanical Basis for Rehabilitation Programs Involving the Patellofemoral Joint. JOSPT 1990;11:535-42. 18. Matheson GO. Commentary on Open versus Closed Kinetic Chain Exercises for Patellar Chondromalacia in Young Women. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine 2009;19:76-7. 19. Borenstein M HL, Higgins J, Rothstein H. Comprehensive MetaAnalysis Version 2. In. Engelwood, NJ: Biostat; 2005. 20. Jewell DV. Guide to evidence-based physical therapy practice: Jones & Bartlett Learning; 2008. 21. Hungerford DS BM. Biomechanics of the patellofemoral joint. Clin Orthop 1979:9-15. 22. Escamilla RF FG, Zheng N, Barrentine SW, Wilk KE, Andrews JR. Biomechanics of the knee during closed kinetic chain and open kinetic chain exercises. Medicine & Science in Sports & Exercise 1998;30:556-69.

References

23. Cohen ZA RH, Grelsamer RP, Henry JH, Levine WN, Mow VCM, Ateshian GA Patellofemoral Stresses during Open and Closed Kinetic Chain Exercises. The American Journal of Sports Medicine 2001;29:480-7. 24. Roush MB ST, Wilson JK, et al. Anterior Knee Pain: A Clinical Comparison of Rehabilitation Models Clinical Journal of Sports Medicine 2000:22-8. 25. Chiu JKW WY-m, Yung PSH, et al. The Effects of Quadriceps Strengthening on Pain, Function, and Patellofemoral Joint Contact Area in Persons with Patellofemoral Pain. Am J Phys Med Rehabil 2012;91:98-106. 26. Kujuala UM JL, Koskinen SK, et al. Scoring of patellofemoral disorders. Arthroscopy 1993:159-63. 27. Crossley KM BK, Cowan SM, et al. Analysis of Outcome Measures for Persons With Patellofemoral Pain: Which are Reliable and Valid? Arch Phys Med Rehabil 2004:815-22. 28. Fukuda TY RF, Magalhaes E, et al. Short-Term Effects of Hip Abductors and Lateral Rotators Strengthening in Females With Patellofemoral Pain Syndrome: A Randomized Controlled Clinical Trial. JOSPT 2010;40:736-42. 29. Nakagawa TH MT, Baldon RDM, et al. The effect of additional strengthening of hip abductor and lateral rotator muscles in patellofemoral pain syndrome: a randomized controlled pilot study. Clinical Rehabilitation 2008:1051-60.

Questions?

Patellofemoral Pain Syndrome

Weak Quads

Foot Kinematics

Muscle Imbalance

PFPS
Hip Weakness Soft Tissue Tightness

Increased Q angle

(Bolga, 2011; Heintjes,