EFFECTS OF OPEN KINETIC CHAIN AND CLOSED

KINETIC CHAIN EXERCISES AFTER LIGAMENT

RECONSTRUCTION

1. INTRODUCTION

Therapeutic exercise is the systematic performance or execution of planned

physical movements, postures, or activities intended to enable the
patient/client to remediate or prevent impairments, enhance function, reduce
risk, optimize overall health and enhance fitness and well-being. Therapeutic
exercise may include aerobic and endurance conditioning and
reconditioning; agility training; balance training, both static and dynamic;
body mechanics training; breathing exercises; coordination exercises;
developmental activities training; gait and locomotion training; motor
training; muscle lengthening; movement pattern training; neuromotor
development activities training; neuromuscular education or reeducation;
perceptual training; postural stabilization and training; range-of-motion
exercises and soft tissue stretching; relaxation exercises; and strength,
power, and endurance exercises.

Therapeutic exercise programs designed by physical therapists are

individualized to the unique needs of each patient or client. A patient is an
individual with impairments and functional limitations diagnosed by a
physical therapist who is receiving physical therapy care to improve function
and prevent disability.

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Physical therapists select, prescribe, and implement exercise activities when
the examination findings, diagnosis, and prognosis indicate the use of
therapeutic exercise to enhance bone density; enhance breathing; enhance or
maintain physical performance; enhance performance in activities of daily
living (ADL) and instrumental activities of daily living (IADL); improve
safety; increase aerobic capacity/endurance; increase muscle strength,
power, and endurance; enhance postural control and relaxation; increase
sensory awareness; increase tolerance to activity; prevent or remediate
impairments, functional limitations, or disabilities to improve physical
function; enhance health, wellness, and fitness; reduce complications, pain,
restriction, and swelling; or reduce risk and increase safety during activity
performance.

What has been called “closed kinetic chain” (CKC) exercise has become
popular in the last 5 to 10 years for use after ligament reconstructive surgery.
Closed kinetic chain exercises appear to have gained popularity over more
traditionally used “open kinetic chain” (OKC) exercises because many
clinicians believe that CKC exercises are safer and more functional. These
clinicians also contend that CKC exercise is equally effective as OKC
exercise in restoring quadriceps femoris muscle force production following
reconstructive surgery. The purpose of this clinical perspective is to examine
the evidence concerning OKC and CKC training after ligament
reconstructive surgery with regard to these issues and discuss how physical
therapists can best apply this knowledge in clinical practice.

1.1 Definition

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 1.1.1 Open Kinetic Chain: Steindler defined an open kinetic chain (OKC)
system as “a combination of successively arranged joints in which the
terminal segment can move freely”. In an OKC system, the distal segment
is therefore free to move in space.

Open-chain exercises involve motions in which the distal segment (hand or foot) is
free to move in space, without necessarily causing simultaneous motions at
adjacent joints. Limb movement only occurs distal to the moving joint. Muscle
activation occurs in the muscles that cross the moving joint. For example, during
knee flexion in an open-chain exercise ,(Figure 1.1.1) the action of the hamstrings
is independent of recruitment of other hip or ankle musculature. Open-chain
exercises also are typically performed in non-weight-bearing positions. In addition,
during resistance training, the exercise load (resistance) is applied to the moving
distal segment.

Characteristics of open kinetic chain exercises -

 Increased joint distraction and rotational forces

 Increased joint deformation (and therefore reduced stability)
 Increased shear forces

In his analysis of human motion, Steindler proposed that the term “open kinetic
chain” applies to completely unrestricted movement in space of a peripheral
segment of the body, as in waving the hand or swinging the leg.

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 Figure 1.1.1

Open chain resisted knee flexion

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1.1.2 Closed Kinetic Chain: Steindler initially defined a closed kinetic chain
(CKC) system as “a condition or environment in which the distal segment meets
considerable external resistance that prohibits or restrains its free motion”. In a
CKC system, a force applied to one of the segments produces motion at all other
segments (kinetic chain) in a predictable fashion.

Characteristics of closed kinetic chain exercises-

 Increased joint compressive forces

 Increased joint congruency (and therefore increased stability)

Closed-chain exercises involve motions in which the body moves on a distal

segment that is fixed or stabilized on a support surface. Movement at one joint
causes simultaneous motions at distal as well as proximal joints in a relatively
predictable manner. For example, when a patient is performing a bilateral
short-arc squatting motion (mini-squat) (Figure 1.1.2) and then returning to an
erect position, as the knees flex and extend, the hips and ankles move in a
predictable pattern along with the knees. Given the complexity of human
movement, it is not surprising that a single classification system cannot
adequately group the multitude of movements found in functional activities and
therapeutic exercise interventions. Closed-chain exercises are primarily
performed in weight-bearing positions. Examples in the upper extremities
include balance activities in quadruped, sitting press-ups, wall push-offs, or
prone push-ups; examples in the lower extremities include lunges, squats, step-
up or step-down exercises, or heel rises to name a few.

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 Figure 1.1.2

Bilateral closed-chain resisted hip and knee extension

The rationale for selecting open- or closed-chain exercises is based on the

goals of an individualized rehabilitation program and a critical analysis of

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the potential benefits and limitations inherent in either form of exercise
because functional activities involve many combinations and considerable
variations of open- and closed-chain motions, inclusion and integration of
task-specific open-chain and closed-chain exercises into a rehabilitation or
conditioning program is both appropriate and prudent. During open-chain
resisted exercises a greater level of control is possible with a single moving
joint than with multiple moving joints as occurs during closed-chain
training. With open-chain exercises stabilization is usually applied
externally by a therapist’s manual contacts or with belts or straps. In
contrast, during closed-chain exercises the patient most often uses muscular
stabilization to control joints or structures proximal and distal to the targeted
joint.

Conscious awareness of joint position or movement is one of the

foundations of motor learning during the early phase of training for
neuromuscular control of functional movements. After soft tissue or joint
injury, proprioception and kinesthesia are disrupted and alter neuromuscular
control. Re-establishing the effective, efficient use of sensory information to
initiate and control movement is a high priority in rehabilitation. Studies of
the ACL-reconstructed knee have shown that proprioception and kinesthesia
do improve after rehabilitation. It is thought that closed-chain training
provides greater proprioceptive and kinesthetic feedback than open-chain
training.

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 Open Kinetic Chain
1. Distal segment moves in space 1. Distal segment remains in contact with or
2. Independent joint movement
3. No predictable joint motion in
adjacent joints
4. Movement of body segments
only distal to the moving joint
5. Muscle activation occurs
predominantly in the prime
mover and is isolated to
muscles of the moving joint
6. Typically performed in non
weight-bearing positions
7. Resistance is applied to the
moving distal segment Use of
external rotary loading
8. External stabilization usually
required
Common characteristics of open- and closed-chain exercises
Closed Kinetic Chain
stationary (fixed in place) on support
surface
2. Interdependent joint movements
3. Relatively predictable movement patterns in
adjacent joints
4. Movement of body segments may occur
distal and/or proximal to the moving joint
5. Muscle activation occurs in multiple muscle
groups, both distal and proximal to the
moving joint
6. Typically but not always performed in
weight-bearing positions
7. Resistance is applied simultaneously to
multiple moving segments
8. Use of axial loading Internal stabilization by
means of muscle action, joint compression,
and congruency and postural control

1.2. Relevant History

The concept of kinetic chain reaction originated from the German

engineering scientist Franz Reuleaux (1829-1905), who is often called the
“father of kinematics.” Reuleaux first proposed the novel “link concept” in

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his book The Kinematics of Machinery in 1876. The link system concept,
although initially related to engineering, has become a widely accepted and
well-reviewed principle in rehabilitation.

As proposed by Reuleaux, in a rigid-link system, pin joints connect a series

of overlapping rigid segments. If both ends of this system are fixed such that
no movement can occur at either end, the application of an external force
causes each segment to receive and transfer force to the adjacent segment,
generating a chain reaction. As a result, movement at any joint will produce
a predictable movement pattern at all other joints in the chain.

The extrapolation of this conceptual framework of kinetic links or the link

system to the analysis of human movement was first introduced by Hans von
Baeyer in 1933 at the International Orthopedic Congress while he gave a
synopsis of muscle function. In his work, which focused on synergistic
muscle actions in the limbs, he contrasted the effects occurring n the limb
periphery with the effects at the proximal end of the limb lever arm.

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Figure 1.2

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Each bony segment in the lower extremity, such as the foot, lower leg, thigh,
and pelvis, can be viewed as a rigid link, with the subtalar, ankle, knee, and
hip joints acting as the connecting joints. In later writings, Steindler
categorized the kinetic chain concept as open or closed depending on the
loading of the terminal (most distal) segment.

The kinetic chain, a concept borrowed from engineering, has helped us

better understand the underlying physiology of human movement. This
understanding, in turn, has facilitated the development of new and more
rational rehabilitation strategies. The kinetic chain concept has application in
a wide spectrum of clinical conditions, including musculoskeletal medicine,
sports medicine, and neurorehabilitation, as well as prosthetics and orthotics.

1.3 Scope of the topic

Intensive research into the biomechanics of the injured and the operated
knee have led to a movement away from the techniques of the early 1980's
characterized by post operative casting, delayed weight bearing and
limitation of ROM, to the current early rehabilitation program with
immediate training of ROM and weight bearing exercises. Physiotherapy
plays a crucial role in rehabilitation after the ligament reconstruction
surgery.

The major goals of rehabilitation are:

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 1. Gain good functional stability
2. Repair muscle strength
3. Reach the best possible functional level
4. Decrease the risk for re-injury

Closed kinetic chain exercises (CKC) and Open kinetic chain exercises
(OKC) play an important role in regaining muscle (quadriceps, hamstrings)
strength and knee stability.

Closed kinetic chain exercises have become more popular than Open kinetic
chain exercises in rehabilitation. Clinicians believe that CKC exercises are
safer than OKC exercises because they place less strain on the ligament
graft. Besides, they also believe that CKC exercises are more functional and
equally effective as OKC exercises

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