1. No category

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.

Symptoms
(Bolga, 2011)
(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
Exercise is
effective for
PFPS
Sole risk factor
for PFPS
Quadriceps
Short + long
term benefits
Tracking
Bolga 2011, Bizzini 2003, Dixit 2005, Herrington 2007, Lankhorst 2012
Theoretical Construct
Open Chain
VS
Closed Chain
Quad Isolation
More Functional
Greater PFJRFs
Co-Contraction
Less Functional
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
• Diagnosed with PFPS
Intervention
• Closed Kinetic Chain exercises
Control
• Open Kinetic Chain exercises
Outcomes
• 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
Exclusion
Criteria
Other
diagnoses
Prevention
Methods: Search Procedures
 Databases
 Search
Terms
› PubMed
› Patellofemoral
› CINAHL
› Anterior knee pain
› Cochrane
› Chondromalacia
Database
› PeDRO
› JOSPT
› Recursive Search
› 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
Length
Study Type*
Total
Subjects
Bahktiary et al.
3 weeks
RCT, 1B
32
Pilot RCT, 2B
45
Herrington et al. 6 weeks
Steine et al.
8 weeks
QuasiExperimental, 2B
23
Witvrouw et al.
5 weeks
RCT, 1B
60
*(Jewell 2008)
Bahktiary et al.
(3 Week Treatment)
Open Chain
Closed Chain
VS
Outcomes
Conclusion
Pain: no difference
Strength: CKC better
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
Conclusion
Pain: no difference
Function: no difference
Strength: CKC better
Triple Jump: no difference
CKC “a little more
effective”
Steine et al.
(8 Week Treatment)
Open Chain
Closed Chain
VS
Outcomes
Conclusion
Function: CKC better
Strength: CKC better
Step Downs: CKC better
CKC superior
Synthesis Across Studies
Outcome
Studies Included
Measurement
Statistically
Significant
Difference
Pain
Herrington et al.
Bahktiary et al.
Witrvouw et al.
VAS
VAS
VAS
No
No
No
Function
Herrington et al.
Witrvouw et al.
Kujala Scale
Kujala Scale
No
No
Knee Extensor
Strength
Herrington et al.
Bahktiary et al.
Steine et al.
Witrvouw et al.
Isometric
Isometric
Isokinetic 180°/s
Isokinetic 180°/s
No
CKC superior
CKC superior
CKC superior
Performance
Based
Functional Tests
Steine et al.
Witrvouw et al.
Step downs
Triple Jump
CKC superior
No
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
• Reject null hypothesis, accept alternative
• CKC group statistically superior
Performance
Based Functional
Tests
• 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
CKC Exercise
Test
Steine et al.
Lateral stepping
Step Ups/Downs
Step Downs
Witvrouw et al.
Single leg squats
Jumping
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

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
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Questions?
Patellofemoral Pain Syndrome
Weak
Quads
Foot
Kinematics
Muscle
Imbalance
PFPS
Hip
Weakness
Soft Tissue
Tightness
Increased
Q angle
(Bolga,
2011;
Heintjes,