Upload
baykal-celik
View
200
Download
2
Tags:
Embed Size (px)
Citation preview
Open vs. Closed Kinetic Chain
Exercises for Patellofemoral
Pain Syndrome: An Evidence
Based Review
Thomas Tsai, DPTc
DPT Candidate
Spring Symposium 2012
Most common cause of
knee pain in the
outpatient setting. (Dixit, 2007)
Accounts for 25% - 40% of
knee problems in sports
medicine centers. (Bizzini, 2003)
11% of MSK complaints in
the office setting caused
by anterior knee pain. (Dixit, 2007)
Significance of Patellofemoral
Pain Syndrome (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
Clinical Problem: PFPS
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
Patellofemoral Joint
Levangie and Norkin, 2005 Levangie and Norkin, 2005
PFPS results in pain, decreased function,
and decreased strength
Conservative treatment first line (Bakhtiray, 2007)
Efficacious, evidence based,
appropriate rehab protocal
Relevance to PT
Theoretical Construct
Exercise is effective for
PFPS Quadriceps
Classically, decreased
quad strength
Sole risk factor for PFPS
Short + long term benefits
Tracking
Bolga 2011, Bizzini 2003, Dixit 2005, Herrington 2007, Lankhorst 2012
Theoretical Construct
Bahktiary 2007, Fagan 2008 Steine 1996, Steinkamp 1993, Syme
2009, Witrvouw 2000
Open Chain
Quad Isolation
Greater PFJRFs
Less Functional
Closed Chain
More Functional
Co-Contraction
Proprioception
Eccentric Activity
Decreased PFJRFs
VS
Clinical studies
› Mixed results
Systematic Reviews (Bolga, 2011; Heintjes 2009)
› Pain and/or function only
› Did not combine effect sizes
Gaps in Literature
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. Pain
2. Function
3. Knee extensor strength
4. Performance based functional tests (PBFTs)
Purpose and Primary Question
PICO
•Diagnosed with PFPS
Population
•Closed Kinetic Chain exercises
Intervention
•Open Kinetic Chain exercises
Control
•1) Pain 2) Function 3) Knee Extensor Strength 4) Performance Based Functional Tests
Outcomes
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
Hypotheses
Expected Findings: 4-5 RCTs, systematic
reviews, case studies
Expected Answer: CKC exercises are
superior to OKC exercises for all
outcomes
Expected Findings
Methods: Search Procedures
Inclusion Criteria
Comparing OKC vs. CKC
Adults
English
Exclusion Criteria
Other diagnoses
Prevention
Databases
› PubMed
› CINAHL
› Cochrane Database
› PeDRO
› JOSPT
› Recursive Search
Search Terms
› Patellofemoral
› Anterior knee pain
› Chondromalacia
› Open kinetic
chain
› Closed kinetic
chain
Methods: Search Procedures
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
Author Length Study Type* Total
Subjects
Bahktiary et al. 3 weeks RCT, 1B 32
Herrington et al. 6 weeks Pilot RCT, 2B 45
Steine et al. 8 weeks Quasi-
Experimental, 2B
23
Witvrouw et al. 5 weeks RCT, 1B 60
List Articles Results
*(Jewell 2008)
Bahktiary et al. (3 Week Treatment)
Outcomes Conclusion
Pain: no difference
Strength: CKC better
CKC superior
VS
Open Chain Closed Chain
Herrington et al. (6 Week Treatment)
Outcomes Conclusion
Pain: no difference
Function: no difference Strength: no difference
OKC and CKC equally
effective
VS
Open Chain Closed Chain
Witvrouw et al. (5 Week Treatment)
Outcomes Conclusion
Pain: no difference
Function: no difference
Strength: CKC better
Triple Jump: no difference
CKC “a little more
effective”
VS
Open Chain Closed Chain
Steine et al. (8 Week Treatment)
Outcomes Conclusion
Function: CKC better
Strength: CKC better
Step Downs: CKC better
CKC superior
VS
Open Chain Closed Chain
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
Synthesis Across Studies
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
Statistics Used
Results: Performance Based
Functional Tests
Combined ES and 95% CI: 0.63 (0.18, 1.08)
Favors OKC Favors CKC
Discussion
• Failed to reject null hypothesis
•No statistically significant difference Pain
• Failed to reject null hypothesis
•No statistically significant difference Function
•Reject null hypothesis, accept alternative
•CKC group statistically superior
Knee Extensor Strength
•Reject null hypothesis, accept alternative
•CKC group statistically superior
Performance Based Functional
Tests
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: Pain
Both groups equal increases in function
Discussion: 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
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:
Discussion: Knee Extensor
Strength
Isometric peak torque MCID
49.86 Nm 10 Nm (Lin 2009)
Moderate effect size favoring CKC
Specificity of training (Herrington 2007, Fagan 2008)
Discussion: Performance based
Functional Tests
Author CKC Exercise Test
Steine et al. Lateral stepping
Step Ups/Downs
Step Downs
Witvrouw et al. Single leg squats
Jumping
Triple Jump Test
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
Implications for Clinical Practice
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
Studies in English
Few studies
Small sample sizes
Varying methodology of outcome
measurement
Sub-optimal treatment periods
No long term follow up
Limitations of study
Long term outcomes for OKC vs. CKC
Looking at OKC vs. CKC for different
diagnoses
Comparing quad strengthening alone to
quad and hip strengthening
Directions for Future Research
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
Conclusions
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
Acknowledgements
1. 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.
References
8. 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.
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 Meta-Analysis 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.
References