open versus closed kinetic chain exercises for patellofemoral pain syndrome_tsai

44
Open vs. Closed Kinetic Chain Exercises for Patellofemoral Pain Syndrome: An Evidence Based Review Thomas Tsai, DPTc DPT Candidate Spring Symposium 2012

Upload: baykal-celik

Post on 29-Nov-2015

201 views

Category:

Documents


2 download

TRANSCRIPT

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: Pain

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

Favors CKC Favors OKC

Results: Function

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

Favors OKC Favors CKC

Results: Knee Extensor Strength

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

Favors OKC Favors CKC

Results: Performance Based

Functional Tests

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

Favors OKC Favors CKC

Results: Outcomes Summary

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

Questions?

PFPS

Weak Quads

Muscle Imbalance

Soft Tissue Tightness

Increased Q angle

Hip Weakness

Foot Kinematics

Patellofemoral Pain Syndrome

(Bolga,

2011;

Heintjes,

2009)