Open-Versus Closed-Kinetic Chain Exercise in Rehabilitation Rehabilitation Techniques for Sports Medicine and Athletic Training William E. Prentice

Introduction Closed Kinetic Chain (CKC): effective technique of rehabilitation Particularly with injuries involving the lower extremity Ankle, knee and hip constitute the kinetic chain of lower extremity When distal segment of lower extremity is fixed/stabilized or weight bearing it is considered Closed Will involve fixed joints with mobile joints in between

Introduction Open Kinetic Chain (OKC): distal segment is mobile or not fixed Isolated joint exercise. i.e.. Seated leg extension Most Upper extremity movements in sports are open chain with the hand moving freely

Concept of Kinetic Chain Closed Link system: each moving body segment receives force from and transfers force to, adjacent body segments Movement and one joint produce predictable movement at all other joints Muscle recruitment and joint movements are different than when distal segment moves freely in OKC ex. Concurrent shift: Concentric and eccentric contractions at opposite ends of a muscle during CKC movement For example: during squat to stand the hip and knee both extend and the rectus femoris shortens at the distal end and lengthens at the proximal end Functional action that cannot be reproduced during isolated OKC ex.

Advantages and Disadvantages of OKC vs. CKC Exercises Choice to use one or the other depends on desired treatment goal Characteristics of CKC: Increased joint compressive forces Increased joint congruency (stability) Decreased shear forces Decreased acceleration forces Stimulation of proprioceptors Large resistance forces Enhanced dynamic stability

Advantages and Disadvantages of OKC vs. CKC Exercises OKC characteristics: Increased acceleration forces Decreased resistance forces Increased distraction and rotational forces Increased deformation of joint and muscle mechanoreceptors Greater shear forces Great moment forces (1 joint in motion) Isolation exercise use contraction of specific muscle or muscle group that produces single plane or occasionally multiplanar movement

Advantages and Disadvantages of OKC vs. CKC Exercises Biomechanical Perspective: CKC : safer and produce stresses and forces that are potentially less of a threat to healing structures Co-contraction of agonist and antagonist must occur during normal movements to provide joint stabilization Decrease shear forces seen in OKC that may damage soft tissue structures that are healing Increase joint compressive forces will further enhance joint stability CKC more functional than OKC: most sport related activity and activities of daily living involve CKC of lower extremity

Advantages and Disadvantages of OKC vs. CKC Exercises Biomechanical Perspective OKC: isolated to single joint Beneficial to improve strength and increase ROM at specific joint Correct strength deficits of specific muscles or joints and beginning of rehabilitation when athlete not able to perform CKC exercises Loss of ROM, pain or swelling may not allow athlete to perform CKC exercises

CKC to regain NM Control Coordinated movement is controlled by CNS that that integrates input from joint and muscle mechanoreceptors acting within kinetic chain CKC Exercises that act to integrate all of the functioning elements would seem to be most appropriate CKC recruit foot, ankle, knee and hip muscles that reproduce normal loading and movement forces in all joints Reestablish joint position sense and proprioception through facilitation of proprioceptive feedback

CKC Exercises for LE Biomechanically shock absorption, foot flexibility, foot stabilization, acceleration and deceleration, multiplanar movement and joint stabilization must occur in all joints of LE for normal function to occur Foot shock absorber and force producer through normal ambulation (gait) OKC exercises produce a lot of shear force on tibiofemoral (knee) joint Co-contraction of hamstring or CKC exercises reduces shear force OKC exercises produce a lot of compressive forces on PTF joint CKC exercises decreases contact stress by increasing contact area on femur

CKC Exercises for LE Mini squats Wall slides Lunges Step ups Leg Press Fwd. & Lateral Leg Press Stationary Bicycle TKE Trampoline BAPS Sideboard

OKC vs. CKC in Upper Extremity UE most functional as OKC system Hand moves freely Dynamic movement High velocity Proximal segment of UE used as stabilization as distal segments have high degrees of mobility

OKC vs. CKC in Upper Extremity CKC in UE: Strengthening and neuromuscular control of shoulder girdle stabilizers and core Co-contraction and muscle recruitment in early stages of rehab to prevent shutdown of rotator cuff Scapular stabilizers and Rotator Cuff control movement about shoulder Provide stabile base for more mobile and dynamic movements at distal end Promote and enhance dynamic joint stability Resistance axially or rotationally Joint compression and approximation acts to enhance muscular co- contraction about the joint producing dynamic stability

OKC vs. CKC in Upper Extremity OKC Exercises in UE: Essential to regain high velocity dynamic movement of shoulder, elbow, wrist and hand CKC and OKC should both be used in rehab to stabilize and build muscular strength and endurance in upper extremity

OKC vs. CKC in Upper Extremity Weight shifting Standing, quadruped, tripod, stable, unstable and movable surfaces Push ups Press ups Step ups Slideboard Push up with rotation

PNF Exercises for Strength and Endurance Uses proprioceptive, cutaneous and auditory input to produce functional movement First used to treat patients with paralysis or other neuromuscular disorders Since 1970’s used in rehabilitation to increase strength, range of motion and flexibility Used to decrease deficiencies in strength , flexibility, and neuromuscular coordination in response to demands that are placed on NM system

PNF Exercises for Strength and Endurance Emphasis on selective re-education of individual motor elements through development of NM control, joint stability and coordinated mobility Each movement learned and reinforced through repetition Holistic, integrating sensory, motor, and psychological aspects of rehabilitation Incorporates reflex activities from spinal level and upward, either inhibiting or facilitating them as appropriate

Basic Principles of PNF Patient taught patterns from starting to terminal position Verbal and physical cues, brief and simple Patient watches moving limb for visual feedback for directional and positional control Manual contact with appropriate pressure is essential Firm and confident Manner in which AT touches patient will facilitate movement Proper body position and mechanics of AT in line with movement patterns Amount of resistance should facilitate maximal response and smooth coordinated movement

Basic Principles of PNF Rotational movement is critical component because maximal contraction is impossible without it Distal movement occurs first: Quick stretch before muscle contractions facilitates a muscle to respond with greater force

Basic strengthening techniques Rhythmic initiation Repeated contraction Slow reversal Slow reversal hold Rhythmic stabilization

PNF patterns Human movement rarely involves straight motion because all muscles are spiral in nature and lie in diagonal directions PNF patterns are diagonal and rotational movements Three components Flexion-extension Abduction-adduction Internal rotation-external rotation

PNF Patterns Figures 14-1 and 14-30 in text Rule of 30’s