1. Copyright 2005 Lippincott Williams & Wilkins Chapter 15 Closed Kinetic Chain Training

2. Copyright 2005 Lippincott Williams & Wilkins Physiologic Principles of Closed Kinetic Chain (CKC) Training 1.Muscular factors 2.Biomechanical factors 3.Neurophysiologic factors

3. Copyright 2005 Lippincott Williams & Wilkins Muscular Factors  Stimulates muscular co-contractions – Enhancing stability in weight-bearing position.  Provides dynamic stabilization – Improved postural holding and support.  Contractions are generally eccentric followed by co-activation and concentric muscle function (e.g., stretch-shortening cycle [SSC]).

4. Copyright 2005 Lippincott Williams & Wilkins Muscular Factor – SSC 1.Combine speed and strength of contractions. 2.Involves rapid closing and opening of the kinetic chain. 3.Closed kinetic chain (CKC) activities that stimulate the use of SSC include:  Running  Jumping  Box drills  Skipping

5. Copyright 2005 Lippincott Williams & Wilkins Biomechanical Factors 1.Shape/geometry of joint surfaces. 2.Joint approximation. 3.Joint receptor stimulation. Joint ApproximationJoint CongruencyJoint Stability

6. Copyright 2005 Lippincott Williams & Wilkins Wolff’s Law Bone Remodels According to the Stresses Placed Upon It. Additional support for using CKC exercises in rehabilitation is provided by the constant remodeling of tissues.

7. Copyright 2005 Lippincott Williams & Wilkins Closed Chain Pronation

8. Copyright 2005 Lippincott Williams & Wilkins Neurophysiologic Factors 1.Mechanoreceptors – CKC activities stimulate mechanoreceptors. 2.Balance – CKC exercises focusing on balance and postural control are used to restore normal kinesthesia. 3.Neural adaptation – CKC training enhances neural drive for muscle group recruitment. 4.Specificity of training – CKC relies on specificity.

9. Copyright 2005 Lippincott Williams & Wilkins Examination and Evaluation  Testing of CKC – Static and dynamic  Static balance testing  Excursion test in single limb stance  “ProWedgeIt” – Assesses patient’s function in frontal plane  Lower extremity functional profile

10. Copyright 2005 Lippincott Williams & Wilkins ProWedgeIt

11. Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Intervention  Position and function of entire kinetic chain should be considered.  Focus rehabilitation on functional limitations of entire limb.

12. Copyright 2005 Lippincott Williams & Wilkins Elements of Movement System Base Element Impairments  Muscle performance  Range of motion  Muscle length  Joint mobility/integrity

13. Copyright 2005 Lippincott Williams & Wilkins Base Element Considerations  Open kinetic chain (OKC) exercises in gravity assisted positions may be necessary until muscle performance improves to a functional level.  Consider proximal and distal segments when choosing CKC exercises.  CKC exercises after joint mobilization can be helpful to ensure proper kinematics.

14. Copyright 2005 Lippincott Williams & Wilkins Biomechanical Element Element Most Affected by CKC Training Major biomechanical considerations: 1.Placement of the center of mass. 2.Placement of the foot and all joint centers proximal to the foot.

15. Copyright 2005 Lippincott Williams & Wilkins Center of Mass and CKC

16. Copyright 2005 Lippincott Williams & Wilkins Dosage – Parameters  Type of contraction  Intensity  Speed  Duration  Frequency  Sequence  Environment  Feedback

17. Copyright 2005 Lippincott Williams & Wilkins Dosage – General Considerations  Acquiring good postural control is important for efficient function and safety.  Intensity should be low early in rehabilitation process.  CKC exercises should be performed slowly and under neuromuscular control.  As coordination and tissue status improves, increase mechanical stress by increasing weight-bearing forces.

18. Copyright 2005 Lippincott Williams & Wilkins Lower Extremity Examples Exercise Addressing Balance Impairment

19. Copyright 2005 Lippincott Williams & Wilkins Exercise Addressing ROM and Joint Mobility Impairment

20. Copyright 2005 Lippincott Williams & Wilkins Exercise Addressing Muscle Performance Impairment

21. Copyright 2005 Lippincott Williams & Wilkins Exercise Addressing Muscle Performance and Balance Impairment

22. Copyright 2005 Lippincott Williams & Wilkins Upper Extremity Examples Exercise Addressing Muscle Performance Impairment

23. Copyright 2005 Lippincott Williams & Wilkins Exercise Addressing Muscle Performance and Balance Impairment

24. Copyright 2005 Lippincott Williams & Wilkins Exercise Addressing ROM and Joint Mobility Impairment

25. Copyright 2005 Lippincott Williams & Wilkins Precautions and Contraindications Safety Is Primary!!  Begin at submaximal levels and progress to functional goals.  Incorporate criteria for gradation of the exercise.  If substitution occurs, alter the exercise to an easier level.

26. Copyright 2005 Lippincott Williams & Wilkins Summary CKC exercises use the forces of weight bearing and the effect of gravity to simulate functional activities. Proximal segments move over more fixed distal segments. Success of using CKC activities in rehabilitation begins with understanding kinetics and kinematics of joints and subsequent kinesiology.

27. Copyright 2005 Lippincott Williams & Wilkins Summary (cont.) Common characteristics of CKC include:  Dependence of joint motion  Motion proximal and distal to center of rotation  Greater joint compressive forces  Stabilization via joint congruency  Muscle recruitment  Eccentric followed by concentric contractions for more functional patterns