Are Open (OKC) or Closed Kinetic Chain (CKC) exercises most effective in the treatment of patello femoral pain?
Date First Published:
February 5, 2008
Last Updated:
February 6, 2008
Report by:
Fiona Creedon & Trevor Lewis Consultant Physiotherapist, Advanced Musculoskeletal Practitioner (Knowsley PCT)
Search checked by:
Katherine Bell, Knowsley PCT
Three-Part Question:
[IN] patients presenting with patello - femoral pain [IS]open kinetic chain exercise or closed kinetic chain exercise more effective [AT]reducing pain & improving function
Clinical Scenario:
A 22 year old female presents to physiotherapy with patello femoral symptoms present for the last six months.At this time, she had moved into a flat on the third floor, & noticed gradual onset of symptoms.You are aware that quadriceps strengthening is known to improve the outcome of conservative treatment.Debate ensues as to whether open or closed kinetic chain exercises will be most beneficial in improving pain & function.
Search Strategy:
AMED on DIAL DATASTAR interface 1985-November 2007; CINAHL on DIAL DATASTAR interface 1982- date November 2007; MEDLINE on DIAL DATASTAR interface 1950 to November 2007; Cochrane Library via National Library for Health.
Search Details:
MESH terms [Patella OR Patellar-dislocation OR patellofemoral pain syndrome OR cartilage disease OR dislocation OR arthralgia] OR Keywords [Patellofemoral pain OR patella femoral OR patella dysfunction OR anterior knee pain OR patellar retinaculum OR patella plica$ OR patellar tendinopathy OR Q angle OR A angle OR hamstring tightness]
AND
MESH terms [Muscle-contraction OR exercise OR exercise-therapy OR bandages OR proprioception OR sports medicine OR gait OR physical-therapy-modalities OR isometric-contraction OR hydrotherapy OR braces OR physical education OR training OR proprioception OR muscle-contaction OR isometric contraction OR muscle strength OR electromyography] OR Keywords [Vastus medialis oblique OR knee control OR knee exercises OR quadriceps regime OR quadriceps drill OR quadriceps exercises OR core stability OR core control Or open kinetic chain OR closed kinetic chain]
AND
MESH terms [Muscle-contraction OR exercise OR exercise-therapy OR bandages OR proprioception OR sports medicine OR gait OR physical-therapy-modalities OR isometric-contraction OR hydrotherapy OR braces OR physical education OR training OR proprioception OR muscle-contaction OR isometric contraction OR muscle strength OR electromyography] OR Keywords [Vastus medialis oblique OR knee control OR knee exercises OR quadriceps regime OR quadriceps drill OR quadriceps exercises OR core stability OR core control Or open kinetic chain OR closed kinetic chain]
Outcome:
Altogether 29 papers were found, 5 of which were relevant to the clinical question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Patellofemoral joint pain: A comparison of two treatment programmes. Kath Gaffney et al 1992 Australia | 72 patients, 65% male, mean age 34 (11-65) with PFP, 50% bilateral.Mean duration of symptoms 40.7 months. Duration 6 weeks, weekly visits to check performance all groups.Group 1 pain free eccentric & isometric exercise, with taping.Group 2 concentric isometric exercise. |
RCT | VAS at baseline & 6 weeks | Both groups showed pain reduction p<0.05 but NSS between groups | Group 1 -8 withdrawals, Group 2 - 4 withdrawals. No ITT analysis performed. No control group. Wide age range included , & the pathology evident may not be homogenous in such a large range. Short follow up period with no indication of long term benefits or problems with either programme. |
| Function grade baseline & 6 weeks | Group 1. Improved = 18, no change =4, variable = 10.Group 2. Improved =15, no change =7, variable = 10.p<0.05 for both groups | ||||
| Clarke's Test at baseline & 6 weeks | Group 1.Improved =20 (28%) 8 (14%).Group 2 = Improved. 28 (39%) 11 (17%) | ||||
| Individuals opinion of success at 6 weeks | 25 (89%) Group 2 24 (75%). p<0.05 for both groups | ||||
| Open Versus Closed Kinetic Chain Exercises for Patellofemoral Pain. A Prospective, Randomized Study Witrouw E. et al 2000 Belgium | 60 patients with PFPS, 45% bilateral, duration 15.1 months (0.5-28). Age 20.3 (14-33). No drop outs during study. Group 1 = 30 patients OKC exercises Group 2 = 30 patients CKC exercises. Both groups stretch post training.Duration 5 weeks, both groups train with a physical therapist 3 tims a week for 30 - 45 minutes.Both groups are retested at 3 months following advice to maintain active muscle strength, but no follow up during this time. |
RCT | VAS pain during daily activity, baseline, 5 weeks, 3 months | Significant improvement during rehabilitation in both groups p =<0.05 but during follow up period 5 weeks to 3 months only Group 2 demonstrated reduction in symptoms. | No control group. Strength only tested in open chain position. |
| KPFS: baseline, 5 weeks, 3 months | Group 1 showed increase in functionality at 5 weeks p=0.001 & 3 months p=0.004. Group 2 showed increase in function at 5 weeks p=0.002 & at 3 months, p= 0.001 | ||||
| VAS during triple jump test, baseline,5 weeks, 3 months | Group 1 NSS p=0.13.Group 2 showed significant increase in jumping distance at 5 weeks p=0.04 & at 3 months p=0.02 | ||||
| Unilateral squat: baseline, 5 weeks, 3 months | Group 1 number of patients asymptomatic at baseline 6 (20%) 5 weeks 11 (37%) 16 (53%). Group 2 number of patients asymptomatic at baseline 6 (20%) 5 weeks13 (43%) 3 months 17 (57%) | ||||
| Step up: baseline, 5 weeks, 3 months | Group 1 number of patients asymptomatic at baseline 11(37%) 5 weeks 23 (77%) 3 months 22(73%).Group 2 Asymptomatic at baseline 8 (27%) 5 weeks 18 (60%) 3 months 22 (73%) | ||||
| Step down: baseline, 5 weeks, 3 months | Group 1 number of patients asymptomatic at baseline 8 (27%) 5 weeks 19 (63%) 23 (77%). Group 2 number of patients asymptomatic at baseline 5 (17%) 5 weeks 12 (40%) 3 months 20 (67%).Increase in asymptomatic patients in both groups p=<0.05.No differences between the number of asymptomatic patients in both groups at any evaluation point p> 0.05 | ||||
| Open Versus Closed Kinetic Chain Exercises in Patellofemoral Pain - A 5 year Prospective Randomized Study Witrouw E et al 2004 Belgium | A continuation of the 2000 trial.49 of the 60 patients were available for a 5 year evaluation which followed on from the evaluations previously at baseline, 5 weeks & 3 months. Assessment of muscular characteristics, subjective symptoms, & function reviewed 5 years post rehabilitation.Comparison of results is made between OKC & CKC Groups at 5 years, & is compared to the 3 month follow up statistics. |
RCT | 9 patients Group 1 painfree, Group 2 10 patients painfree. | Group 1 complained of less swelling than Group2 p=.04 | No ITT analysis. No control group |
| Swelling of the knee | Group1 less pain than Group 2 p=.01 | ||||
| Pain on stair descent | Group1 had less night pain p=.04 | ||||
| Night pain | NSS between groups | ||||
| Kujala score | NSS between groups | ||||
| Triple jump & maximal painfree knee bend | NSS between groups | ||||
| Muscle strength measurements | NSS between 17/18 VAS | ||||
| Subjective Assessment comparison between 3 months & 5 years Group 1 | More pain at 5 years p=.04 | ||||
| Pain during sitting | NSS | ||||
| Group1 Kujala Pain score at 3 months & 5 years | Improved at 5 years p =.01 | ||||
| Group 1 pain free maximal knee bend & 45 cm step test | NSS | ||||
| Group1muscle strength at 3 months & 5 years | Worsened p=.01 - p=.04 | ||||
| Group 2 at 3 months & 5 years descending stairs, jumping, sport, & prolonged sitting with knees flexed, triple jump, | NSS | ||||
| Group 2 at 3 months & 5 years Kujala score, 45 cm step test, pain free maximal knee bend & quadriceps muscle strength | Deteriorated at all 3 velocities p=0.01 | ||||
| Group2 at 3 months & 5 yearshamstring strength | |||||
| A Controlled Trial of Weight - Bearing versus Non - Weight Bearing Exercises for Patellofemoral Pain Herrington L et al 2007 UK | N = 45 male patients 18 - 35 years (mean = 26.9) with PFPs. Group 1 = single joint non-weight bearing quadriceps exercise (SJNWBE) Group 2 = Weight bearing multiple joint exercise (MJWBE) Group 3 = Control . Subjective symptoms, knee extensor muscle strength, & function measured at initial examination & at completion at 6 weeks. |
RCT | Modified Kujala Score at baseline & 6 weeks | Group 1 significantly increased function p=.03.Group 2 significantly increased function p=.01.NSS between both groups post intervention.Post intervention scores significantly better for intervention groups as compared to the Control Group p=<0.01.Control Group showed decrease in function over 6 weeks p=.03 | No long term folllow up. |
| Knee extension strength measured at 60 degrees knee flexion with Cybex II dynamometer | Isometric Quadriceps muscle peak force at 6 weeks - Both groups increased significantly. Group 1 p-0.01, & Group 2 p=0.005.Post intervention NSS between both groups. Knee extension strength greater for both exercise groups than for the control group Group 1 p=.01 Group 2 p=.035. | ||||
| Pain During Knee Extension Strength Test | Pain reduction following intervention for Group 1 p=.005 & Group 2 p=.025.NSS post intervention for both groups p>.05.Post intervention, both exercise groups had lower pain compared to the control group. Group 1 p=.015, Group 2 p=.005 | ||||
| VAS with step down | Both groups had a significant decrease post intervention p=<.001, NSS between both groups.No change in pain level in the control group. | ||||
| Open verus closed kinetic chain exercises for patellar Chondromalacia Bakhitary A et al 2007 Iran | N= 32 university females Group 1 = OKC exercises, Group 2 = CKC exercises. Outcomes assessed at baseline, at completion of treatment at 3 weeks & 2 weeks post completion. |
RCT | Q angle | Reduced in both groups p=0.016. No results for 2 weeks later. | No control group. No long term follow up. Some results incomplete. No details of what was included in VAS. No reporting of side effects. |
| Crepitation | Present in 90% of both groups at baseline.Group 1 decreased to 55.6% & Group 2 to36.7%.No change 2 weeks later. | ||||
| MIVCF | Increased muscle force in Group 2 at 3 weeks p=0.01.No results for 2 weeks later. | ||||
| Thigh circumference | Both groups show increase Group1 p=0.02, Group 2 p=0.002. Results unchanged 2 weeks later. | ||||
| VAS | Both showed pain reduction, NSS between both groups at completion & 2 weeks later p=0.13 |
Author Commentary:
There is evidence for the effectiveness of exercise therapy in the treatment of PFPS in reducing pain & improving function.
A six week programme appears to improve subjective & clinical outcomes.
The belief that OKC exercises are to be avoided in PFPS has not been substantiated.
The Gaffney & Witrouw (2000) papers were included in a Cochrane review (Hientjes et al) which looked at all forms of exercises for PFPS.
A six week programme appears to improve subjective & clinical outcomes.
The belief that OKC exercises are to be avoided in PFPS has not been substantiated.
The Gaffney & Witrouw (2000) papers were included in a Cochrane review (Hientjes et al) which looked at all forms of exercises for PFPS.
Bottom Line:
Exercise therapy is effective in the treatment of PFPS irrespective of its type.
References:
- Kath Gaffney et al. Patellofemoral joint pain: A comparison of two treatment programmes.
- Witrouw E. et al. Open Versus Closed Kinetic Chain Exercises for Patellofemoral Pain. A Prospective, Randomized Study
- Witrouw E et al. Open Versus Closed Kinetic Chain Exercises in Patellofemoral Pain - A 5 year Prospective Randomized Study
- Herrington L et al. A Controlled Trial of Weight - Bearing versus Non - Weight Bearing Exercises for Patellofemoral Pain
- Bakhitary A et al. Open verus closed kinetic chain exercises for patellar Chondromalacia