The Effectiveness of Open Versus Closed Kinetic Chain Exercises In Accelerated Rehabilitation After Anterior Cruciate Ligament Reconstructive Surgery: A Systemic Review Malak Azab PT

1
The Effectiveness of Open Versus Closed Kinetic
Chain Exercises In Accelerated Rehabilitation
After Anterior Cruciate Ligament Reconstructive
Surgery A Systemic ReviewMalak Azab PT
Table 1 summarizes the literature that indicates
the effectiveness of OKC versus CKC exercises in
accelerated rehabilitation after ACL
reconstructive surgery.
Discussion This review summarizes the
results of twelve studies that investigate the
effect of OKC and CKC exercises on knee function,
laxity and pain level, different types of CKC
exercises, effect of CKC exercises in accelerated
rehabilitation after ACLR and the functional
outcomes, and the biomechanics of the knee during
OKC and CKC exercises. ? Four studies reflect
the effect of CKC exercises in accelerated
rehabilitation after ACLR and the functional
outcome. It was found that CKC exercises have a
very important role in strengthening the
quadriceps muscle, and they may be protecting the
ACL grafts. ? Two studies compared different
types of CKC exercises in their effect during ACL
rehabilitation. It was found that CKC exercises
decrease the anterior shear force so it can be
safely used after ACLR. ? One study investigated
the biomechanics of the knee during OKC and CKC
exercises. And found that OKC exercises plays an
important role in strengthening rectus femoris
while as CKCE plays an important role in
strengthening vasti muscles. ? Five studies
investigated the effect of OKC and CKC exercises
on knee function, laxity and pain level after
ACLR and found that no differences between both
programs.


Introduction Anterior cruciate ligament
(ACL) injuries are common in athletes. The
mechanism of injury usually occurs with
deceleration of the planted limbs tibia in
relation to the femur combined with turning
around, pivoting, twisting, or changing of
direction suddenly (valgus stress at knee joint
combined with sudden rotation). The ACL plays a
very important part in establishing the
functional stability of the knee and is
considered a primary restraint to the anterior
translation of the tibia on the femur.
During the last 10 years there was a move toward
favoring closed kinetic chain exercises (CKC)
over the open kinetic chain (OKC) exercises in
the rehabilitation of the ACL for the following
reasons 1- Decreases the anterior shear forces
between tibia and femur 2- Decrease the
compression forces of the tibiofemoral joint 3-
Increase the hamstrings co contraction 4- CKC
exercises are involved in most of our daily
living activities than OKC exercises and, 5-
Decrease the complication of patellofemoral joint
as chondromalacia, patella maltracking, patella
tendenosis, and pre patellar bursitis . One of
the very important decisions the clinician has to
make is to choose which program is more effective
in accelerating the rehabilitation process after
an ACL injury. Because of the above reasons we
are trying to investigate the effectiveness of
CKC versus OKC exercises after ACL
reconstruction. CKC exercises replicate most of
our daily living activities. A strong
quadriceps muscle plays an important role in
preventing ACL injury and in accelerating the
rehabilitation following ACL reconstruction by
preventing the anterior translation of the tibia.
Due to the confusion regarding which program is
more effective following the anterior cruciate
ligament reconstruction (ACLR), it is important
to understand the role of quadriceps and
hamstring muscles during daily living activities.
During the OKC activities (kicking, swimming,
wrestling), the hamstrings are considered an ACL
protector or agonists, and the quadriceps as
antagonists. While as during CKC activities
(running, standing, walking, jumping, skiing),
the quadriceps plays the role of ACL supporter
or main protagonists of ACL.
Citation Purpose Subjects Interventions Results
Perry et al., 20051 This study compared the effects of closed and open knee exercises on knee laxity and functions in patients with ACLD knees. 64 participants with knee anterior Cruciate ligament deficiency. Their age was between 18-60 (49 males and 15 females). Were randomized to two groups CKC group (n32) OKC group (n32). The CKC group received CKC strengthening exercises for the hip and knee extension. The OKC group received OKC knee strengthening exercises for the hip and knee extensor. Strengthening exercises were performed 3 sets of 20 each session until the wk 4 then 3 sets of 6 at wk 6. The results of this study showed that OKC and CKC knee extensors exercises have no significant differences in their effect on knee laxity and functions with patients with ACLD knees.
Morrissey et al., 20022 This study compared the effect of CKC and OKC on the level of knee pain in the early stage after ACL reconstruction. 43 subjects with ACL reconstruction surgery, Their age between 16-54 (9 females and 34 males) were randomized to two treatments groups. Group C (CKC training) (n21) and Group O (OKC training) (n 22) Group C received CKC exercises for hip and knee extensors muscles. Group O received resistance for hip and muscle extensors group. all participants received 3 sessions per wk for 4 wks. Resistance exercises were 3 sets of 20 RM in each session with no additional resistance exercises. The results showed that there were no differences between the two groups in muscle performance also there was no significant change in pain reduction between CKC and OKC groups.
Conclusion The review supports that there
are no differences between OKC and CKC exercises
in their effect on accelerated rehabilitation
after ACLR. It can be concluded that combining
OKC and CKC exercises could be more effective in
accelerated rehabilitation.
Morrissey et al., 20003 This study compared the effect of OKC versus CKC on knee laxity in the early stage following ACLR. 36 participants with ACL reconstructive surgery, with a mean age of 30 were assigned randomly to two groups CKC (18 with 6 F and 12 M) OKC (18 with 1 F and 17 M). CKC group received CKC resistive exercises for the knee and hip extensor. The OKC group received resistive exercises for the hip and knee extensor. Both groups received physical therapy 3T X WK X 4 wks and with 3 sets of 20 repetitions in each session. The results showed no statistically significant differences between OKC and CKC training exercises of knee and hip extensor in the knee laxity or anterior tibial displacements (ATD) in the early period following ACLR.
Mikkelsen et al., 20004 This study compared CKC program versus a combined program of CKC and OKC for quadriceps hamstring strength, knee laxity, and return to sport after ACLR. 44 participants with ACL reconstruction with ages between (18- 40) years were assigned randomly to two groups. CKC group (17 M and 5 F) and CKC combined with OKC group (17 M and 5 F). 1st group received only CKC quadriceps exercises. The 2nd group received the same quadriceps CKC exercise as in the 1st group, but from the 6th wk after the surgery OKC quadriceps exercises were added. The rehabilitation period was for 6 months. There were no significant differences between both groups in knee laxity at 6 month. OKC combined with CKC showed a significant improvement in the concentric and eccentric strength of quadriceps at 6 month, and no difference in strength of hamstring. Combined group returned earlier to sport than CKC group.
Recommendation Further randomized clinical
trials are needed to be done to determine the
best time to starts these exercises and to
investigate how and when to combine OKC and CKC
exercises to accelerate rehabilitation of ACLR
and to provide strong evidence about selective
OKC and CKC exercises that could be used in
acceleration rehabilitation after ACLR.
Purpose The purpose of this work was to
investigate the effectiveness of OKC compared to
CKC in accelerated rehabilitation after anterior
cruciate ligament reconstructive surgery.

• Methods
• A computerized search of the literature was
  performed using the following databases MEDLINE,
  CINHAL, COCHRANE and PEDro database. The key
  words for the search were ACL reconstruction,
  ACL rehabilitation, open kinetic chain, closed
  kinetic chain, and exercises. Studies meeting the
  following criteria were selected for review
• Studies were related to open versus closed
  kinetic chain exercises and their effect in
  accelerated rehabilitation after anterior
  cruciate ligament reconstructive surgery.
• Meta- analysis and randomized controlled trials
  and,
• Published in a peer reviewed source

References 1- Perry MC, Morrissey D, Knight PR,
McAuliffe TB, King JB Knee extensors kinetic
chain training in anterior cruciate ligament
deficiency. Knee Surg Sports Traumatol Arthro.
2005 Nov13(8)638-48. Epub 2005 May
5. 2-Morrissey MC, Drechsler WI, Morrissey D,
Knight PR, Armstrong PW, McAuliffe TB Effects of
distally fixated versus no distally fixated leg
extensor resistance training on knee pain in the
early period after anterior cruciate ligament
reconstruction. Phys Ther. 2002 Jan 82(1)35-43.
3- Morrissey MC, Hudson ZL, Drechsler WI, Coutts
FJ, Knight PR, King JB Effects of open versus
closed kinetic chain training on knee laxity in
the early period after anterior cruciate ligament
reconstruction. Knee Surg Sports Traumatol
Arthro. 2000 8(6)343-8. 4- Mikkelsen C, Werner
S, Eriksson EClosed kinetic chain alone compared
to combined open and closed kinetic chain
exercises for quadriceps strengthening after
anterior cruciate ligament reconstruction with
respect to return to sports a prospective
matched follow-up study. Knee Surg Sports
Traumatol Arthro. 20008(6)337-42. 5- Graham VL,
Gehlsen GM, Edwards JA Electromyographic
Evaluation of Closed and Open Kinetic Chain Knee
Rehabilitation Exercises. J Athl Train. 1993
Spring 28(1)23-30.
Results Twelve studies were selected
according to the mentioned criteria. Five studies
investigated the effect of open kinetic chain and
closed kinetic chain exercises on knee function,
laxity and level of pain in the early stage after
ACL reconstruction. Two studies compared
different types of CKC exercises in their effect
during ACL rehabilitation. Four studies reflect
the effect of CKC exercises in accelerated
rehabilitation after ACLR and the functional
outcome. One study investigated the biomechanics
of the knee during OKC and CKC exercises.