Open vs. Closed Kinetic Chain Exercises for Patellofemoral Pain Syndrome: An Evidence Based Review

Transcription

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

2 Significance of Patellofemoral Pain Syndrome (PFPS) 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)

3 Clinical Problem: 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

4 Patellofemoral Joint 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 Levangie and Norkin, 2005 Levangie and Norkin, 2005

5 Relevance to PT PFPS results in pain, decreased function, and decreased strength Conservative treatment first line (Bakhtiray, 2007) Efficacious, evidence based, appropriate rehab protocal

6 Theoretical Construct Classically, decreased quad strength Exercise is effective for PFPS Quadriceps Sole risk factor for PFPS Short + long term benefits Tracking Bolga 2011, Bizzini 2003, Dixit 2005, Herrington 2007, Lankhorst 2012

7 Theoretical Construct Open Chain VS Closed Chain Quad Isolation More Functional Greater PFJRFs Co-Contraction Less Functional Proprioception Eccentric Activity Decreased PFJRFs Bahktiary 2007, Fagan 2008 Steine 1996, Steinkamp 1993, Syme 2009, Witrvouw 2000

8 Gaps in Literature Clinical studies Mixed results Systematic Reviews (Bolga, 2011; Heintjes 2009) Pain and/or function only Did not combine effect sizes

9 Purpose and Primary Question 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)

10 PICO Population Diagnosed with PFPS Intervention Closed Kinetic Chain exercises Control Open Kinetic Chain exercises Outcomes 1) Pain 2) Function 3) Knee Extensor Strength 4) Performance Based Functional Tests

11 Hypotheses 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

12 Expected Findings Expected Findings: 4-5 RCTs, systematic reviews, case studies Expected Answer: CKC exercises are superior to OKC exercises for all outcomes

13 Methods: Search Procedures Comparing OKC vs. CKC Inclusion Criteria Adults English Exclusion Criteria Other diagnoses Prevention

14 Methods: Search Procedures Databases PubMed CINAHL Cochrane Database PeDRO JOSPT Recursive Search Search Terms Patellofemoral Anterior knee pain Chondromalacia Open kinetic chain Closed kinetic chain

15 Search Results 212 from database search 182 excluded due to irrelevance 30 for further review 4 articles selected for inclusion 26 excluded due to: 1. Not comparing OKC vs. CKC 2. Other knee pathologies 3. Not English 4. Prevention Confirmed by 2 independent reviewers

16 List Articles Results 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 Witvrouw et al. 5 weeks RCT, 1B *(Jewell 2008)

17 Open Chain Bahktiary et al. (3 Week Treatment) Closed Chain VS Outcomes Conclusion Pain: no difference Strength: CKC better CKC superior

18 Open Chain Herrington et al. (6 Week Treatment) Closed Chain VS Outcomes Conclusion Pain: no difference Function: no difference Strength: no difference OKC and CKC equally effective

19 Open Chain Witvrouw et al. (5 Week Treatment) Closed Chain VS Outcomes Pain: no difference Function: no difference Strength: CKC better Triple Jump: no difference Conclusion CKC a little more effective

20 Steine et al. (8 Week Treatment) Open Chain Closed Chain VS Outcomes Function: CKC better Strength: CKC better Step Downs: CKC better Conclusion CKC superior

21 Synthesis Across Studies 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

22 Statistics Used 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

23 Results: Pain Favors OKC Favors CKC Combined ES and 95% CI: (-0.45, 0.27)

24 Results: Function Favors OKC Favors CKC Combined ES and 95% CI: (-0.42, 0.40)

25 Results: Knee Extensor Strength Favors OKC Favors CKC Combined ES and 95% CI: 1.15 (0.77, 1.54)

26 Results: Performance Based Functional Tests Favors OKC Favors CKC Combined ES and 95% CI: 0.63 (0.18, 1.08)

27 Results: Outcomes Summary Favors OKC Favors CKC

28 Discussion Pain Failed to reject null hypothesis No statistically significant difference Function Failed to reject null hypothesis No statistically significant difference Knee Extensor Strength Reject null hypothesis, accept alternative CKC group statistically superior Performance Based Functional Tests Reject null hypothesis, accept alternative CKC group statistically superior

29 Discussion: Pain 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

30 Discussion: Function Both groups equal increases in 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

31 Discussion: Knee Extensor 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: Strength Isometric peak torque MCID Nm 10 Nm (Lin 2009)

32 Discussion: Performance based Functional Tests Moderate effect size favoring CKC Specificity of training (Herrington 2007, Fagan 2008) Author CKC Exercise Test Steine et al. Lateral stepping Step Ups/Downs Step Downs Witvrouw et al. Single leg squats Jumping Triple Jump Test

33 Implications for Clinical Practice 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

34 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

35 Limitations of study Studies in English Few studies Small sample sizes Varying methodology of outcome measurement Sub-optimal treatment periods No long term follow up

36 Directions for Future Research Long term outcomes for OKC vs. CKC Looking at OKC vs. CKC for different diagnoses Comparing quad strengthening alone to quad and hip strengthening

37 Conclusions 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

38 Acknowledgements 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

39 References 1. Dixit Sameer DJP, Burton Monique, Mines Brandon. Management of Patellofemoral Pain Syndrome. American Family Physician 2007;75: 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: Bakhtiary AH, Fatemi E. Open versus closed kinetic chain exercises for patellar chondromalacia. British Journal of Sports Medicine 2008;42: Levangie PKNCC. Joint Structure & Function: A Comprehensive Analysis. Fourth ed. Philadelphia: F.A. Davis Company; Bolga Lori A BMC. An Update for the Conservative Management of Patellofemoral Pain Syndrome: A Systematic Review of the Literature from 2000 to The International Journal of Sports Physical Therapy 2011;6: Collado Herve FM. Patellofemoral Pain Syndrome. Clinical Sports Medicine 2010: 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:CD

40 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: 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: Lankhorst NE B-ZS, Van Middelkoop M. Risk Factors for Patellofemoral Pain Syndrome: A Systematic Review JOSPT 2012;42: Fagan V, Delahunt E. Patellofemoral pain syndrome: a review on the associated neuromuscular deficits and current treatment options. Br J Sports Med 2008;42: Steinkamp LA, Dillingham MF, Markel MD, Hill JA, Kaufman KR. Biomechanical considerations in patellofemoral joint rehabilitation. Am J Sports Med 1993;21: 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: 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: 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:

41 References 16. Iguchi M, Shields RK. Quadriceps low-frequency fatigue and muscle pain are contraction-type-dependent. Muscle & nerve 2010;42: Woodall W WJ. A Biomechanical Basis for Rehabilitation Programs Involving the Patellofemoral Joint. JOSPT 1990;11: 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: Borenstein M HL, Higgins J, Rothstein H. Comprehensive Meta- Analysis Version 2. In. Engelwood, NJ: Biostat; Jewell DV. Guide to evidence-based physical therapy practice: Jones & Bartlett Learning; Hungerford DS BM. Biomechanics of the patellofemoral joint. Clin Orthop 1979: 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:

42 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: Roush MB ST, Wilson JK, et al. Anterior Knee Pain: A Clinical Comparison of Rehabilitation Models Clinical Journal of Sports Medicine 2000: 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: Kujuala UM JL, Koskinen SK, et al. Scoring of patellofemoral disorders. Arthroscopy 1993: 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: 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: 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:

43 Questions?

44 Patellofemoral Pain Syndrome Weak Quads Foot Kinematics Muscle Imbalance PFPS Hip Weakness Soft Tissue Tightness Increased Q angle (Bolga, 2011; Heintjes,