Open vs. Closed Kinetic Chain Exercises for Patellofemoral Pain Syndrome: An Evidence
Transcription
Open vs. Closed Kinetic Chain Exercises for Patellofemoral Pain Syndrome: An Evidence
Open vs. Closed Kinetic Chain Exercises for Patellofemoral Pain Syndrome: An Evidence Based Review Thomas Tsai, DPTc DPT Candidate Spring Symposium 2012 Significance of Patellofemoral Pain Syndrome (PFPS) Most common cause of knee pain in the outpatient setting. Accounts for 25% - 40% of knee problems in sports medicine centers. 11% of MSK complaints in the office setting caused by anterior knee pain. (Dixit, 2007) (Bizzini, 2003) (Dixit, 2007) Clinical Problem: PFPS Definition › Peri or retropatellar pain (Bizzini, 2003) Cause › Abnormal patellar tracking. Symptoms (Bolga, 2011) (Heintjes, 2009) › Pain with Stairs, Squatting, Sitting Impairments › quadriceps and hip strength › Frontal plane imbalances › Posture dysfunctions 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 Relevance to PT PFPS results in pain, decreased function, and decreased strength Conservative treatment first line Efficacious, evidence based, appropriate rehab protocal (Bakhtiray, 2007) Theoretical Construct Classically, decreased quad strength Exercise is effective for PFPS Sole risk factor for PFPS Quadriceps Short + long term benefits Tracking Bolga 2011, Bizzini 2003, Dixit 2005, Herrington 2007, Lankhorst 2012 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 Gaps in Literature Clinical studies › Mixed results Systematic Reviews (Bolga, 2011; Heintjes 2009) › Pain and/or function only › Did not combine effect sizes 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. 2. 3. 4. Pain Function Knee extensor strength Performance based functional tests (PBFTs) 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 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 Expected Findings Expected Findings: 4-5 RCTs, systematic reviews, case studies Expected Answer: CKC exercises are superior to OKC exercises for all outcomes Methods: Search Procedures Comparing OKC vs. CKC Inclusion Criteria Adults English Exclusion Criteria Other diagnoses Prevention Methods: Search Procedures Databases Search Terms › PubMed › Patellofemoral › CINAHL › Anterior knee pain › Cochrane › Chondromalacia Database › PeDRO › JOSPT › Recursive Search › Open kinetic chain › Closed kinetic chain Search Results 212 from database search 182 excluded due to irrelevance 30 for further review 26 excluded due to: 1. Not comparing OKC vs. CKC 2. Other knee pathologies 3. Not English 4. Prevention 4 articles selected for inclusion Confirmed by 2 independent reviewers List Articles Results Author Length Study Type* Total Subjects Bahktiary et al. 3 weeks RCT, 1B 32 Pilot RCT, 2B 45 Herrington et al. 6 weeks Steine et al. 8 weeks QuasiExperimental, 2B 23 Witvrouw et al. 5 weeks RCT, 1B 60 *(Jewell 2008) Bahktiary et al. (3 Week Treatment) Open Chain Closed Chain VS Outcomes Conclusion Pain: no difference Strength: CKC better CKC superior Herrington et al. (6 Week Treatment) Open Chain Closed Chain VS Outcomes Conclusion Pain: no difference Function: no difference Strength: no difference OKC and CKC equally effective Witvrouw et al. (5 Week Treatment) Open Chain Closed Chain VS Outcomes Conclusion Pain: no difference Function: no difference Strength: CKC better Triple Jump: no difference CKC “a little more effective” Steine et al. (8 Week Treatment) Open Chain Closed Chain VS Outcomes Conclusion Function: CKC better Strength: CKC better Step Downs: CKC better CKC superior 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 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 Results: Pain Favors OKC Favors CKC Combined ES and 95% CI: -0.09 (-0.45, 0.27) Results: Function Favors OKC Favors CKC Combined ES and 95% CI: -0.01 (-0.42, 0.40) Results: Knee Extensor Strength Favors OKC Favors CKC Combined ES and 95% CI: 1.15 (0.77, 1.54) Results: Performance Based Functional Tests Favors OKC Favors CKC Combined ES and 95% CI: 0.63 (0.18, 1.08) Results: Outcomes Summary Favors OKC Favors CKC 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 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 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 Discussion: Knee Extensor Strength 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: Isometric peak torque MCID 49.86 Nm 10 Nm (Lin 2009) 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 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 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 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 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 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 Acknowledgements Diane D. 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