The Ease (Es) of Practice: Evidence, Experts & Experience. Open Kinetic Chain vs Closed Kinetic Chain Exercise ACL & PFPS.

Transcription

1 The Ease (Es) of Practice: Evidence, Experts & Experience Open Kinetic Chain vs Closed Kinetic Chain Exercise ACL & PFPS Nadine Plotnikoff Alison Hoens Evidence The relative contribution of each will vary depending on the characteristics of each specific situation Clinical Experience EBP / EIP Patient Values / Goals 2 1

2 The Evidence: Process Ask Apply Acquire Appraise 3 ASK See Deb s tutorials PICO Population Age Patellofemoral pain syndrome, anterior cruciate ligament (injury, rehabilitation, repair) Acuity/Stage Intervention Physiotherapy, Physical Therapy, Rehab Open kinetic chain, Closed kinetic chain Comparison Outcome ROM, strength, laxity, function, specific OM, performance 4 2

3 ACQUIRE 1. Which Databases? Google Scholar for the Absolute Beginner PubMed/Medline + CINAHL = best coverage of PT Search all databases here 2. Which search terms? Next slides 3. How do I do a search? How do I limit to highest levels of evidence, populations, etc? Webinar series recordings, upcoming 4. How do I get full-text articles? Step 1: Is it free on the Web? Step 2: Is it available in the PABC elibrary A-Z Journals List or Rehab Reference Center via CPA Journals? Step 3: If not, ask Deb librarian@bcphysio.org Webinar recording and/or read Summary 5 Quick & Dirty Search in Google Scholar for PFPS Try different keyword combos. Googly (not exact searching).use quotations to search a phrase 6 Some free full-text. Look in PABC A-Z Journals List to find full-text or ask Deb 3

4 Search Terms: OKC CKC 1. Keyword = open kinetic chain, closed kinetic chain or just kinetic chain. 2. MeSH (for Medline/PubMed) No specific MeSH. Use keywords 3. CINAHL Headings (for CINAHL) Open kinetic chain exercises Closed kinetic chain exercises 7 EBSCO Medline & CINAHL (Best physio coverage via PABC. Deb teaches this!) You could then limit the 73 results to highest levels of evidence, age groups, etc. Final search AND s s4 and s7 The second search uses subject headings and keywords and OR s in s6 The first search uses both subject headings and keywords and OR s them together in s4 4

5 APPRAISE See Journal Club webinar recordings How to appraise an RCT Worksheet Tennis elbow, Achilles tendinopathy and exercise and LASER, osteoarthritis & knee joint mobs, hip protectors How to appraise a Systematic Review or meta-analysis Worksheet Orthoses & patellofemoral pain syndrome 9 Kinetic Chain Kinetic Chains: A review of the concept and its clinical applications. Karandikar et al, : first proposed link concept ; engineering. Pin joints connect a series of overlapping rigid segments. 1950s: extended concept to human body 10 5

6 Characteristics CKC distal segment meets considerable external resistance (but not necessarily fixed) that prohibits or restrains its motion. Increased joint compression forces Increased joint congruency thus increased stability Decreased shear *cause co-contraction OKC terminal segment can move freely Increase joint distraction & rotational forces Increased joint deformation thus decreased stability Increased shear forces 11 Focus for tonight: OKC vs CKC Patellofemoral Pain Syndrome Anterior Cruciate Ligament 12 6

7 Review of Common Exercises OKC CKC chments/after%20surgery%20rehabilitation%20prog ram%20acl%20reconstruction.pdf PFPS 1990s: CKC preferred d/t better restoration of function Recently: PF stress can be equally high in both CKC and OKC Compressive forces equally high in near full flexion with CKC and full extension with OCK 7

8 PFPS Cochrane Review: Exercise therapy for PFPS. Heintjes et al studies compared CKC to OKC No sig diff in Improvement of function Reduction in pain Thus, equally effective 16 8

9 PFPS OKC vs CKC exercises in PFPS: 5 year prospective randomized study. Witvrouw et al (2004) 69 pts (all had MRI); randomized into 5 wks of either CKC or OKC (most affected knee) 3X/wk min *see pg 1123 At 5 years: both grps had maintained good subj & fxnal outcomes; 0n 3/18 VAS scales OKC sig less complaints than CKC *Table 1 Clicking sensation Pain descending stairs Pain during prolonged sitting PFPS A systematic review of RCTs on exercise parameters in the treatment of PFPS: what works? Harvie et al, 2011 SPORTDiscus, MEDLINE< CINAHL< Science Direct, PEDro, EMBASE, Google Scholar. PICO pg RCT, 14 active exercise interventions 9

10 Harvie et al cont d PFPS Exercise type: OKC and CKC Program duration: 6 wks (longer better) Freq/Intensity: 5 days/wk; dep on goals & attention to overload & progression Strength: knee, hip, core Flexibility: HS, Q, ITB, ant hip Selective recruitment: VMO not great evidence Sets/reps: total reps PFPS Quads EMG in Open and Closed Kinetic Chain Tasks in Women with PF Pain. Stensdotter et al, (2010) Females with PFPS (17) and 17 controls; isometric quads in CKC & OKC Hypothesis: VMO activity would be more delayed and decreased in CKC than OKC But, EMG showed PFPS group reacted later and activated quads more in the CKC task 10

11 Clinical Impressions What are your biggest concerns clinically when treating patients with PFPS? Mine are: Finding how to best manage their pain Trying to determine where is the biggest bang for my buck in choosing where to prioritize their rehab efforts OKC & PF pain PF compressive forces are equal in endrange OKC knee extension and end-range CKC knee flexion. I find that attempts to work repetitively on corrective CKC drills walk a fine line between helping and causing more pain. Witvrouw s study results certainly pique my interest in this regard. 11

12 PFPS and protocols (or lack of) Although the literature advocates an exercise therapy intervention period of 6 weeks+, we still don t know which of the possible influencing factors are best focused on. Core strength Lumbar referral SI joint dysfunction Hip flexibility And the list goes on.. Hip strength Eccentric mechanics VMO bulk Patellar position Ankle and foot hypo and hypermobility Activity modification External devices (braces, PF taping) Orthotics 12

13 What am I left with? Motivation to not to be so nervous about prescribing OKC quadricep exercises for these PFPS patients Still a lot of questions about what approach works best. ACL: Changing perspectives Mid 1990s: CKC preferred d/t less stress on graft 2000 s: CKC preferred d/t less pain & laxity Co-contraction of Q/H/gastroc, < shear, > compression thus better joint stability Recently: at equal training loads, OKC as safe as CKC 26 13

14 ACL Laxity Is knee laxity change after ACL injury and surgery related to OKC knee extensor training load. (Morrissey et al. 2009) 49 subjects (13 female) ACL deficient or ACL reconstruction OKC ex for 6 wks Linear regression: variables potentially related to laxity (see Table 2 p. 373) *explanation provided Only factor sig related: average absolute load Thus, at an appropriate load OKC ex can be beneficial to stability ACL injury Open kinetic chain versus closed kinetic chain exercise after ACL injury. Dolan MG OKC exercise is more effective in restoring quads strength than CKC exercise in ACL-deficient patients. OKC knee extension exercise did not increase static or dynamic tibial translation. OKC exercise should be included in a comprehensive rehabilitation program following ACL injury. 14

15 ACL reconstruction CKC alone compared to open & closed KC exercises for quads strengthening after ACL reconstruction with respect to return to sport Mikkelsen et al (2000). 44 pts with unilat ACL recon: CKC only vs CKC + OKC starting at wk 6 No diff in knee laxity at 6 months Sig > quads torque in CKC+OCK Sig > # of pts returned to sport (and earlier) in CKC +OKC See Table 1 for program Note: ROM for OKC deg flexion It is our belief that unrestricted OKC ex might place too much strain on the ACL graft ACL reconstruction Heijne & Werner (2007). Early vs late start of OKC quadriceps exercises after ACL reconstruction 68 patients: reconstruction with patellar tendon or hamstrings RCT: 4 groups (see fig 1 p. 405; Table 2 p. 406) Early start OKC at 4 wks Late start OKC at 12 wks Pre, 3, 5, 7 months: ROM, laxity (KT 1000), postural sway, strength (KinCom), anterior knee pain score 15

16 ACL reconstruction Heijne & Werner cont d Early start of OKC quads after HS ACL reconstruction resulted in sig more knee laxity than both late start HS and early and late start patellar tendon early intro OKC quads didn t influence quads torques for HS or patellar graft: choice of graft affects strength of mm more than type of ex Thus, HS recon ACL should not include early start of OKC quad ex ACL Reconstruction OKC exercises in a restricted ROM after ACL reconstruction. Fukuda et al (2013). 49 pts: semitend or gracilis EOKC (4 wks) deg LOKC (24 wks) 0-90 deg No difference in knee laxity Essentially, similar outcomes but the EOKC had a faster recovery in strength *5% greater strength not clinically sig as both grps had same functional strength on hop test 16

17 ACL reconstruction Note: 2 Cochrane reviews withdrawn 33 ACL Reconstruction Lobb et al (2012) cont d Strong evidence: no additional benefit of bracing (ito ROM, strength laxity, pain, function, RTS) in short (6 months) and long term (2-5 yrs) Moderate evidence: no additional benefit of CPM (ito ROM and laxity) in short term Equal effectiveness of OKC and CKC (at least in the short term 6-14 wks) 4 RCTs Equal effectiveness of location (supervised vs home) 34 17

18 How do I feel as a clinician? Curious but still very cautious Seems there is a case to be made for the role that OKC quads exercises play but I m not convinced that there still isn t a risk from a laxity perspective. Another clinical impression I am now curious about whether we are following our ACL reconstruction patients long enough and whether our long-term outcome measures are adequate in this regard. Several of the articles have cited that these individuals may not get back to their desired level of activity long-term and are at risk for ACL tear in their other knee. 18

19 ACL protocols: Adams et al, 2012 Criterion-based guideline meant to build on their previous work in OKC long arc quads and SLR in week 1 and no further expansion on this. Utilizes a system to evaluate progress (see p. 605) KOS from week 2 onwards Quad index from week 3 onwards An effusion grading scale Soreness rules A series of hop tests to start at 12 weeks 37 ACL protocol: Manske et al (2012) OKC SLR and extension from 90 to 40 degrees (with no additional weight distally) are both prescribed in Phase 1 (1-4 weeks post op) Between 6 and 12 weeks post-op, isolated knee extension continues to be prescribed from 90 to 45 degrees. 19

20 ACL protocol: Wright et al, 2008 Inconclusive with regards to OKC Reference made to a local researcher (Liu-Ambrose) and her 2003 study which compared strength training to proprioception training ACL protocol: Fowler Kennedy protocol Advocates the addition of OKC exercises at the appropriate time and within a restricted range to complement the classic CKC rehab program Start at 6-9 weeks 20

21 What is being done in Western Canada? iles/bp_attachments/after%20surgery%20 Rehabilitation%20Program%20ACL%20R econstruction.pdf roviders/assets/pdf/prot_aclreconstruct.p df What am I left with? I am curious about the role of OKC but I don t think I m ready to try it out yet with this group. Laxity? Protocols refer to isokinetic machines for appliction of OKC quads but I don t have access to one Is my long-term follow-up sufficient and are my battery of outcome tests adequate? I think I can expand on both of these in my practice. The University of Calgary has a formal system of long-term evaluation for their post-op ACL reconstruction patients. Check it out. 21

22 Resources Please refer back to the Western Canadian and Fowler-Kennedy post-operative protocols already referenced in this presentation. They are excellent! also has some unique self-report outcome measures The Adams et al article also has some nice examples of an effusion grading scale, soreness rules and a series of hop tests. Take home messages - Nadine While there is evidence to question previous conceptions about the risks of OKC quads exercises with PFPS and ACL reconstruction patients, there still remains challenges with practicality and application of these exercises due to a variety of factors, including lack of specific protocols and lack of specific equipment. 22

23 Take home messages - Alison The pendulum swings There is evidence, built over multiple studies, that OKC is: Safe for both PFPS and ACL reconstruction under the right conditions (eg. Type of graft patellar tendon; time period ~6 wks; restricted ROM deg; load progress carefully) Can enhance outcomes in terms of strength, function and pain However, consider relative risk general laxity, re-injury, gender (hormonal influence), irritability Your turn Please answer the post-webinar questionnaire when you sign off. Now, 15 minutes to address your questions 23