Knee-Joint Position Sense: The Relationship Between Open and Closed Kinetic Chain Tests

Transcription

1 J Sport Rehabil. 2005;14: Human Kinetics, Inc. Knee-Joint Position Sense: The Relationship Between Open and Closed Kinetic Chain Tests Lee Herrington Context: Authors have investigated knee joint-position sense (JPS) in nonweight-bearing open kinetic chain (OKC) manner, but few have investigated JPS during closed kinetic chain (CKC) weight-bearing activities or the relationship between these two. Objective: To investigate the relationship between knee JPS during OKC and CKC maneuvers. Design: 2-group (men and women) repeatedmeasures. Setting: Biomechanics laboratory. Participants: 80 asymptomatic subjects. Interventions: None. Main Outcome Measure: Absolute error score of knee JPS during 2 conditions, a CKC squat or OKC knee-flexion maneuver. Results: Statistical analysis by 2-way ANOVA showed sex not to have a significant effect on error score (P =.475), but statistically significant differences between error scores occurred during the 2 tests (P =.0001), the CKC test producing lower error scores (group mean absolute error score OKC [5.6 ± 4.3 ] and CKC [2.8 ± 2.4 ]), with the absence of a correlation between scores of each test (r =.1). Conclusion: Testing JPS in a CKC scenario would seem appropriate the ability is greatest (least errors), and conversely any deficits might be most obvious. Key Words: error scores, proprioception, gender differences An inability to dynamically control the loads imposed on the limb during sporting activities has frequently been implicated in the etiology of knee-ligament injuries, for instance, those to the anterior cruciate ligament. Most noncontact anterior cruciate ligament injuries of the knee occur when the knee is in a semiflexed position with the foot fixed on the ground and the patient then attempts a sudden change of direction or cutting maneuver. 1 It is believed that the injury might occur as a result of a poor movement pattern during these maneuvers, either excessive femoral rotation on a relatively fixed tibia or reduced flexion at the knee as the forces are absorbed on landing. 2 In either case it would appear that normal motor (motion) control is failing to occur. Motor control has been defined as the control of posture and balance; its optimal functioning depends on a number of subsystems including the visual, vestibular, and somatosensory working in tandem. Proprioceptive sense is an important aspect The author is with the Directorate of Sport, University of Salford, Greater Manchester M6 6PU, England Herrington(356) /14/05, 3:02:39 PM

2 Knee-Joint Position Sense 357 of the somatosensory system. Proprioception is an all-encompassing term that incorporates joint-position sense (JPS) and kinesthesia. 3,4 JPS is the awareness of the static position of the joint in space. 5 Kinesthesia is the awareness of joint position during an active or passive movement. 3 Numerous authors have investigated knee JPS in a non-weight-bearing open kinetic chain (OKC) manner, but few have investigated JPS at the knee during closed kinetic chain (CKC) weight-bearing activities. 6-8 Those who did 6-8 found normal asymptomatic subjects to have better JPS during the CKC test than OKC test (Table 1). The rationale given for the superior results of CKC testing was the increased sensory input from the multiple joints and muscles involved in the movement as opposed to afferent information from the structures of only a single joint and limited involved muscles in the OKC maneuver. 6-8 The major problem with this previous research was that during these CKC JPS tests the testing positions used failed to carry out an isolated single-leg squat, which would be a close approximation to the injurious movement reported. These studies either provided support through the contralateral limb 8 or had the subjects lean against and slide up and down the wall during the single-leg-squatting action. 6,7 This extra support could have provided increased sensory input, aiding in appreciation of joint position, hence skewing the results toward higher accuracy of JPS in CKC activities. A second problem with the previously presented research is that it either failed to compare the effect of a participantʼs sex on performance or did not report the level of any differences. 6,8 Because neuromuscular deficits have been related to increased injury risk in females, 9 there might be sex-based differences in JPS. The aim of this study was compare JPS of the knee during OKC and CKC testing and also report on any differences in performance between male and female subjects and right and left limbs. This study differed from those previously investigating this area by minimizing any extraneous sensory input other than that from the weight-bearing limb during CKC testing. Table 1 Measures of Absolute Angular Error in Active Joint-Position Sense From Previous Studies* Target Angle Study Condition Andersen et al WB 4.03 ± ± 1.8 (1995) NWB 5.17 ± ± 3.86 Higgins and Perrin WB 1.7 ± 1.96 (1997) NWB 4.05 ± 2.76 Drouin et al WB 3.44 ± 1.6 (2003) NWB 6.47 ± 2.94 *WB indicates weight bearing (CKC), and NWB, non-weight-bearing (OKC). 09Herrington(356) /14/05, 3:02:41 PM

3 358 Herrington Design Methods We used a 2-group (male and female) repeated-measures design looking for withingroup differences in JPS for limb (left or right) and testing procedure (OKC or CKC) and between-group effects of sex on performance. Subjects Eighty healthy, physically active subjects (40 men, 40 women) age 21.7 (± 4) years (range 18 to 31 years) without any reported lower limb, spinal, or neurological impairments or injuries participated in the study. Average height for male subjects was cm (± 10), and weight was 70.3 kg (± 10.2); average height for the women was cm (± 9), and their weight was 70.1 kg (± 10.4). All gave informed consent, and the study was approved by the institutional research-ethics committee. Procedures Subjects attempted to reproduce a knee-joint-flexion index angle of 45 during both testing procedures and on both knees. Limb order and testing sequence, that is, CKC or OKC test, were randomly ordered for each subject. Knee-joint-position index angle and reproduced angle were measured by taking a digital photograph of the subject using a Fuji Finepix S304 digital camera (with a picture resolution of 3 megapixels). The camera was positioned on a tripod 10 m away from the subject, the subject was framed in the picture to maximize the limb within the frame, and the camera settings were then not changed until all pictures had been taken. The photograph was then symmetrically expanded and printed onto an A4 (21 cm 29.7 cm) sheet. Lines were drawn between the markers placed on the greater trochanter, lateral knee-joint line, and lateral malleolus; the angle of intersection of these 2 lines was then measured using a 360 universal goniometer. During OKC knee JPS testing the subject was seated on a treatment couch, knees and hips flexed to 90, hands folded across chest, and blindfolded. The subject was then instructed to slowly actively extend the knee to the target angle. The tester used a goniometer, held a few centimeters away from the subject as an indicator that the subject had reached the target angle. The tester verbally cued the subjects to stop and hold the position for the photograph to be taken. The subject held this position for 5 seconds and then lowered the limb back to the resting position of 90. After a 5-second rest the subject attempted to actively reproduce the target angle. The subjects were asked to say OK when they had achieved the angle and hold the position while a photograph was taken. The subjects carried out 2 further attempts to reproduce the target angle. For CKC knee JPS testing the subject stood unsupported on 1 leg; the other leg was held in hip and knee flexion so that the medial malleolus was held in contact with the weight-bearing leg just superior to its medial malleolus. Both hands were placed on their respective iliac crests, and the subject was blindfolded. The subject was then instructed to slowly squat to the target angle. The tester used a goniometer, 09Herrington(356) /14/05, 3:02:43 PM

4 Knee-Joint Position Sense 359 held a few centimeters away from the subject, as an indicator that the subject had reached the target angle. The tester verbally cued the subjects to stop and hold the position for the photograph to be taken. The subject held this position for 5 seconds and then returned to the standing position, placed the non-weight-bearing leg down, and rested. After a 5-second rest the subject attempted to actively reproduce the target angle. The subjects were asked to say OK when they had achieved the angle and hold the position while a photograph was taken. The subjects carried out 2 further attempts to reproduce the target angle. Pilot work was carried out on the measurement technique to ascertain intratester reliability. Ten subjectsʼ photographs (of target and reproduced angles) were selected randomly for reassessment of angle. Comparison of first and second measurements using intraclass correlation coefficient revealed a strong correlation of r =.98 (P =.001) between the 2 measurements and no statistically significant differences (P =.47) on testing with a repeated-measures t test. Mean difference between the 2 measurements was 0.5 ( ± 0.3 ) with 95% confidence interval of 0 to 1.1. Analysis For each subject the target angle was subtracted from the reproduced angle to give a resultant absolute error score (angle). An average was taken from the 3 trials for each limb and procedure. The average absolute error scores were then statistically analyzed using an SPSS (version 11, SPSS Inc, Chicago, Ill) statistical package. The difference in level of error scores was analyzed with a repeated-measures ANOVA with 2 factors sex (male and female) and exercise type (OKC and CKC). The critical alpha level chosen was α =.05. Paired t tests were used to evaluate specific differences, and with the Bonferroni correction α =.025. Correlations were calculated using Pearsonʼs product moment for the relationships between limbs and sexes for the 2 tests. Results There was a strong, statistically significant relationship between errors scored for left and right legs for both sexes. In the female subjects, OKC test r =.96, P =.005, and CKC test r =.97, P =.004. For male subjects, OKC test r =.94, P =.007, and CKC test r =.96, P =.003. Therefore, for purposes of further analysis the left- and right-leg data were grouped together, so in all,160 limbs were examined. The average error scores for the 2 tests for male and female subjects are presented in Figure 1. In the female subjects, for the OKC test mean absolute error score was 5.3 (± 4.2 ), range 0 to 17, and for the CKC test mean absolute error score was 2.6 (± 2.3 ), range 0 to 9 ; a Kolmogorov Smirnov test revealed a normal distribution for these data. In the male subjects, for the OKC test mean absolute error score was 5.3 (± 4.4 ), range 0 to 16, and for the CKC test mean absolute error score was 2.9 (± 2.4 ), range 0 to 11 ; a Kolmogorov Smirnov test revealed a normal distribution for these data. The effect of sex on absolute error scores was not a statistically significant one (F = 0.475, df = 1, P =.475), exercise type had a significant effect on error score (F = , df = 1, P =.0001), and interaction of sex and exercise type was a 09Herrington(356) /14/05, 3:02:44 PM

5 360 Herrington Figure 1 Mean absolute error scores. OKC indicates open kinetic chain, and CKC, closed kinetic chain. nonsignificant one (F = 0.603, df = 1, P =.442). Paired t tests demonstrated for both the male (P =.002) and female subjects (P =.0001) that there was a statistically significant differences between error scores during the OKC and CKC tests, with OKC testing producing greater error scores. Grouped scores demonstrated a similar statistically significant difference between error scores during the OKC and CKC tests (P =.0068), with an extremely low correlation between exercise types (r =.1). Comments The primary findings of this study were that physically active asymptomatic male and female subjects produced similar levels of absolute error scores for OKC and CKC knee-jps tests. Both these tests show symmetry in results between left and right knees, and CKC testing produces significantly more accurate JPS than OKC testing. The previous studies that have included male and female subjects 6,8 failed to make any comparison between the performances of male and female subjects, so no direct comparisons can be made. The findings of this study would indicate that sex has little influence on error scores with this mode of testing, which to a degree disputes the purported neuromuscular differences between males and females, increased female injury risk. 9 The reason for this difference might be a result of the populations studied, In the current the study, the participants, although physically active, were not elite sports performers, and the male and female subjects were relatively matched anthropometrically, which differs from the previous studies. 09Herrington(356) /14/05, 3:02:46 PM

6 Knee-Joint Position Sense 361 It is difficult to compare this studyʼs finding of significant limb symmetry in the performance of the JPS tests with other findings, because the studies of Drouin et al 7 and Higgins and Perrin 8 used the dominant leg only, and Andersen et al 6 failed to state which knee was used. This study found the relationship between limbs to be a strong one. All 3 studies that have previously compared JPS in CKC and OKC tests 6-8 found JPS to be superior in the CKC condition, which supports the findings of the current study. As can be seen from Table 1, the findings of this study (group mean absolute error score OKC [5.6 ± 4.3 ] and CKC [2.8 ± 2.4 ]) are also comparable with the previously undertaken studies. Even though Andersen et al 6 found no significant effect for joint angle, caution must be exercised when comparing studies that have used different target angles, because Olsson et al, 10 using an OKC test of JPS, found the degree of target angle to have a significant effect on error score. The awareness of knee-joint position was significantly greater during the CKC activity than during the OKC activity. This higher accuracy might reflect a better ability to perceive the target angle or actively replicate the target angle and so could imply that greater proprioceptive acuity or motor control is occurring in CKC activities in normal individuals. 7 It would therefore seem appropriate to test JPS in a CKC scenario, wherein the ability is greatest and conversely any deficits might be most obvious. Furthermore, this test position would also reflect performance in a more functional (injurious) position. 6 The greater accuracy of joint-position reproduction occurring during CKC testing might indicate higher joint mechanoreceptor, Golgi tendon organ. and muscle-spindle stimulation as a result of the increased joint forces and muscle contraction involved in the CKC test action. 7 Although it is beyond the scope of this study to demonstrate, if the increased accuracy in CKC is a result of increased proprioceptor stimulation creating improved conscious awareness of joint position, CKC activities might provide an advantage over OKC exercises during proprioceptive or motion-control training exercises, 8 enhancing the potential for motor learning. 7 Using the method described, JPS at the knee was found to be bilaterally equal and equitable between the sexes. Testing knee JPS in a CKC manner produced a lower magnitude of error than when testing in an OKC manner. When testing for proprioceptive acuity either for injury prevention or to monitor the progress of rehabilitation, it might prove more appropriate to test knee JPS in a CKC condition, in which for a normal population the margin for error is smaller; hence, differences might be more obvious and the test position more akin functionally to those related to injury. References 1. Bollen S. Ligament injuries of the knee limping forward? Br J Sports Med. 1998: 32;1, Fagenbaum R, Darling W. Jump landing strategies in male and female college athletes and the implications of such strategies for anterior cruciate ligament injury. Am J Sports Med. 2003:31; Corona J, Cashman W, Brady M. Proprioception in the cruciate deficient knee. J Bone Joint Surg Br. 1992;74B: Herrington(356) /14/05, 3:02:47 PM

7 362 Herrington 4. Lephart S, Riemann B, Fu F. Introduction to the sensorimotor system. In: Lephart S, Fu F, eds. Proprioception and Neuromuscular Control in Joint Stability. Champaign, Ill: Human Kinetics; 2000: Barrack R, Lund PJ, Skinner H. Knee joint proprioception revisited. J Sport Rehabil. 1994;3: Andersen B, Terwilliger D, Denegar C. Comparison of open versus closed kinetic chain test position for measuring joint position sense J Sport Rehabil. 1995;4: Drouin JM, Houglum PA, Perrin DH, Gansneder BM. Weight-bearing and non-weightbearing knee-joint reposition sense and functional performance J Sport Rehabil. 2003;12: Higgins M, Perrin D. Comparison of weight bearing and non-weight bearing conditions on knee joint position sense. J Sport Rehabil. 1997;6: Murphy D, Connolly D, Beynnon B. Risk factors for lower extremity injury: a review of the literature. Br J Sports Med. 2003;37: Olsson L, Lund H, Henriksen M, Rogind H, Bliddal H, Danneskiold-Samsoe B. Test retest reliability of a knee joint position sense measurement method in sitting and prone. Adv Physiother. 2004;6: Herrington(356) /14/05, 3:02:49 PM