Closed kinetic chain training

Presented bySaurav Sharma

Guided by Dr.Sandeep singh

INDEX1. Introduction2. Characterstics common to CKC

training3. Decieding CKC exercises4. Basic physiological principles of CKC

training5. Examination and evaluation6. Treatment intervention7. Guidelines for selecting CKC exercises8. Dosage guidelines9. Contraindications and precautions

Introduction History The kinetic chain concept originated in 1955,when

Steindler used mechanical engineering theories of closed kinematic and link concepts to describe human kinesiology. in the link concept rigid overlapping segments are connected in a series by movable joints. this system allows for predictable movement of one joint based on the movement of other joints and is considered as close kinematic chain.

Applying the concepts to human movement, Steindler observed 2 types of kinetic chain exists depending on loading of terminal joint

Open kinetic chain and Closed kinetic chain

Open kinetic chain in which end segment is free to move.eg hip flexion of swing limb during walking.

Closed kinetic chain in which the terminal joints meet

considerable resistance which prohibits or restrains its free motion.eg descending stairs.

The use of CKC exercises in rehabilitation began in 1980s, when physician began looking for safe ways to rehabilitate the quadriceps mechanism in patients after anterior cruciate ligament reconstruction.

During 1960s and 1970s documentation in biomechanics literature demonstrated an increase in the anterior shear forces during the last 30 degrees of OKC knee extension. Numerous researches thought that this increase in anterior shear placed a detrimental strain on healing graft that could compromise the surgical result.

Using cadaveric experiments, Grood and

associates documented increase in anterior tibial translation with OKC knee extension and subsequently suggested exercising in an upright posture to use the forces of weight bearing to minimize anterior tibial translation.

Increased joint compressive forces, improved joint congruency and muscular contraction are enhanced in weight bearing position.

Examples

Performing the CKC activity of sitting results in a predictable pattern of movement of hip, knee and ankle joints. Hip flexion depends on the amount of ankle joint dorsiflexion and knee joint flexion.

OKC activity includes kicking a ball or reaching overhead to retrieve an object.

GOAL of CKC exercise is to use the forces of weight bearing and effect of

gravity to stimulate functional activities, ultimately enabling the patients to return to their usual environments and perform activities safely.

Characteristics common to CKC activities

Interdependence of joint motion Motion occurring proximal and distal to the axis of

the joint in a predictable fashion Recruitment of muscle contractions that are

predominantly eccentric, with dynamic muscular stabilization in the form of co contraction

Greater joint compressive forces resulting in decreased shearing

Stabilization afforded by joint congruency Normal posture and muscle contractions Enhanced proprioception due to increased number

of stimulated mechanoreceptors.

Characteristics common to CKC activities

Independence of joint motion Motion occurring distal to the axis of the

joint Muscle contractions are predominantly

concentric Greater distraction and rotatory forces Stabilization afforded by outside means Activation of mechanoreceptors limited to

the moving joint and surrounding structures

Alternative classification Dillman and associates proposed classification

based on biomechanics of the exercise – the mobility of distal segment and application of an external load. The researcher referred to distal segment as boundary. The boundary condition may be fixed or movable. An external load may or may not be present at distal segment.

fixed boundary with an external load(FEL) correspond to CKC exercises Movable boundary with an external load(MEL) correspond to partially closed system Movable boundary no load(MNL) correspond to OKC exercises

Deciding CKC exercise for rehabilitation

When analysing functional activities ,determining the type of muscle contractions and joint motions necessary to complete the task should help guide the decision-making process about the type of kinetic chain exercise to prescribe.

NOTE- All closed chain exercises are not functional. Similarly all open chain exercises should not be dismissed because they are non-weight bearing activities.

Example Consider a patient who is unable to stand from

a seated position. The patient presents with concentric quadriceps and hip extensor muscle weakness, mild knee jiont anterior laxity, moderate tibiofemoral arthritis and limited ankle dorsiflexion.

Which exercise to be given ???????

Example

Consider another patient who presents with left arm hemiplegia and with a subluxated humeral head in glenoid fossa, poor scapulothoracic rhythm and altered kinesthsia.

Which exercise should be given ??????

Basic physiological principles of CKC training

1) Muscular contraction CKC exercise stimulate muscular contractions,

joint approximation and joint congruency, thereby providing dynamic stabilization and postural holding around the joint.

Weight bearing activities decrease shear stress and stimulate co-contraction of hamstring musculature, providing dynamic stabilization that results in improved postural holding and additional support for the joint.

2) Biomechanical factors These contributing to joint stability are

accomplished through the geometry of the joint surfaces, joint approximation and stimulation of joint receptors. The geometry of joint surface appears to aid in the decrease of anterior tibial displacement in the loaded joint.

Wolfs law –remodelling of soft tissue Collagen fibres organize themselves along lines

of mechanical stress-important in rehabilitating ligamentous injury. Gradual mechanical stress strengthen injured tissue and resist reinjury

3) Neurophysiologic factor Neurophysiologic support for using CKC

activities in rehabilitation is provided by stimulation of proprioceptive system. The sensory receptor consist of mechanoreceptor and nociceptors found in muscles, joints, periarticular structures and skin.

Four major joint receptor, the muscle spindle, the Golgi tendon organ and cutaneous receptors have been identified as structures providing sensory input to central nervous system deformation and loading of soft tissues surrounding a joint trigger mechanoreceptor that convert mechanical energy to electrical impulses. The electrical impulses are transmitted to and integrated by the CNS to produce a motor response.

4) Neural adaptation It involves changes in the ability of nervous

system to recruit the appropriate muscles to obtain a desired result. In new exercise program strength gain occurs in few weeks can be attributed to improved coordination from neural adaptation as the person becomes more efficient in performing the activity.

5) Specificity of training A greater increase in strength was measured when

the test activity was similar to the actual training exercise.

This approach involves the use of the specific adaptations to imposed demands(SAID) principle.

neuromuscular system apply specific mechanical stress to it (imposed demands) specific adaptation in muscle recruitment

pattern(eccentric to control movement followed by concentric)

Example Using 4 inch step to perform stem up exercises

to gain the lower extremity hip and thigh strength needed to improve functional performance of ascending stairs

6) Stretch-shortening cycle Involves plyometrics – a method of training

neuromuscular system to increase power by combining speed and strength of muscle contractions.

done in rehabilitation of athletes after orthopaedic injury

firstly eccentric action stores energy followed by strong concentric action

so CKC activities like running, jumping, skipping enhance muscle contractions

7) Influence of motion on the kinetic chain Influence of foot and ankle biomechanics on

entire kinetic chain is essential to ensure accurate prescription of CKC exercises

example 1. Subtalar joint- calcaneal eversion and talar

plantar flexion and adduction 2. Lower leg follows talus with internal rotation

and superior and anterior translation of fibular head

3. Flexion with valgus stress at knee 4. Femoral adduction and internal rotation as hip

moves into flexion 5. Pelvis flexes and internally rotates in the phase

with limb 6. Lumbar spine extends and counter rotates

Now if excessive subtalar pronation it is coupled with the frontal plane motions of femoral adduction and increased valgus stress on knee. Clinical result limb is inefficient during propulsion.

Examination and evaluation

CKC training has unique advantage of becoming the test. ; the test becomes the exercise and consequently the exercise becomes test

Example Testing of static balance Stand on 1 leg for 30 sec If possible then alter the difficulty level by altering position and making it difficult to

stand If any problem then this test becomes the

patient’s home exercise programme

Treatment intervention

CKC training is a valuable form of exercise for enhancing patient’s ability to function in their work, home, or recreational environments. Rehabilitation of muscular strength and neuromuscular coordination must take into account the position and function of entire kinetic chain.

Flexibility, simplicity, and creativity associated with CKC training affords countless possibilities for exercise to be included in a home exercise programme

Guidelines selecting CKC

1) Placement of center of mass Depending on center of mass of body where it falls

muscle action follows2) Placement of foot Influence efficiency of performing CKC like flat foot can

cause patello femoral pain or hinder medial collateral ligament repair

3) Relationship between the proximal and distal segments Example Functional CKC activity, the proximal segment is

moving on a more stationary distal segment. closed chain knee extension – sit to stand

Dosage guidelines

1) Variables of force, speed, complexity and control of movement must be considered alone and in combination.

2) It should be performed slowly and in a controlled manner and then progressed as the healing tissue can tolerate stress and neuromuscular control improves.

3) Initiation of CKC should be in a single plane and then progresses to include multiplanes.

Contraindications and precautions

1) Patient safety - * So begin sub maximally and progress to

functional goals the patient can tolerate. * There should be criteria for gradation of

exercise. * Exercise should be easier levels, then

repitition to achieve target.2) Pain, joint effusion and inability of joint to

handle compressive forces3) Environmental conditions must be evaluated

so the activities are performed on a flat, hard surface with proper footwear.

THANK YOU