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Why is the Integrated Approach
(OKC + CKC) necessary for
optimum rehabilitation for knee
Functional injuries ?
Isokinetics Biodex
UK
September, 2009
Closed vs Open Chain Thanks-Biodex & IPRS Mediquipe
Thanks-Biodex & IPRS Mediquipe
Rehabilitation for ACL Thank for the kind invitation to share this
professional presentation.
Reconstruction.
Does it Matter?
Biodex It is indeed an honor and a privilege to be
UK invited to participate and share
information.
September, 2009
George J. Davies, DPT, MED, PT, SCS, ATC, LAT,
CSCS, ACSM-CET, APTA-CCI, SMAC, (REMT), EBP and KNEE REHABILITATION for
FAPTA
ACLs:
ACLs:
Professor of Physical Therapy, AASU, Savannah, GA. (2004- )
OKC (Isolated)
Professor Emeritus UW-LaCrosse, WI. (1975-2004)
Consultant, Clinician, Co-Director Clinical and Research Services–
Sports PT Residency Program , GLSM, La Crosse, WI. (1995-2006) VS
Sports PT, Coastal Therapy, Savannah, GA. (2004- )
Past President Sports Physical Therapy Section – APTA (1992-1998) (Multi-
CKC (Multi-joint)
JOSPT - GJD-JAG Excellence in Clinical Research Award, 2004
Fellow, APTA, 2005 or
Hall of Fame Award, SPTS-APTA, 2006
NATA Challenge Award, 2007
NATA Most Distinguished Athletic Trainer Award, 2009 Integrated
(SUN/SNOW BIRD) Approach
MedLine Search: 9/1/09
Knee + ACL + rehab + OKC = 16 Semantics:
Knee + ACL + rehab + CKC = 19
OKC = 81 OKC: isolated testing
CKC = 114 and/or
Isokinetics + Knee = 1782 rehabilitation
Limiters: 238
Isokinetics + Shoulder = 324
Limiters: 25 CKC: multiple joint
Isokinetics = 3896 testing and/or
Limiters: (Level I & II) =470
rehabilitation
Historical Perspective
Interestingly, there are publications by
et.al. 20- ago,
Davies, et.al. from 20-30 years ago,
that discuss the concept of integrated
functional rehabilitation which
includes:
OKC
CKC
Neuromuscular dynamic stability
exercises
Functional specificity rehabilitation
TO PRESENT
P & S M, 1978
Historical Perspective: References Historical Perspective: References
Davies, GJ, et al. Isokinetic
Characteristics of Professional Football
Davies, GJ, R Larson. Players: I. Normative Relationships
Examining the Knee. The Between Quadriceps and Hamstring
Muscle Groups and Relative to Body
Physician and SportsMedicine, Weight. Medicine and Science in Sports
7(4): 48-73, 1978 and Exercise, 13(2): 76-77, 1981
Kirkendall, DT, Davies, GJ, et al.
Davies, GJ, Wallace, L. Isokinetic Characteristics of
Professional Football Players: II.
Mechanisms of Selected Knee Absolute and Relative Power Velocity
Injuries. Physical Therapy, Relationships. Medicine and Science in
60(12): 1590-1595, 1980 Sports and Exercise, 13(2): 77, 1981
Historical Perspective: References Historical Perspective:
References
Davies, GJ, et al. Cybex II Isokinetic
Dynamometer and Digital Work Davies, GJ, et al. Computerized Cybex
Integrator Evaluation of Muscular Testing of ACL Reconstructions
Endurance in Prospective Professional Assessing Quadriceps Peak Torque,
Football Players. Medicine and Science TAE, Total Work and Average Power.
in Sports and Exercise, 14(2): 177, Medicine and Science in Sports and
1982 Exercise, 16(2): 204, 1984
Davies, GJ, et al. Torque Acceleration Gould, JA, Davies, GJ, et al.
Energy and Average Power Changes in Computerized Cybex Testing of ACL
Quadriceps and Hamstrings Through Reconstructions Assessing Hamstrings
the Selected Velocity Spectrum as Peak Torque, TAE, Total Work, and
Determined by Computerized Cybex Average Power. Medicine and Science
Testing. Medicine and Science in Sports in Sports and Exercise, 16(2): 204,
and Exercise, 15(2): 144, 1983 1984
Historical Perspective: References
Davies, GJ. A Compendium of
Isokinetics in Clinical Usage , First
Edition, S & S Publishers, La
Crosse, WI, 1984, 1985, 1987,
1992
Gould, JA, Davies, GJ. (Eds)
Orthopaedic and Sports Physical
Therapy . C.V. Mosby Company, St.
Louis, MO, 1984
Davies, GJ. (Ed) Rehabilitation of
the Surgical Knee . Cypress, NY,
1984 1995
CLINICAL ARTICLE
1997 The scientific and
clinical rationale for
the integrated
approach
to open and closed
kinetic chain
rehabilitation.
et.al.
Davies, GJ, et.al. Orthop Phys Ther
9:247- 267
Clinics North America, 9:247-267,
2000
CLINICAL ARTICLE
Strength &
Functional Conditioning
progression of a Journal,
patient through a
rehabilitation 2000
program
Davies, GJ, et.al.
Orthop Phys Ther
Clinics North
America, 9:103-
118, 2000
MSSE,
MSSE,
2000
2000
2000
2001 Clinical
Biomechanics
17:551-
17:551-554,
2002
Historical Perspective: References Historical Perspective: References
Manske,
Manske, RC, Davies, GJ, McElveen, M, Riemann, BL, Davies, GJ.
DeCarlo, M, Paterno, M.
DeCarlo, Paterno, Bilateral comparison of propulsion
mechanics during single leg vertical
jumping.
Rehabilitation Concepts Abstract presented at ACSM Annual
following ACL Conference, Seattle, WA., 2009
Reconstructions.
Riemann, BL, Davies, GJ. Kinematic and
kinetic analysis of the forward lunge
Kibler, Ellenbecker,
In Kibler, B, Ellenbecker, TS during four external load conditions.
Eds).
(Eds). Orthopaedic Knowledge Abstract presented at ACSM Annual
Update: Sports Medicine 4. Conference, Seattle, WA., 2009
American Academy of
Surgeons,
Orthopaedic Surgeons, 2008
Etc.
Proximal Stability (HIP)
Kinematic
Back Importance
Chain Concept Hip
bones
bones
Thigh
bone
Importance of the
Knee
bone
functional regional
Shin
inter-dependence and
bone
relatedness of the
Foot
bones
entire kinematic chain
CKC – Testing REFERENCE
Lower-extremity compensations
following ACL reconstruction
With CKC testing everything
Ernst, GP, et.al. PT, 80:251-260,
is being tested and we do NOT 2000
KNOW which muscles are
contributing to the force No difference in summated ext.
moment
production;
Knee extensor moment lower
Or which muscles are NOT
contributing to the force Hip and/or ankle extensors
compensate for knee
production
Linea
Bi-
Bi-lateral
Tandem
Concentric/
Eccentric
Exercises
Linea
Bi-
Bi-lateral Bi-
Linea Bi-lateral
Reciprocal
Concentric Tandem
Exercises Concentric/Eccentric
Isokinetic Exercises
Linea CKC Isokinetic – WB - Testing & Rehab
Bi-
Bi-lateral
Reciprocal
Concentric
Isokinetic
Exercises
TLS Screening
During the last decade , and even
TLS
within the last few years, I think Total Leg Strength
we have become more aware and
have revisited the old philosophy (OKC/Isolated testing)
of:
“Proximal stability for
distal functional mobility” !
**Popular – “HOT TOPIC”**
A Study of Thigh OKC/Isolated
Muscle Weakness in Isokinetic Testing
Different Pathological
30, 90, 180/sec.
States of the Lower
Extremity. Gravity Corrected
TLS – 5 motions added
Nicholas, JA, et al together (hip and knee)
Am J Sports Med 4(6): 241-248, 1976
Recreational Athletes
Thorough Isokinetic Testing of these
Muscles will reveal their weakness Results
Isokinetic Testing
Hip Abduction Characteristic patterns
Hip Adduction of muscle weakness
Hip Flexion
Knee Extension could be correlated
Knee Flexion
with the specific
Ankle Plantar Flexi
pathologic syndromes.
Ankle Dorsi Flexion
In… Ankle and Foot
1.Ankle and Foot Problems
2. Knee Ligamentous 1.Ipsilateral weakness – hip
Instabilities abductors (p <0.05)
2. Ipsilateral weakness – hip
3. Intra-articular Defects adductors (p <0.005)
4. Patella Groups 3.Ipsilateral weakness –
quadriceps (NS-Trends)
There is an irrefutable deficit
in TLS (p <0.01) 4.Ipsilateral weakness –
hamstrings (NS-Trends)
Patello-Femoral Lesions
Knee Ligamentous 1. Ipsilateral weakness – quadriceps
Instability (p <0.005)
1. Ipsilateral weakness – hamstrings
(p < 0.01)
1.Ipsilateral weakness – 1. Ipsilateral weakness – hip flexors
quadriceps (p <0.025) (p < 0.005)
2.Ipsilateral weakness – 1. Ipsilateral weakness – hip abductors
hamstrings (NS-Trends) (NS - Trend)
2. Ipsilateral weakness – hip adductors
(NS - Trend)
The quadriceps, while being the PF Rehabilitation
muscle that is most commonly tested et.al.
Tyler, T, et.al. The role of hip muscle
and rehabilitated, is not the only function in the treatment of PFPS.
muscle that contributes to TLS 34:630-
AJSM. 34:630-636, 2006
weakness
Results:
Other major muscles of the thigh (hip
Successful Outcomes:
flexors, adductors, abductors, ER & Lower extremities combination:
IR) must also be tested and improved hip flexor strength,
rehabilitated improved Ober and Thomas tests –
93%
References References
Research supports the existence
Research supports the existence
of hip weakness/dysfunction of hip weakness/dysfunction
after a variety of lower extremity after a variety of lower extremity
injuries. injuries.
Nicholas, et.al. AJSM, 1976 Beckman, et.al. Arch Phys Med Rehab,
Gleim, et.al. PSM, 1978 1995
Perry, J. Gait analysis, 1992 Riegger-Krugh, et.al. JOSPT, 1996
Wilk, Davies, et.al. JOSPT, 1998
Bullock-Saxton, et.al. NZJ Physiother,
1993 Ernst, GP, et.al. PT, 80:251-260, 2000
Frederiscon, et.al. Clin J Sports Med,
Sahrmann, The Athletic Female, 1993
2000
Janda, Modern Manual Therapy…, 1994 Earl, JE. J Sport Rehab, 2005
Etc.
Kinematic
Back Test, Don’t Guess
Chain Concept bones
Hip
bones And frankly, if we do not
TEST for the individual
Thigh
bone
Knee
bone links in the kinematic
Shin
bone
chain, then we do not
know if there is a deficit
Foot
bones and then as clinicians, we
also miss it!
Descriptive Clinical
Research Study OKC (Isolated) vs. CKC
Davies, GJ.
(Multi-joint) Isokinetic
Descriptive study comparing open
kinetic chain and closed kinetic chain
Testing :
isokinetic testing of the lower
extremity in 200 patients with selected
knee pathologies. (Abst.) Bilateral Peak Torque
Proceedings of the 12th International
Congress of the World Confederation
Comparison Deficits in
for Physical Therapy, pp. 906
APTA, Wash. DC, June, 1995
Patients with Knee
Conditions
All patients were tested All patients were tested with
on an OKC (Isolated) consistent protocols to
measure slow, intermediate
Cybex Computerized and fast velocities
Isokinetic Dynamometer respectively on the testing
and a CKC (Multi-Joint) devices. The specific details of
Linea Computerized test methods (positions,
Isokinetic Dynamometer velocities, reps, ROM, etc.)
will be described.
OKC
(Isolated-joint)
Testing
CKC
(Multi-joint)
Testing
Isolated Testing or Isolated Testing or
Rehabilitation Rehabilitation
Even though it is not popular
for testing or rehabilitation for
the knee, isn’t it rather
interesting that the
Of the
“trendiest” thing in
rehabilitation of patient’s with HIP muscles
ACL injuries,
Is, in fact, isolated (OKC)
rehabilitation…. BUT
References
Research supports the existence Isolated Testing or
of hip weakness/dysfunction
after a variety of lower extremity Rehabilitation
injuries. And what is one of the most
common recommendations for
But how do we know there is hip prevention or rehabilitation of
weakness with many of these patients
with knee injuries or hip weakness is a ACLs???
contributing factor to ACL injuries?
Isolated strengthening of the
hip abductors, hip ER,
OKC (Isolated) TESTING (particularly eccentric actions
!!!!! of the hip ER)
Isolated Testing or
Rehabilitation Historical Research
Why if OKC (isolated) testing
TLS
and rehabilitation are not
effective, is there so much Weak hip flexors, abductors
emphasis in isolated
rehabilitation of those CKC exercises do not address
muscles? the muscles that have been
Then, of course, integrating identified as the weakest in
them back into functional the L.E. kinematic chain
specificity activities Specificity rehabilitation
Rehabilitation
CKC-Lunges
When we work CKC multi- Most clinicians use lunges for L.E.
joint exercises, it targets rehabilitation for TLS and
multiple muscles, quadriceps strengthening
i.e., a squat or lunge (or
the many variations) NO!!!
does NOT isolate the
quadriceps….. Lunges are a hip dominant
muscle activity
Rehabilitation
Research Paper
isolated-
When we work OKC isolated-joint
Riemann, BL, Davies, GJ.
exercises, it targets the specific
Kinematic and kinetic analysis group,
muscle group, i.e., knee extension
of the forward lunge during quadriceps…
DOES isolate the quadriceps…..
four external load conditions.
Abstract presented at ACSM Of course, contraindications are
Annual Conference, identified BEFORE performing
Indianapolis, IN., 2008 these exercises
Use of Isokinetics OKC (ISOLATED)
ISOKINETIC KNEE TESTING
Isokinetics
Overview
Fall-Risk Assessment & Conditioning Program
? Questions ?
Click to edit master text styles
So why do we have Second level
Third level
to test “each link” Fourth level
Fifth level
in the kinematic
chain?
OKC Testing
Open Kinetic Chain
Open Kinetic Chain
OKC testing can be tested in
(Isolated Testing)
(Isolated Testing) numerous ways:
vs.
vs. MMT
Closed Kinetic Chain
Closed Kinetic Chain HHD
Bathroom scale
Integrated Testing &
Integrated Testing & Cable Tensiometry
1 or 10 RM isotonic PRE’s
Rehabilitation
Rehabilitation Isokinetics
Advantages of OKC/Isolated Exercises
OKC Check for proximal and distal muscles
compensating for weak areas.
Testing Check to see if there are deficits distant
And/or from the actual injury site.
Prevent compensations from other muscle
Rehab groups in the kinetic chain from “masking”
weaknesses
You know you are specifically “targeting” a
muscle group when you test it
There is a correlation between OKC testing
and functional activities
Functional Correlation: OKC vs. CKC
OKC Testing No Correlation
and Anderson, et al. JOSPT, 1991
Correlation to Positive Correlation
Tegner, et al. AJSM, 1986
Functional Performance Wiklander, et al. IJSM, 1987
Sachs, et al. AJSM, 1989
Barber, Noyes, et al. CORR, 1989
Karlsson, et al. AJSM, 1991
Noyes, et al. AJSM, 1991
Wilk, KE, et al.
Functional Rehabilitation
The relationship between subjective knee
scores, isokinetic (OKC) testing, and We all want to have the same
functional testing in the ACL- end result, but the challenge
reconstructed knee and DEBATE lies in how we
JOSPT 20(2): 60-73, 1994 (Breg Award get there:
Winning Paper)
Results: A positive correlation was noted
between isokinetic knee extension peak ********
Integrated
torque (180, 300°/sec) and subjective knee OKC
******** CKC
scores, and the 3 hop tests (p <0.001)
REHABILITATION
Functional Rehabilitation
Muscle activation/
Motor Control/Learning
vs
Muscle strength, power,
endurance
vs
Neuro-muscular dynamic
stability
vs
Functional Specificity
Rehabilitation Phases and Key
Motor-
Motor-Learning Principles in Each
Phases Acute Subacute Chronic
CNS
Task
Characteristics
Discrete Discrete/
Serial
Discrete/
Serial/
The CNS recognizes
Continuous
movement patterns, but it
Practice Blocked Blocked Random or does not recognize individual
Schedule Random/
Blocked muscle actions
Skill Part/ Part/ Part to
* Feedback
Progressive-
Progressive-
Part
KP and KR
Progressive-
Progressive-
Part
KP and KR
Whole
Intrinsic
Feedback
But that is also part of the
problem….
CNS
Because the CNS recognizes
CNS
Furthermore, because the
movement patterns, but it does
not recognize individual muscle CNS recognizes movement
actions, patterns, but it does not
Is part of the reason there may be recognize individual muscle
deficits in the muscles in the actions
kinematic chain, but yet, the CNS Because of this, the CNS
does not recognize it………. develops compensatory motor
strategies because it does not
even recognize them
Bottom Line Levels of Evidence
There are certainly some Let’s look at the research and
compelling arguments using the outcomes studies that
EMG and descriptive studies meet the rigorous criteria of
for the use of CKC exercises, the higher levels of evidence:
But Level I studies
They are indirect evidence of RCTs
the efficacy in rehabilitation of Systematic Reviews
patients with ACL-R
Meta-analysis studies
Research
Research et.al.
Wright, RW, et.al.
217-
J Knee Surg 21(3); 217-234,
No meta-analysis studies 2008
A systematic review of ACL rehabilitation:
One systematic review for the post-
part I: CPM, early WB, post-op bracing,
best exercises home-
and home-based rehabilitation.
A systematic review of ACL rehabilitation:
For ACL-rehabilitation part II: OKC vs CKC, NMES, accelerated
rehab, and miscellaneous.
Cochrane Database
Research Systematic Reviews
Wright, RW, et.al.
A systematic review of ACL Trees, et.al. Exercise for
rehabilitation: part II: OKC vs treating isolated ACL injuries
CKC, NMES, accelerated rehab, in adults. Cochrane Database
and miscellaneous. Syst Rev. 19(4):CD005316,
2005
J Knee Surg 21(3); 225-234,
2008 9 trials; 391 patients
5 prospective RCTs Methodological quality scores
varied
Both effective
Cochrane Database
Functional Rehabilitation
Systematic Reviews
Fleming, et.al. OKC or CKC exercises after
“This review has ACL-R? Exerc Sports Sci Rev. 33: 134-40,
demonstrated an absence of 2005
evidence to support one form
of exercise intervention Recent biomechanical studies have shown
that the peak strains produced on an ACL
against another and the use of graft are similar
supplementary exercises in Clinical studies suggest that both play a
the management of isolated beneficial role in the early rehabilitation
of the knee
ACL injuries.”
Knowledge is Power:
Knowledge is Power: Evidence-Based Practice
Level I & II
Level I & II Critically
Therapeutic
Therapeutic appraising
Intervention
Intervention
Outcome
Outcome
the evidence
Studies
Studies
Evidence Pyramid
Meta-analysis (Stat analysis of stats
of RCT’s)
Systematic Review (of RCT’s) J
Randomized Controlled Trial
B
Cohort Studies
Case Control Studies J
Case Series/Case Reports S
Expert testimony/Clinical Experiences
Animal Research
Feb, 2009
2009
Special Issue:
Shoulder
9 Articles
Companion to
ALL LEVEL V AJSM
CONSORT
Statement
Flow
Diagram
SORT:
Strength of
Recommendation
Taxonomy
CONSORT
Statement
Checklist
Knowledge
is Power
Advantages of OKC
(Isolated) Exercises Reference
Efficacy of rehabilitation with OKC
exercises.
Timm, AJSM, 1988 Timm, K. Post Surgical Knee
Snyder-Mackler, et.al., JBJS, 1995 Rehabilitation: A Five Year Study
Hooper, et.al. AJSM, 2001
of 5,381 Patients.
Perry, Knee Surg, 2005 AJSM 16:463-468,1988
Morrisey, et.al. PT, 2002
Ross,et.al. JSCR, 2001 SS improvements in OKC/CKC
Mikkelson, et.al. KSTA, 2000 integrated rehab program
Witvrouw, E, et.al. AJSM, 2004
Level I&II Evidence - RCTs Strength of the quadriceps
Bynum, et.al. AJSM, 1995
et.al.
femoris muscle and functional
Snyder-Mackler, et.al. JBJS, 1995
Snyder- Mackler, et.al.
recovery after reconstruction of
Hooper, et.al. AJSM, 2001
et.al. the ACL: A prospective,
Morrisey, et.al. PT, 2002
Morrisey, et.al. randomized clinical trial of
Perry, Knee Surg, 2005
Surg, electrical stimulation.
Mikkelson, et.al.
Mikkelson, et.al. KSTA, 2000 Snyder-Mackler, L, et al.
Witvrouw, et.al.
Witvrouw, E, et.al. AJSM, 2000 JBJS, 77-A(8): 1166-1173, 1995
Witvrouw, et.al.
Witvrouw, E, et.al. AJSM, 2004
Tagesson, et.al.
Tagesson, S, et.al. AJSM. 2008
110 Patients-ACL Results
reconstructions. evaluation”
Functional “gait evaluation”
All patients participated in an Evaluated by motion analysis
intensive program of closed and EMG
kinetic chain exercises.
All patients had SS deficits in
the quads as demonstrated by
Strength of quads and kinetics increased knee flexion and
of the knee during stance were prolonged knee flexion during
measured. the gait cycle
Importance of Quads
We believe that judicious Palmierei-Smith, et.al.
application of open kinetic chain Maximizing quad strength
exercises for the quads (with the after ACL-R.
knee in a position that does not Clin Sports Med 27:405-24,
stress the graft) ….improves the 2008
strength of this muscle and the “The quadriceps is critical to
functional outcome after dynamic joint stability and
reconstruction of the ACL. weakness of this muscle group
is related to poor functional
Snyder-Mackler, L, et al.
outcomes.”
JBJS, 77-A(8): 1166-1173, 1995
Importance of Quads Open and closed kinetic chain
Eitzen, I, et.al. Preoperative quadriceps
Eitzen, et.al.
strength is a significant predictor of knee
exercises in the early period
function two years after ACL-R. Br. J Sports
Med. 43:371-376, 2009
43:371-
ACL- after ACL reconstruction
Preoperative quadriceps muscle strength has Hooper, DM, et al.
significant negative consequences for the
long-term functional outcome after ACL
long-
reconstruction. Patients with quad deficits
AJSM, 29:167-174, 2001
above 20% also had SS strength deficits 2
years after surgery.
Recommendation: Quad strength < 20%
ACL-
before ACL-R
OKC and CKC exercises early CKC vs OKC
in ACL-R rehabilitation Perry, MC, et.al.
Effects of CKC vs OKC knee
extensor resistance training on
These data suggest there are no
knee laxity and leg function in
clinically significant differences in
patients during the 8-14 week
the functional improvement
post-op period after ACL-R.
resulting from OKC or CKC
exercises in the early period after Knee Surg, Sports Traum,
an ACL-R (Pat. Tendon) Arthroscopy
13:357-69, 2005
CKC vs OKC CKC vs OKC
RCT-single blind clinical trial NS differences:
49 patients s/p ACL-R KT 1000
33 y.o. Leg function- questionnaire
Tests 8 and 14 weeks s/p ACL-R Leg function- single leg maximal
KT1000, Hughston Clinic hop
questionnaire, single leg maximal “OKC and CKC knee extensor
hop
training in the middle period of
From 8-14 weeks patients trained rehab after ACL-R surgery do not
using only CKC or OKC training 3 x
differ in their effects on knee laxity
/ week
of leg function”
CKC vs OKC Rehab
Will OKC Exercises will
stretch the surgery? Morrissey, MC, et.al.
Isberg, J, et.al. Early active Effects of distally
extension after ACL-R DOES NOT fixated (CKC) vs
nondistally fixated
result in increased laxity of the
(OKC) leg extensor
knee. resistance training on
Knee Surg Sports Traumatol knee pain in the early
Arthrosc 14:1108-15, 2006 period after ACL
reconstruction
PT, 82; 35-43, 2002
Title says it all!!!!!
CKC/OKC
CKC/OKC
CKC vs OKC Ross, et.al. Implementation of
OKC and CKC quadriceps
Morrissey, MC, et.al.
strengthening exercises after
ACL-R. JSCR. 15:466-73, 2001
OKC and CKC leg extensor On the basis of our review,
training in the early period after both OKC and CKC exercises
ACL reconstruction surgery do can be modified and
not differ in their immediate implemented for quad
effects on anterior knee pain. strengthening after ACL-R
without causing excessive ACL
strain or PF joint stress
Integrated OKC/CKC
Integrated OKC/CKC Integrated OKC/CKC
Integrated OKC/CKC
Mikkelsen, et.al. Knee Surg 44 patients
Sports Traum Arthro. 8:337-42,
2000
1 group: CKC quad exercises
only
CKC alone compared to OKC
and CKC exercises for
quadriceps strengthening after 2 group: CKC & OKC
ACL reconstruction with
respect to return to sports: a 31 month f.u.
prospective matched follow-up
study
Integrated OKC/CKC
Integrated OKC/CKC Integrated OKC/CKC
Integrated OKC/CKC
CKC/OKC group – SS increase
NS KT 1000 differences in number returning to sports
at same level as before the
surgery
CKC/OKC group – SS
increases in Q torque CKC/OKC group – those
returning to sports at same
level as before the surgery
NS diff. in H torque returned 2 months earlier than
those with CKC exercises only
Integrated OKC/CKC
Integrated OKC/CKC Integrated OKC/CKC
Integrated OKC/CKC
Conclusion: The addition of Conclusion: The addition of
OKC quadriceps training after OKC quadriceps training after
ACL reconstruction results in: ACL reconstruction results in:
1) SS better improvement in 3) leads to higher number of
quadriceps torque athletes returning to their
2) without reducing knee joint previous activity earlier and at
stability at 6 months the same level as before injury
4) returned 2 months earlier
RCT-Isokinetic Muscle
RCT-Isokinetic Muscle
Training after ACL’s
Training after ACL’s
Hehl, G, et.al. Isokinetic “Significant improvements in
muscle training with high muscle strength were found with
motion speeds in the the addition of isokinetic
rehabilitation following strength training between the
surgical treatment of fresh seventh and ninth weeks after
ACL rupture. ACL reconstruction; at the 6-
Orthop Ihre Grenzgeb, month FU, there were no
133: 306-310, 1995 differences in knee joint laxity”.
CKC or OKC??? CKC or OKC???
Bottom Line !!!!!! Bottom Line !!!!!!
Witvrouw, E, et.al. Open versus CKC Witvrouw, E, et.al. Open versus
Exercises in patellofemoral pain. A
prospective randomized study. AJSM. CKC Exercises for patellofemoral
28:687-694, 2000 pain. AJSM. 28:687-694, 2000
60 patients
RCT-CKC vs OKC rehab programs
3 x/wk x 30-45 min x 5 wks. Both groups (no stat. sign. diff.)
Straight therapeutic exercise program Good subjective outcomes
No meds, no tape, no bracing, etc. (no
frills) Good functional outcomes
CKC or OKC??? CKC or OKC???
Bottom Line !!!!!! Bottom Line !!!!!!
Witvrouw, E, et.al. Open versus CKC
Exercises in patellofemoral pain. A 5-year
Now, let’s fast forward five years prospective randomized study.
later, and see if all those patients AJSM.32:1122-1130, 2004
that we “tore up there PF joints 60 patients
RCT-CKC vs OKC rehab programs
with OKC exercises”
3 x/wk x 30-45 min x 5 wks.
Straight therapeutic exercise program
And how they are actually doing. No meds, no tape, no bracing, etc. (no
frills)
PF-
PF-Cochrane Database of
CKC or OKC??? Systematic Reviews. 3, 2006
Bottom Line !!!!!! Exercise therapy for PFPS
Witvrouw, E, et.al. Open versus CKC
Exercises in patellofemoral pain. A 5- 750 articles, 12 RCTs
year prospective randomized study.
AJSM.32:1122-1130, 2004 Review of exercise therapy found some
evidence that exercise therapy might
help to reduce PFPS.
Both groups (no stat. sign. diff.)
Whether exercise reduces knee pain
Good subjective outcomes during ADLs is conflicting
Good functional outcomes ***There is strong evidence that
3 of 18 VAS, the OKC had SS less OKC and CKC exercises are
complaints than CKC group equally effective***
Integrated OKC/CKC
Integrated OKC/CKC Integrated OKC/CKC
Integrated OKC/CKC
Tagesson, S, et.al. A
comprehensive rehabilitation “There is no consensus
program with quadriceps
strengthening in CKC vs OKC regarding the optimal
exercise in patients with ACL rehabilitation regimen
deficiency. A RCT evaluating for increasing
dynamic tibial translation and
muscle function. quadriceps strength
AJSM. 36: 298, 2008 and ACL injury.”
Integrated OKC/CKC
Integrated OKC/CKC Integrated OKC/CKC
Integrated OKC/CKC
There were no group Hamstring strength, static
differences in static or and dynamic translation,
dynamic translation after and functional outcome
rehabilitation. were similar between
Rehab with OKC quadriceps groups.
exercises led to SS greater Patients with ACL deficiency
quad strength compared may need OKC quad
with rehab with CKC strengthening to regain
quadriceps exercises. good muscle torque.
Importance of Quads
Palmierei-Smith, et.al. Research
Maximizing quad strength
after ACL-R.
No meta-analysis studies
Clin Sports Med 27:405-24,
2008 One systematic review for the
“The quadriceps is critical to best exercises
dynamic joint stability and
weakness of this muscle group
is related to poor functional For ACL-rehabilitation
outcomes.”
Research
Wright, RW, et.al. Functional Rehabilitation
A systematic review of ACL Beynnon, et.al. Sports med.
rehabilitation: part II: OKC vs 22:54-64, 1996
CKC, NMES, accelerated rehab,
and miscellaneous.
“Post-operative rehabilitation
J Knee Surg 21(3); 225-234,
2008 is a major factor in the
success of an ACL-R
5 prospective RCTs
procedure.
Both effective
Functional
Functional Rehabilitation
Rehabilitation
We all want to have the same
Fleming, et.al. OKC or CKC exercises after
ACL-R? Exerc Sports Sci Rev. 33: 134-40, 2005
end result, but the
challenge and
Recent biomechanical studies have shown controversy lies
that the peak strains produced on a graft are
similar in how we get
Clinical studies suggest that both play a
beneficial role in the early rehabilitation of the
there:
knee
Empirically-
Empirically-based programs Rehabilitation Approach
Rehabilitation Approach
Foundational “Specificity”
Every clinician has (Core) Exercises Exercises
for all Patients
“their” methods
because it “works Each link in the Neuromuscular
kinematic chain reactive training
for them’!!! Functional
specificity
rehabilitation
Summary Why the need
and for Research?
Conclusions There are no meta-
analysis studies
for lower
extremity “best”
exercises
Rehabilitation programs
Rehabilitation programs
are evolving –
are evolving –
Clinical Implications
Clinical Implications
NEED TO INCLUDE As Davies has said for the last 35
NEED TO INCLUDE years, it MUST be an
OKC (ISOLATED)
OKC (ISOLATED) INTEGRATED OKC/CKC –TLS
exercises as part of
exercises as part of Testing, Rehabilitation,
rehabilitation for
rehabilitation for and DC criteria
optimum outcomes For Outcome Studies!!!
optimum outcomes
Thanks to
Biodex Summary
& IPRS
