Maimonides Inservice

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Open and Closed Kinetic Chain Exercises used in Various Joint Injuries Christina Machado, SPT NYIT Class of 2017

Transcript of Maimonides Inservice

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Open and Closed Kinetic Chain Exercises used in Various Joint Injuries

Christina Machado, SPT NYIT Class of 2017

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Objectives

• Understand the importance of tissue healing• Understand the differences between OKC/CKC• Current evidence that addresses the two

forms of exercises (LE/UE)• General Rehab ‘protocols’ • Warning signs to take a step back• Conclusion

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RESPECT Tissue Healing • Inflammatory Response Phase (1-6 days)

– Tx: Modalities to reduce circulation, pain, enzyme activity rate and TherEx that do NOT stress the injured area

– Goal: Prevent disruption of new tissue • Fibroplastic Repair Phase (3-20 days)

– Tx: Modalities to increase circulation, enzyme activity rate, collagen deposition and TherEx to improve neuromuscular control

– Goal: Prevent muscle atrophy & joint deterioration of injured area • Maturation-Remodeling Phase (Day 9- 2 years)

– Tx: Modalities to modulate balance of collagen deposition/resorption to improve collagen alignment and TherEx that is sport/functional specific

– Goal: optimize tissue function to return to PLOF• PMH is VITAL: contraindications/precautions to the modalities

Haff G and Triplett T. Essentials of Strength and Conditioning. 4th ed. 2015.Cameron M. Physical Agents in Rehabilitation: From Research to Practice. 4th ed.

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Definitions OPEN KINETIC CHAIN• Exercise that uses of a

combination of successively arranged joints, which terminal joint is FREE to move

• Allows for greater concentration on isolated joint/muscle movement

• Ex: seated knee extension

CLOSED KINETIC CHAIN • Exercise, which the terminal

joint meets considerable resistance that prohibits or restrains free ROM as the distal joint is STATIONARY

• Ex: squat/push-up

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Advantages & Disadvantages

Ellenbecker TS, Davies GJ. Closed kinetic chain exercises. A comprehensive guide to multiple-joint exercises. J Chiropr Med 2002;1(4):200.

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Common LE Injuries – I. Post Operative Procedure – II. Overuse/Arthritis/Tendinopathy Injuries

• Hip– THA– OA

• Knee– TKA– ACL Reconstruction/Repair– Mensicus Injury– MCL Tear – Patellofemoral syndrome

• Ankle – Achilles rupture– Fracture

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HIP I: THA & OA

THA• Surgeon precautions to prevent

dislocation • WB status • Progressive strength focusing on

abductor mm strength • Gait training • CKC• OKC

OA • Decrease pain • Maybe offer AD • CKC • OKC

Goal: restore ambulation & ADLsAssess leg length discrepancies

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Hip II: ITB Syndrome

• Weak muscles in the trunk and hip• Hip flexor tightness and glut medius weakness• Tightness of piriformis • CKC• OKC

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Knee I: TKA

• Mobilization, static strength, dynamic strength, and stabilization – Patella mobility, knee extension ROM, quad strength

• Goals for D/C– 120 degrees knee flexion – QI 70% – Reciprocal stair negotiation – Unlimited walking distance

• CKC• OKC

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Knee II: ACL Reconstruction/Repair • Weeks 1-3

– Normalized gait/stair negotiation by week 2-3– A/PROM 0-90 degrees by week 1 – Quad set with superior glide– Effusion control – CKC 0-60 degrees

• Weeks 3-8– Full knee ROM– QI of 80% – OKC: Start 90-45 degrees

• Weeks 9- 12– CKC: Full range squat– OKC: 90-10 degrees – Initiate running program

• Week 13+– Plyometric training– Agility progression

Focus on Quad strength early*

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Types of Grafts

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Knee III: Meniscus Repair • Goal: Minimize stress– WB limitation (based on surgeon) – 0-90 degrees x 4 weeks– No loaded flexion or isolated hamstrings until weeks

4-6 – CKC then OKC

• Time frame variables:– Size of tear, location of tear, tissue quality, activity

level, specific procedure

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Knee IV: MCL Tear/Repair • Depends on the grade of the tear• Acute Management:

Adams D, Logerstedt DS, Hunter-Giordano A, Axe MJ, Snyder-Mackler L. Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression. JOSPT. 2012;42(7):601-614.

Which of these exercises are appropriate at the early stages of MCL Rehab?

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Knee IV: MCL Tear/Repair • Restorative to Advanced Phase:– Continue to address the kinetic chain and NM control – Exercise progression: sagittal plane frontal plane – Leg press/partial squats – Balance/Perturbation • If you implement side stepping…

– Plyos/Agility training

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Knee V: Patellofemoral Syndrome• Patellar instability– Bracing/Taping– Dynamic stability of kinetic chain

• Soft tissue lesions– Limit painful activities– Restore biomechanics

• Overuse syndromes– Decrease tendon compression with rest– Progressive quad/patella loading

• CKC OKC

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“I have pain right here!”

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Ankle I: Achilles Rupture

• Early AROM but NO Achilles stretching!• Progressive tendon loading • Heel raise progression by week 8 • DF within 5 degrees of CL side • *Proprioceptive deficits may persist up to 6

months *Weber AJSM 2003

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Ankle II: Fracture • Ottowa Ankle and Foot Rules• NWB for 4 weeks to allow for

wound healing & WBAT after 4 weeks

• ROM early even with brace/cast to restore DF

• Incline walking by 1% • PF strength is a good predictor of

stair climbing/walking • Risk of OA • CKC• OKC?

Weber AJSM 2003

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Common UE Injuries

• I. Post Operative Procedure• II. Overuse/Tendinopathy • Shoulder– RTC tear– RTC tendinopathy – Labral tear

• Elbow– Medial/Lateral epicondylitis

• Wrist/Hand– Fracture

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Shoulder I: RTC Repair • Mostly supraspinatus repair • Size of tear impacts treatment • Weeks 0-6 weeks

– Pt education (lifting, sleeping, pain control. raising arm 90– PROM shoulder in scap plane, AROM elbow wrist/hand– CKC

• Weeks 6-8– Progress full ROM, hor AD, extension, IR – Emphasize scapulohumeral rhythm – Nueromuscular control – CKC

• Weeks 8-16– Normalize strength and endurance – Functional activities – CKC, OKC

• Weeks 16- 6 months– Return to sport/work– Injury prevention education – CKC, OKC

Subscapularis:No AROM IR >4 wksNo IR strengthening >6wks

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Treatment of Non-traumatic RC tears

• “Results suggest that at one-year follow-up, operative treatment is no better than conservative treatment with regard to non-traumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this [RTC tear] condition”

Kukkonen J1, et al. Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. Bone Joint J. 2014 Jan;96-B(1):75-81. doi: 10.1302/0301-620X.96B1.32168

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Shoulder II: RTC Tendinopathy

• Reactivity Stage – Decrease pain/reactivity – Rest – Submax isometrics (45 sec) – Scapulohumeral rhythm– Restore posterior shoulder ROM– CKC, OKC

• Degeneration Stage – Progressive RTC loading – CKC, OKC

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Elbow I: Medial/Lateral Epicondylitis • Rehab: pain management with anti-inflammatory med, ultrasound,

phonophoresis, iontophoresis, laser, E-stim• Cyriax: cross friction tissue massage• Mill’s manipulation • Ther-Ex: static stretching ECRB (30-45 sec. hold, 3x, 30 sec. rest)

then eccentric strengthening with NO weight. Once patient has minor discomfort/pain, add free weights based on pt’s 10RM.

• CKC, OKC • What above above and below the elbow in terms of ther-ex?

Viswas R. Comparison of Effectiveness of Supervised Exercise Program and Cyriax Physiotherapy in Patient with Tennis Elbow. 2012.

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Wrist/Hand I: Fracture

• Management plan: – modalities, splinting, tissue mobilizations

• OKC, CKC• *Burning in cast • Hand specialist

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General UE Protocol

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Core/Trunk Stability

• McKenzie Method • Correcting lateral shift • Yoga, Pilates

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The Tricky Neck

• STRETCH– Levator scapula–Upper trapezius –Chin tucks

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How to Judge if We are Doing Too Much?

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Conclusion

• Respect the tissue healing process– Too much, too soon= no bueno

• Assess patient status each day• Treat the symptoms not just the diagnoses• Isometrics Isotonics Plyometrics – Every patient is different

• Be as functional and sport-specific as possible• Remember we are one kinetic chain

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References • Haff G and Triplett T. Essentials of Strength and Conditioning. 4th ed. 2015.• Cameron M. Physical Agents in Rehabilitation: From Research to Practice. 4th ed. • Ellenbecker TS, Davies GJ. Closed kinetic chain exercises. A comprehensive guide to multiple-joint

exercises. J Chiropr Med 2002;1(4):200.• http://www.running-physio.com. Accessed November 26, 2016. • Zhang F, Wang J, Wang F. Comparison of the Clinical Effects of Open and Closed Chain Exercises

after Medial Patellofemoral Ligament Reconstruction. Journal of Physical Therapy Science. 2014;26(10):1557-1560. doi:10.1589/jpts.26.1557.

• Kukkonen J1, et al. Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. Bone Joint J. 2014 Jan;96-B(1):75-81. doi: 10.1302/0301-620X.96B1.32168

• Viswas R. Comparison of Effectiveness of Supervised Exercise Program and Cyriax Physiotherapy in Patient with Tennis Elbow. 2012.

• Hoogvliet, P. ,Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review, (Ann Rehabil Med. 2012 Oct).., geraadpleegd op 2 mei 2014, http://www.ncbi.nlm.nih.gov/pubmed/23709519

• Greenberg, Eric. Common LE/UE Injuries. New York Institute of Technology. Accessed November 2016.

• Adams D, Logerstedt DS, Hunter-Giordano A, Axe MJ, Snyder-Mackler L. Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression. JOSPT. 2012;42(7):601-614.