Which OKC are you using in the early lower limb rehabilitation?

New study 🔰The Effect of Open vs Closed Kinetic Chain Exercises on Anterior Tibial Laxity, Strength, and Function Following Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis.
Perriman A, et al. J Orthop Sports Phys Ther. 2018.🔰

➡️494 participants, (Mean age 19-34 year)

➡️ N=10 studies compared CKC exercises with either

  1. solely OKC exercises (seven studies)
  2. a combination of OKC and CKC exercises (three studies).
  3. OKC (or combined OKC and CKC) exercises were introduced early (less than six weeks) (6 studies)
  4. 4 studies they were introduced OKC later (greater than six weeks)

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Adverse events

4 reported on adverse events.

  • 1 study reported no adverse events.
  • 1 study (100 participants) reported 2 graft failures in the early OKC group less than 3 months postoperatively) (see the CKC and OKC protocol),
  • 1 one study reported 2 graft failures in each group.
  • 1 study reported the requirement for 2 follow up 340 arthroscopes but were not clear in which groups these adverse events occurred

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Bynum EB, Barrack RL, Alexander AH. Open versus closed chain kinetic exercises after anterior cruciate ligament reconstruction. A prospective randomized study. Am J Sports Med. 1995;23:401-406. http:dx.doi.org/10.1177/036354659502300405

There was limited to moderate evidence of no significant difference in clinically important anterior tibial laxity, strength, patient reported function or physical function with the early introduction of OKC exercises in the ACLR population when compared to CKC exercises at all follow up time points. The hamstrings graft may potentially be more vulnerable to laxity than the patellar graft, but this is based on limited evidence.

Exercise protocols which made up the interventions varied between studies (online Appendix 2). However for both groups there was some common exercises.

Fukuda TY, Fingerhut D, Moreira VC, et al. Open kinetic chain exercises in a 513 restricted range of motion after anterior cruciate ligament reconstruction: a 514 randomized controlled clinical trial. Am J Sports Med. 2013;41:788-794. 515 http:dx.doi.org/10.1177/0363546513476482

Both groups

  • PWB 2 weeks post op with 2 crutches
  • Isometric CKC exercises for hip and knee strengthening started 2 week. Isometric CKC exercises for hip and knee strengthening followed by dynamic CKC exercises at the sixth postoperative week.
  • 1 week: PROM E/F; patellar mobs
  • 2 weeks: bike; core; strength: hip, calf, squat; leg press; balance
  • 3 weeks: FWB nil aid; AROM F
  • 5-7 weeks: increase ROM in leg press, bridges; step ups/downs; SL sit to stand; trampoline
  • 8-9 weeks: SL HR; increase ROM in leg press; hamstrings curl
  • 10-11 weeks: straight line running; hip strength with theraband; SL trampoline; DL jumping 4 months: SL squats; SL jumping; lateral shuttle runs; seated knee E.

Heijne A, Werner S. Early versus late start of open kinetic chain quadriceps exercises after ACL reconstruction with patellar tendon or hamstring grafts: A prospective randomized outcome study. Knee Surg Sports Traumatol Arthrosc. 2007;15:402-414. http:dx.doi.org/10.1007/s00167-006-0246-z

Both groups

  • 0-2 weeks: patellar mobilisations; PROM E; AROM F/E; gait; squats; HR
  • 2-5 weeks: bike; leg press and curl in machine
  • 6-8 weeks: AROM knee E 30-0 deg; steps up/downs; SL HR and sit-stand; lunges, DL trampoline
  • 9-11 weeks: jumping; SL trampoline; straight line running
  • 3-4 months: OKC quads full ROM; continue balance; plyometric drills
  • 4-6 months: running and cutting, acceleration/deceleration; sports specific training

Mikkelsen C, Werner S, Eriksson E. Closed kinetic chain alone compared to combined open and closed kinetic chain exercises for quadriceps strengthening after anterior cruciate ligament reconstruction with respect to return to sports: a prospective matched follow-up study. Knee Surg Sports Traumatol Arthrosc. 575 2000;8:337-342. http:dx.doi.org/10.1007/s001670000143

Both groups

  • 0-2 weeks: PROM E, AROM F
  • 2-6 weeks: patellar mobilisation; gait; CKC quadriceps/hamstrings; proprioception and balance; isokinetic hamstrings; bike
  • 6-12 weeks: stairs; skipping, slide board skating 3-4 months: straight line jogging
  • 4-6 months: jogging and running on uneven surfaces, turns, cutting, acceleration/deceleration; sports specific

Ucar M, Koca I, Eroglu M, et al. Evaluation of open and closed kinetic chain exercises in rehabilitation following anterior cruciate ligament reconstruction. J Phys Ther Sci. 2014;26:1875-1878. http:dx.doi.org/10.1589/jpts.26.1875

Both groups

  • 24 hr post op: standing and WBAT with crutches
  • Day 3-7: ankle pumps, isometric quadriceps , SLR
  • Day 7-15: Knee PROM with CPM 0-90, amb with crutches FWB
  • Day 15-30: if knee flexion > 110 deg ok to walk quickly, run on smooth surface, ascend / descend stairs