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Three Part Question

[IN] patients presenting with patello - femoral pain [IS]open kinetic chain exercise or closed kinetic chain exercise more effective [AT]reducing pain & improving function

Clinical Scenario

A 22 year old female presents to physiotherapy with patello femoral symptoms present for the last six months.At this time, she had moved into a flat on the third floor, & noticed gradual onset of symptoms.You are aware that quadriceps strengthening is known to improve the outcome of conservative treatment.Debate ensues as to whether open or closed kinetic chain exercises will be most beneficial in improving pain & function.

Search Strategy

AMED on DIAL DATASTAR interface 1985-November 2007; CINAHL on DIAL DATASTAR interface 1982- date November 2007; MEDLINE on DIAL DATASTAR interface 1950 to November 2007; Cochrane Library via National Library for Health.
MESH terms [Patella OR Patellar-dislocation OR patellofemoral pain syndrome OR cartilage disease OR dislocation OR arthralgia] OR Keywords [Patellofemoral pain OR patella femoral OR patella dysfunction OR anterior knee pain OR patellar retinaculum OR patella plica$ OR patellar tendinopathy OR Q angle OR A angle OR hamstring tightness]
AND
MESH terms [Muscle-contraction OR exercise OR exercise-therapy OR bandages OR proprioception OR sports medicine OR gait OR physical-therapy-modalities OR isometric-contraction OR hydrotherapy OR braces OR physical education OR training OR proprioception OR muscle-contaction OR isometric contraction OR muscle strength OR electromyography] OR Keywords [Vastus medialis oblique OR knee control OR knee exercises OR quadriceps regime OR quadriceps drill OR quadriceps exercises OR core stability OR core control Or open kinetic chain OR closed kinetic chain]

Search Outcome

Altogether 29 papers were found, 5 of which were relevant to the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Gaffney K et al 1992 Australia	72 patients, 65% male, mean age 34 (11-65) with PFP, 50% bilateral.Mean duration of symptoms 40.7 months. Duration 6 weeks, weekly visits to check performance all groups.Group 1 pain free eccentric & isometric exercise, with taping.Group 2 concentric isometric exercise.	RCT	VAS at baseline & 6 weeks	Both groups showed pain reduction p<0.05 but NSS between groups	Group 1 -8 withdrawals, Group 2 - 4 withdrawals. No ITT analysis performed. No control group. Wide age range included , & the pathology evident may not be homogenous in such a large range. Short follow up period with no indication of long term benefits or problems with either programme.
			Function grade baseline & 6 weeks	Group 1. Improved = 18, no change =4, variable = 10.Group 2. Improved =15, no change =7, variable = 10.p<0.05 for both groups
			Clarke's Test at baseline & 6 weeks	Group 1.Improved =20 (28%) 8 (14%).Group 2 = Improved. 28 (39%) 11 (17%)
			Individuals opinion of success at 6 weeks	25 (89%) Group 2 24 (75%). p<0.05 for both groups
Witrouw E et al 2000 Belgium	60 patients with PFPS, 45% bilateral, duration 15.1 months (0.5-28). Age 20.3 (14-33). No drop outs during study. Group 1 = 30 patients OKC exercises Group 2 = 30 patients CKC exercises. Both groups stretch post training.Duration 5 weeks, both groups train with a physical therapist 3 tims a week for 30 - 45 minutes.Both groups are retested at 3 months following advice to maintain active muscle strength, but no follow up during this time.	RCT	VAS pain during daily activity, baseline, 5 weeks, 3 months	Significant improvement during rehabilitation in both groups p =<0.05 but during follow up period 5 weeks to 3 months only Group 2 demonstrated reduction in symptoms.	No control group. Strength only tested in open chain position.
			KPFS: baseline, 5 weeks, 3 months	Group 1 showed increase in functionality at 5 weeks p=0.001 & 3 months p=0.004. Group 2 showed increase in function at 5 weeks p=0.002 & at 3 months, p= 0.001
			VAS during triple jump test, baseline,5 weeks, 3 months	Group 1 NSS p=0.13.Group 2 showed significant increase in jumping distance at 5 weeks p=0.04 & at 3 months p=0.02
			Unilateral squat: baseline, 5 weeks, 3 months	Group 1 number of patients asymptomatic at baseline 6 (20%) 5 weeks 11 (37%) 16 (53%). Group 2 number of patients asymptomatic at baseline 6 (20%) 5 weeks13 (43%) 3 months 17 (57%)
			Step up: baseline, 5 weeks, 3 months	Group 1 number of patients asymptomatic at baseline 11(37%) 5 weeks 23 (77%) 3 months 22(73%).Group 2 Asymptomatic at baseline 8 (27%) 5 weeks 18 (60%) 3 months 22 (73%)
			Step down: baseline, 5 weeks, 3 months	Group 1 number of patients asymptomatic at baseline 8 (27%) 5 weeks 19 (63%) 23 (77%). Group 2 number of patients asymptomatic at baseline 5 (17%) 5 weeks 12 (40%) 3 months 20 (67%).Increase in asymptomatic patients in both groups p=<0.05.No differences between the number of asymptomatic patients in both groups at any evaluation point p> 0.05
Witrouw E eta al 2004 Belgium	A continuation of the 2000 trial.49 of the 60 patients were available for a 5 year evaluation which followed on from the evaluations previously at baseline, 5 weeks & 3 months. Assessment of muscular characteristics, subjective symptoms, & function reviewed 5 years post rehabilitation.Comparison of results is made between OKC & CKC Groups at 5 years, & is compared to the 3 month follow up statistics.	RCT	9 patients Group 1 painfree, Group 2 10 patients painfree.		No ITT analysis. No control group
			Swelling of the knee	Group 1 complained of less swelling than Group2 p=.04
			Pain on stair descent	Group1 less pain than Group 2 p=.01
			Night pain	Group1 had less night pain p=.04
			Kujala score	NSS between groups
			Triple jump & maximal painfree knee bend	NSS between groups
			Muscle strength measurements	NSS between groups
			Subjective Assessment comparison between 3 months & 5 years Group 1	NSS between 17/18 VAS
			Pain during sitting	More pain at 5 years p=.04
			Group1 Kujala Pain score at 3 months & 5 years	NSS
			Group 1 pain free maximal knee bend & 45 cm step test	Improved at 5 years p =.01
			Group1muscle strength at 3 months & 5 years	NSS
			Group 2 at 3 months & 5 years descending stairs, jumping, sport, & prolonged sitting with knees flexed, triple jump,	Worsened p=.01 - p=.04
			Group 2 at 3 months & 5 years Kujala score, 45 cm step test, pain free maximal knee bend & quadriceps muscle strength	NSS
			Group2 at 3 months & 5 yearshamstring strength	Deteriorated at all 3 velocities p=0.01
Herrington L et al 2007 UK	N = 45 male patients 18 - 35 years (mean = 26.9) with PFPs. Group 1 = single joint non-weight bearing quadriceps exercise (SJNWBE) Group 2 = Weight bearing multiple joint exercise (MJWBE) Group 3 = Control . Subjective symptoms, knee extensor muscle strength, & function measured at initial examination & at completion at 6 weeks.	RCT	Modified Kujala Score at baseline & 6 weeks	Group 1 significantly increased function p=.03.Group 2 significantly increased function p=.01.NSS between both groups post intervention.Post intervention scores significantly better for intervention groups as compared to the Control Group p=<0.01.Control Group showed decrease in function over 6 weeks p=.03	No long term folllow up.
			Knee extension strength measured at 60 degrees knee flexion with Cybex II dynamometer	Isometric Quadriceps muscle peak force at 6 weeks - Both groups increased significantly. Group 1 p-0.01, & Group 2 p=0.005.Post intervention NSS between both groups. Knee extension strength greater for both exercise groups than for the control group Group 1 p=.01 Group 2 p=.035.
			Pain During Knee Extension Strength Test	Pain reduction following intervention for Group 1 p=.005 & Group 2 p=.025.NSS post intervention for both groups p>.05.Post intervention, both exercise groups had lower pain compared to the control group. Group 1 p=.015, Group 2 p=.005
			VAS with step down	Both groups had a significant decrease post intervention p=<.001, NSS between both groups.No change in pain level in the control group.
Bakhitary A et al 2007 Iran	N= 32 university females Group 1 = OKC exercises, Group 2 = CKC exercises. Outcomes assessed at baseline, at completion of treatment at 3 weeks & 2 weeks post completion.	RCT	Q angle	Reduced in both groups p=0.016. No results for 2 weeks later.	No control group. No long term follow up. Some results incomplete. No details of what was included in VAS. No reporting of side effects.
			Crepitation	Present in 90% of both groups at baseline.Group 1 decreased to 55.6% & Group 2 to36.7%.No change 2 weeks later.
			MIVCF	Increased muscle force in Group 2 at 3 weeks p=0.01.No results for 2 weeks later.
			Thigh circumference	Both groups show increase Group1 p=0.02, Group 2 p=0.002. Results unchanged 2 weeks later.
			VAS	Both showed pain reduction, NSS between both groups at completion & 2 weeks later p=0.13

Comment(s)

There is evidence for the effectiveness of exercise therapy in the treatment of PFPS in reducing pain & improving function. A six week programme appears to improve subjective & clinical outcomes. The belief that OKC exercises are to be avoided in PFPS has not been substantiated. The Gaffney & Witrouw (2000) papers were included in a Cochrane review (Hientjes et al) which looked at all forms of exercises for PFPS.

Clinical Bottom Line

Exercise therapy is effective in the treatment of PFPS irrespective of its type.

References

1. Kath Gaffney et al Patellofemoral joint pain: A comparison of two treatment programmes. Excel 1992 p179-189
2. Witrouw E. et al Open Versus Closed Kinetic Chain Exercises for Patellofemoral Pain. A Prospective, Randomized Study The American Journal of Sports Medicine Volume 28, No. 5, 2000
3. Witrouw E et al Open Versus Closed Kinetic Chain Exercises in Patellofemoral Pain - A 5 year Prospective Randomized Study The American Journal of Sports Medicine Vol 32 No 5 2004 p.1123-1130
4. Herrington L et al A Controlled Trial of Weight - Bearing versus Non - Weight Bearing Exercises for Patellofemoral Pain Journal of Orthopaedic & Sports Physical Therapy Vol 37 Number 4 April 2007 p155-160
5. Bakhitary A et al Open verus closed kinetic chain exercises for patellar Chondromalacia British Journal of Sports Medicine July 2007 p1473-1480