Hindawi

Journal of Sports Medicine

Volume 2017, Article ID 4721548, 10 pages
https://doi.org/10.1155/2017/4721548

Review Article
Open versus Closed Kinetic Chain Exercises following an
Anterior Cruciate Ligament Reconstruction: A Systematic
Review and Meta-Analysis

Daniel Jewiss,1 Cecilia Ostman,1 and Neil Smart2

1
School of Rural Medicine, University of New England, Armidale, NSW 2351, Australia
2
School of Science and Technology, University of New England, Armidale, NSW 2351, Australia

Correspondence should be addressed to Neil Smart; [email protected]

Received 8 February 2017; Revised 19 May 2017; Accepted 28 May 2017; Published 17 August 2017

Academic Editor: Ian L. Swaine

Copyright © 2017 Daniel Jewiss et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. There is no consensus on whether closed kinetic chain (CKC) or open kinetic chain (OKC) exercises should be
the intervention of choice following an anterior cruciate ligament (ACL) injury or reconstruction. Methods. A systematic search
identified randomized controlled trials of OKC versus CKC exercise training in people who had undergone ACL reconstructive
surgery. All published studies in this systematic review were comparisons between OKC and CKC groups. Results. Seven studies
were included. Lysholm knee scoring scale was not significantly different between OKC and CKC exercise patients: MD: −1.03%; CI:
−13.02, 10.95; 𝑝 value = 0.87 (Chi2 = 0.18, df = 1, and 𝑝 value = 0.67). Hughston clinic questionnaire scores were not significantly
different between OKC and CKC exercise patients: MD: −1.29% (−12.02, 9.43); 𝑝 value = 0.81 (Chi2 = 0.01, df = 1, and 𝑝 value =
0.93). Conclusions. While OKC and CKC may be beneficial during ACL surgical rehabilitation, there is insufficient evidence to
suggest that either one is superior to the other.

1. Introduction assumption was thus made that OKC was more dangerous
than CKC given that increased laxity is associated with graft
Open kinetic chain (OKC) exercises are lower limb activities failure and loosening. Beynnon and Fleming (1998) cast
performed where the distal segment of the limb is free to doubt as to whether measurable differences in strain between
move. The opposite of OKC is closed kinetic chain exercises the two forms of exercise exist [4]. Many physiotherapists
(CKC). There is no consensus among the existing published strongly believe that OKC exercises exert greater strain on
evidence as to whether closed kinetic chain (CKC) or open the ACL and the patellofemoral joint than CKC exercises
kinetic chain (OKC) exercises should be the intervention of [4]. Moreover, the opinion of many physiotherapists is that
choice following an anterior cruciate ligament (ACL) injury adverse symptoms such as pain and joint laxity are more likely
or reconstruction. Several outcome measures are recom- with OKC exercises than with CKC exercises.
mended to assess ACL injury and rehabilitation outcomes [1]. We conducted a systematic analysis of all clinical ran-
The commonly held belief has been that OKC exercises cause domized controlled trials comparing OKC exercises and CKC
increased strain on the ACL as well as increased joint laxity exercises in patients following ACL reconstruction. We aimed
and anterior tibial translation [2]. to determine whether there are any differences in clinical
The doubts about the safety of OKC exercises are arguably outcomes between OKC and CKC exercise protocols.
unsupported by substantial published evidence and are pos-
sibly an intuitive opinion. Intuitively, a distally fixed foot 2. Methods
in the case of CKC is safer than a nondistally fixed foot in
OKC. This stance follows the work of Yack et al., 1993, who 2.1. Search Strategy. Studies were identified through a MED-
showed that there was greater joint laxity using the Anterior LINE search strategy (1966 to October 4, 2016), Cochrane
Tibial Displacement test during OKC exercises [3]. The Controlled Trials Registry (1966 to October 4, 2016),
2 Journal of Sports Medicine

CINAHL, SPORTdiscus, and Science Citation Index. The 2.6. Data Synthesis. Meta-analyses were completed for con-
search strategy included a mix of MeSH and free text terms tinuous data by using the change in the mean and standard
for the key concepts related to anterior cruciate ligament deviation of outcome measures. It is an accepted practice
reconstruction, exercise training, open chain exercises, and to only use postintervention data for meta-analysis but
closed chain exercises (see PubMed search strategy in Supple- this method assumes that random allocation of participants
mentary Files available online at https://doi.org/10.1155/2017/ always creates intervention groups matched at baseline for
4721548). Studies were included if patients had undergone age, disease, severity, and so on. Change in postintervention
ACL reconstruction. Searches were limited to prospective mean was calculated by subtracting baseline from postin-
randomized or controlled trials in humans. No restrictions tervention values. Data required was either (i) 95% confi-
were placed on the language of publication. Reference list of dence interval data for pre/postintervention change for each
papers and latest editions of relevant journals which were group or, when this was unavailable, (ii) actual 𝑝 values for
not available online were scrutinized for new references. pre/postintervention change for each group or, if only the
Full articles were read and assessed by two reviewers (C. O. level of statistical significance was available, (iii) default 𝑝
values; for example, 𝑝 < 0.05 becomes 𝑝 = 0.049, 𝑝 < 0.01
and D. J.) for relevance and study eligibility. Disagreements
becomes 𝑝 = 0.0099, and 𝑝 = not significant becomes 𝑝 =
on methodology were resolved by discussion, and a third
0.05.
reviewer (N. S.) adjudicated over any disputes. Study authors
were contacted and requested to provide further data if 2.7. Heterogeneity. Clinical heterogeneity was expected given
required. that the data were obtained from patients represented in
the included trials. As such, a random effects model was
2.2. Study Selection. Included studies were randomized con- employed. Heterogeneity was quantified using the 𝐼2 test
trolled trials of OKC versus CKC exercise training in people [7], as it does not inherently depend upon the number of
who had undergone ACL reconstructive surgery. All pub- studies considered. 𝐼2 values range from 0% (homogene-
lished studies in this systematic review were comparisons ity) to 100% (greatest heterogeneity); a CI that does not
between OKC and CKC groups. include 0% indicates that the hypothesis of homogeneity
In addition to the studies identified through database is rejected, and an inference of heterogeneity is merited
searching, reference lists of identified studies were scru- [7].
tinized. Only the principal study with the greatest num-
ber of subjects was included where multiple publications 3. Results
existed from the same dataset. After initial screening we
removed overlapping, duplicates, duplicate data, and irrel- Our initial search identified 151 studies. After excluding
evant articles such as editorials and discussion papers that studies based on title and abstract, as well as removing
did not match the inclusion criteria. We excluded studies duplicates, 23 studies remained. The full-text articles were
where the subjects had not yet undergone ACL reconstruc- assessed for study inclusion, and 16 were excluded (see
tive surgery, nonrelevant studies, and those reporting only Table 2); 4 studies were not randomized controlled trials, 6
acute exercise testing responses. We excluded studies from studies were not postsurgical, and 6 studies did not compare
specific analyses if incomplete data was reported and the OKC to CKC exercise rehabilitation. Seven studies remained,
authors did not respond to our requests to provide missing four were included for meta-analysis and three for systematic
data. review only. The search details are provided in the CONSORT
statement (Figure 1).
2.3. Outcome Measures. We extracted all possible data; how- Our analysis of the 4 studies totalled 229 participants: 112
ever there were only two outcomes which were reported by from OKC exercise groups and 117 from CKC exercise groups.
more than one paper, the Lysholm knee scoring scale [1] Table 1 summarizes the details of the included studies.
and the Hughston clinic questionnaire [5]. We also recorded
exercise training frequency, intensity, duration per session, 3.1. Meta-Analyses
length of exercise program, participant exercise adherence,
3.1.1. Lysholm Knee Scoring Scale. Two studies provided data
and completion rates.
on the Lysholm knee scoring scale. Results show that there
2.4. Data Synthesis. From extracted data we calculated the was no significant change in OKC exercise patients versus
mean difference for pre/postintervention change in outcome CKC exercise patients: MD: −1.03% and CI: −13.02, 10.95; 𝑝
measures and medical events. value = 0.87 (Chi2 = 0.18, df = 1, and 𝑝 value = 0.67; between
studies variability: 𝐼2 = 0%); see Figure 2.
2.5. Assessment of Study Quality. We assessed study quality
with regard to eligibility criteria specific, random allocation 3.1.2. Hughston Clinic Questionnaire. Two studies provided
of participants, concealed allocation, similarity of groups at data on the Hughston clinic questionnaire. Results show that
baseline, assessors blinded, outcome measures assessed in there was no significant change in OKC exercise patients
85% of participants, and intention of treatment analysis. The versus CKC exercise patients: MD: −1.29% (−12.02, 9.43); 𝑝
study quality was assessed according to the validated TESTEX value = 0.81 (Chi2 = 0.01, df = 1, and 𝑝 value = 0.93; between
scale which has a maximum score of 15 [6]. studies variability: 𝐼2 = 0%); see Figure 3.
 Table 1: Characteristics of included studies.
Frequency Session time
Author(s) Participants Country Intervention Weeks Intensity Surgical approach Outcomes
(session/week) (min)
Patients in the CKC
group performed a
mixture of resistance Adverse events, graft
exercises including failure, Lysholm knee
knee bends, seated function scoring
leg press, stationary scale, modified
Journal of Sports Medicine

97 patients Arthroscopically
biking, and running. Tegner activity rating
randomized to assisted patellar
Bynum et al. The OKC group scale, overall patient
OKC (𝑛 = 47) US 52 Not provided Not provided Not provided tendon autograft
1995 [8] performed a variety assessment rating,
and CKC and fixed with 9-mm
of exercises patellofemoral pain,
(𝑛 = 50). interference screws.
including leg raises, extension deficit, and
isotonic quadriceps flexion deficit using a
with low weights, KT-1000 (20 lb and
and treadmill max)
jogging forwards
and backwards.
3 sets of 20 RM were
done in each session
Patients in the CKC
for each training
group performed
group. The training Either Graft failure,
unilateral resistance
ROM for both hip arthroscopically Hughston clinic visual
training of the hip
37 patients and knee extensors in assisted patellar analog scale, knee
and knee extensors
randomized to both groups was 90 to tendon autograft or flexion at heel-strike,
Hooper et al. on a leg press
OKC (𝑛 = 19) UK 4 3 0 degrees. Target the technique peak extensor
2001 [18] machine; patients in
and CKC speed settings were described by moment, extensor
the OKC group
(𝑛 = 18). 1.5 s for the concentric Kennedy et al. (1980) impulse, peak
performed exercises
phase and 3.0 s for the using a fixed patellar concentric power, and
using knee and hip
eccentric phase of tendon allograph. concentric energy.
extension machines
training repetition,
or ankle weights.
with a 1.0 s interval
between phases.
Stationary cycling
for 5 minutes for
warm-up and
Extensor isokinetic
cool-down. OKC
36 patients were strength, flexor
exercises were
randomized to 70% intensity of 1 isokinetic strength,
Kang et al. composed of
OKC (𝑛 = 18) Korea 12 3 repetition maximum 30 minutes Not provided. extensor isokinetic
2012 [12] straight leg raise, leg
and CKC (RM). endurance, flexor
extension, and leg
(𝑛 = 18). isokinetic endurance,
curl; CKC exercised
and squat.
were composed of
squat, leg press, and
lunge.
3
 4

Table 1: Continued.
Frequency Session time
Author(s) Participants Country Intervention Weeks Intensity Surgical approach Outcomes
(session/week) (min)
3 sets of 20 RM were
done in each session
Patients in the CKC
for each training
group performed
group. The training Either
unilateral resistance
ROM for both hip arthroscopically
training of the hip
36 patients were and knee extensors in assisted patellar
and knee extensors
randomized to both groups was 90 to tendon autograft or
Morrissey et on a leg press
OKC (𝑛 = 18) UK 4 3 0 degrees. Target Not provided the technique ADT
al. 2000 [11] machine; patients in
and CKC speed settings were described by
the OKC group
(𝑛 = 18) 1.5 s for the concentric Kennedy et al. (1980)
performed exercises
phase and 3.0 s for the using a fixed patellar
using knee and hip
eccentric phase of tendon allograph.
extension machines
training repetition,
or ankle weights.
with a 1.0 s interval
between phases.
Total cycling time,
3 sets of 20 RM (rep number of treatment
max) were done in sessions where patient
Patients in the CKC each session for each was treated for
group performed training group. The pain/swelling,
Either
unilateral resistance training ROM for hypomobility, or poor
arthroscopically
training of the hip both hip and knee balance/position
43 patients were assisted patellar
and knee extensors extensors in both sense, frequency for
randomized to tendon autograft or
Morrissey et on a leg press groups was 90 to 0 pain site location,
OKC (𝑛 = 22) UK 4 3 Not provided the technique
al. 2002 [15] machine; patients in degrees. Target speed Hughston clinic
and CKC described by
the OKC group settings were 1.5 s for questionnaire (items
(𝑛 = 21). Kennedy et al. (1980)
performed exercises the concentric phase 1, 2, and 25), knee
using a fixed patellar
using knee and hip and 3.0 s for the extensor isometric
tendon allograph.
extension machines eccentric phase of peak torque, and knee
or ankle weights. training repetition, pain during knee
with a 1.0 s interval extensor isometric
between phases. maximum peak
torque.
Journal of Sports Medicine
 Table 1: Continued.
Frequency Session time
Author(s) Participants Country Intervention Weeks Intensity Surgical approach Outcomes
Journal of Sports Medicine

(session/week) (min)
Patients in the CKC
group performed
Either
unilateral resistance
arthroscopically
training of the hip Hughston clinic
49 patients assisted patellar
and knee extensors questionnaire,
randomized to tendon autograft or
Perry et al. on a leg press training parameters,
CKC (𝑛 = 25) UK 6 3 20 RM Not provided the technique
2005 [13] machine; patients in ATD, horizontal
and OKC described by
the OKC group jump, vertical jump,
(𝑛 = 24). Kennedy et al. (1980)
performed exercises and crossover jump.
using a fixed patellar
using knee and hip
tendon allograph.
extension machines
or ankle weights.
Patients in the CKC
group performed
squatting lunges,
standing weight
shift, wall sits,
one-legged quad
dips, and lateral
66 patients were Subjective pain visual
step-ups; patients in
randomized to Arthroscopically analog scale, thigh
Ucar et al. the OKC group Not
CKC (𝑛 = 33) Turkey Not provided Not provided Not provided assisted hamstring circumference, knee
2014 [10] performed isometric provided
and OKC autograft. flexion, and Lysholm
quadriceps,
(𝑛 = 33). score.
flexor-extensor
bench, isotonic
quadriceps, long leg
press on-off, and
knee
flexion-extension
stretching exercises.
5
6 Journal of Sports Medicine

Table 2: Excluded studies.

Study Reason for exclusion
Bird and Bulkeley 2010 [19] Review paper
Chrzan et al. 2013 [20] Intervention was not OKC versus CKC
Davis 1996 [21] Population was not postsurgical
Dolan 2010 [22] Not an RCT
Fitzgerald 1997 [23] Not an RCT
Hooper et al. 2002 [24] Intervention was not OKC versus CKC
Jenkins et al. 1997 [25] Population was not postsurgical
Keays et al. 2013 [26] Population was not postsurgical
Laboute et al. 2008 [27] Intervention was not OKC versus CKC
Lage et al. 1995 [28] Population was not postsurgical
Mikkelsen et al. 2000 [29] Intervention was not OKC versus CKC
Neeter et al. 2006 [30] Intervention was not OKC versus CKC
Perry et al. 2005 [13] Population was not postsurgical
Petschnig and Baron 1997 [31] Intervention was not OKC versus CKC
Rennison 1996 [32] Not an RCT
Ross et al. 2001 [33] Not an RCT
Tagesson et al. 2008 [34] Population was not postsurgical
Identification

Records identified through Additional records identified

database searching through other sources
(n = 151) (n = 0)

Records after duplicates removed

(n = 23)
Screening

Records excluded: not

Records screened controlled trials
(n = 23) (n = 4)

Full-text articles assessed Full-text articles excluded,

for eligibility with reasons
Eligibility

(n = 19) (n = 12)
Included

Studies included in
quantitative synthesis
(meta-analysis)
(n = 7)

Figure 1: CONSORT statement.

Journal of Sports Medicine 7

Study or subgroup OKC CKC Mean difference Mean difference

Weight
Mean SD Total Mean SD Total IV, random, 95% CI IV, random, 95% CI
Bynum et al. 1995 20 29.6393 41 20 30.938 44 86.6% 0.00 [−12.88, 12.88]
Ucar et al. 2014 20.1 51.5922 28 27.8 74.101 30 13.4% −7.70 [−40.38, 24.98]

Total (95% CI) 69 74 100.0% −1.03 [−13.02, 10.95]

Heterogeneity: 2 = 0.00; 2 = 0.18, df = 1 (p = 0.67); I2 = 0% 0 25 50

−50 −25
Test for overall effect: Z = 0.17 (p = 0.87)
OKC CKC

Figure 2: Lysholm score.

Study or subgroup OKC CKC Weight Mean difference Mean difference

Mean SD Total Mean SD Total IV, random, 95% CI IV, random, 95% CI
Hooper et al. 2001 14 29.0466 19 16 32.1745 18 29.4% −2.00 [−21.79, 17.79]
Perry et al. 2005 9 21.3137 24 10 24.226 25 70.6% −1.00 [−13.76, 11.76]

Total (95% CI) 43 43 100.0% −1.29 [−12.02, 9.43]

2 2 2
Heterogeneity:  = 0.00;  = 0.01, df = 1 (p = 0.93); I = 0%
−50 −25 0 25 50
Test for overall effect: Z = 0.24 (p = 0.81) OKC CKC

Figure 3: Hughston score.

3.2. Systematic Review. Insufficient data existed to conduct 3.3. Study Quality. The TESTEX scale [6] of study quality
meta-analyses for other outcome measures, so these are revealed a median score of 7 (out of a possible 14). As
systematically described here. there was no sedentary control group in included studies
TESTEX was scored out of 14 not usual 15. Study quality
3.2.1. Patellofemoral Joint Pain. Although Bynum et al., 1995 items that were not exhibited by more than 50% of studies
[8], reported significantly less pain in CKC compared to were allocation concealment (1 study), assessor blinding (0
OKC, they also reported no significant difference of Tegner studies), intention of treatment analysis (0 studies), point
activity scale score [9] in OKC versus CKC groups. Aside measures and measures of variability reporting (3 studies),
from varying levels of activity between groups, the authors relative exercise intensity review (1 study), and exercise
also stated that these findings are not likely to be clinically volume and expenditure (1 study).
significant. Ucar et al., 2014, reported more pain with OKC,
but level of statistical significance was unclear [10]. Morrissey 4. Discussion
et al., 2000, found no significant difference between the
groups in regard to knee extensor knee pain [11]. Our systematic review and meta-analysis suggest that a few
direct, randomized, controlled comparisons of OKC and
3.2.2. Knee Extensor Strength. Kang et al., 2012, reported that CKC knee extensor resistance training after anterior cruciate
isokinetic strength, isokinetic endurance, and squat strength ligament reconstruction exist in the published literature. Both
improved significantly after both interventions (𝑝 < 0.05), the statistical and descriptive analyses suggest both open
but changes in isokinetic strength and isokinetic endurance and closed kinetic chain exercises are beneficial interventions
of the extensor muscles were significantly greater in the OKC for people with reconstructed ACLs. Moreover, of the few
group than the CKC group (𝑝 < 0.05) [12]. In contrast studies that do exist, our meta-analyses showed no significant
Morrisey et al., 2000, found no difference between groups difference between OKC and CKC for pain scores, knee
[11]. extensor strength, laxity, and knee flexion.

3.2.3. Knee Anterior Laxity. Morrissey et al., 2000 [11], and 4.1. Pain. Some previous work has asserted that CKC reha-
Perry et al., 2005 [13], both found no statistically significant bilitative exercises are safer in terms of pain [14]. We also
difference between OKC and CKC groups on Anterior Tibial found evidence to the contrary [15]. Overall we found that
Displacement test. there is insufficient evidence within the literature pool to
either support or dispel this opinion. The meta-analyses of
3.2.4. Active Knee Flexion. Ucar et al., 2014, reported knee pain are unable to discern between OKC and CKC exercise
flexion was greater in the CKC group than the OKC group; rehabilitation programming. There are several explanations
however they do not report whether these differences were why no significant difference was seen. First, it may be that the
statistically significant [10]. questionnaire is not sensitive enough to detect small changes
8 Journal of Sports Medicine

in pain and function. Second, the statistical power of the Limitations. The small volume of data precluded meta-
analyses is limited by a small number of studies with small analyses in several outcome measures and in those that were
sample size and the addition of future studies will determine conducted statistical power was limited. Many of the outcome
if there is truly a difference. The final explanation is that measures are self-reported subjective measurements. The
there is actually no difference in pain experienced by people existing literature has yet to optimize use of advances in
undertaking OKC versus CKC. imaging techniques. Study quality assessment suggests that
future study designs could be more robust and strictly
4.2. Strength. We were unable to pool data for an analysis of implement assessor blinding. Both of these enhancements
knee extensor strength. Descriptive analysis of the included would be likely to produce data more meaningful than those
studies of our systematic review was also inconclusive. A currently existing.
study of normal anterior cruciate ligament subjects was also
unable to show either OKC or CKS to be superior for 5. Conclusions
improving knee strength [16].
Based upon existing published data it is difficult to make a
case for superiority of either open or closed chain kinetic
4.3. Knee Anterior Laxity. We were unable to pool data for
exercise rehabilitation after ACL reconstruction. Meta-
analysis of knee extensor strength and descriptive analysis of
analyses failed to show a benefit of either type of exercise
included studies did not provide further clarity on superiority
in terms of joint laxity and patellofemoral joint pain scores.
of either an OKC or CKC approach.
While there was weak evidence that open chain exercises are
better for improving knee extensor strength, this is countered
4.4. Knee Flexion. Only one study reported on the outcome by weak evidence for better active knee flexion in closed chain
measure knee flexion and this work claimed OKC exercise to activities.
be superior for restoring knee flexion after ACL reconstruc-
tive surgery. This work did not however provide statistical
analyses to support the superiority of OKC. Further work
Conflicts of Interest
on restoration of knee flexion after ACL surgery is clearly The authors declare that they have no conflicts of interest.
required.
The systematic review part of our work does appear to
provide a stronger case for improvements in knee extensor References
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