Healing Knees and Closed Chain Vs. Open Chain Exercises

This is a continuation of last week’s post, a success story with a twist near the end. Pat, who was suffering from knee pain, met a physical therapist who, upon hearing of how she improved by “walking small steps” around her apartment, approvingly said, “closed chain.”

So what are “closed chain” exercises, and are they the key to chasing away knee pain?

I had come across the closed/open chain terminology before, but never bothered to really look into it. Generally, I distrust geeks bearing jargon. I’m an Occam’s Razor kind of guy. When simple reasons explain phenomena as well as complex, why not keep it simple?

So I delved a little into the book, Closed Kinetic Chain Exercise: A Comprehensive Guide to Multiple Joint Exercise. I was far from an expert on the subject, but the same surely couldn’t be said of authors Todd Ellenbecker and George Davies.

Open-chain exercises, they tell us, isolate joint and muscle movements. Further, the movement pattern is “often nonfunctional.” And the “distal end of the extremity is free in space.”

To understand these points better, consider a pure open-chain exercise -- the seated leg extension (that’s the one in the gym where you straighten your bent leg forward, against the resistance of weights). The “distal end” of the limb (that would be your foot) is out there in open space, not fixed to anything. The exercise recruits only a few muscles and joints. And functionally, well, it’s pretty much useless, unless your daily activities entail punting a football repeatedly.

So that brings us back to closed-chain exercises (such as squats). Are they then superior? Sure sounds like it.

However, it turns out that things aren’t that clear. Here I’m just going to step back and let the authors of the book explain.

First, the functional vs. nonfunctional distinction doesn’t exactly hold up after all:

One of the common arguments against the primary use of open kinetic chain exercises in the lower extremity is that they are not functional. For example, there are limited instances in the lower extremity where an individual functions in a seated position bending and strengthening the leg ... Closed kinetic chain exercises are considered to be more functional, because they closely simulate the actual movement patterns encountered in both sport and daily activities.

Analysis of most functional activities reveals that they are, in fact, a series of successive open kinetic chain and closed kinetic chain motions. An example is the normal gait cycle. During walking, approximately 65% of the gait cycle is weight bearing (closed kinetic chain) and 35% is non-weight bearing (open kinetic chain). Interestingly, during running, the percentages of closed and open kinetic chain motions essentially reverse.

Further complicating matters:

Activities progress along a continuum from closed to open kinetic chain, with many activities of daily living and sport activities incorporating components of both. For example, during the gait cycle, the stance phase is a closed kinetic chain pattern, whereas the swing phase is an open kinetic chain pattern. Another example that shows the interplay between these two movement patterns is riding a bike, during which the foot is fixed on the pedal in a closed kinetic chain pattern, yet the pedal and foot freely move in space. Another example is skiing, where the feet are fixed to the skis (closed kinetic chain), but the skis move on the snow and are not fixed to an object (open kinetic chain).

What’s more, some purported benefits of closed-chain exercises may not actually exist:

Many clinicians have assumed that in the closed kinetic chain position of the lower extremity there is automatically a resultant co-contraction of the muscles that should dynamically stabilize the knee joint. Although some studies did demonstrate this phenomenon, several recent studies actually refuted that significant co-contractions occur with some closed kinetic chain exercises.

Finally, in conclusion, I found this quoted comment (my bold) from other researchers (cited as Snyder and Mackler; sorry I didn't get the full footnote) quite interesting. It refers to rehabbing after surgery to repair the anterior cruciate ligament, but I think the phrase “after reconstruction of the anterior cruciate ligament” could easily be replaced by lots of other phrases, such as “for patients with chronic knee pain.”

Rehabiliation after reconstruction of the anterior cruciate ligament continues to be guided more by myth and fad than by science ... The present study ... suggests that closed kinetic chain exercise alone does not provide an adequate stimulus to the quadriceps femoris to permit more normal function of the knee in stance phase in most patients in the early period after reconstruction of the anterior cruciate ligament.

Now if all this “open chain” vs. “closed chain” stuff sounds a bit faddish, well, the physical therapy trends (according to the authors) looked like this:

1970s Functional rehabiliation
1980s Open kinetic chain exercises (with emphasis on isokinetics)
1990s Closed kinetic chain exercises

How’s that for inducing whiplash? The same physical therapist you saw in 1985 who was saying, “You gotta do open chain, open chain, open chain,” ten years later was probably saying, “You gotta do closed chain, closed chain, closed chain.”

My personal take is that you need to do gentle, high-repetition activities (and if they’re functional, so much the better) to heal bad knees, giving yourself lots of time to achieve results. I wouldn’t worry too much about where my activities lie on the open-closed chain continuum.

Full disclosure: I own a bike chain. I like it. It gets me places. :)

A Quick Note About Drive-By Comment Spam

Happily, the pageviews have been rising for this blog.

Unhappily, that has drawn some opportunist spammers. They leave what I consider "drive-by" spam. It usually goes like this: "I found this article informative and useful for knee osteoarthritis," with an embedded link on "knee osteoarthritis" that leads to some surgeon's website.

Whenever I find this kind of comment, I delete it immediately.

Here are the ground rules:

I have a high tolerance for many different kinds of negative and critical comments. You can even call me an idiot (I'd rather you didn't, but if you feel that strongly ...). As long as you're not offensively profane, I won't delete your comment.

And I don't mind if you make a remark relevant to the blog post and mention a book that helped you heal. Or even if you mention you wrote a book that might help others heal. Or even if you know a doctor who might help others, and include a link to his (or her) Web site.

I'm more interested in whether you're contributing in some way to the dialogue. But when someone writes a throwaway line like "Great post! I like it a lot." and scatters similar comments across multiple posts, with links to a Web site, it's clear they're not interested in participating in a dialogue. They've just been paid to hawk someone's product.


That, to me, is spam. I report it as such. So spammers be forewarned.

Yet Another Success Story

I love success stories. I especially love it, of course, when they validate my own thinking ;), but any good story will do. Let’s share what works!

Here’s a gem from “Pat” that I recently discovered among the comments. I’ve edited it a bit, mainly for length.

I had a Synvisc shot (3 in 1) November 30 and had virtually no relief. Regular PT of the quad strengthening type did not help. End of April of this year, I was certain I needed a total knee replacement (4 surgeons concurred I have patellofemoral arthritis of my left knee). 

By chance, I found your little ebook on Amazon at that time and read it in a couple of hours. I scoffed at the idea that I could recover as you had done because I couldn't really walk at all on hard ground without excessive pain. I had a limp. I had almost fainted from the pain at the market the week before. But I said what do I have to lose -- nothing else had worked -- so I started padding around my apt. wood floors in my bare feet, since barefoot had always felt better than shoes. 

At that time I was so close to scheduling TKR surgery that I had grab bars put in my shower in the beginning of May. Believe it or not, within a couple of days of starting to walk 60 steps every hour or so around my apartment, I started to feel much better -- almost right away, really. 

Then within a week or so by a great stroke of luck I met a woman who had been scheduled for TKR with my same surgeon (coincidence), and she had found a physical trainer very near where I live in Santa Monica, CA, at a place called Drive Cardio. This guy she said had virtually cured her -- she was leaving the next day on a 3-week hiking trip in Turkey. 

I started seeing him and told him that walking small steps had started to help me. He said "closed chain" (I don't know this stuff) and I have continued to see him once a week. He does different things every time -- uses a bosu ball, a stability ball (small "micropushes" with it against a wall), etc. Every week is usually a new series of movements in different order and different intensity. He says what's important is increasing "vascularity." 

I am doing more strengthening stuff each week but it's been very gradual. Certainly not the kind of quad strengthening I had been doing before. I continue to walk around my apt. but I can also walk outside now without pain and use cardio machines which I couldn't use before. 

My recovery was so fast after reading your book, maybe because I didn't have a long history of pain -- only since Nov. 2011. Last week I went on a short trip to Vegas and walked pretty much all day for 3 days. I still have a tiny bit of pain in my knee here and there but it's more like a 1/10 versus 6/10. Am even feeling well enough to plan a trip to Europe this fall. 

I feel so grateful for having chanced upon your book. I've recommended it to others. By the way, I'm a 66-year-old woman. I should say I was quite flexible and athletic for my age before my knee pain.

Hooray!

Okay, a few comments:

I’m glad that walking around the apartment in short bursts provided such rapid, positive results. Sounds like that therapy fit Pat perfectly! However, other knee pain sufferers won’t see benefits that are that fast or remarkable -- so keep that in mind, everyone. All bad knees are different.

My favorite part of the story: She’s 66! And considering a total knee replacement! This is someone at the age where I’m sure many doctors would wag their heads sorrowfully and say, “I’m sorry, you’re just too old, your knees will never get better.”

But they did.

Let me be clear. It’s not that I think age doesn’t matter. It’s that I think age matters much less than the medical community currently thinks it does. You don’t suddenly lose the ability to heal when you reach 40, or 50, or 60. Maybe you heal more slowly. But you can still heal.

Congrats to Pat on finding a physical therapist whose approach suits her (and her bad knee). The description that struck me the most about his program was “very gradual.” The proper way to heal knees, I’m convinced, is very, very slowly and very, very patiently.  

I was intrigued when she said he counseled “closed chain” exercises. I had heard some about these, but had never looked into them. So I did. Next week, I’ll tell you what I found.

Cheers!

Botox for Knee Pain? Be Careful What You Wish For.

Recently I blogged about an article written by an accomplished doctor, in which he mentioned this Mayo Clinic study about the relationship between quad strength and cartilage loss.

The same article also mentioned something I’d never heard of: Botox for knee pain! Naturally I was intrigued. I didn’t do extensive research into the subject (alas, I don’t really have time to do much research into anything these days), but I read enough to have a few thoughts worth sharing.

First, the Botox study isn’t exactly new. As noted by Arthritis Today (which summarized the findings), the results were presented at the American College of Rheumatology’s Annual Scientific Meeting in 2006. For the study, neurotoxins (which is what botulism is) were used to target “the pain nerves within the joint.”

Over six months, 37 patients with moderate to severe knee pain received either a  placebo or Botox injected into their knee joints. The 18 patients with severe pain experienced a “significant decrease in pain and improvement in physical function” after the Botox shots, compared with the placebo group. Oddly, for those with moderate pain, the placebo group had a 25% reduction in daytime pain while the Botox subjects had no benefit.

So, does this mean Botox isn’t just for your forehead wrinkles anymore? If so, should we celebrate?

Maybe not. Because what is Botox? A toxin. A toxin that does what? According to this ezine article, “When Botox is injected into the muscles of the forehead, it blocks nerve impulses which results in the weakening of the muscles that cause frowning."

Sure, it would be great to banish knee pain. But Botox does it by basically disabling your nerves. That’s fine if your nerves don’t perform any useful function. But of course they do.

Your nerves give you constant feedback about what you shouldn’t be doing with your bad knees. Eliminate that negative feedback, and I’m sure you'd feel better, but at what price to your joints? If I removed the right set of nerves, I’m sure a knee pain sufferer with bone-on-bone arthritis could run a 10k road race without feeling a thing -- while doing terrific damage to his joints.

If the preceding has a familiar ring to it, that’s because this is basically a variation on my argument “why I don’t like pain meds for knee pain.” Of course, sometimes there really is no choice -- I don’t mean to sound unsympathetic.

But the long process of healing from chronic knee pain, I found, involves a very tricky sort of calculus. You need to find, and stay within, your "sweet spot," that area of maximum motion where you move as much as possible, but not more than your knees are ready for. It’s hard enough to find that "sweet spot" as it is. Without fully functioning nerves to guide you, it seems it would be nearly impossible.

So be careful what you wish for. The only thing worse than a life with knee pain may be a life without any knee pain -- if that pain is sending you signals that help you figure out how to get better.

News Flash: Injections of Hyaluronic Acid May Do Your Knees More Harm Than Good

For anyone thinking of having Synvisc, or some other artificial lubricant that uses hyaluronic acid, injected into their decaying knee joints, there’s a new study out that will give you pause.

Apparently the shots have little effect on pain and none on function. And that’s the good news.

The bad news is the procedure may lead to cardiovascular and gastrointestinal problems.

Products such as Synvisc treat bad knees through viscosupplementation. In unhealthy or diseased joints, the synovial fluid becomes thin and watery, less capable of effectively doing its job (healthy fluid has the consistency of egg whites and both lubricates the knee joint and cushions it from impacts).

Viscosupplementation injections (approved by the FDA in 1997) are intended to artificially boost the viscosity and performance of your ailing synovial fluid. The cost can be more than $1,800 (based on 2006 prices), according to this article.

Here are some details about the study (here’s another article that’s a bit more granular about the results):

* It was a meta-analysis, which means that no new research was conducted. Rather, the conclusions and methodologies of existing studies were examined. The findings of such broad, sweeping meta-studies are typically more powerful because of their much greater reach (in this case, 89 clinicial trials and more than 12,600 participants).

* A weakness was the poor quality of many trials. Also, some studies were unpublished (thus not vigorously vetted) and funded by pharmaceutical companies. The funding point, though, makes it likely that the results overstated the efficacy of viscosupplementation, if anything.

* 18 large-scale trials with 5,094 subjects found the injections made so little difference for pain as to be “clinically irrelevant.”

Okay, now my 2 cents: As I’ve said before, my reading of message boards (which I did a lot of when I was trying to fix my own knees) led me to conclude that about half of Synvisc takers claim an improvement, while half say the shots worsened their condition or hurt a lot or did nothing -- and unfortunately, beforehand you can’t tell which group you’ll be in. And even if you get the improvement, it’s only temporary, wearing off in as little as 4 weeks, it appears.

I know a shot seems simple. I know we’re frequently conditioned, when in chronic pain, to look to a deft surgeon’s hand or the miracle of 21st century medical technology. But just be careful. Often there are no good shortcuts to fixing a hard problem.