APPLIED SCIENCES Biodynamics Quadriceps Activation in Closed and in Open Kinetic Chain Exercise ANN-KATRIN STENSDOTTER1,3, PAUL W. HODGES2, REBECCA MELLOR2, GUNNEVI SUNDELIN1, and CHARLOTTE HÄGER-ROSS1 1 Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, SWEDEN; 2Department of Physiotherapy, The University of Queensland, Brisbane, AUSTRALIA; and 3Department of Physiotherapy, School of Health Education and Social Work, Sør-Trøndelag University College, Trondheim, NORWAY ABSTRACT STENSDOTTER, A.-K., P. W. HODGES, R. MELLOR, G. SUNDELIN, and C. HÄGER-ROSS. Quadriceps Activation in Closed and in Open Kinetic Chain Exercise. Med. Sci. Sports Exerc., Vol. 35, No. 12, pp. 2043–2047, 2003. Purpose: For treatment of various knee disorders, muscles are trained in open or closed kinetic chain tasks. Coordination between the heads of the quadriceps muscle is important for stability and optimal joint loading for both the tibiofemoral and the patellofemoral joint. The aim of this study was to examine whether the quadriceps femoris muscles are activated differently in open versus closed kinetic chain tasks. Methods: Ten healthy men and women (mean age 28.5 ⫾ 0.7) extended the knees isometrically in open and closed kinetic chain tasks in a reaction time paradigm using moderate force. Surface electromyography (EMG) recordings were made from four different parts of the quadriceps muscle. The onset and amplitude of EMG and force data were measured. Results: In closed chain knee extension, the onset of EMG activity of the four different muscle portions of the quadriceps was more simultaneous than in the open chain. In open chain, rectus femoris (RF) had the earliest EMG onset while vastus medialis obliquus was activated last (7 ⫾ 13 ms after RF EMG onset) and with smaller amplitude (40 ⫾ 30% of maximal voluntary contraction (MVC)) than in closed chain (46 ⫾ 43% MVC). Conclusions: Exercise in closed kinetic chain promotes more balanced initial quadriceps activation than does exercise in open kinetic chain. This may be of importance in designing training programs aimed toward control of the patellofemoral joint. Key Words: ELECTROMYOGRAPHY, WEIGHT BEARING, COORDINATION, PHYSICAL THERAPY, PATELLOFEMORAL T here is a considerable debate regarding the relative efficacy of open (OKC) and closed kinetic chain (CKC) exercise for increased strength and control of the knee muscles. In general, open kinetic chain (OKC) exercises are single joint movements that are performed in nonweight bearing with a free distal extremity. In contrast, CKC exercises are multi-joint movements performed in weight bearing or simulated weight bearing with a fixed distal extremity (22). Although clinical trials suggest that the functional outcome from programs that incorporate these exercise strategies are similar (11), there is a tendency toward better results in terms of strength (2) and functional (28) performance enhancement from CKC exercise. The basis for selection of each exercise regime is based on the hypothesis that there are physiological differences between these strategies and that one strategy may lead to greater improvements in specific physiological variables. Several rationales for CKC exercises have been presented. First, CKC has been argued to be more “functional” as it simulates the role of lower limb muscles in daily activities (1,6). For instance, rectus femoris (RF) shortens across the knee and lengthens across the hip in walking and climbing stairs due to simultaneous knee and hip extension. Second, it has been argued that proprioceptive feedback differs between CKC and OKC tasks, perhaps due to compression from body mass in CKC (14) and pressure under the foot (13). Third, CKC exercise has been suggested to produce less shear force between the tibiofemoral joint surfaces as co-contraction of the hamstrings will counteract the anterior tibial shear force generated by the quadriceps (16). Thus, from a biomechanical perspective, it is likely that CKC knee exercise places less strain on the anterior cruciate ligament (15,16), although the placement of the body center of mass above the axis of the knee joint determines how the quadriceps and hamstrings co-contract (18,27). Fourth, the interrelationship between patellofemo- Address for correspondence: Ann-Katrin Stensdotter, Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, S-901-87 Umeå, Sweden; E-mail: anki.stensdotter@physiother.umu.se. Submitted for publication December 2002. Accepted for publication July 2003. 0195-9131/03/3512-2043 MEDICINE & SCIENCE IN SPORTS & EXERCISE® Copyright © 2003 by the American College of Sports Medicine DOI: 10.1249/01.MSS.0000099107.03704.AE 2043 ral joint forces and contact area differs between the two tasks. In closed chain tasks, such as squatting, compressive forces are augmented with increased knee flexion as greater torque develops as a product of the lengthening lever arm between the knee joint and the body’s center of mass when it moves further posterior to the joint axis. However, this compressive force is distributed by greater contact between the patella and femur. In contrast, in OKC exercise the joint stress increases from 90° flexion as the knee extends (5,8) as a result of the greater torque produced by the lengthening lever arm when the center of mass of the leg and eventual load around the ankle moves. Finally, it has been argued that the coordination of the knee muscles may vary between the tasks. For instance, electromyographic activity of vastus medialis has been suggested to be greater in closed chain tasks than in open chain tasks (7). One study has investigated onset times for the different portions of the quadriceps in CKC and OKC under different loading conditions and joint angles but failed to find significant difference (12). Despite the argument that coordination of the lower limb muscles may be influenced by closed or open chain tasks, for the reasons presented above, there is limited direct evidence of differences in recruitment. The present study was designed to investigate this question by comparison of recruitment of muscles in a simple reaction-time knee extension task performed in both OKC and CKC. This task was selected as it allowed us to control relevant aspects of the activity. Specifically, we were interested in whether the onset and initial amplitude of muscle activity of different portions of the quadriceps would differ between these tasks. METHOD Subjects. Ten healthy subjects, three males and seven females, (mean age 28.5 ⫾ 0.7, mean height 171 cm ⫾8.5, mean weight 64 kg ⫾15.6) participated in the study. Subjects were excluded if they had a current or previous record of knee pain, trauma, surgery, or other joint disease or were involved in competitive sports. The tests were performed in agreement with the Declaration of Helsinki and informed written consent was obtained from the subjects. The study was approved by the institutional research ethic committee. Electromyography. EMG activity of vastus medialis obliquus (VMO), vastus lateralis (VL), vastus medialis longus (VML), and RF was recorded with surface electrodes (5 mm disks, Grass, U.S.) placed approximately in parallel with the muscle fibers over the muscle bellies, based on a modification of standard proposed by Zipp (30). The distances and angles were measured for optimal electrode placement (Fig. 1). The skin was carefully prepared by rubbing with abrasive gel and alcohol. EMG data were amplified 2000 times, filtered between 20 and 1000 Hz (Neurolog, UK) and sampled at 2 kHz using Power1401 and Spike2 software (CED, UK). Force recordings. Knee extension force was measured with a strain gauge (Validyne, U.S.). Force data were amplified and sampled at 1 kHz with the EMG data. 2044 Official Journal of the American College of Sports Medicine FIGURE 1—Placement of surface EMG electrodes. The angle between the electrode placement and the long axis of the femur (thin line) and the approximate distance from the supra patellar border: VMO 4 cm, VML 15 cm, VL 8 cm, and RF 15 cm. Polar distance for electrodes was 22 mm. The ground electrode was placed over the tibia inferior to patella. Procedure. Subjects sat on a firm plinth with the hip flexed to 90° and knee flexion 30° from full extension. Ankle joint position was kept at 90°. The pelvis was firmly strapped to the plinth. This position was used as it represented a mid range position and allowed the joint position to be kept constant between tasks. Knee extension efforts were performed as a reaction-time task in two different conditions. For OKC, the strain gauge was connected from the plinth to a strap around the ankle, approximately 10 cm proximal to the malleoli and isometric knee extension efforts were made against the resistance of the cable. In the CKC task, the strain gauge was incorporated into an inelastic belt that passed around the trunk support of the plinth and under the sole of the foot (Fig. 2). Isometric extension efforts were performed by pushing the foot into the belt. Subjects were instructed to respond as quickly as possible (by either extending the knee or pushing into the belt depending on condition) in response to an auditory stimulus and to use a moderate effort. Twenty repetitions in sets of 10 were performed for each condition and subjects were allowed 0 –30 s of rest between each repetition and 2–3 min FIGURE 2—Experimental setup. Subjects where seated with 90° hip flexion and 30° knee flexion (from full extension). A strap was placed over the hip. Arrows indicate direction of force applied by subject against the resistance of the strain gauge. http://www.acsm-msse.org of rest between sets of 10. Subjects were encouraged to relax their quadriceps between each repetition. Experimenters observed EMG activity with high gain to ensure activity was minimal during the rest period. The order of task presentation was randomized between sets of OKC and CKC. Subjects performed a single maximal voluntary contraction for 5 s against manual resistance and with loud verbal encouragement for each task after completion of 20 repetitions. Data analysis. The onset of EMG activity of each muscle and the onset of force measure were identified visually for each trial. To remove observer bias, data were presented for each individual trial in random order with no reference to muscles or order of repetition. The time of onset of force was identified in a similar manner. EMG amplitude was calculated for the initial 100 ms of the response and normalized to the amplitude recorded during the maximum voluntary contraction. Data were presented as the difference between EMG onsets of muscle pairs (VMO:VML, VMO: VL, VMO:RF, VML:VL, VML:RF, VL:RF), difference between onset of EMG and onset of force, and difference in peak amplitude. Statistical analysis. Differences in EMG onset latency for muscle pairs and EMG amplitude between the open and closed chain tasks were evaluated with a repeated-measures ANOVA; two factors, condition (OKC and CKC) and muscle portion (N ⫽ 4). Differences between onset of EMG and onset of force between the open and closed chain tasks were evaluated with a repeated-measures ANOVA two factors; condition (OKC and CKC) and latency (force-muscle portion (N ⫽ 4)). Values where corrected for sphericity (Greenhouse-Geisser). Paired t-tests were used to evaluate specific differences. The level of probability chosen as statistically significant was p ⬍ 0.05. RESULTS When subjects performed rapid knee extension efforts in response to an auditory stimulus, there were differences in the pattern of recruitment of the portions of the quadriceps muscles between OKC and CKC (condition ⫻ muscle interaction: P ⬍ 0.001). The onset of activity was more simultaneous in the CKC task than in OKC (Fig. 3). Figure 4 illustrates the EMG onset data expressed relative to the initiation of the force for each muscle and shows that there was no difference between muscles for CKC, that is, the onsets of EMG of all muscles were simultaneous. In contrast, for OKC, there was a difference in latency between EMG onset and onset of force increase between muscles. The latency was greatest for RF (mean 62 ms ⫾ 20) and shortest for VMO (mean 55 ms ⫾ 22). The data indicate that for the OKC task the EMG onsets of all muscles occurred before that of VMO. The relative latency between all pairs of muscles is significantly different between tasks for all pairs (RF:VML P ⬍ 0.05, for all the rest P ⬍ 0.001) except VMO:VL. Differences in EMG amplitude between tasks were also identified. The mean amplitude for the normalized EMG was significantly larger for RF (P ⬍ 0.001) in the OKC task QUADRICEPS ACTIVITY IN KINETIC CHAIN TASKS FIGURE 3—Representation of EMG raw data for muscle activity in CKC and OKC from single subject. Note the more simultaneous onset of activation in CKC than in OKC and that RF was activated first and VMO last in OKC. Data are presented with high gain to optimize the difference of EMG onsets; thus, some data are clipped. compared with CKC, whereas the mean amplitude for VMO was significantly larger (P ⬍ 0.05) in the CKC task than in OKC. Amplitude of activity was not significantly different between the tasks for other muscles (Fig. 5). The differences between the EMG amplitudes within a task showed that in CKC, the VMO amplitude was greater than that of VML and RF, but less than VL. In the OKC task the VMO EMG amplitude was less than for VL. RF was less active than VL in OKC and was in CKC less active than all other muscle portions. In OKC, VML was least active. DISCUSSION The present study shows that there is a difference in time of onset and amplitude of EMG for the different knee extensors in open and closed kinetic chain tasks. Most notably, the nearsimultaneous onset of activity of the quadriceps muscles during closed chain knee extension was not apparent when the task was performed in open chain. In general, there was agreement between the temporal and spatial EMG parameters. In CKC where VMO is activated early (Fig. 3), its am- FIGURE 4 —Group mean values (SEM) for onsets of activity relative to onset of force increase. There was no difference in EMG onset time between muscle portions relative to force in CKC. In OKC, the latency between onset of activity and onset of force was shorter for VMO than for all other muscle portions, whereas the latency between onset of activity in RF relative to onset of force was longer than all others. Medicine & Science in Sports & Exercise姞 2045 FIGURE 5—Group mean (SEM) for EMG amplitude normalized to MVC. VMO had greater amplitude in CKC than OKC. RF showed greater amplitude in OKC than CKC. * P < 0.05. plitude was greater compared with OKC, in which its onset of activity was later. Rectus femoris had greater EMG amplitude in OKC when it was the first muscle active compared with a smaller amplitude in CKC where its EMG onset was later. This may suggest that the initial relative contribution of muscles with early onset of activity is larger than for the muscles with later onset of activity. The differences in EMG onset and amplitude for RF in the two conditions may be explained by its nature as a two-joint muscle. In OKC where the force is directed upward, the contribution of RF is increased, presumably as a result of its dual function as a knee extensor and hip flexor. In CKC, where the force is directed downward, this is more akin to hip and knee extension. Indeed the subjects had to be firmly strapped down during testing conditions, to prevent extension at the hip in CKC. On the contrary, in OKC there was less tendency to extend at the hip. The result from our study shows that CKC provides more simultaneous activity in the different portions of the quadriceps muscle than OKC, with earlier onset and greater amplitude of EMG activity in VMO. Because muscle function has significant impact on the biomechanics of the knee joint, CKC tasks may provide more optimal loading conditions for the patellofemoral joint due to more central tracking of the patella (20). A mediolateral muscular imbalance in force production (3,7,24) and timing (4,26,29) has been suggested by several authors as important factors contributing to malalignment of the patella. Malalignment affects the pressure distribution between patella and femur. In vitro and modeling studies of forces show increased lateral pressure as tension from the VMO is decreased (20). The main cause for patellofemoral pain syndrome (PFPS) is believed to be lateral tracking and/or tilt of patella in the femoral groove. Weakness of the knee extensors and atrophy of vastus medialis muscle are common findings (25). Patients with this syndrome also show a decrease in VMO activity relative to VL. In knee extension the ratio between VMO and VL activity increases closer to full extension, whereas the ratio in nonsymptomatic subjects remains steady (3,24). For onset of muscle activity, PFPS patients show 2046 Official Journal of the American College of Sports Medicine a delayed onset of activity in VMO relative to VL, when ascending and descending stairs, by 16 and 19 ms, respectively (4). In nonsymptomatic subjects, there is no difference in onset time for VMO and VL in these same tasks. These findings are supported by other similar studies, however, with smaller time differences (7,26,29). Degree of decreased reflex response time in VMO and duration of symptoms have been reported to be the only factors that significantly predict the outcome of training intervention for this patient group. Shorter reflex time of VMO predicts a better functional outcome (28). Clinical implications. Seemingly small time differences (5–10 ms) appear significant for the central nervous system to coordinate muscle activity for a certain task. Even with the same joint configuration, the net mechanical effect of different loading conditions requires the central nervous system to adjust the strategy accordingly (9). For instance, recent biomechanical studies have indicated that a delay in VMO onset of 5 ms has significant consequences for patellofemoral joint mechanics in terms of increased peak and average lateral contact force (17). In addition increased relative contribution of VMO force produces a reduction in lateral patellofemoral joint loading (17). The findings from the present study, particularly regarding onset and activity of the VMO may have clinical implications for how to design training intervention programs for patients suffering from PFPS. For knee rehabilitation in general, CKC exercises have been promoted in favor over OKC, because CKC exercises are considered more functional, safe, and effective (19,21). Exercises designed to remedy muscular imbalances as described for PFPS should be particularly aimed at VMO. Our study shows in healthy subjects that CKC promotes more simultaneous quadriceps activity and earlier onset and greater amplitude in EMG activity for VMO than does OKC. To what extent this also applies to PFPS needs to be investigated. We compared OKC and CKC tasks under isometric conditions in identical positions, seated with the hip in 90° and 30° knee flexion from full extension, with moderate force exertion. However, activation patterns may be different for OKC and CKC as other biomechanical conditions apply for dynamic conditions with different joint angles and loading conditions. Evaluation of CKC training intervention has showed that for patients with patellofemoral pain, more selective VMO activation can be obtained in closed kinetic chain exercises at 60° knee flexion (23). Hodges and Richardson (10) reported greater VMO activity in CKC, which could be further augmented by additional hip adduction. Even though CKC in PFPS may elicit earlier and greater VMO activity than OKC exercises, this may not guarantee a normalization of VMO activity in other activities. It also remains to be investigated whether and to what extent an eventual normalization of VMO activity in an exercise condition has a carry over effect to daily activity with improvement of physical function and reduced pain. This project has been funded by the National Health and Medical Research Council of Australia, Sør-Trøndelag University College, Trondheim, Norway, Trygg Hansa’s Research Foundation, Sweden, Faculty of Medicine and Odontology, Umeå University, Sweden, and The Swedish Research Council (no. 220-3-02). http://www.acsm-msse.org REFERENCES 1. AUGUSTSSON, J., and R. THOMEE. Ability of closed and open kinetic chain tests of muscular strength to assess functional performance. Scand. J. Med. Sci. Sports 10:164 –168, 2000. 2. AUGUSTSSON, J., A. ESKO, R. THOMEÉ, et al. Weight training of the thigh muscles using closed versus open kinetic chain exercises: a comparison of performance enhancement. J. Orthop. Sports Phys. Ther. 27:3– 8, 1998. 3. BOUCHER, J. P., M. A. KING, R. LEFEBVRE, and A. REPIN. Quadriceps femoris muscle activity in patello-femoral pain syndrome. Am. J. Sports Med. 20:527–532, 1992. 4. COWAN, S. M., K. L. BENNELL, P. W. HODGES, K. M. CROSSLEY, and J. MCCONNELL. Delayed onset of electromyographic activity of vastus medialis obliquus relative to vastus lateralis in stair ascent, and stair descent. Am. J. Sports Med. 29:167–174, 2001. 5. ESCAMILLA, R. F., G. S. FLEISIG, N. ZHENG, S. W. BARRENTINE, K. E. WILK, and J. R. ANDREWS. Biomechanics of the knee during closed kinetic chain and open kinetic chain exercises. Med. Sci. Sports Exerc. 30:556 –569, 1998. 6. FITZGERALD, G. K. Open versus closed kinetic chain exercise: issues in rehabilitation after anterior cruciate ligament reconstructive surgery. Phys. Ther. 77:1747–1754, 1997. 7. GRABINER, M. D., T. J. KOH, and J. T. ANRDISH. Decreased excitation of vastus medialis oblique and vastus lateralis in patellofemoral pain. Eur. J. Exp. Musculoskel. Res. 1:33–39, 1992. 8. GRELSHAMMER, R. P., W. W., COLEMAN, and V. C. MOW. Anatomy and mechanics of the patellofemoral joint. Sports Med. Arthroscopy Rev. 2:178 –188, 1994. 9. HäGER-ROSS, C., K. J. COLE, and R. S. JOHANSSON. Grip-force responses to unanticipated object loading: load direction reveals body-and gravity-referenced intrinsic task variables. Exp. Brain. Res. 110:142–150, 1996. 10. HODGES, P. W., and C. A. RICHARDSON. The influence of isometric hip adduction on quadriceps femoris activity. Scand. J. Rehabil. Med. 25:57– 62, 1993. 11. HOOPER, D. M., M. C. MORRISSEY, W. DRECHSLER, D. MORRISSEY, and J. KING. Open and closed kinetic chain exercises in the early period after anterior cruciate ligament reconstruction: improvements in level walking, stair ascent, and stair descent. Am. J. Sports Med. 29:167–174, 2001. 12. KARST, G. M., and G. M. WILLETT. Onset timing of electromyographic activity in the vastus medialis oblique and vastus lateralis muscles in subjects with and without patellofemoral pain syndrome. Phys. Ther. 75:813– 823, 1995. 13. KAVOUNOUDIAS, A., R. ROLL, and J. P. ROLL. The plantar sole is a dynamometric map for human balance control. Neuroreport 9:3247–3252, 1998. 14. KIEFER, G., L. FORWELL, J. KRAMER, and T. L. BIRMINGHAM. Comparison of sitting and standing protocols for testing knee proprioception. Physiother. Can. 30 –34. 1998. 15. KVIST, J., and J. GILLQUIST. Sagittal plane knee translation and electromyographic activity during closed and open kinetic chain exercises in anterior cruciate ligament-deficient patients and control subjects. Am. J. Sports Med. 29:72– 82, 2001. 16. LUTZ, G. F., R. A. PALMITIER, K. N. AN, and E. Y. S. CHAO. Comparison of tibiofemoral joint forces during open-kinetic-chain QUADRICEPS ACTIVITY IN KINETIC CHAIN TASKS 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. and closed-kinetic-chain exercises. J. Bone Joint Surg. Ser. A 75:732–739, 1993. NEPTUNE, R. R., I. C. WRIGHT, and A. J. VAN DEN BOGERT. The influence of orthotic devices and vastus medialis strength and timing on patellofemoral loads during running. Clin. Biomech. 15:611– 618, 2000. NINOS, J. C., J. J. IRRGANG, R. BURDETT, and J. R. WEISS. Electromyographic analysis of the squat performed in self selected lower extremity neutral rotation and 30° of lower extremity turn-out from the self selected neutral position. J. Orthop. Sports Phys. Ther. 25:307–315, 1997. RIVERA, J. E. Open versus closed kinetic chain rehabilitation of the lower extremity: a functional and biomechanical analysis. J. Sports Rehabil. 3:154 –167, 1994. SAKAI, N., Z. P. LUO, J. A. RAND, and K. N. AN. The influence of weakness in the vastus medialis oblique muscle on the patellofemoral joint: an in vitro biomechanical study. Clin. Biomech. (Bristol, Avon) 15:335–339, 2000. SNYDER-MACKLER, L. Scientific rationale and physiological basis for the use of closed kinetic chain exercise in the lower extremity. J. Sports Rehabil. 5:2–12, 1996. STEINDLER A. Kinesiology of the Human Body under Normal and Pathological Conditions. Springfield, IL: Charles C Thomas, 1977, p. 63. TANG, S. F., C. K. CHEN, R. HSU, S. W. CHOU, W. H. HONG, and H. L. LEW. Vastus medialis obliquus and vastus lateralis activity in open and closed kinetic chain exercises in patients with patellofemoral pain syndrome: an electromyographic study. Arch. Phys. Med. Rehabil. 82:1441–1445, 2001. TASKIRAN, E., Z. DINEDURGA, A. YAGIZ, B. ULUDAG, C. ERTEKIN, and V. LöK. Effect of the vastus medialis obliquus on the patellofemoral joint. Knee Surg. Sports Traumatol. Arthrosc. 6:173– 180, 1998. THOMEE, R. P., J. AUGUSTSSON, and J. KARLSSON. Patellofemoral pain syndrome: a review of current issues. Sports Med. 28:245– 262, 1999. VOIGHT, M., and D. WEIDER. Comparative reflex response times of the vastus medialis and vastus lateralis in normal subjects and subjects with extensor mechanism dysfunction. Am. J. Sports Med. 10:131–137, 1991. WILK, K. E., R. F. ESCAMILLA, G. S. FLEISIG, S. W. BARRENTINE, J. R. ANDREWS, and M. L. BOYD. A comparison of tibiofemoral joint forces and electromyographic activity during open and closed kinetic chain exercises. Am. J. Sports Med. 24:518 –527, 1996. WITVROUW, E., R. LYSENS, J. BELLEMANS, K. PEERS, and G. VANDERSTRAETEN. Open versus closed kinetic chain exercises for patellofemoral pain: a prospective, randomized study. Am. J. Sports Med. 28:687– 694, 2000. WITVROUW, E., C. SNEYERS, R. LYSENS, J. VICTOR, and M. BELLEMANS. Reflex response times of vastus medialis oblique and vastus lateralis in normal subjects with patellofemoral syndrome. J. Orthop. Sports Phys. Ther. 24:160 –165, 1996. ZIPP, P. Recommendations for the standardization of lead position in surface electromyography. Eur. J. Appl. Physiol. 50:41–54, 1982. Medicine & Science in Sports & Exercise姞 2047