J. Phys. Ther. Sci.

Original Article 26: 1363–1366, 2014

Effects of Open and Closed Kinetic Chains of Sling

Exercise Therapy on the Muscle Activity of the
Vastus Medialis Oblique and Vastus Lateralis

Wen-Dien Chang, PhD1), Wei-Syuan Huang1), Chia-Lun Lee, PhD2), Hung-Yu Lin, PhD3),
Ping-Tung Lai, BS4)*
1) Department of Sports Medicine, China Medical University, Taiwan
2) Physical Education Section of General Education, National Sun Yat-sen University, Taiwan
3) Department of Occupational Therapy, I-Shou University, Taiwan
4) Department of Physical Therapy and Rehabilitation, Da-Chien General Hospital: No. 6, Shin Guang

Street, Miaoli, Taiwan

Abstract. [Purpose] The muscle strength of the quadriceps muscle is critical in patellofemoral pain syndrome.
The quadriceps muscle supplies the power for dynamic patellar movement, and the vastus medialis oblique (VMO)
and vastus lateralis (VL) enable the patella to stabilize during tracking. We followed the theories about open and
closed kinetic chain exercises to design two exercises, sling open chain knee extension (SOCKE) exercise and sling
closed chain knee extension (SCCKE) exercise. The purpose of our study was to research the changes in quadriceps
muscle activity during both exercises. [Methods] Electromyographic analysis was used to explore the different ef-
fects of the two exercises. The MVC% was calculated for the VMO and VL during exercise for analysis. [Results]
We found that the mean MVC% values of the VMO and VL during the SOCKE exercise were higher than those
during the SCCKE exercise. The ratio of the VMO to VL was 1.0 ± 0.19 during the SOCKE exercise and 1.11 ± 0.15
during the SCCKE exercise. [Conclusions] The SOCKE exercise is targeted at quadriceps muscle training and has
a recruitment effect on the VMO. The beneficial effect of the SOCKE exercise is better than that of the SCCKE
exercise.
Key words: Patellofemoral pain syndrome, Sling exercise therapy, Electromyography
(This article was submitted Jan. 23, 2014, and was accepted Feb. 27, 2014)

INTRODUCTION results indicated that specific VMO exercise training can

effectively prevent and reduce the incidence of PFPS7, 8).
Patellofemoral pain syndrome (PFPS) is a common or- However, there is still no suitable exercise for VMO muscle
thopedic disease, and often induces patella pain during activity.
climbing and long-distance running1). The results of a pre- Lower extremity exercise training includes open kinetic
vious study indicate that athletes have high risks of knee chain and closed kinetic chain exercises. The open kinetic
overuse2). The quadriceps supplies the power of dynamic chain is a movement in which the distal end of the extremity
patellar movement, and the vastus medialis oblique (VMO) is not fixed to a relatively stable surface. In the closed kinet-
and vastus lateralis (VL) enable the patella to stabilize dur- ic chain, movement of a joint cannot occur without causing
ing tracking3). A lack of muscle strength in the VMO de- predictable movements in the other joints of the extremity9).
creases the medial muscular tension the patellar and causes A closed kinetic chain exercise for the knee joint can cause
the muscle imbalance to increase patellar maltracking4). quadriceps and hamstring co-contraction to reduce dis-
The ideal ratio of the VMO to VL is 1:1, but many PFPS placement and improve joint stability, but this will increase
patients have had a low ratio for both muscles in electro- the intra-articular pressure10). This exercise can cause quad-
myography studies5). Some studies indicated that increas- riceps contracture, and this is similar to the muscle activity
ing the muscle strength of the VMO is a useful method of recruitment occurring during weight-bearing in the gait11).
preventing PFPS6, 7). Integration of a specific VMO exercise Open kinetic chain exercise uses a lower amount of weight
into knee muscle training has been suggested. Some study loading for PFPS patients than closed kinetic chain exer-
cise. It is often used for knee rehabilitation in therapeutic
exercise. The results of some studies show that closed ki-
*Corresponding author. Ping-Tung Lai (E-mail:
netic chain exercise has a significant therapeutic effect for
steven-mandy@yahoo.com.tw)
PFPS patients11–13). However, these studies often focused
©2014 The Society of Physical Therapy Science. Published by IPEC Inc.
on the pain decrease and ignored discussing the effect of
This is an open-access article distributed under the terms of the Cre-
VMO muscle activity during the exercise training. Sling
ative Commons Attribution Non-Commercial No Derivatives (by-nc-
exercise therapy (SET) is a new training method for athletes
nd) License <http://creativecommons.org/licenses/by-nc-nd/3.0/>.
1364 J. Phys. Ther. Sci. Vol. 26, No. 9, 2014

and orthopedic patients utilized in recent years14). Because

of its convenience and practicality, SET has become more
and more common in rehabilitation clinics and fitness train-
ing centers15). However, studies about the effects of using
SET with open and closed kinetic chains on VMO muscle
training in PFPS patients are rare. We followed the theories
about open and closed kinetic chain exercises to design two
exercises using SET and explore the VMO and VL muscle
activity. To our knowledge, this is the first study to investi-
gate this theme, and we think that the results of this study Fig. 1. SOCKE (A) and SCCKE (B) exercises
are important for PFPS patients as well as physical thera-
pists and athletic trainers providing therapeutic exercise.
Table 1. MVC results of the seven participants
SUBJECTS AND METHODS
SOCKE exercise SCCKE exercise
This study was a cross-over study and was approved by no VMO (%) VL (%) VMO (%) VL (%)
the Institutional Review Board of China Medical Univer- 1 98.9 ± 2.4 84.4 ± 2.3 79.9 ± 3.3 63.2 ± 1.3
sity and Hospital. We informed all participants about the 2 89.8 ± 3.1 89.4 ± 3.1 93.7 ± 3.2 98.4 ± 2.8
experimental process in detail and then obtained their in- 3 60.6 ± 3.5 86.3 ± 4.2 78.6 ± 2.6 71.2 ± 2.3
formed consent before the study. We recruited healthy fe- 4 99.6 ± 3.7 98.1 ± 3.8 82.5 ± 3.5 81.5 ± 1.4
male college students and randomly assigned them to the 5 73.3 ± 3.2 89.9 ± 2.7 82.2 ± 3.3 86.2 ± 3.3
two SET exercises, comprising sling open chain knee ex- 6 96.5 ± 2.6 77.1 ± 3.3 92.1 ± 4.1 70.1 ± 2.1
tension (SOCKE) exercise and sling closed chain knee ex-
7 85.4 ± 1.4 78.2 ± 2.9 90.7 ± 3.2 74.4 ± 3.2
tension (SCCKE) exercise (Fig. 1). A Redcord suspension
SOCKE, sling open chain knee extension; SCCKE, sling close
system (Redcord Trainer, Record, Staubø, Norway) was
chain knee extension exercise; VMO, vastus medialis oblique;
used to train the quadriceps muscle by one athletic trainer. VL, vastus lateralis
The two exercises were performed for 10 min, and 3 rep-
etitions of maximum force were completed in this period.
The SOCKE exercise used SET to suspend the knee and
mum force of the resistance test) × 100%.
maintain knee flexion at 60 degrees. The SCCKE exercise
The study data were analyzed using descriptive statistics
used SET to suspend the ankle and maintain the hip in full
with SPSS 17.0 (SPSS Inc., Chicago, IL, USA) to compare
extension. We asked the individual to extend the knee to
the activations of the of VMO and VL. The Wilcoxon test
strengthen the concentric contraction of the quadriceps.
was used to compare the differences in the MVO% values
These exercises were designed to improve the strength of
of the VMO and VL between the SCCKE and SOCKE ex-
the VMO for application in the field of sports medicine. An
ercises. A 2-tailed test was adopted, and the p value was set
electronic goniometer (Flexible 2D goniometer, Noraxon
at 0.05. The consistencies of activation of the VMO and VL
USA Inc., Scottsdale, AZ, USA) was fixed to the lateral
for 3 repetitions of maximum contraction of one exercise
knee joint, which was the axis of the goniometer, and the
within each individual were analyzed by using the intra-
stationary and movable arms were tied to the lateral midline
class correlation coefficient (ICC).
of the thigh and shank. The range of motion of the knee was
monitored, and the VMO and VL muscle activity was col- RESULTS
lected by electromyography by one examiner.
Electromyography (MyoTrace 400, Noraxon USA Inc., Seven healthy college students (age = 21.3 ± 0.6; weight
Scottsdale, AZ, USA) was used to calculate the maximal = 51.3 ± 6.3 kg; height = 161.5 ± 4.8 cm) were recruited and
voluntary contraction (MVC). The VL electrodes were performed 3 repetitions of maximum contraction for each
placed on the line from the anterior superior iliac spine exercise. The ICC for activation of the VMO and VL for 3
to the superolateral boarder of the patella and 10 cm from repetitions of maximum contraction was 0.91 ± 0.23, and
the patella. The VMO electrodes were placed at a distance there were no significant differences in the SOCKE and
of 4 cm from the superior side of the patella along a line SCCKE exercises among the 3 repetitions of maximum
inclined 50° that ran parallel to the line from the anteri- contraction. Table 1 shows that 5 participants (Nos. 1, 2,
or superior iliac spine to the superolateral boarder of the 4, 6, and 7) had higher MVC% values for the VMO than
patella16). In the electromyography signal processing, the for the VL during the SOCKE exercise. Five participants
sampling frequency was set to 1,000 Hz. We used a band- (Nos. 1, 3, 4, 6, and 7) had higher MVC values for the VMO
pass filter of 40 to 400 Hz to reduce external noise and per- than for the VL during the SCCKE exercise. The mean
formed full-wave rectification. Then, setting the root mean MVC% values for the VMO (86.30 ± 14.61) and VL (86.20
square at 100 ms smoothed the signal17). Finally, we set the ± 7.25) during the SOCKE exercise were higher than those
amplitude normalization at 300 ms and normalized the dif- for the VMO (85.67 ± 6.27) and VL (77.85 ± 11.81) during
ferent movement data by transforming MVC into MVC% the SCCKE exercise. No significant differences in MVC%
with the following formula: MVC% = (mean MVC / maxi- values for the VL and VMO were found between the exer-
 1365

cises (p > 0.05). However, the MVC% values for the VMO SOCKE and SCCKE exercises. We found that large muscle
and VL during the SOCKE exercise were higher than dur- fibers were recruited for VMO activity during the SOCKE
ing the SCCKE exercise. The MVC% of the VL was higher exercise, and the ratio of the VMO to VL was 1.11:1. Previ-
than that of the VMO during both exercises. We also found ous studies showed high ratios of the VMO to VL at knee
that the ratio of the VMO to VL was 1.0 ± 0.19 during the extension from 60 to 180 degrees during isokinetic open
SOCKE exercise and 1.11 ± 0.15 during the SCCKE exer- chain exercise21, 22). We used SET to suspend the lower ex-
cise. tremity and maintain extension of the knee from 60 to 180
degrees during the SOCKE and SCCKE exercises. Further-
DISCUSSION more, our results showed that both exercises can recruit
VMO activity, presenting ratios of the VMO to VL higher
This study compared the VMO and VL muscle activi- than 1:1. So, both exercises can improve the VMO muscle
ties during the SCCKE and SOCKE exercises. Our results contraction of PFSP patients, and the beneficial effect on
showed that both exercises had a recruitment effect on the VMO to VL ratio of the SOCKE exercise is better than that
VMO muscle. In addition, the SOCKE exercise had higher of the SCCKE exercise.
MVC% values for the VMO and VL than the SCCKE ex- There are still some limitations within our study. First,
ercise. Many studies have used closed kinetic chain and the healthy individuals in this study did not have pain and
weight-bearing exercises, e.g., double-leg squat and lunge symptoms related to the patella and did not conform to the
exercise, to improve the VMO strength5, 18, 19). Their results muscle activity of a PTPS patient. Second, the small sample
showed that these exercises can significantly increase the size, 7 participants only, means that the findings cannot
activation of the VMO and VL. Some studies showed that be generalized to all PTPS patients. So, we suggest that a
closed kinetic chain exercises can cause greater activation larger sample of symptomatic PTPS patients is required in
in the VMO than in the VL5, 6, 19). However, combining a future study.
closed kinetic chain exercise with weight-bearing exercise
often provides a large increase in pulling strength, and in-
ACKNOWLEDGEMENTS
creases the intra-articular pressure. This causes the symp-
toms of PFPS to worsen during exercise training. We found
that the using SET in the SCCKE exercise can also cause The authors are grateful for financial support from the
greater activation in the VMO than in the VL. SET can re- National Science Council of the Republic of China and
duce the effect of body weight on the knee intra-articular China Medical University under the contract Nos. NSC
pressure and can be used to train knee extension with non- 102-2815-C-039-091-B and CMU102-SR-21.
weight bearing. The SCCKE exercise may be useful and
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