7/13/2023

The Effects of Open and Closed Chained

Exercises on Individuals with Hemiparesis
By Delaney Harris & Francis Prins

Key Impairments
● 65 year-old man who had a stroke (1 month ago) resulting in right-
sided hemiparesis
● Decreased range of motion of the right extremities
● Decreased strength (3-/5) across the right leg
● Difficulty ambulating
● Decreased speed, knee hyperextension, toe drag during swing, and
instability during walking
● Uses a quad cane
● Lack of drive and motivation

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Clinical Question
Will a 65-year-old man with right-sided hemiparesis (P) achieve a
meaningful outcome on functional mobility of the ankle joint (O) with open
or closed kinetic chain therapeutic exercises(I/C)?

Introduction
• An ischemic stroke is a disease that is caused by a blockage in an artery
leading to the brain. A hemorrhagic stroke is due to bleeding in the brain
tissue after a blood vessel is ruptured.1
• Hemiparesis is classified by muscular weakness or paralysis on one side
of the body.2
• The severity of hemiparesis from stroke is dependent on harshness of
stroke and the individual’s level of independence or capabilities while
performing functional tasks.
• Distribution of muscle impairment follows the pattern of more distal
muscles usually weaker than the proximal muscles.
• Muscle strength is sometimes regained in a faster manner in lower
extremities than upper extremities.3

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Purpose
To compare open and closed kinetic chain exercise outcomes on the functional
mobility at the ankle joint.

Subjects
• Stroke patients with hemiparesis
• Recruited from hospitals, assisted living facilities, and outpatient clinics in the
upper peninsula of Michigan
• Inclusion criteria:
– Ages 60 to 80 years of age
– Post-stroke with symptoms of hemiparesis
– Single unilateral stroke
– Minimum to moderate range of motion and strength in joints on affected
side
– Cognitive ability to follow instructions
– Can tolerate testing sessions

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Subjects
Exclusion Criteria:
• Presence neurological disorders not related to stroke
• Acute heart impairments
• Severely affected muscle tone or paresis
• Other orthopedic or musculoskeletal comorbidities that may limit
strength and range of motion in the lower extremity

Study Design
• Experimental Trial
• 2 randomized groups
– Group 1: Open kinetic chain exercises
– Group 2: Closed kinetic chain exercises
• Therapy will be in-clinic, led by two trained physical therapist
• Sample size: 30 participants
• Parameters: 3x a week for 6 weeks
• Each session will last 45 minutes
– 10 minute warm up on NuStep
– 25 minutes for 3 exercises
– 10 minute cooldown for range of motion (ROM) stretching

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Methodology
• Open kinetic chain exercises: (3 sets, 10 repetitions)
– Calf raises on leg press machine
– Seated resistive band dorsiflexion/ plantarflexion (calf pumps)
– Total Gym squats
• Closed kinetic chain exercises: (3 sets, 10 repetitions)
– Standing calf raises
– Squats
– Forward lunges
• Use weight as tolerated, increase weight every 2 weeks

Methods: Data Collection

Primary outcomes: Valid and reliable clinical scales
• Modified Ashworth Scale (muscle tone and spasticity)4
• ROM (measure dorsiflexion using a goniometer)5
• Functional Gait Assessment (timed 10 meter walk at patients preferred
speed)6
• Manual muscle test (MMT) (ankle dorsiflexion and subtalar inversion
test)7

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Modified Ashworth Scale

https://www.semanticscholar.org/paper/A-Review-%3A-The-Validity-and-Reliability-of-the-as-a-Bauch-Steinberg/aac2976b83964df77646c38137c6143fcdd658b6

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Manual Muscle Test Scale

Standard Scale

https://www.prohealthcareproducts.com/blog/manual-muscle-testing-principles-explained/

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Methodology- Data Analysis

• Pre-Test
– Test both groups ROM, muscle tone and spasticity on the Modified
Ashworth Scale, Functional Gait Assessment, and MMT
• Pre-Test II
– Retest after three weeks
• Final Test
– Retest after the six weeks are complete

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Data Analysis
Independent Variable #1: Group 1&2 (open kinetic chain/closed kinetic chain
exercises)
Independent Variable #2: Test time (pre/week 3/week 6)
Dependent Variable: ROM, strength, muscle spasticity/tone, and functional
gait assessment

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Conclusion
• Anticipated study findings:
– It’s believed that closed kinetic chain exercises will have a more
favorable outcome than open kinetic chain exercises
• Limitations:
– Exercises may require guarding
– No minimal detectable change within six weeks
– Large range of deficits present
– Poor intra-rater reliability

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References
1. Paul S, Candelario-Jalil E. Emerging neuroprotective strategies for the
treatment of ischemic stroke: An overview of clinical and preclinical
studies. Exp Neurol. 2021;335:113518.
doi:10.1016/j.expneurol.2020.113518
2. Inatomi Y, Nakajima M, Yonehara T, Ando Y. Ipsilateral hemiparesis in
ischemic stroke patients. Acta Neurol Scand. 2017;136(1):31-40.
doi:10.1111/ane.12690
3. Andrews AW, Bohannon RW. Distribution of muscle strength
impairments following stroke. Clinical Rehabilitation. 2000;14(1):79-87.
doi:10.1191/026921500673950113 (Slide 5)

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References Continued
4. Li F, Wu Y, Li X. Test-retest reliability and inter-rater reliability of the
Modified Tardieu Scale and the Modified Ashworth Scale in hemiplegic
patients with stroke. Eur J Phys Rehabil Med. 2014;50(1):9-15.
5. Konor MM, Morton S, Eckerson JM, Grindstaff TL. Reliability of three
measures of ankle dorsiflexion range of motion. Int J Sports Phys Ther.
2012;7(3):279-287.
6. Middleton A, Fritz SL, Lusardi M. Walking speed: the functional vital
sign. J Aging Phys Act. 2015;23(2):314-322. doi:10.1123/japa.2013-0236
7. Berryman Reece N. Muscle and sensory testing. 4. ed. Elsevier, Inc.;
2020:pages cm.

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