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Test-Retest Reliability of the Closed Kinetic Chain Upper Extremity Stability Test: • A Clinical Field Test

Todd G. Goldbeck and George |. Davies
Context: Functional testing of patients is essential to clinicians because it provides objective data for documentation that can be used for serial reassessment and progression through a rehabilitation program. Furthermore, new tests should require minimal time, space, and money to implement. Purpose: To determine the test-retest reliability of the Closed Kinetic Chain (CKC) Upper Extremity Stability Test. Participants:Twenty-four male college students. Methods: Each subject was tested initially and again 7 days later. Each subject performed 1 submaximal test followed by 3 maximal efforts. A 45-second rest was given after each 15-second test. The 2 maximal-test scores were averaged and compared with those from the retest. ffesu/ts:The intraclass correlation coefficient was .922 for test-retest reliability. Apairedsamples t test {.927) was conducted, and the coefficient of stability was .859. The results indicate that the CKC Upper Extremity Stability Test is a reliable evaluation tool. Key Words; closed kinetic chain, upper extremity, functional testing
Goldbeck TG, Davies CJ. Test-retest relUbiiity of the Closed Kinetic Chain Upper Extremity Stability Test: a cliniciil field test. / Sport Rehabil. 2000;9:35-45. © 2000 Human Kinetics Publishers, inc.

Functional testing of patients is becoming increasingly important to the rehabilitation clinician. We need to develop new tests that provide objective data to help the clinician determine a patient's readiness to retum to activities, resume competition, or continue further rehabilitation. These tests should be easy for clinicians to use and for patients to understand. They also must be cost-efficient, take up minimal space in the clinic, be generalizable to many different patient populations, and be reliable. The concept of body segments interacting with each other in a kinetic chain has existed in the rehabilitation profession for many years. It was first introduced by Steindler,' and since then the terms have been defined in many ways. In a kinetic chain, all segments are interdependent. Each moving
Todd C. Goldbeck is with Beloit Memoria] Hospital, Beloit, WI53551. George J. Davies is a professor of physical therapy at the University of Wisconsin-LaCrosse and director of clinical and research services at Giindersen Lutheran Sports Medicine, Onalaska, WI 54650. 35

and movable boundary no external load. which has no accepted standards of criteria.'"'^-'^ but carryover to the upper extremities is still unclear. there has been an increase in the use of closed kinetic chain exercises in clinical rehabilitation.^'^'" These terms are used freely in rehabilitation settings. The following are characteristics of closed kinetic chain activities: They occur with multiple joint movements or multiple joint axes.have pointed out the various inconsistencies in the literature concerning clinicians' use of the terms open and closed kinetic chain and their subsequent application to patient treatment. It is called the functional classification system and is based on the boundary. They suggest a move from the existing classification. increases the dynamic stability of the glenohumeral . and the direction in which the load is applied to the upper extremity. A system of classification was proposed that includes 3 categories: fixed boundary. Weight bearing through the upper extremities. Research and rationale for using closed kinetic chain exercise in the lower extremities is prevalent in the literature. This 4-class system consists of fixed boundary. the primary axis is translatory motion occurs both proximal and distal to the axis. external axial load. external axial load. and both segments of the extremity that form the joint aie moving simultaneously. movable boundary. and the muscle activation required. as in the case of closed kinetic chain activities. In both the upper and the lower extremity. no load. there has been a recent increase in the interest of testing and rehabilitation procedures for the upper extremities.'" There is a continuum of activities along the kinetic chain. external rotary load.^-^'^"'^'^^ oillman et al'. as opposed to the traditional terms of open and closed kinetic chain. Lephart and Henry also feel that a more comprehensive set of criteria is needed to accurately define the various exercises in a rehabilitation prograjn. external load. The following are characteristics of open kinetic chain activities: They occur in isolated joint movements.36 Goldbeck and Davies segment exhibits force on every other and affects those segments' motions in a predictable manner. movable boundary. to a description of each exercise based on the biomechanics involved. Lephart and Hemy^ have also suggested an alternative method for classifying rehabilitative exercises. external load. Because of the lack of information in the current literature. particularly with emphasis on closed kinetic chain activities. and the axis is relatively stable. movable boundary. yet there is no strict adherence to a standard definition of what open or closed kinetic chain exercises are. Open kinetie ehain is commonly defined as an activity in which the distal segment of the extremity terminates freely in space. motion occurs only distal to the axis. the load. and movable boundary. ranging from the open kinetic chain to the closed kinetic chain. the load placed on the body. with 1 part of the extiemity that forms the joint stabilized and 1 segment moving?'^^' Closed kinetic chain is commonly defined as an activity in which the distal segment of the extremity isfixedto an object and can be stationary (push-ups) or moving (bench press).

. Because the study tested the reliability of the evaluation tool.^ '^-"•^*''^^^' Therefore. before participating in the study. New and innovative testing procedures must continually be scrutinized to ensure that they provide the most accurate account of a patient's progress. The purpose of this study was to determine the test-retest reliability of the Closed Kinetic Chain Upper Extremity Stability Test.5-in width) were placed on the ground parallel to each other 36 in apart.CKC Upper Extremity Stability Test 37 joint through joint approximation and by producing a muscular cocontraction of the agonists/antagonists about the joint. its reliability must be examined. Closed kinetic chain exercises should help accomplish this goal. Rehabilitation should be structured in a manner that most closely simulates the way that the muscles and joints are used in sport. Therefore. rehabilitative procedures should maximize the use of mechanoreceptors to allow for more accurate joint-position sense. A standard tape measure of at least 36 in was used to measure the distance between the hand lines. athletes that function with their upper extremities in a closed kinetic chain during sport would receive the greatest benefit from closed kinetic chain rehabilitation. Proprioceptive deficits must be addressed in order for the rehabilitation program to be complete. a standard battery-operated stopwatch was used.3 years) volunteered to participate in the study. Methods Subjects Twenty-four male college students (mean age = 20. For example. data collected were not affected by neuromuscular adaptations to exercise.'^-^*^^^ Static stability is enhanced via stimulation of joint mechanoreceptors resulting from compression of the capsule. which was approved by the University of Wisconsin-LaCrosse institutional review board. Stone^' stated that the use of closed kinetic chain activities in rehabilitation should be used.''^^•^'"'''There is also some information that suggests that weight bearing through the upper extremities increases overall stability because of the anatomical structures of the glenohumeral joint. When a new fimctional test is developed that is relevant to multiple upper extremity injuries and can be used in any clinical setting. Each subject read and signed an informed consent form. based on the concept of specificity of training. To ensure that all tests were of equal duration.'•"•^''^^•^ Joint proprioception has been found to be negatively affected after injury. the subjects did not start a new training program or alter their current workouts during the course of the study. Instrumentation Two pieces of standard athletic tape (1.

When the examiner said "go. Figure 2 Subject touches a line opposite. the subject assumed a push-up position. . and then replaced the hand on the original line (Fig- Figure 1 Starting position of closed kinetic chain test." the subject removed 1 hand from the floor (either one). with 1 hand on each piece of tape and body as straight and parallel to the ground as possible. touched the opposite line (Figure 2).38 Goldbeck and Davies Protocol To begin. The shoulders were positioned directly over the hands (Figure 1).

Each subject performed a submaximal test and then 3 maximal efforts.CKC Upper Extremity Stability Test 39 ure 3). He then removed the other hand from the floor. A single test consisted of continuing this alternating procedure for 15 seconds. The 3 maximal tests were averaged and became Figure 3 Subject returns hand to original position. A touch was defined as when a hand was crossed over and touched the opposite line. Subjects attempted as many "touches" as possible in the allotted time during the maximal tests. and returned it to its original line (Figure 5). . touched the opposite line (Figure 4). Figure 4 Subject touches the opposite line.

If not deemed ready for competition. Third. That score is then divided by 15. which is the weight of the arms. and trunk. which is the duration of the test in seconds. Statistical Analysis The SPSS 6. and the tapes were reviewed to ensure accuracy of test scores.40 Goldbeck and Davies Figure 5 Subject returns hand to original line. head. Data analysis for this test can occur in 1 of 3 ways. A single rest pericd of 45 seconds was given after every trial. wliich allows for optimal recovery following a short-duration. The power scctre reflects the amount of work performed in a unit of time. First. high-intensity test such as this. instead of continually changing the width of the hand lines based on each patient's size. A test-retest period of 1 week was chosen to simulate the period of time used to serially test a patient in the clinic. the number of touches can be counted for each subject. the athlete is tested again 1 week later after further rehabilitation of the injury.1 statistical package was used for all data analysis. the test becomes more efficient in .3 busy clinical setting.'" The intradass correlation coefficient was determined to establish reliability of . This is the method that was used for this study. By normalizing the data to each patient. This method is the easiest because it provides absolute numbers that can be used for statistical analysis. Second. The same prtx:edure was followed for theretest1 week later. several tests are performed to determine his or her functional level. All tests were administered and data collected by the principal investigator. When a patient is thought to be ready for retum to activities.^-^** All subjects were videotaped. the subject's test score. The work-rest ratio was 1:3. the number of touches can be divided by the patients' height to normalize the data to each patient. a power score can be developed by multiplying the average number of touches with 68% of the patient's body weight in kilograms.

The paired-samples correlation coefficient was . with a standard deviation of 1. and single-arm dynamic stabilization on a multidirectional surface.927. and plyometrics. They describe many . and the retest scores had a mean of 27. because there are no commonly used clinical tests to identify deficits in upper extremity closed kinetic chain function. Davies and Dickoff-Hoffman^' discuss several methods of upper extremity rehabilitation. press-ups. Comments Functional tests are useful when gathering baseline data for a patient. which yielded a 95% confidence level. as well as many recent publications. They suggest many closed kinetic chain exercises including plyometric push-ups. The test mean was 27. Lephart and Henry' propose a functional classification system to be used to restore proprioceptive deficits and reestablish neuromuscular control during the rehabilitation of upper extremity injuries. closed kinetic chain exercises. The Intraclass correlation coefficient provides that measure of reliability.8. By determining the reliability of this clinical evaluation tool.05 was used for all analyses. The exercises are derived from kinesthetic training.^" it is necessary to assess the reliability of a test in order to know the extent to which the measurements are measuring what they say.are emphasizing the use of closed kinetic chain exercises in the rehabilitation of patients with upper extremity injuries. The coefficient of stability was also calculated. as well as performing serial reassessments. The coefficient of stability (R') was . There is a need for the development and research of new functional tests that can be used in a clinical rehabilitation setting for assessing closed kinetic chain upper extremity activities. This causes a dilemma.922 for test-retest reliability. Each of the techniques suggests using the upper extremity in a closed kinetic chain manner with varying degrees of difficulty. More and more clinicians.^-^ "•^''^^•^-^. The single-measure intraclass correlation coefficient was . we can now say that it can be used confidently as a method to objectively show a patient's progression of recovery from an upper extremity pathology.CKC Upper Extremity Stability Test 41 the test and retest scores. According to Shrout and Fleiss. Results The results indicate that the reliability of measurements obtained with the Closed Kinetic Chain Upper Extremity Stability Test has a high correlation. The purpose of this study was to determine the test-retest reliability of the Closed Kinetic Chain Upper Extremity Stability Test.97.77. A paired-samples t test was also used to compare the 2 groups of scores. Borsa et aP^ address rehabilitation techniques to Improve the proprioceptive ability of an unstable glenohumeral joint.9 and a standard deviation of 1. Exercises include dynamic stabilization and push-ups on uneven surfaces. A P value of .859.

appropriate treatments that are effective in decreasing swelling are implemented.42 Goldbeck and Davies closed kinetic chain exercises. heating.J. In addition. Therefore. and then. Appropriate strengthening exercises are indicated if weakness is found. It is appropriate to state that. and stair stepping. muscle weakness can be identified through manual muscle testing. Another example is the use of goniometry to measure joint ranges of motion. We found no commonly used closed kinetic chain upper extremity tests in the literature after performing a thorough MedLine search. based on the test results. They illustrated many exercises in which the patient is bearing weight with the upper extremity while performing activities of varying difficulty. requires minimal set-up. depending on the severity of injury and soft tissue healing constraints. clinicians must ask themselves why closed kinetic chain upper extremity exercises are being integrated into treatment programs when no testing has been performed to demonstrate any deficits in those areas. no clinician would apply treatment modalities to decrease swelling in a joint if anthropometric measurements were similar with bilateral comparison and there were no other indications of swelling. plyometric step-ups and step-downs. there is a need to develop a test that is easily administered in any clinical setting.D. If it is present. They rehabilitate the upper extremity using the same type of closed kinetic chain exercises that are commonly used for the lower extremity The exercises described include slide board in all directions. and mobilizations are performed to create a plastic deformation of the tissue to improve range of motion and retum it to normal. If no tests exist that objectively measure closed kinetic chain performance of the upper extremity. a measurement or test is performed to evaluate the status of a particular parameter. inverted push-ups on a shuttle. Typically. If a patient has rangeof-motion deficits caused by noncontractile tissues. With these clinical examples. clinicians should not incorporate such exercises into a rehabilitation program. A common clinical example is the use of anthropometric measurements to determine whether effusion or edema is present in an injured area. Wilk et aF**-^^ encourage the use of closed kinetic chain activities in an upper extremity rehabilitation program. the senior author (G. appropriate intervention strategies are applied to improve the deficit.) developed the test described in this paper. stretching. Stone et a F suggest using rehabilitative methods that replicate function as closely as possible. dynamometer testing. The same argument can be made for the other 2 examples. as well. such as 1-arm balancing on an uneven surface in a tripod position and upper extremity exercise on a slide board in a push-up position. The purposes of the test are to determine whether there are deficits in closed kinetic chain upper extremity functional performance and to use the re- . After many pilot test procedures. in clinical practice. or functional performance testing. and is reliable. ethically.

Finally. First. A. Manske. G. D. J. There are several limitations to this study. Similar to the findings of Sekiya et al. especially during the eccentric deceleration phase of the test. It is an easy test to perform in the cliruc. In addition. Conclusion This study demonstrated that the Closed Kinetic Chain Upper Extremity Stability Test is a reliable clinical evaluation tool. The work of Manske et al supports that concept and demonstrates that the function of the shoulder complex should be evaluated with various tests. R. relating to gender. certain patients are contraindicated to perform the test. More specificity regarding descriptive norms. The test is clinically useful because it can be applied to many upper extremity injuries.D.J. Camey.'^' they foimd that no single test is sufficient in itself to determine overall functional performance from subjective responses to objectively evaluating sport-specific performance tasks. In addition.) have shown that patients who were unwilling or imable to perform or developed pain during the test were not able to participate in their sport pain-free in the glenohumeral complex. As discussed previously. requires a mirumai amount of floor space to set up. correlations between test performance and sport-spedfic skills must also be developed. apprehension. and costs nothing to maintain. few patients who had difficulty while performing this test—from pain. Ongoing research is evaluating the validity of our test relative to retumto-sport performance. 1999) evaluated the correlation of the Closed Kinetic Chain Upper Extremity Stability Test to other tests of the shoulder complex. or low scores—were able to retum to their previous level of performance in their sports. to randomly implement therapeutic exercises without any basis from a clinical examination or testing is not the ideal scientific or clinical method to design a rehabilitation program. Our test has been used for several years as an assessment tool for upper extremity closed kinetic chain function in an orthopedic and sports medicine clinic. must be compiled. Also. Empirically based clinical observations by a clinician with over 30 years of clinical experience (G. and specific sports. . Elfessi (unpublished data.CKC Upper Extremity Stability Test 43 suits to guide the progression of a rehabilitation program. Davies. the patient must be willing and able to accept his or her body weight with the upper extremities. and it provides objective data on closed kinetic chain testing that can be used to chart a patient's progress through a rehabilitation program. Hundreds of patients have been evaluated with this test on their willingness to use their upper extremities in a closed kinetic chain manner and their ability to perform the test for an objective score. no studies have correlated closed kinetic chain tests with other functional activities. C. age. and A. such as the elderly and patients with wrist or elbow pathologies or posterior instabilities of the shoulder. In a recent paper.

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