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Citation: An, J.; Son, Y.-W.; Lee, B.-H.
Effect of Combined Kinematic Chain
Exercise on Physical Function,
Balance Ability, and Gait in Patients
with Total Knee Arthroplasty: A
Single-Blind Randomized Controlled
Trial. Int. J. Environ. Res. Public Health
2023, 20, 3524. https://doi.org/
10.3390/ijerph20043524
Academic Editor: Paul B. Tchounwou
Received: 4 December 2022
Revised: 14 February 2023
Accepted: 15 February 2023
Published: 16 February 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
International Journal of
Environmental Research
and Public Health
Article
Effect of Combined Kinematic Chain Exercise on Physical
Function, Balance Ability, and Gait in Patients with Total Knee
Arthroplasty: A Single-Blind Randomized Controlled Trial
Jungae An 1 , Young-Wan Son 1 and Byoung-Hee Lee 2,*
1 Graduate School of Physical Therapy, Sahmyook University, Seoul 01795, Republic of Korea
2 Department of Physical Therapy, Sahmyook University, Seoul 01795, Republic of Korea
* Correspondence: 3679@syu.ac.kr; Tel.: +82-2-3399-1634
Abstract: Total knee arthroplasty (TKA) is an effective treatment for end-stage osteoarthritis. How-
ever, evidence of combined kinematic chain exercise (CCE) in early-phase rehabilitation after TKA
remains lacking. This study investigated the effects of CCE training on physical function, balance
ability, and gait in 40 patients who underwent TKA. Participants were randomly assigned to the CCE
(n = 20) and open kinematic chain exercise (OKCE) groups (n = 20). The CCE and OKCE groups
were trained five times a week (for 4 weeks) for 30 min per session. Physical function, range of
motion (ROM), balance, and gait were assessed before and after the intervention. The time × group
interaction effects and time effect as measured with the Western Ontario and McMaster Universities
Osteoarthritis Index, ROM, Knee Outcome Survey-Activities of Daily Living, balancing ability (e.g.,
confidence ellipse area, path length, and average speed), and gait parameters (e.g., timed up-and-go
test, gait speed, cadence, step length, and stride length) were statistically significant (p 65 years who could communi-
cate with medical staff, those who underwent TKA owing to degenerative arthritis, and
those with cemented TKA. The exclusion criteria were as follows: older patients aged
>75 years; those with a history of knee joint surgery before TKA; those who possibly had
a systematic inflammatory disease such as rheumatoid arthritis; those who had difficultywalking independently; those who had psychological problems or nervous disease; those
who had previously received surgery for spine disease (Figure 1).
2.2. Ethical Statement
The purpose and requirements of this study were explained to the participants in
detail. Patients could withdraw their consent to participate in the study at any time during
the experimental procedure. Written informed consent was obtained from all patients. This
study was approved by the Sahmyook University Institutional Review Board (approval
number: 2-7001793-AB-N-012019064HR) and the Clinical Research Information Service
(KCT0005823). Participants’ rights were protected according to the ethical principles of the
Declaration of Helsinki.
Int. J. Environ. Res. Public Health 2023, 20, 3524 3 of 14Int. J. Environ. Res. Public Health 2023, 20, 3524 3 of 15 
 
 
 
Figure 1. Flow diagram of the total experiment. CCE: combined kinetic chain exercise; OKCE: open 
kinetic chain exercise; WOMAC: the Western Ontario and McMaster Universities Osteoarthritis In-
dex; ROM: knee range of motion; KOD-ADLs: Knee Outcome Survey-Activities of Daily Living. 
2.2. Ethical Statement 
The purpose and requirements of this study were explained to the participants in 
detail. Patients could withdraw their consent to participate in the study at any time during 
the experimental procedure. Written informed consent was obtained from all patients. 
This study was approved by the Sahmyook University Institutional Review Board (ap-
proval number: 2-7001793-AB-N-012019064HR) and the Clinical Research Information 
Service (KCT0005823). Participants’ rights were protected according to the ethical princi-
ples of the Declaration of Helsinki. 
 
Figure 1. Flow diagram of the total experiment. CCE: combined kinetic chain exercise; OKCE: open
kinetic chain exercise; WOMAC: the Western Ontario and McMaster Universities Osteoarthritis Index;
ROM: knee range of motion; KOD-ADLs: Knee Outcome Survey-Activities of Daily Living.
2.3. Study Design
This study had a single-blind, randomized controlled trial design. The assessors and
participants were blinded to the grouping of each participant. Five physical therapists
with more than 5 years of musculoskeletal field experience participated in the study
procedures. The assessors were trained on equipment usage and measurement methods
for 1 h twice a week before evaluating the participants. All evaluations and exercise
training were conducted individually. G*Power Version 3.1.9.7 (Franz Faul, University
Kiel, Germany, 2020) was used to calculate the sample size (two-tailed, effect value: 0.5,
significant level α: 0.05, and power: 0.8) of the study. The number of required samples
was 34. Considering a drop-out rate of 10–15%, 40 patients were recruited, and all study
participants were pretested. To minimize the error related to the experiment, 40 patients
were randomly assigned to the CCE and OKCE groups using the Research Randomizer
program (http://www.randomizer.org/, accessed on 30 August 2019).
2.4. Study Procedure
The experimental setting was an in-patient acute care unit at an orthopedic surgery
hospital. All participants underwent TKA using a minimally invasive quadriceps-sparing
http://www.randomizer.org/
Int. J. Environ. Res. Public Health 2023, 20, 3524 4 of 14
technique with a high-flexion mobile prosthesis (Implantcast; GMBH Lüneburger Schanze,
Buxtehude, Germany). From the 3rd day after TKA, the CCE and OKCE groups performed
the exercise five times a week for 30 min (20 times for 4 weeks). Additionally, CPM was
applied on the 1st day after TKA in both groups (once a day for 20 min, five times a week for
4 weeks). The CCE and OKCE groups were subjected to the same treatment conditions and
environment. To examine the effect of the exercise program after the experiment, each group
was administered the same procedure as the pretest and posttest. The baseline assessment
was performed 1 day before the TKA procedure, and the posttest was performed 6 weeks
after TKA. The Western Ontario and McMaster universities osteoarthritis (WOMAC), Knee
Outcome Survey-Activities of Daily Living (KOS-ADLs), and an electronic goniometer
were used to evaluate physical functions, and a Zebris PDM multifunction force measuring
plate was used to measure balance ability and gait. The timed up-and-go (TUG) test was
performed for dynamic balance ability.
2.5. Intervention
The CCK and CKCE groups performed each kinetic chain exercise starting on the
3rd day after TKA, and the participants each wore a knee brace and used a walker. The
exercise program was based on that outlined in a previous study and was performed each
week, considering each patient’s level of performance.
2.5.1. Combined Kinetic Chain Exercise Program
In the 1st week of training, two sets of 10 repetitions (reps) were performed: quadriceps
setting in the supine position, ankle full exercise in the supine position, wall slide, getting
up and down from a chair, and standing up and off heels. For the 2nd to 3rd week of
training, two sets of 10 reps were performed, including quadriceps setting while sitting,
getting up and down from a chair, standing up and off heels, stepping up and down from a
step box forward and sideward, and wall squatting. In the 4th week of training, getting up
and down from a chair, stepping up and down from a step box forward and sidewards, hip
abduction exercise while standing, and mini squats with a walker were performed in two
sets of 10 reps for each movement, and two sets of one rep of toe gait were performed for
1 min [25,30,31]; the whole routine was performed for 30 min with a rest period of 30–40 s
between sets (Table 1).
Table 1. Combined kinetic chain exercise program.
Week Contents of Program Times
1st week
1. Quadriceps setting in the supine position
2. Ankle full exercise in a supine
3. Wall slide
4. Getting up and down from a chair
5. Standing up and off heels
10 times, 2 sets
2nd to 3rd week
1. Quadriceps setting while sitting
2. Getting up and down from a chair
3. Standing up and off heels
4. Wall squat
5. Stepping up and down the step box forward and sideward
10 times, 2 sets
4th week
1. Getting up and down from a chair
2. Hip abduction exercise while standing
3. Stepping up and down from a step box forward and sideward
4. Mini squat with a walker
5. Toe gait
10 times, 2 sets
Total exercise time was 30 min with a rest time of 30–40 s between sets.
Int. J. Environ. Res. Public Health 2023, 20, 3524 5 of 14
2.5.2. Open Kinetic Chain Exercise Program
In the 1st to 2nd week, the training program consisted of knee ROM exercises, quadri-
ceps setting exercises by placing a foam roller under the knee in a supine position, straight
leg raising, and ankle pull exercises in the supine position. In the 3rd to 4th weeks of train-
ing, ROM exercise of the knee, quadriceps setting in a sitting position, and hip abduction
exercises while standing up were performed [32,33]; the rest period between the sets was
30–40 s for 30 min of exercise (Table 2).
Table 2. Open kinetic chain exercise program.
Week Open-Kinetic Chain Exercise Program Reps
1st to 2nd week
1. Knee range of motion exercise
2. Quadriceps setting in a supine position with a foam roller
under the knees
3. Straight leg-raising
4. Ankle full exercise in a supine position
Each 5 s 10 reps/6 sets
3rd to 4th week
1. Knee range of motion exercise
2. Ankle full exercise in a supine position
3. Quadriceps setting in a sitting position
4. Hip abduction exercise in a standing position
Each 5 s 10 reps/6 sets
Total exercise time was 30 min with a rest time of 30–40 s between sets.
2.6. Outcome Measurements
2.6.1. Physical Function
The WOMAC, ROM, and KOS-ADLs were used to measure the physical function in
this study.
The WOMAC, which is widely used in patients with knee arthritis (intraclass cor-
relation coefficient, ICC = 0.92), consists of 24 subjective questions about knee joint pain
and functional limitations that can be felt daily [34,35].The evaluation consisted of three
subscales: pain, stiffness, and body function. Therefore, compared to other evaluation tools,
the questions were formed on a simple and detailed scale such that knee joint pain and
functional impairment can be evaluated very effectively [35]. In this study, the items on the
pain scale ranged from 0–20 points, those on the stiffness scale ranged from 0–8 points, and
those on the physical function scale ranged from 0–68 points. The three items were summed
from 0–96, with a score of 0 indicating “none,” 4 indicating “very severe,” and a higher
score indicating pain, stiffness, ROM, low level of body function, or physical disability.
Goniometer Biometrics (USA, 2008) was used to measure the flexion ROM of the
knee joint (ICC = 0.99) [36]. To reduce the error between the measurements, the angle was
adjusted to 0◦ for each measurement. The active joint ROM was measured thrice, and
the average value was calculated. The examiner’s gaze was placed horizontally on the
treatment table, and measurement was performed in a sitting position. The measurement
position was fixed by placing the axis of the biometric goniometer at the lateral condyle of
the tibia and the stabilization arm in the middle of the femur at the greater trochanter of
the femur. The movement arm was measured by placing it in a straight line from the head
of the calf to the lateral malleolus of the ankle.
The KOS-ADL was used to evaluate knee joint function in daily life. The symptoms
included six items of influence on general daily living ability. The knee joint condition
has 8 (of the total 14) items that influence the ability to perform functionally specific tasks
and represents a reliable scale questionnaire to identify knee joint condition and functional
ability for daily living (ICC = 0.97) [37].
2.6.2. Balance
Balance ability was measured using a Zebris PDM platform (FDM 1.5, Zebris Medical
GmbH, Isny, Germany, 2016), and “Zebris Win FDM” software was used for data collection
Int. J. Environ. Res. Public Health 2023, 20, 3524 6 of 14
and analysis. The Zebris PDM multifunction force-measuring plate consisted of a pressure
mat (1580 mm in length × 605 mm in width × 21 mm in height; 11,264 sensors per
64 × 176 cm; range 1–120 N/cm2). The force measuring plate comprised four force sensors
per 1 cm2, which measured postural sway during the patient’s standing posture and gait
parameters while walking. The static and dynamic sampling pressure extraction rates were
2–5 Hz and 90 Hz, respectively, and the accuracy was within ±5%. The patient was asked
to stand on the force plate and gaze at a fixed point, and postural sway, including the center
of pressure 95% confidence ellipse area (CEA), the center of pressure path length (CPL), and
the center of pressure and average velocity (CAV), was measured. The measurements were
performed three times, and the average values were used for the analysis. The equipment
showed high reliability (ICC = 0.8–0.9) [38].
2.6.3. Gait
Gait parameters, such as gait velocity, cadence, step length, and stride length, were
measured using the Zebris PDM platform. The TUG test was used to measure functional
mobility [39], balance, and walking ability. The patients were asked to get up from a
sitting position on a chair with an armrest at a height of 46 cm at the same time as the
examiner’s signal, make a 3 m round-trip return, and sit down; this was repeated thrice,
and the average value was calculated [40]. The TUG test (ICC = 0.91–0.92) [41] showed
high reliability.
2.7. Statistical Analysis
All tasks and statistics used in the analysis were based on SPSS ver. 22.0, which
was used to calculate the means and standard deviations. All participants were normally
distributed using the Shapiro–Wilk normality test. Descriptive statistics were used for the
general characteristics of the participants. An independent sample t-test was performed
to confirm the differences between the groups. A paired-sample t-test was performed to
compare the differences before and after the intervention. The interaction effect between
groups over time was analyzed using a two-way repeated measures analysis of variance
(ANOVA). All statistical significance levels for the data were set to 0.05.
3. Results
A total of 71 patients were assessed for eligibility, and among them, 40 participants
were randomized to complete the study intervention. All participants were women, and all
had Kellgren–Lawrence grade 3–4 osteoarthritis before TKA. The demographic characteris-
tics of the 40 patients who underwent TKA at baseline are shown in Table 3.
Table 3. Demographic characteristics (n = 40).
Characteristics CCE Group
(n = 20)
OKCE Group
(n = 20) X2/F(p)
Surgery side (left/right) 10/10 9/11 0.309 (0.759)
Age (years) 71.60 ± 3.53 70.04 ± 2.47 1.244 (0.221)
Height (cm) 152.47 ± 6.05 151.34 ± 5.82 0.599 (0.605)
Weight (kg) 61.08 ± 8.67 59.57 ± 9.54 0.522 (0.553)
BMI (kg/m2) 26.15 ± 2.89 25.92 ± 3.30 0.237 (0.814)
CCE: combined kinetic chain exercise; OKCE: open kinetic chain exercise; BMI: body mass index. Values are
expressed as the mean ± standard deviation. Significant: pVariable CCE Group
(n = 20)
OKCE Group
(n = 20)
t (p)
Time Group Time × Group
F (p) F (p) F (p)
CEA (mm2)
Pretest 456.42 ± 188.43 517.72 ± 231.21 –0.919 (0.364)
Posttest 285.30 ± 212.74 403.15 ± 248.05
Mean difference 171.11 ± 76.02 114.57 ± 89.09 2.159 (0.037) 304.42 (0.000) 6.060 (0.018) 26.725 (0.000)
95% CI (135.54 to 206.70) (72.88 to 156.27)
t (p) 10.066 (0.000) 5.751 (0.000)
CPL (mm)
Pretest 130.20 ± 32.68 127.28 ± 38.69 0.258 (0.798)
Posttest 99.29 ± 29.95 109.22 ± 37.00
Mean difference 30.90 ± 15.30 18.05 ± 13.23 2.842 (0.007) 119.00 (0.000) 1.699 (0.200) 4.661 (0.037)
95% CI (23.75 to 38.07) (11.86 to 24.25)
t (p) 9.031 (0.000) 6.102 (0.000)
Int. J. Environ. Res. Public Health 2023, 20, 3524 8 of 14
Table 5. Cont.
Variable CCE Group
(n = 20)
OKCE Group
(n = 20)
t (p)
Time Group Time × Group
F (p) F (p) F (p)
CAV (mm/sec)
Pretest 14.49 ± 3.12 14.56 ± 4.75 –0.053 (0.958)
Posttest 10.24 ± 3.26 11.75 ± 4.08
Mean difference 4.24 ± 1.32 2.80 ± 1.49 3.228 (0.003) 117.13 (0.000) 0.106 (0.746) 8.076 (0.007)
95% CI (3.63 to 4.87) (2.11 to 3.51)
t (p) 3.228 (0.003) 8.407 (0.000)
CCE: combined kinetic chain exercise; OKCE: open kinetic chain exercise; CEA: confidence ellipse area; CPL: center
of pressure path length; CAV: center of pressure average velocity. Values are expressed as the mean ± standard de-
viation; 95% CI: 95% confidence interval; significant: p635.1 mm to
508.9 mm, and from 1093.3 mm to 914.9 mm in the experimental group (pof
Daily Living; MCID: minimal clinically important difference; OKCE: open kinetic chain exercise;
ROM: range of motion; TKA: total knee arthroplasty; TUG: timed up-and-go; WOMAC: The Western
Ontario and McMaster Universities Osteoarthritis Index.
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	Introduction 
	Materials and Methods 
	Participants 
	Ethical Statement 
	Study Design 
	Study Procedure 
	Intervention 
	Combined Kinetic Chain Exercise Program 
	Open Kinetic Chain Exercise Program 
	Outcome Measurements 
	Physical Function 
	Balance 
	Gait 
	Statistical Analysis 
	Results 
	Primary Outcomes 
	Secondary Outcome 
	Discussion 
	Effects of Physical Function 
	Effects of Balance 
	Effects of Gait 
	Conclusions 
	References