PT
Classroom -
The Initial Investigation of the Church Pew Exercise
(CPE) to Facilitate Quadriceps Function Following Total Knee
Arthroplasty
׀ by John O'Halloran
DPT, OCS, ATC, CSCS, Cert MDT
Dr. John W. O'Halloran, DPT, PT, OCS, ATC, CSCS,
cert MDT, is a licensed Physical Therapist and Athletic Trainer with over 24
years of experience in the field of rehabilitation. He is a board certified
orthopaedic clinical specialist by the American Physical Therapy Association. He
earned his post-professional Doctor of Physical Therapy from Temple University.
Currently, Dr. O'Halloran is a director of physical therapy/sports medicine at
Southeastern Orthopedics in Greensboro, North Carolina, co-owner of GOSMC
Properties, LLC and owner of O'Halloran Consulting, LLC in Summerfield, North
Carolina. He has also worked in a variety of settings including universities and
hospitals. Dr. O'Halloran is also a former orthopedic instructor at the physical
therapy assistant program at Guilford Technical Community College in Greensboro,
North Carolina. In 1999, he became credentialed with the McKenzie Institute in
the mechanical diagnosis and treatment of the spine. Dr. O'Halloran is also a
certified functional capacity evaluator in the Blankenship Method. His unique
evaluation and treatment skills make him a sought after clinical instructor for
physical therapy and athletic training topics. He has spoken both locally and
internationally on topics such as sports specific rehabilitation of the
shoulder, spine rehabilitation and treatment of foot and ankle injuries. Dr.
O'Halloran has studied orthopedic and sports therapy abroad in Australia and New
Zealand. His post graduate work has included manipulative therapy. His wide
range of clinical experience combined with his extensive knowledge in the fiscal
management of physical therapy outpatient rehabilitation services make him a
very knowledgeable and skilled instructor.
For a complete listing of upcoming courses for John O’Halloran,
click here.
The Initial Investigation of the Church Pew Exercise (CPE)
to Facilitate Quadriceps Function Following Total Knee Arthroplasty
Introduction
500,000 total knee replacements are performed in the USA
annually (1). Knee replacements are expected to rise to 3
million by 2030 (2). When surveyed total knee replacement
patients rate their satisfaction as very high when the
studied question is inquiring about pain differences pre and
post surgery. In contrast to the self reported outcomes,
functional performances measures, such as the timed
stair-climbing or walking test, depict only modest
improvements following TKA (3). Total knee arthroplasty
reduces pain and improves health-related quality of life in
90% of patients (4). However when these same patients are
asked about function they rate their satisfaction very low
one year post knee replacement (5, 6). The goals of total
knee arthroplasty are to decrease pain, improve functional
mobility, such as walking, stair climbing and to promote
return to physical activity. It is well established that TKA
reduces pain post surgery however 30% of patients report
dissatisfaction in their physical abilities 1 year following
the surgery (5). Statistically one year after post-op TKA
patients walk 18% slower and climb stairs 51% slower and
have quadriceps deficits of nearly 40% than their age
matched non total knee counterparts (6, 7). Approximately
75% of TKA patients report difficulty negotiating stairs
(6). Another staggering statistic is that 24% of total knee
patients fall in the first year (8). In 2000 Lingard
reported that only 26% of TKA patients are referred to
outpatient rehabilitation following total knee arthroplasty
(9). Based on the above mentioned information it is
imperative that today’s rehabilitation programs for TKA
needs to be critically examined and a new thinking process
be implemented . Failure to do so can definitely impede the
ability of the TKA patient’s long term functional abilities.
Quadriceps Function
Individuals with knee osteoarthritis prior to undergoing a
traditional Total Knee Arthroplasty on average have a 20%
quadriceps deficit (10). It has been reported that at one
year that deficit is 40% despite standard rehabilitation
programs (7, 11). Investigators have linked the decline in
walking speed, stair climbing ability and falls to the
persistent quadriceps deficit (7). Researchers who have
incorporated neuromuscular electrical stimulation into the
post –operative rehabilitation to augment traditional
strengthening exercises found that patients who had the NMES
walked and performed stairs faster and had less torque
deficits than those patients who did not incorporate NMES
into the rehabilitation program (12, 13, 14).
So, what is it about the NMES? To answer this we must first
review some basic electrical stimulation modality principles
as well as the effects post operative effusions can have on
quadriceps inhibition. NMES selectively recruits fast twitch
type II muscle fibers before slow twitch type I fibers. Type
II fibers are the first to atrophy following disuse
immobilization. So can we speculate that the selective fiber
recruitment of the NMES provides the necessary neural drive
to the quadriceps muscle thus reducing the inhibitory
effects of disuse immobilization following TKA surgery? Can
we also clinically reason that post operative NMES delivered
to the quadriceps has a muscle pumping effect thus reducing
effusion?
All my life I have been curious about how things worked and
what were the common denominators to successful methods. My
question was now is how can I implement this information to
enhance my clinical outcome if I do not have a NMES unit? I
do not want to deprive my patient of this evidence.
Therefore we must create an alternative therapeutic
approach. That approach is the neuromuscular exercise I
developed. The exercise is the CHURCH PEW EXERCISE (CPE).
When you watch our patient walk I really would like for you
to focus on his stride length pre and post CHURCH PEW
EXERCISE and his walking speed.
Press Play to Begin
Joint Replacement Quadriceps Facilitation Exercise-"The
Church Pew": it has been documented in the literature
that prior to a knee replacement surgery the patient can
have at least a 20% quadricep deficit. This deficit persists
following a total knee replacement. Traditional knee
replacement exercises do not specifically address the neural
inhibition that occurs in the quadricep muscle. The
persistent inhibition of the quadricep muscle affects a
total knee replacement patient’s walking and stair climbing
abilities. The "church pew" exercise facilitates the
quadricep by causing an involuntary muscle contraction, just
the way the quadricep muscle functions during the gait
cycle. Traditional quadricep exercises are volitional
contractions and thus do not stimulate the muscle
functionally. The "church pew" exercise is a great way to
get that neurological-re-education and augment the
traditional exercises. The church pew exercise is for
neuromuscular re-education of the quadricep and augments all
the other traditional quadricep exercises. I recommend that
you assess your patients gait before and after the exercise
and document the change in stance time, speed and the
patients subjective comments post exercise.
Church Pew Exercise (CPE)
Following my investigation of the quadriceps deficit that
occurs following total knee arthroplasty and the review of
the literature of implementing NMES, I decided to explore
where exactly does the TKA patients gait deviate. I studied
many hours of TKA patients gait and concluded that those
patients that had a gait deviation in stance phase resulted
in a two to five inch excursion at initial contact to mid
stance. Patients either had a genu recurvatum or a flexion
moment type gait upon initial contact to weight acceptance
.Another interesting finding was that the patients I studied
all had a different ankle strategy than non TKA patients.
The TKA patients consistently had a more rigid ankle from
initial contact through stance phase. The patients I looked
at were on average 6-9 weeks post and was either ambulating
with a cane or no assistive device. The ankle was stiff and
they would strike, deviate into recurvatum or slight flexion
buckle. All of the patients that I studied had full
extension passively and at least good quadriceps strength
with manual muscle testing. My objective was to create an
exercise that promoted an involuntary quadriceps contraction
at the specific functional position that total knee patients
gait deviates. So over a course of two months I experimented
with various methods of implementing the CHURCH PEW
EXERCISE. I had patients perform the exercise for 30
seconds, 60 seconds, and 90 seconds and there was no change
in their gait speed or stair climbing speed. However when
they tried it for two minutes there was a change so I tried
three minutes and found it to be no more effective than two
so I settled on two minutes. I then proceeded to study the
church pew and compare it to patients who did not perform
the exercise. Listed below are my initial investigation
findings. The most striking finding was that during the sway
(lowering) phase of the exercise both the quadriceps and
hamstrings are working virtually in a co-contraction manner.
I then randomly assigned patients to two groups post TKA.
Both groups had patients who were at least 3 weeks post TKA
and not more than 7 weeks. The patients were from various
orthopedic surgeons in Greensboro, North Carolina. They all
underwent the traditional surgical approach. All patients
went through the same rehabilitation regimen and kinetic
activities however the 22 patients in the investigational
group performed the CHURCH PEW EXERCISE for 2 minutes 4
times per day for 3 weeks. My investigation wanted to look
at whether patients who performed the CHURCH PEW EXERCISE
would have faster walking and stair climbing times. My
outcome measurements were the Ten Meter Walk Test –TMWT and
the 12 Step Stair Test.
Initial Investigation – EMG Findings of the Church
Pew Exercise
Results
·
Sample of 22 patients-TKA
·
Age 58-83, 14 females 8 males
·
Acute increases of 17% for TMWT(Ten Meter Walk Test) and
18% improvement in 12 Step Stair Test
Conclusion
When observing this very initial evidence it appears that
the church pew exercise might be more relevant to improve
activation of the quadriceps during weight acceptance
So the question we should be asking ourselves was how could
a simple exercise like the CHURCH PEW EXERCISE acutely
improve TKA patients walking speed and stair climbing
abilities? I would like to discuss a couple of thoughts I
have. First of all the CHURCH PEW EXECISE facilitates an
involuntary quadriceps contraction at the specific angle of
motion that the lower extremity goes through during gait.
This result in a neural drive to the kinetic chain that does
not exist with any of the standard therapeutic and kinetic
activities performed during TKA rehab. I believe that
triggering this neuromuscular drive enhances the
effectiveness of the traditional hypertrophy exercises
clinicians use to strengthen patients and improve gait
following total knee arthroplasty. I also strongly feel that
the CHURCH PEW EXECISE facilitates ankle mobility that is
often lacking following TKA. As stated previously TKA
patients tend to hold their ankle in a rigid position at
initial contact through push off. This results in the
inability of the kinetic chain to properly go through the
necessary supination at initial contact, pronation at mid
stance and re-supination at push off. If the ankle joint is
held rigid, the sequence of the gait cycle is obviously
compromised. The CHURCH PEW EXERCISE allows the natural
femoral and tibia rotational movements during gait creating
the necessary stride length , cadence and proprioception.
My findings also are in agreement with the Blade et al
article that stressed that more progressive rehabilitation
programs need to be performed following total knee
arthroplasty (15). Today knee arthroplasty is being performed
with advanced surgical techniques such as computer –assisted
guidance and minimally invasive approaches therefore it is
imperative that the rehabilitation clinician augments these
advances with corrective therapeutic exercises and
activities that facilitate functional outcomes far superior
than what has been reported in the literature to date.
Last revised: December 9, 2010
by John O'Halloran DPT, OCS, ATC, CSCS, Cert MDT
References
1. American Academy of Orthopaedic Surgeons. Surgical Treatments. May 2010
2. Kurtz , Ong K, Lau E, Mowat F, Halpren M. Projections of primary and
revision hip and knee arthroplasty in the United States for 2005-2030. J
Bone Joint Surg Am. 2007;89:780-785
3. Mizner RL,Snyder-Mackler L. Patients perceptions do not match functional
performance or clinical presentation after total knee arthroplasty . 10th
World Congress on Osteoarthritis. Praque, Czech Republic: 2006
4. National Institutes of Health. NIH Consensus Statement on total knee
replacement. NIH Consens State Sci Statements. 2003; 20:1-34.
5. Dickstein R, Heffes Y, Shabtai EI, Markowitz E. Total Knee Arthroplasty
in the elderly patients self-appraised 6 and 12 months postoperatively.
Gerontology. 1998; 44:204-210.
6. Noble PC, Gordon MJ. Weiss JM, Reddix RN, Conditt MA, Mathis, KB. Does
total knee replacement restore normal knee function? Clin Orthop Relat Res.
2005:157-165
7. Walsh M, Woodhouse LJ, Thomas SG, Finch E. Physical impairments and
functional limitations: a comparison of individuals 1 year after total knee
arthroplasty with control subjects. Phys Ther.1998; 78:248-258.
8. Swinkles A, Newman JH, Allain TJ. A prospective observational study of
falling before and after knee replacement surgery. Age Ageing. 2009;
38:175-181.
9. Lingard EA, Berven S, Katz JN. Management and care of patients undergoing
total knee arthroplasty: variations across different health care settings.
Arthritis Care Res. 2000; 13:19-136.
10. Slemanda C, Brandt KD, Heilman DK, et al. Quadriceps weakness and
osteoarthritis of the knee. Ann Intern Med. 1997; 127:97-104.
11. Mizner RL, Petterson SC, Snyder-Mackler L. Quadriceps strength and the
time course of functional recovery after total knee
arthroplasty.JOSPT.2005;35:424-436.
12. Avramidis K, Strike PW, Taylor PN, Swain ID. Effectiveness of electrical
stimulation of the vastus medialis muscle in the rehabilitation of patients
after total knee arthroplasty . Arch Phys Med Rehabil. 2003; 84:1850-1853.
13. Mintken PE, Carpenter KJ,Eckhoff D,Kohrt WM, Stevens JE. Early
neuromuscular electrical stimulation to optimize quadriceps muscle function
following total knee arthroplasty: a case report. JOSPT. 2007; 37:364-371.
14. Stevens JE, Mizner RL, Snyder-Mackler L. Neuromuscular electrical
stimulation for quadriceps muscle strengthening after bilateral total knee
arthroplasty: a case report. JOSPT. 2004; 34:21-29.
15. Bade MJ, Kohrt WM, and Stevens-Lapsley JE. Outcomes Before And After
Total Knee Arthroplasty Compared to Healthy Adults. JOSPT.2010; 40:9
559-567.
Please review our terms and conditions
carefully before utilization of the Site. The information on this Site is for
informational purposes only and should in no way replace a conventional visit to
an actual live physical therapist or other healthcare professional. It is
recommended that you seek professional and medical advise from your physical
therapist or physician prior to any form of self treatment.
Copyright 2005-2022 CyberPT Inc. All rights reserved.