Church Pew Exercise Integrated With Conventional Physical Therapy Following Total Knee Arthroplasty (TKA): Case Report

Abstract

Background and Purpose: Physical therapy treatment following Total knee Arthroplasty (TKA) consists of a combination of strengthening and range of motion exercises. The exercise technique, church pew exercise (CPE), has been proposed to enhance quadriceps facilitation and improve function. This is a technique that has the patient standing and rocking forward/back. The backward motion is arrested by engagement of the upper calf against a solid object, creating a sudden flexion torque at the knee and a sudden extension torque at the hip. The combination of CPE with standard physical therapy is claimed to provide better quadriceps control and faster walking post TKA. In this case study, a 51-year-old female with decreased knee active and passive range of motion (ROM), decreased lower extremity (LE) muscle strength, and limited ambulation post left knee TKA, received conventional physical therapy treatment plus CPE. Methods: The patient received 11 physical therapy home sessions. The first 8 sessions were used to strengthen her knee and increase active and passive ROM. The CPE intervention was performed 3 weeks post-surgery, during the last 3 physical therapy sessions. At these three sessions the patient performed the Timed Up and Go (TUG) before and after CPE. Outcomes: At initial evaluation, 4 days post left knee TKA, this patient’s left knee active ROM was only 15 to 76 degrees, and manual muscle testing at her hip and knee indicated strengths of 2- (hip flexors), 3- (hamstrings and quadriceps), and 3+ (hip abductors), all out of 5, and her times on two trials of the TUG were 30.31 and 30.65 sec, indicating impaired functional ability. At all CPE sessions (3 weeks post-surgery) the patient demonstrated increased gait speeds (i.e. shorter times) on the TUG after the CPE (pre CPE mean = 13.2 sec; post CPE mean = 11.2), increased stance time on her affected lower extremity, and increased step length on her contra-lateral lower extremity. The patient reported increased knee stability. Clinical Relevance: Rationale for CPE is based on neurological facilitation of quadriceps and other lower extremity muscles. However, to engage in this exercise the patient must have the ability to balance and to control the hip and knee joints. This patient required several weeks of strengthening and active and passive ROM exercises before she could perform the CPE. Once able to perform the CPE, she demonstrated improvements in her walking ability, and she expressed greater confidence. Conclusion: Provided a minimal level of strength and active and passive ROM has been attained, CPE may be a valuable short-term supplement to current strengthening regimens addressing quadriceps functional deficits following TKA. Other conditions that involve gait problems related to quadriceps insufficiency might also benefit. The long-term efficacy of CPE remains to be determined.