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Knee Replacement Rehab: Activating Quadriceps with NMES and the Church Pew Exercise

By John O'Halloran, PT, DPT, OCS, ATC, CSCS, Cert. MDT

on February 17, 2016

Categories: Geriatrics, Geriatrics, Occupational Therapy, Orthopedics, Physical Therapy

Individuals with knee osteoarthritis prior to undergoing a traditional Total Knee Arthroplasty (TKA) on average have a 20% quadriceps deficit.¹ It has been reported that at one year this deficit is 40% despite standard rehabilitation programs.^{2, 3} Investigators have linked the decline in walking speed, stair climbing ability, and falls to the persistent quadriceps deficit.²

NMES improves the quadriceps deficit

Researchers who have incorporated neuromuscular electrical stimulation (NMES) into the post-operative rehabilitation to augment traditional strengthening exercises found that patients who received the NMES walked and performed stairs faster and had less torque deficits than those patients who did not incorporate NMES into the rehabilitation program.^4-6

So, what is it about the NMES? To answer this question, we must first review two aspects:

Basic electrical stimulation modality principles
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, we can speculate that NMES provides the necessary neural drive to the quadriceps muscle, reducing the inhibitory effects of disuse immobilization.
The effects of post-operative effusions on quadriceps inhibition
We can also clinically reason that post-operative NMES delivered to the quadriceps has a muscle pumping effect that reduces effusion.

What if you don’t have a NMES unit?

All my life I have been curious about how things worked and what were the common denominators to successful methods. My question now was, how can I implement this information to enhance my clinical outcomes if I do not have a NMES unit? I didn’t want to deprive my patient of this evidence, so I developed an alternative therapeutic approach – the neuromuscular exercise Church Pew Exercise (CPE).

Below, watch a case study of the Church Pew Exercise in a short video from my course, Knee Arthroplasty: Increasing Range of Motion. When you watch our patient walk, I’d really like for you to focus on his stride length and walking speed before and after the exercise.

John O'Halloran, PT, DPT, OCS, ATC, CSCS, Cert. MDT

Dr. John W. O’Halloran, PT, DPT, OCS, ATC (retired), CSCS (retired), cert MDT, is an American Physical Therapy Association board-certified orthopedic clinical specialist with over 30 years of experience in the field of orthopedics. He earned his post-professional Doctor of Physical Therapy from Temple University and has studied orthopedic and sports therapy abroad in Australia and New Zealand. Dr. O’Halloran is the sole owner of O’Halloran Rehabilitation, a division of O’Halloran Consulting, LLC.

John is credentialed with the McKenzie Institute in the mechanical diagnosis and treatment of the spine and has extensive post-graduate training in manipulative therapy of the spine and extremities. He is a certified SCTM-1 Practitioner and has certificates in SMT-1, SMT-2, and SMT-3 with the American Spinal Manipulative Institute. Dr. O’Halloran is also a certified functional capacity evaluator in the Blankenship Method. He has presented over 1,300 times both locally and internationally on various orthopedic and geriatric orthopedic topics. In 2014, John was the recipient of Clinician of the Year and Excellence in Clinical Practice Award by the North Carolina Physical Therapy Association. Recently, Dr. O’Halloran’s investigational work on the earlier facilitation of gait in the total knee arthroplasty patient has been cited in peer-reviewed journal publication.

References:

Slemanda C, Brandt KD, Heilman DK, et al. Quadriceps weakness and osteoarthritis of the knee. Ann Intern Med. 1997; 127:97-104.
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.
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.
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.
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.
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.