Evidence-based practice (EBP) Yoga asanas have been shown to improve pain, function, and mobility for rehabilitating knee patients compared to conven- tional physical therapy interventions. A 2018 study by Patel et al. examined the effectiveness of yoga asanas over conventional physical therapy interventions in patients with knee OA. The yoga program consisted of the following yoga asanas performed a total of 3 sets of 10 repetitions: mountain pose, tree pose, chair pose, wind-removing pose, warrior i pose, head-to-knee pose, and triangle pose. Participants allocated to the yoga group achieved a greater improvement in pain (VAS), functional- ity (WOMAC), and mobility (30-Second Chair Stand Test) after four weeks compared to those who performed conventional physical therapy exercises (Patel, 2018). Another 2018 study looked at the effects of a biomechanically based yoga exercise program in patients with knee OA. The yoga program consisted of alignment-based postures that activate the lower limb musculature while maintaining a low knee adduction moment, including chair pose, warrior i pose, warrior ii pose, triangle pose, and bridge pose. The yoga-based exercise program produced clinically meaningful improvements in pain, self-reported physical function, and mobility in patients with clinical knee OA compared to a traditional exercise- based program (Kuntz, 2018). Only one study exists in the literature on the effects of additional yoga therapy on conservative physical therapy man- agement of total knee replacement. The additional yoga asanas performed after TKA included corpse pose, mountain pose, seated forward bend, wind-relieving pose, bound angle pose, half locust pose, warrior i pose, and chair pose. The study con- cluded that a combination of physical therapy and yoga asana protocol is more effective at improving functional outcomes than physical therapy protocol alone (Bedekar et al., 2012).
Case study According to a 2014 case study by Ebnezar et al., yoga therapy has been shown to be "a scientifically proven effective treatment for OA knees" (Ebnezar, 2014). The following case examined the role of yoga therapy on a patient after a failed postoperative bi- lateral total knee replacement. History A 52-year-old female patient presented with severely limited mo- bility and pain after undergoing total knee arthroplasty for severe OA of both knees in July 2012. Three months postoperatively the patient was unable to walk and was dependent on a wheelchair for mobility. She was unable to walk, stand, climb, or do any ac- tivities with her lower limbs. Prior to surgery she was able to walk and do her day-to-day activities with pain. When the patient went back to the surgeon seeking remedy, she was told that in order to walk again, she needed to undergo bilateral hip replacement. The patient expressed an unwillingness to undergo the surgery due to her previous unfavorable experience, extreme financial burden, and reluctance to have four artificial joints in her body. On request for any alternative method of treatment, the surgeon categori- cally said nothing could be done, which is when the patient ap- proached the researcher for treatment. Medical history In 2009, the patient underwent a diagnostic arthroscopy for pain in both knees. During the diagnostic arthroscopy she was diag- nosed with left medial meniscus tear with synovitis. Medial men- iscectomy, synovectomy, and chondroplasty were performed. The patient was diagnosed with diabetes and hypertension and was treated for these ailments. X-ray reports suggested that the pa- tient had OA of the knees, hips, and lumbar spine. Exam findings The patient was wheelchair dependent. Her knee pain as per the Numerical Pain Analog scale was 9/10 bilaterally. She had 86% disability as per the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), a questionnaire widely used as an
outcome measure to evaluate symptoms and physical disability in patients with hip and knee osteoarthritis. Higher scores on the in- dex are associated with perceived “extreme” difficulty with many activities of daily living, including walking, standing, sitting, stand- ing from sitting, dressing, bathing, and using stairs. Hip range of motion was severely restricted: 5° right and 10° left flexion, 10° abduction, 5° adduction, 5° extension, nil external rotation and internal rotation. Her walking time was 2 minutes 20 seconds (sup- ported) for 50 meters. She completed 30 days of integrated physical therapy consisting of ultrasound, interferential therapy, moist heat, and yoga therapy practices. Data was collected after the 10th day, 20th day, and 30th day. Treatment: ● 10 min transcutaneous electrical nerve stimulation (TENS). ● 10 min therapeutic ultrasound. ● 10 min sithilikarana vyayama (loosening exercises). ● 10 min yoga asanas: mountain pose, lateral arc pose, half wheel pose, wide-legged forward bend, cobra pose, locust pose. ● 10 min pranayama (deep breathing exercises). Results The patient improved steadily in all the clinical parameters, in- cluding hip range of motion and WOMAC disability score (42%), and her pain decreased from 9/10 to 2/10 by the end of the four weeks. The patient was less dependent on the wheelchair and graduated to walking with support on both sides by the third day, one side support by the seventh day, and walking without support by the tenth day. She expressed satisfaction at the outcome of the treatment, as she had progressed from wheelchair to indepen- dent walking after being told she had no other alternative. For this patient who had undergone bilateral TKA, had multiple joint problems and comorbidities, and was severely debilitated, yoga therapy facilitated a recovery.
YOGA POSES
Based on the clinical practice guidelines, consensus exists on the need to perform (1) knee range of motion, (2) high-intensity strengthening, and (3) balance training following a TKA. Listed
below are yoga poses that have been clinically shown to meet each of these clinical practice guidelines.
POSES FOR RANGE OF MOTION
ditional yoga therapy on conservative management of total knee replacement, a handful of poses were safely performed in the im - mediate postoperative recovery period. Corpse pose and seated forward bend pose, poses that promote full knee extension, were performed within seven days of surgery. Wind-relieving pose and bound angle pose, poses that promote knee flexion, were added at one week. Another study that included corpse pose and seated
Postoperative knee range of motion is critical to success after knee replacement. As a general rule, a minimum knee flexion of around 105° to 110° is required for daily living, and about 125° will allow the individual to carry out most normal activities. Knee extension range of motion of 0° to 5° is required for normal gait. Limitations in ROM after TKA could lead to revision surgery or lifelong issues. In the Bedekar et al. (2012) study examining ad-
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