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 bilateral total knee replacement. History A 52-year-old female patient presented with severely limited mobility 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 activities 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 categorically said nothing could be done, which is when the patient approached 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 diagnosed with left medial meniscus tear with synovitis. Medial meniscectomy, 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 patient had OA of the knees, hips, and
as an outcome measure to evaluate symptoms and physical disability in patients with hip and knee osteoarthritis. Higher scores on the index are associated with perceived “extreme” difficulty with many activities of daily living, including walking, standing, sitting, standing 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 (supported) 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, including 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 independent 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.
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
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 Poses for range of motion 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 additional yoga therapy on conservative management of total knee replacement, a handful of poses were safely performed in the immediate 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 forward bend pose found clinically relevant improvements in knee range of motion goniometry after one week of yoga intervention in patients with knee osteoarthritis. (Deepeshwar et al., 2018). Using biomechanical analysis, chair pose has been shown to increase knee flexion ROM an average of 12.9° (Polsgrove et al., 2016). Downward dog pose has been shown to increase knee extension ROM by an average of 3.7° (Polsgrove et al., 2016). Triangle pose has been shown to extend the knee over its baseline by an average of 9.5° (Whissell, 2021). Using three-dimensional motion capture, equestrian pose has been shown to have the highest amount of knee flexion, peaking at 109.8° ± 27.3° (Mullerpatan et al.,
below are yoga poses that have been clinically shown to meet each of these clinical practice guidelines.
2019). Based on these findings, it can be clinically supported to incorporate corpse pose, seated forward bend pose, triangle pose, and downward dog pose to improve knee extension range of motion. Wind-relieving pose, bound angle pose, equestrian pose, and chair pose improve knee flexion range of motion. CORPSE POSE (SHAVASANA) Indications: Knee extension range of motion. Instructions: 1. Sit upright with your knees bent and feet flat. 2. Lean backwards and bring your lower arms and elbows down. 3. Slowly extend your legs with your feet apart and toes turned out. 4. Rest your arms beside your body so that the armpits are free and the palms are facing up toward the ceiling; if this is not possible, put your hands on your abdomen. 5. Exhale as you relax your body fully, letting your knees sink into full extension. 6. Stay in this pose for 5–15 minutes. 7. To exit, exhale and gently roll onto one side. With another exhale, use your hands to lift your torso to a seated position. Modifications using props: 1. If unable to tolerate laying completely flat, support the head with a folded blanket or pillow (Wörle et al., 2010).
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