What is the recommended approach for quadriceps muscle contraction after a below-knee amputation (BKA)?

Quadriceps Muscle Rehabilitation After Below-Knee Amputation

Isometric quadriceps exercises should begin in the first postoperative week for reactivating the quadriceps muscles when they provoke no pain, followed by progressive concentric and eccentric strengthening to optimize functional outcomes and prevent complications. 1, 2

Early Rehabilitation Phase (0-2 weeks)

• Immediate mobilization: Begin knee mobilization within the first week to increase range of motion and prevent extension deficit 2
• Isometric quadriceps exercises: Start isometric quadriceps contractions and straight leg raises in the first week if pain-free 1, 2
• Weight bearing: Implement immediate weight bearing as tolerated if a correct gait pattern can be maintained, using crutches initially if needed 1, 2
• Pain management: Apply cryotherapy in the first postoperative week to manage pain and swelling 1, 2
• Neuromuscular electrical stimulation: Consider adding electrostimulation to isometric strength training for re-educating voluntary contraction of the quadriceps muscles 1, 2

Intermediate Rehabilitation Phase (2-4 weeks)

• Closed kinetic chain (CKC) exercises: Begin CKC exercises from week 2 (e.g., partial weight-bearing squats, step-ups) 1, 2
• Progressive strengthening: When quadriceps is reactivated, transition from isometric to concentric and eccentric exercises, provided there is no pain, effusion or increase in temperature 1
• Neuromuscular training: Add neuromuscular training to strength training to optimize outcomes and prevent complications 1, 2
• Range of motion: Focus on achieving full extension and progressive flexion 2

Advanced Rehabilitation Phase (4+ weeks)

• Open kinetic chain (OKC) exercises: Start OKC exercises from week 4 in a restricted ROM of 90°-45° 1, 2
• Progressive ROM: Gradually increase ROM in OKC exercises: 90°-30° in week 5,90°-20° in week 6,90°-10° in week 7, and full ROM in week 8 1
• Eccentric training: Implement eccentric training for greater strength gains and muscle hypertrophy 1
• Functional progression: Progress to functional activities based on individual response and quality of movement 2

Special Considerations for Below-Knee Amputees

• Preventing muscle atrophy: Quadriceps strength in below-knee amputees decreases significantly (up to 25%) during the first years after amputation, with greater atrophy on the medial side 3, 4
• Hamstring function: Hamstrings replace the triceps as the main muscles for propulsion in below-knee amputees, so balanced strengthening is essential 4
• Energy expenditure: Below-knee amputees have higher energy expenditure for walking, requiring specific training for optimal balance control 4
• Prosthetic considerations: Stump muscles must contract to ensure a good fit with the prosthesis, which should be addressed in rehabilitation 4

Monitoring and Progression

• Quality of movement: Pay attention to correct quality of movement during all exercises 1, 2
• Pain monitoring: Progress exercises only if they do not provoke pain, effusion, or increase in temperature 1
• Functional assessment: Use objective measures to evaluate progress, including strength testing and functional activities 2
• Long-term maintenance: Encourage self-strengthening exercises for the thigh muscles of the amputated limb to maintain function 3

Common Pitfalls to Avoid

• Delaying mobilization: Can lead to extension deficit and other complications 2
• Neglecting quadriceps strengthening: Results in significant negative consequences for long-term outcomes 2
• Focusing only on strength: Without neuromuscular control can lead to poor movement patterns 2
• Using time alone for progression: Should incorporate functional criteria and quality of movement 2
• Ignoring psychological factors: Fear and other psychological factors can impact rehabilitation outcomes 2

This rehabilitation protocol emphasizes early, progressive quadriceps strengthening combined with neuromuscular training to optimize functional outcomes for patients with below-knee amputations, addressing the specific muscular changes and functional adaptations required for successful rehabilitation.