Variations in knee range of motion during repeat knee extension with an amputated lower leg at different contraction rhythms over 8 consecutive days in a patient with severe diabetic neuropathy: A clinical study

1,2*Takuya Osada, 1Masahiro Ishiyama, 1Ryuichi Ueno

1Rehabilitation Center, Tokyo Medical University Hospital, Tokyo, Japan
2Cardiac Rehabilitation Center, Tokyo Medical University Hospital, Tokyo, Japan

Background: This clinical study sought to understand the knee range of motion (KROM) in an amputated stump during repeat voluntary knee extension with or without a 0.5 kg weight in the acute/early phase after amputation can vary between different target knee extension rhythm frequency (KER) levels in the amputated lower leg of a patient with severe diabetic sensory disorder and leg ischemia.

Case Presentation: A 51-year-old male patient with severe diabetic neuropathy had a right lower leg amputation due to necrosis and ulcer lesion following a burn injury to the first toes and severe ischemic peripheral vascular disease. In a sitting position with the base of the foot of the non-amputated left leg on the ground, he performed repeat knee extension of the resected stump (knee active extension and passive flexion without a target KROM) for 1 min with both self-controlled free KER and different target KERs (30, 40, 50, 60, and 80 contractions per minute [cpm] using a metronome), with or without a 0.5 kg weight placed on the resected stump over 8 consecutive days. The KROM was measured using a goniometer placed between the resected stump and the thigh muscle with a continuous data acquisition system. The mean values achieved for KER, KROM, and angle rate during a 1 min session was determined during each daily session, and consecutively average values over sessions on 8 consecutive days was also evaluated. The achieved mean KER at all target KERs corresponded closely with the target KER. The average KROM was approximately 60 degrees over a range of targets between 30 and 60 cpm, but the value was lower at approximately 50 degrees at 80 cpm. The angle rate increased consistently with the increase from a target of 30 to 60 cpm, but it was reduced at 80 cpm. The mean KROM was inversely related (r=-0.390, P<0.01, n=40) to the mean KER without the weight, but not significantly (r=-0.256, P=ns, n=40) with the 0.5 kg weight. The achieved KER in the self-controlled free trial with or without the 0.5 kg weight might increase with an increase in sessions over 8 days with a range between approximately 30 and 60 cpm.

Conclusion: The present case study showed that a higher contraction frequency may limit KROM determined below 60 cpm because of the reduced angle rate in an amputated lower leg. A low and moderate KER below 60 cpm may be appropriate to maintain KROM with a stable angle rate. Furthermore, voluntary KER with free self-controlled rhythm may increase over the course of multiple sessions as familiarity improves with kicking the amputated limb and generating a potential improvement in performance/ability effect with consecutive leg exercise with no use of a prothesis such as in the early/acute phase post-amputation using audible biofeedback.

Keywords: Knee extension rhythm (frequency), below knee amputation, knee joint range of motion, diabetic sensory disorder

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Takuya Osada, Masahiro Ishiyama, Ryuichi Ueno. Variations in knee range of motion during repeat knee extension with an amputated lower leg at different contraction rhythms over 8 consecutive days in a patient with severe diabetic neuropathy: A clinical study. International Journal of Sports Medicine and Rehabilitation, 2021; 4:23. DOI: 10.28933/ijsmr-2021-11-1305


1. Nesti L, Pugliese NR, Sciuto P, Natali A. Type 2 diabetes and reduced exercise tolerance: a review of the literature through an integrated physiology approach. Cardiovascular Diabetology, 2020, 19: 134.
2. Narres M, Kvitkina T, Claessen H, Droste S, Schuster B, Morbach S, Ru¨menapf G, Van Acker K, Icks A. Incidence of lower extremity amputations in the diabetic compared with the non-diabetic population: A systematic review. PLoS One, 2017, 12: e0182081.
3. Ohmine S, Kimura Y, Saeki S, Hachisuka K. Community-based survey of amputation derived from the physically disabled person’s certification in Kitakyushu City, Japan. Prosthetics and Orthotics International, 2012, 36: 196-202.
4. Ghazali MF, Abd Razak NA, Abu Osman NA, Gholizadeh H. Awareness, potential factors, and post-amputation care of stump flexion contractures among transtibial amputees. Turkish Journal of Physical Medicine and Rehabilitation, 2018, 64: 268-276.
5. Broomhead P, Clark K, Dawes D, Hale C, Lambert A, Quinlivan D, Randell T, Shepherd R, Withpetersen J. Evidence based clinical guidelines for the managements of adults with lower limb prostheses, 2nd Edition. Chartered Society of Physiotherapy: London. 2012.
6. Hermodsson Y, Ekdahl C, Persson BM, Roxendal G. Gait in male trans-tibial amputees: a comparative study with healthy subjects in relation to walking speed. Prosthetics and Orthotics International, 1994, 18: 68-77.
7. Pedrinelli A, Saito M, Coelho RF, Fontes RBV, Guarniero R. Comparative study of the strength of the flexor and extensor muscles of the knee through isokinetic evaluation in normal subjects and patients subjected to trans-tibial amputation. Prosthetics and Orthotics International, 2002, 26: 195-205.
8. Tugcu I, Safaz I, Yilmaz B. Göktepe AS, Taskaynatan MA, Yazicioglu K. Muscle strength and bone mineral density in mine victims with transtibial amputation. Prosthetics and Orthotics International, 2009, 33: 299-306.
9. Moirenfeld I, Ayalon M, Ben-Sira D, Isakov E. Isokinetic strength and endurance of the knee extensors and flexors in trans-tibial amputees. Prosthetics and Orthotics International, 2000, 24: 221-225.
10. Orekhov G, Robinson AM, Hazelwood SJ, Klisch SM. Knee joint biomechanics in transtibial amputees in gait, cycling, and elliptical training. PLoS One, 2019, 14: e0226060.
11. Osada T, Ishiyama M, Ueno R. Time-course of thigh muscle contraction-induced blood flow magnitude in amputated lower limb with prosthesis during dynamic knee extensions: A case study. Physical Therapy and Rehabilitation, 2018, 5: 21.
12. Osada T, Ishiyama M, Ueno R. Voluntary thigh muscle strength with resection stump-dependent blood flow and vasodilation in an amputated lower leg with total surface bearing prosthesis during dynamic knee extensor: A case trial. Open Journal of Therapy and Rehabilitation, 2019, 7: 151-169.
13. Osada T, Katsumura T, Hamaoka T, Inoue S, Esaki K, Sakamoto A, Murase N, Kajiyama J, Shimomitsu T, Iwane H. Reduced blood flow in abdominal viscera measured by Doppler ultrasound during one-legged knee extension. Journal of Applied Physiology, 1999, 86: 709-719.
14. Osada T, Rådegran G. Femoral artery inflow in relation to external and total work rate at different knee extensor contraction rates. Journal of Applied Physiology, 2002, 92: 1325-1330.
15. Osada T. Muscle contraction-induced limb blood flow variability during dynamic knee extensor. Medicine & Science in Sports & Exercise, 2004, 36: 1149-1158.
16. Osada T, Rådegran G. Alterations in the rheological flow profile in conduit femoral artery during rhythmic thigh muscle contractions in humans. Japanese Journal of Physiology, 2005, 55: 19-28.
17. Osada T, Rådegran G. Differences in exercising limb blood flow variability between cardiac and muscle contraction cycle related analysis during dynamic knee extensor. Journal of Sports Medicine and Physical Fitness, 2006, 46: 590-597.
18. Osada T, Rådegran G. Alterations in the blood velocity profile influence the blood flow response during muscle contractions and relaxations. Journal of Physiological Science, 2006, 56: 195-203.
19. Osada T, Rådegran G. Femoral artery blood flow and its relationship to spontaneous fluctuations in rhythmic thigh muscle workload. Clinical Physiology and Functional Imaging, 2009, 29: 277-292.
20. Osada T, Rådegran G. Difference in muscle blood flow fluctuations between dynamic and static thigh muscle contractions: How to evaluate exercise blood flow by Doppler ultrasound. Physical Medicine and Rehabilitation Research, 2016, 1: DOI: 10.15761/PMRR.1000128
21. Broomhead P, Dawes D, Clinical guidelines for the pre and post operative physiotherapy management of adults with lower limb amputation. Chartered Society of Physioherapy, London.
22. Salsich GB, Mueller MJ. Relationships between measures of function, strength and walking speed in patients with diabetes and transmetatarsal amputation. Clinical Rehabilitation, 1997, 11: 60-67.
23. Kosasih JB, Silver-Thorn MB. Sensory changes in adults with unilateral transtibial amputation. Journal of Rehabilitation Research and Development, 1998; 35: 85-90.
24. Armstrong DG, Lavery LA. Plantar pressures are higher in diabetic patients following partial foot amputation. Ostomy Wound Manage 1998; 44: 30-32.
25. Lieber RL. Skeletal muscle structure and function: Implications for rehabilitation and sports medicine, Williams & Wilkins, Baltimore. 1992.

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