Early Neuromuscular Electrical Stimulation to Improve Quadriceps Muscle Strength After Total Knee Arthroplasty: A Randomized Controlled Trial

Background. The recovery of quadriceps muscle force and function after total knee arthroplasty (TKA) is suboptimal, which predisposes patients to disability with increasing age. Objective. The purpose of this investigation was to evaluate the efficacy of quadriceps muscle neuromuscular electrical stimulation (NMES), initiated 48 hours after TKA, as an adjunct to standard rehabilitation. Design. This was a prospective, longitudinal randomized controlled trial. Methods. Sixty-six patients, aged 50 to 85 years and planning a primary unilateral TKA, were randomly assigned to receive either standard rehabilitation (control) or standard rehabilitation plus NMES applied to the quadriceps muscle (initiated 48 hours after surgery). The NMES was applied twice per day at the maximum tolerable intensity for 15 contractions. Data for muscle strength, functional performance, and self-report measures were obtained before surgery and 3.5, 6.5, 13, 26, and 52 weeks after TKA. Results. At 3.5 weeks after TKA, significant improvements with NMES were found for quadriceps and hamstring muscle strength, functional performance, and knee extension active range of motion. At 52 weeks, the differences between groups were attenuated, but improvements with NMES were still significant for quadriceps and hamstring muscle strength, functional performance, and some self-report measures. Limitations. Treatment volume was not matched for both study arms; NMES was added to the standard of care treatment. Furthermore, testers were not blinded during testing, but used standardized scripts to avoid bias. Finally, some patients reached the maximum stimulator output during at least one treatment session and may have tolerated more stimulation. Conclusions. The early addition of NMES effectively attenuated loss of quadriceps muscle strength and improved functional performance following TKA. The effects were most pronounced and clinically meaningful within the first month after surgery, but persisted through 1 year after surgery.