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University of Groningen
Sports and amputationBragaru, Mihail
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Publication date:2013
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Chapter 2
Amputees and Sports: a Systematic Review
Sports Medicine 2011, 41(9); 721-740 M. Bragaru, R. Dekker, J.H.B. Geertzen & P.U. Dijkstra
16 Chapter 2
ABSTRACT
Amputation of a limb may have a negative impact on the psychological and physical well-being, mobility and social life of individuals with limb amputations. Participation in sports and/or regular physical activity has a positive effect on the above mentioned areas in able-bodied individuals. Data concerning participation in sports or regular physical activity together with its benefits and risks for individuals with limb amputations are scarce. No systematic review exists that addresses a wide range of outcomes such as biomechanics, cardiopulmonary function, psychology, sport participation and sport injuries. Therefore, the aim of this article is to systematically review the literature about individuals with limb amputations and sport participation. MEDLINE (PubMed), EMBASE, CINAHL® and SportDiscus® were searched without time or language restrictions using free text words and MeSH terms. The last search date was 31 March 2010. Books, internet sites and references of included papers were checked for papers relevant to the topic under review. Papers were included if the research topic concerned sports and a mini- mum of ten individuals with limb amputations were part of the study population. Papers were excluded if they included individuals with amputations of body parts other than upper or lower limbs or more distal than the wrist or ankle, or if they consisted of case reports, narrative reviews, books, notes or letters to the editor. Title, abstract and full-text assessments were performed by two independent observers following a list of preset criteria. Of the 3689 papers originally identified, 47 were included in the review. Most of the included studies were older than 10 years and had cross-sectional designs. Study participants were generally younger and often had more traumatic amputations than the general population of individuals with limb amputations. Heterogeneity in population characteristics, intervention types and main outcomes made data pooling impossible. In general, sports were associated with a beneficial effect on the cardiopulmonary system, psychological well-being, social reintegration and physical functioning. Younger individuals with unilateral trans-tibial amputations achieve better athletic performance and encounter fewer problems when participating in sports compared with older individuals with bilateral trans-femoral amputations. Regardless of their amputation level, individuals with limb amputations participate in a wide range of recreational activities. The majority of them were not aware of the sport facilities in their area and were not informed about available recreational activities. Sport prosthetic devices were used mostly
Amputees and sports: a systematic review 17
by competitive athletes. For football, the injury rate and pattern of the players with an amputation were similar to those of able-bodied players. Individuals with limb amputations appear to benefit both physically and psychologically from participation in sports and/or regular physical activity. Therefore, sports should be included in rehabilitation programs, and individuals with limb amputations should be encouraged to pursue a physically active life following hospital discharge.
18 Chapter 2
INTRODUCTION
Amputation of a limb may cause permanent disability and decreases mobility temporarily or permanently.[24] Individuals with limb amputations often see themselves as part of a special group that, according to able-bodied people, has special needs and requires additional attention.[25] These perceptions contribute to the relatively high depression and anxiety rates recorded amongst individuals with limb amputations, especially in the first two years after amputation.[26;43;44] Consequently, they will experience difficulties with social participation and in returning to everyday life.
Individuals with limb amputations in general are in poor physical condition not only due to the amputation itself but also because of the illness preceding and leading to the amputation. In the United States, about 82% of all lower and upper limb amputations are due to vascular conditions, whereas 16% of amputations are due to trauma.[45] The remaining 2% of amputations are necessary due to cancer or inflammation or represent congenital birth defects. It has been predicted that the number of individuals with limb amputations will increase as a consequence of the population’s increasing age and increasing incidence of diabetes mellitus and cardiovascular diseases.[41]
In general, participation in sports or physical activities is important in maintaining physical fitness.[5;17] Lack of physical exercise is the most important determinant of a deteriorating physical state, often leading to coronary heart disease.[46] Health organisations recommend 30 minutes or more of moderately vigorous daily physical activity.[47] Because of the amputation and the underlying diseases persisting after amputation, individuals with limb amputations tend to be less active than the able-bodied.[34] Participation in sports and an active lifestyle are assumed to be important for individuals with limb amputations as they enhance psychological well-being, self-confidence and coping behaviour.[48]
Publications focusing on sports participation among individuals with limb amputations are generally characterised by a limited number of participants, anecdotal reports and diverse outcome variables.[49-53] Even though there are a number of reviews[48;54;55] concerning some aspects of the sport participation of individuals with limb amputations, none of them address both upper and lower limb amputations, nor do they offer a full picture of all important variables
Amputees and sports: a systematic review 19
associated with sport participation, like participation rate, psychosocial modifications or injury rate. A complete overview may help professionals working in the sector of rehabilitation of individuals with limb amputations to evaluate sports or a physical training program as part of a treatment program for their patients and to better understand the benefits and risks of sports participation for this group. Therefore, the aim of this study was to systematically review the literature on participation in sports and/or physical activity among individuals with upper and/or lower limb amputations and to identify their biomechanical characteristics, cardiopulmonary function, psychological well-being, sport participation and physical functioning and injury characteristics.
REVIEW METHODS
For this systematic review, sports were defined as an activity involving physical exertion, with or without game or competition elements, with a minimal duration of half an hour and where skills and physical endurance are either required or to be improved.[39] Physical activity was defined as any bodily movement produced by skeletal muscles that require energy expenditure. [40]
Four databases were searched: MEDLINE (PubMed), EMBASE, CINAHL® and SportDiscus®. The search strategy used consisted of a combination of database-specific Mesh terms, free text, “wild cards” (words truncated by using “*”) and Boolean operators (“AND”, “OR”, “NOT”). No time or language restrictions were applied. The search was structured in two parts. One part concerned papers related to amputations, while the second part concerned papers related to sports and physical activity. The two parts of the search were combined using the Boolean operator “AND”. The search details are presented in Appendix 1, Table A1. Sports were only searched as Mesh headings and as a general free text word, not by means of specific types of sports, like running, cycling or basketball. All retrieved papers were combined in a single database and duplicates were removed. The most recent search date was March 31, 2010.1
1 Authors’ note: the literature search was updated on 21 February 2011. Following
the same inclusion/exclusion criteria as described in section 1; The newly identified studies [31;35;90;91] were added to table 1 under the relevant characteristics analyses. The results of these studies did not influence the conclusion of this review and therefore they were not brought up for discussion.
20 Chapter 2
Papers were selected for this review in three stages after evaluation of the title, abstract and full text. Papers were included if the research topic was sports or physical activity and a minimum of ten individuals with limb amputations were part of the study population. Papers were excluded if they concerned minor amputation (distal to the wrist or ankle), amputation of body parts other than upper and lower limbs (e.g. ear, breast) or endoprostheses. In addition, case reports, narrative reviews, editorials, notes and letters to the editor were excluded. If, after title and abstract assessment, the paper’s inclusion or exclusion remained questionable, the paper was included in the next selection stage. References of papers selected for inclusion in the final assessment stage of the review were checked for relevant citations, which were later retrieved and assessed in the same way. Each assessment was performed by two independent observers. If the observers were not fluent in the language of the paper, a native speaker translated the paper into English with the two observers present. In case of assessor disagreement, a consensus meeting was held. If disagreement persisted, a third observer gave a binding verdict. The full text of a paper was assessed if the paper fulfilled the following inclusion criteria: a minimum of ten (1) individuals with limb amputations (2) were part of the study population and sport or physical activity was considered (3). Methodological quality was based on the assessment of the following criteria: reporting of inclusion (1) and exclusion (2) criteria; the numbers or percentages of males and females (3); age (4) [as mean and standard deviation or median and inter-quartile range]; cause of amputation (general description of cause [5] and exact number [6] per cause) and level (7); and side (8) of amputation.
RESULTS
A total of 3689 papers were identified, of which 895 were duplicates. After title and abstract assessment, 85 full-text papers were selected for further assessment. As a result of reference checking, 29 additional potentially relevant papers were identified. In total, 17 papers could not be retrieved for bibliographic reasons or because there was no complete paper available. After full text assessment, 50 papers were excluded because they did not fulfil the inclusion criteria, leaving 47 for final inclusion in this systematic review (figure 1). Inter-observer agreement, expressed as Cohen’s Kappa, for the full-text assessment of
Amputees and sports: a systematic review 21
the 47 included papers was 0.83 (95% CI 0.78, 0.89). The quality of the included papers was moderate, with only four papers fulfilling all eight criteria. The frequency distribution of the methodological quality of all studies is presented in figure 2.
In general, there was substantial heterogeneity in interventions, population characteristics and main outcomes between the studies. In order to provide structure to the findings, main outcomes were organized into five categories:
• Biomechanical aspects and athletic performance: papers in this category had to present data regarding forces or any other biomechanical variables of the subjects or activity.
• Cardiopulmonary function: papers in this category had to present biometric data recorded during or after physical activity or sports
• Psychological aspects and quality of life: papers in this category had to present data regarding psychological aspects and quality of life.
• Sports participation and physical functioning: papers in this category had to present data about sports participation and modifications in physical functioning following participation in sports or physical activities.
• Sports injuries: papers in this category had to present data about sports injuries.
Biomechanical Aspects and Athletic Performance
Ten studies analysed the biomechanical aspects of swimming,[56] running[57-59] and long jump[60-65] and athletic performance of individuals with upper and lower limb amputations. Video cameras, force plates or Doppler devices were used to measure step length and rate, joint angles, ground reaction force and speed, among other variables. An overview of these papers is presented in Table 1. Young individuals with unilateral trans-tibial amputations who were provided with prostheses and were adequately trained were able to run.[57;58] Runners with lower limb amputations demonstrated a difference between the prosthetic and non-prosthetic limbs regarding step length and vertical, mediolateral and horizontal displacement of the centre of mass. The prosthetic and non-prosthetic limbs also differed in these variables from those of able-bodied individuals.[59;65]
22 Chapter 2
Long jumpers with trans-tibial amputations jumped further than those with trans-femoral amputations did.[60;64] Long jumpers with trans-tibial amputations who used their prosthetic limb for take-off had a shorter last step and a lower vertical velocity at touch-down than did those jumpers using their sound limb for take-off.[61] Runners with lower limb amputations[58;59] and swimmers with upper limb amputations[56] increase their speed by increasing their pace rather than their step or stroke length.
Figure 1 Flow chart of the systematic review
Amputees and sports: a systematic review 23
Cardiopulmonary Function
Twelve studies analysed cardiopulmonary function in relation to sports or physical activity among individuals with limb amputations.[22;24;27;28;52;66-72] Training equipment such as an exercise cycle or rowing ergometer was used. An ECG, spirometer, sphygmomanometer, and Doppler device were used to measure maximal oxygen intake (VO2max), heart rate (HR), blood pressure (BP), anaerobic threshold (AT), and maximum power output (Wmax). An overview of these papers is presented in Table 1. The general physical condition of individuals with limb amputations is worse than the reference values for able-bodied people of similar age.[24;66] Nevertheless, individuals with limb amputations have better aerobic and anaerobic power outputs than do individuals with other locomotor disabilities.[70] Participation in sports or physical activity has beneficial influences on the cardiopulmonary system, muscle force and body mass of individuals with limb amputations.[27;28;52;69] The rehabilitation time of individuals with limb amputations was shorter when physical training was part of their rehabilitation program.[71]
Figure 2 Methodological quality of identified papers
24 Chapter 2
Psychological Aspects and Quality of Life
Six studies analysed the relationship between sport participation and the psychological aspects and quality of life of individuals with limb amputations.[23;29;30;32;73;74] Questionnaires or interviews were used to measure motivation to participate in sports, self-esteem and perceived benefits and barriers in physically active individuals with limb amputations. An overview of these papers is presented in Table 1. Quality of life and self-esteem of individuals with limb amputations who participated in sports and physical activities were higher than those of people with limb amputations who did not participate in these activities.[29;73] Sports and physical activity helped these individuals to increase their number of social contacts and their knowledge about sporting equipment that could facilitate their participation in sports. It also helped them to accept their disability and to improve their motor skills.[32;74] Participation in sports and/or physical activity decreased following the amputation as a direct result of physical constraints and accessibility issues.[74]
Sport Participation and Physical Functioning
Fifteen studies analysed associations between sport participation and/or physical activity and physical functioning of individuals with limb amputations.[33;36-38;75-85] A combination of self-developed and published questionnaires as well as specific tests addressing mobility outcomes were used as measurement tools. The main outcome variables were sport participation rate, the type of preferred physical activity, type and use of prosthesis and modifications of physical functioning following a physical training program. An overview of these papers is presented in Table 1. From the included papers, it appears that between 11% and 61% of individuals with lower limb amputations participate in sports and/or physical activities.[37;75] The choice of which sports to take part in was influenced by gender, the sport’s specific energy requirements and the load on the prosthetic limb.[80;85] Fishing, swimming, golfing, walking and cycling were favoured sports. Younger individuals with unilateral trans-tibial amputations due to non-vascular causes were more active than older individuals with bilateral trans-femoral amputations due to vascular causes.[38;79] A short but intensive physical training program improved walking distance and speed of individuals with traumatic lower limb amputations.
Amputees and sports: a systematic review 25
Sports Injuries
Four studies analysed the sports injuries suffered by individuals with limb amputations.[86-89] Questionnaires were used to assess the injury rate and injury-related phenomena such as pain or activity restriction. An overview of these papers is presented in Table 1. The injury pattern and rate among individuals with limb amputations who play football (soccer) appear to be the same as for able-bodied individuals. Sport-related muscle pain occurs more frequently in those with limb amputations than in individuals with other types of locomotor disabilities.[88] The emotional benefits of participating in sports outweighed the possible risk of injury.[86] The presence of pain did not influence perceived activity restrictions.[87]
26 Chapter 2
Auth
ors
(yea
r)Q
SS(
n);
Ic/E
cGe
nder
M
/W;
Agea
Ampu
tatio
n ch
arac
teris
tics
Stud
y de
sign
Anal
ysis
aim
Resu
lts
Leve
lCa
use
(G/S
)Si
de
Biom
echa
nica
l Asp
ects
and
Ath
letic
Per
form
ance
Enok
a et
al.
(198
2) [5
8]4
10;
N/N
9/1;
39
10 T
TN
/N10
Uni
; LL
CSRu
nnin
g ga
it ch
arac
-te
ristic
s60
% o
f you
ng in
divi
dual
s with
Uni
TT
ampu
tatio
ns w
ho
used
a p
rost
hesis
wer
e ab
le to
run
at sp
eeds
rang
ing
from
2.7
to 8
.2 m
/s; S
peed
incr
ease
is re
late
d to
an
incr
ease
in st
ride
rate
; Ste
p le
ngth
of t
he P
rosL
is d
irect
ly
rela
ted
to sp
eed
incr
ease
.
Engs
berg
et
al. (
1993
) [57
]4
21
(221
); N
/N
17/4
; 11
21 T
TN
/N21
Uni
; LL
CSRu
nnin
g ch
arac
teris
tics
of A
B an
d ch
ildre
n w
ith
TT a
mpu
tatio
ns
Non
Pros
L ge
nera
ted
grea
ter v
ertic
al, a
nter
opos
terio
r an
d m
edio
late
ral f
orce
s as c
ompa
red
to P
rosL
of A
B;W
ith in
crea
sing
spee
d, th
e N
onPr
osL
gene
rate
d gr
eate
r fo
rwar
d pr
opul
sion
than
the
Pros
L.
Gavr
on e
t al
. (19
95) [
59]
412
; N
/N12
/0; N
12 T
TN
/N12
Uni
; LL
CSSp
rintin
g ch
arac
teris
tics
of in
divi
dual
s with
TT
ampu
tatio
ns
Pros
L an
d N
onPr
osL
wer
e as
ymm
etric
with
resp
ect t
o st
ride
leng
th a
nd ti
me
and
verti
cal d
ispla
cem
ent o
f ce
ntre
of m
ass;
Non
Pros
L st
ride
cont
ribut
ed m
ore
to
horiz
onta
l disp
lace
men
t tha
n Pr
osL
strid
e.
Nol
an e
t al.
(200
0) [6
0]4
16;
N/N
16/0
; N8
TT /
8 TF
N/N
16 U
ni;
LLCS
Take
-off
char
acte
ristic
s du
ring
long
jum
ping
Athl
etes
with
TT
ampu
tatio
ns ju
mpe
d fu
rthe
r, ha
d a
fast
er a
ppro
ach
spee
d an
d a
low
er c
entr
e of
mas
s com
-pa
red
to a
thle
tes w
ith T
F am
puta
tions
.
Sim
pson
et
al. (
2001
) [65
]4
23;
N/N
17/6
; (1
8-36
)20
TT
/ 3
TFN
/N22
Uni
/ 1B
il; L
LCS
Loco
mot
or c
hara
cter
is-tic
s of l
ong
jum
pPr
osL
of in
divi
dual
s with
TT
ampu
tatio
ns h
ad a
gre
ater
st
ep le
ngth
com
pare
d to
thei
r Non
Pros
L; M
ore
prox
imal
am
puta
tions
gen
erat
ed la
rger
inte
rlim
b ki
nem
atic
asym
-m
etry
Indi
vidu
als w
ith T
F am
puta
tions
incr
ease
d sp
eed
by in
crea
sing
step
leng
th o
f the
ir N
onPr
osL;
Indi
vidu
als
with
TT
ampu
tatio
ns in
crea
sed
spee
d by
incr
easin
g st
ep
leng
th o
f the
ir Pr
osL.
Patr
itti e
t al.
(200
5) [6
4]
334
; N
/N11
/9; N
20 T
T /
14 T
FN
/NN
/LL
CSAp
proa
ch v
eloc
ity o
f lo
ng ju
mpe
rsIn
divi
dual
s with
TT
ampu
tatio
ns ra
n fa
ster
and
jum
ped
furt
her t
han
indi
vidu
als w
ith T
F am
puta
tions
MikeTypewritten TextTable 1. Studies analyzing characteristics of individuals with limb amputations
MikeTypewritten Text
MikeTypewritten Text
MikeTypewritten Text
MikeTypewritten Text
MikeTypewritten Text
Amputees and sports: a systematic review 27
Nol
an e
t al.
(200
5) [6
1]3
14;
N/N
14/0
; N7
TT /
7 TF
N/N
N/L
LCS
Influ
ence
of t
ake-
off le
g du
ring
the
long
jum
pAt
hlet
es w
ith T
T am
puta
tions
who
took
off
from
thei
r Pr
osL
wer
e ab
le to
bett
er c
ontr
ol th
eir d
ownw
ard
velo
c-ity
at t
ouch
-dow
n an
d ha
d a
shor
ter l
ast s
trid
e.
Nol
an e
t al.
(200
6) [6
2]4
17;
N/N
0/17
; N9
TT /
8 TF
N/N
17 U
ni
/ LL
CSKi
nem
atic
char
acte
r-isti
cs o
f wom
en w
ith
TT a
nd T
F am
puta
tions
du
ring
long
jum
p
Appr
oach
vel
ocity
mor
e st
rong
ly in
fluen
ced
the
jum
ped
dist
ance
of w
omen
with
TT
ampu
tatio
ns th
an th
at o
f the
w
omen
with
TF
ampu
tatio
ns; W
omen
with
TF
ampu
ta-
tions
had
a lo
wer
cen
tre
of m
ass t
han
the
ones
with
TT
ampu
tatio
ns; W
omen
with
TF
ampu
tatio
ns h
ad g
reat
er
join
t ang
les (
hip,
kne
e an
d le
g) o
n al
l jum
p ph
ases
com
-pa
red
to th
e at
hlet
es w
ith T
T am
puta
tions
.
Nol
an e
t al.
(200
7) [6
3]4
13;
N/N
13/0
; N6
TT /
7 TF
N/N
13 U
ni
/ LL
CSKi
nem
atic
and
tem
pora
l ch
arac
teris
tics o
f lon
g ju
mp
Athl
etes
with
TF
ampu
tatio
ns h
ad sl
ower
hor
izont
al v
e-lo
city
and
shor
ter s
trid
e le
ngth
on
the
seco
nd to
last
and
la
st st
rides
com
pare
d to
ath
lete
s with
TT
ampu
tatio
ns;
Athl
etes
with
TF
ampu
tatio
ns lo
wer
ed th
eir c
entr
e of
m
ass i
n th
e la
st st
ride
mor
e th
an a
thle
tes w
ith T
T am
pu-
tatio
ns; A
thle
tes w
ith T
F am
puta
tions
had
gre
ater
join
t an
gles
(hip
, kne
e an
d le
g) o
n al
l jum
p ph
ases
com
pare
d to
ath
lete
s with
TT
ampu
tatio
ns.
Osb
orou
gh
et a
l. (2
009)
[5
6]
413
; N
/N3/
10;
16.9
(±
3.1)
13 E
DN
/ N
13 U
ni
/ UL
CSSw
imm
ing
char
acte
ris-
tics o
f ind
ivid
uals
with
U
L am
puta
tions
rela
ted
to th
eir a
nthr
opom
etric
ch
arac
teris
tics
SF w
as re
late
d to
max
imum
swim
min
g sp
eed
(r=.
72);
SF
was
rela
ted
to b
iacr
omia
l bre
adth
(r=.
86),
shou
lder
girt
h (r
=.64
) and
upp
er-a
rm le
ngth
(r=.
58).
Osb
orou
gh
et a
l. (2
010)
[9
0]
613
; N
/N3/
10;
16.9
(±
3.1)
13 E
DN
onPV
D / Y
13 U
ni
/ UL
CSSw
imm
ing
char
acte
ris-
tics o
f ind
ivid
uals
with
U
L am
puta
tions
rela
ted
to th
eir i
nter
-arm
coo
r-di
natio
n
Swim
min
g sp
eed
(r=.
59) a
nd S
F (r
=.66
) wer
e re
late
d to
th
e co
ordi
natio
n of
the
ampu
tate
d ar
m.
Card
iopu
lmon
ary
Func
tion
Tom
asze
-w
ska
et a
l. (1
965)
b [5
2]
319
; N
/N16
/3; N
6 TT
/ 11
TF
N /
N17
Uni
/ 2
Bil;
LLLo
ngCh
ange
s of c
ardi
opul
-m
onar
y an
d m
uscl
e fo
rce
char
acte
ristic
s aft
er tr
aini
ng
HR a
nd B
P de
crea
sed
in th
e m
ajor
ity o
f ind
ivid
uals
with
lim
b am
puta
tions
afte
r 2 w
eeks
of i
ndoo
r tra
inin
g; In
spi-
ratio
n fr
eque
ncy
and
mus
cle
forc
e of
han
d, sh
ould
er a
nd
back
incr
ease
d in
the
maj
ority
of i
ndiv
idua
ls w
ith li
mb
ampu
tatio
ns in
the
seco
nd d
ay o
f ski
ing.
28 Chapter 2
van
Alst
e et
al
. (19
85) [6
6]7
39;
Y/N
28/1
1;
6710
TT
/ 13
TF
/ 11
KD
PVD/
Y35
Uni
/ 4
Bil;
LLCS
HR d
urin
g PA
and
the
thre
shol
d of
pro
sthe
tic
ambu
latio
n
Indi
vidu
als w
ith li
mb
ampu
tatio
ns a
chie
ved
80%
of t
he
pred
icte
d HR
max
val
ue fo
r AB
of sa
me
age;
Wor
k ca
paci
ty
of 6
0 w
atts w
as th
e th
resh
old
of p
rost
hetic
am
bula
tion.
Pite
tti e
t al.
(198
7) [2
7]6
10;
Y/N
N; 3
94
TT /
3 TF
Non
PVD
/ Y8
Uni
/ 2
Bil;
LLLo
ngCh
ange
s of c
ardi
o-pu
lmon
ary
and
wor
k ca
paci
ty c
hara
cter
istics
aft
er a
erob
ic tr
aini
ng
HR d
urin
g re
st a
nd e
xerc
ise d
ecre
ased
; HR
durin
g vo
li-tio
nal e
xhau
stion
incr
ease
d; V
O2m
ax a
nd W
max
incr
ease
d.
Alar
anta
et
al. (
1988
) [67
]5
10;
N/N
9/1;
35
(23-
57)
3 TT
/ 3
TF, 4
UL
Non
PVD
/ YN
; 6 L
L /
4 U
LCS
Suita
bilit
y of
test
s eva
lu-
ating
skie
rs’ p
hysic
al
capa
city
Mos
t tes
ts w
ere
not s
uita
ble
for s
kier
s with
lim
b am
-pu
tatio
ns; R
ecom
men
ded
test
s: ro
win
g er
gom
eter
for
indi
vidu
als w
ith T
F am
puta
tions
; “w
alki
ng w
ith sti
cks”
c fo
r ind
ivid
uals
with
TT
ampu
tatio
ns a
nd/o
r ind
ivid
uals
with
Uni
UL
ampu
tatio
ns, t
read
mill
runn
ing
for i
ndiv
idu-
als w
ith B
il U
L am
puta
tions
.
Chin
et a
l. (1
997)
[68]
553
; Y/
N40
/13;
42
11 T
T /
37 T
F / 5
HD
N/N
53 U
ni;
LLCS
Valid
ity o
f the
one
-leg
cycl
ing
ergo
met
er te
st
in d
eter
min
ing
AT
AT c
orre
late
d (r
=0.6
6) w
ith p
redi
cted
VO
2max
; One
-leg
cycl
e er
gom
eter
is v
alid
in A
T de
term
inati
on.
Kurd
y-ba
ilo e
t al.
(1
997)
[69]
578
(9
0);
N/N
78/0
; N34
TT
/ 37
TF
Non
PVD
/ Y61
Uni
/ 1
7 Bi
l; LL
Long
Chan
ges o
f car
diov
ascu
-la
r cha
ract
eristi
cs a
nd
body
mas
s afte
r sw
im-
min
g po
ol e
xerc
ises
BP d
ecre
ased
as a
resu
lt of
supp
ress
ing
the
influ
ence
of
the
sym
path
etic
nerv
ous s
yste
m; B
ody
mas
s dec
reas
ed
Hutz
ler e
t al
(199
8) [7
0]4
10
(50)
; Y/
N
10/0
; 39
(±9.
2)d
NN
/ N
N /
LLCS
Diffe
renc
e in
pow
er
outp
uts b
etw
een
indi
vidu
als w
ith li
mb
ampu
tatio
ns a
nd in
di-
vidu
als w
ith o
ther
type
s of
phy
sical
disa
biliti
es
Indi
vidu
als w
ith li
mb
ampu
tatio
ns h
ad b
etter
aer
obic
an
d an
aero
bic
pow
er o
utpu
ts a
nd fa
tigue
indi
ces t
han
indi
vidu
als w
ith o
ther
type
s of p
hysic
al d
isabi
lities
.
Chin
et a
l. (2
001)
[28]
624
; Y/
NN
; 41
(±18
.4)
24 T
FN
onPV
D / Y
24 U
ni
/ LL
Long
Chan
ges i
n ca
rdio
-pul
-m
onar
y ch
arac
teris
tics
after
end
uran
ce tr
aini
ng
base
d on
AT
VO2m
ax in
crea
sed
for t
he e
ndur
ance
gro
up c
ompa
red
to
pre-
trai
ning
and
to a
con
trol
gro
up; A
T in
crea
sed
for
the
endu
ranc
e gr
oup
com
pare
d to
pre
-tra
inin
g an
d to
a
cont
rol g
roup
.
MikeTypewritten Text
Amputees and sports: a systematic review 29
Chin
et a
l. (2
002)
[24]
7
31
(49)
; Y/
N
18/1
3;
26
(±5.
7)
10 T
T /
20 T
F / 1
KD
Non
PVD
/ Y31
Uni
/ L
LLo
ngCh
ange
s of c
ardi
o-pu
lmon
ary
and
phys
ical
fit
ness
afte
r phy
sical
tr
aini
ng c
ompa
red
to A
B
VO2m
ax in
crea
sed
to th
e le
vel o
f AB;
AT
incr
ease
d to
the
leve
l of A
B; W
max
inc
reas
ed to
the
leve
l of A
B.
Kobz
ev e
t al
. (20
02) [
71]
418
; N
/N18
/0;
(19-
44)
NN
onPV
D / Y
N /
LLCS
Influ
ence
of P
A le
vel o
n BP
, HR
and
reha
bilit
a-tio
n tim
e
High
er P
A le
vel w
as a
ssoc
iate
d w
ith lo
wer
BP
and
HR;
High
er P
A le
vel w
as a
ssoc
iate
d w
ith a
shor
ter r
ehab
ilita
-tio
n tim
e.
Huon
ker e
t al
. (20
03) [
22]
317
(1
25);
Y/N
N; 3
4 (±
11.5
)17
TT
N /
N17
Uni
/ L
LCS
Vasc
ular
cha
ract
eristi
cs
of p
hysic
ally
acti
ve
indi
vidu
als w
ith li
mb
ampu
tatio
ns a
nd A
B
Bloo
d flo
w a
nd d
iam
eter
of t
he c
omm
on fe
mor
al a
rter
y of
the
Pros
L w
ere
smal
ler c
ompa
red
to N
onPr
osL
and
to
untr
aine
d AB
.
Chin
et a
l. (2
006)
[72]
749
; Y/
N34
/15;
67
(±
5.6)
19 P
VD,
30 N
on-
PVD
/Y
49U
ni
/ LL
CSTo
iden
tify
the
thre
shol
d of
pro
sthe
tic a
mbu
la-
tion
Exer
cise
inte
nsity
of ≥
50%
VO
2max
was
the
thre
shol
d of
pr
osth
etic
ambu
latio
n.
Psyc
holo
gica
l Asp
ects
and
Qua
lity
of L
ife
Valli
ant e
t al
. (19
85) [
29]
133
(1
61);
N/N
19 /
14; N
NN
/ N
NCS
Rela
tions
hip
betw
een
self-
este
em, l
ocus
of
cont
role
and
PA
of
indi
vidu
als w
ith li
mb
ampu
tatio
ns
Phys
ical
ly a
ctive
indi
vidu
als w
ith li
mb
ampu
tatio
ns h
ad
high
er se
lf-es
teem
than
inac
tive
indi
vidu
als;
Activ
e m
en
with
lim
b am
puta
tions
had
a lo
wer
locu
s of c
ontr
ol th
an
inac
tive
men
; Acti
ve w
omen
with
lim
b am
puta
tions
had
a
high
er lo
cus o
f con
trol
than
inac
tive
wom
en.
Mas
tro
et
al. (
1996
) [23]
322
(1
38);
Y/N
17 /
5;
29N
N /
NN
CSAt
hlet
es’ a
ttitu
des
tow
ards
eac
h ot
her a
nd
thei
r ran
king
of d
isabi
l-ity
pre
fere
nces
Indi
vidu
als w
ith li
mb
ampu
tatio
ns w
ere
rank
ed h
ighe
st
in th
e hi
erar
chy
of p
refe
renc
es d
ue to
the
low
est p
er-
ceiv
ed d
isabi
lity.
Wett
erha
hn
et a
l. (2
002)
[3
0]
656
; Y/
N36
/ 20
; N34
TT/
22
TF8
PVD
48
Non
PVD
/ Y
48 U
ni /
8Bil
/LL
CSRe
latio
nshi
p be
twee
n PA
and
bod
y im
age
MBS
RQ a
nd A
BIS
scor
es w
ere
signi
fican
tly h
ighe
r (p
=0.0
001
resp
ectiv
ely
p=0.
01) f
or a
ctive
indi
vidu
als
with
lim
b am
puta
tions
com
pare
d to
an
inac
tive
grou
p; A
re
latio
nshi
p ex
ists b
etw
een
PA le
vel a
nd b
ody
imag
e of
in
divi
dual
s with
lim
b am
puta
tions
; No
data
pre
sent
ed to
su
bsta
ntiat
e th
e na
ture
of t
he re
latio
nshi
p be
twee
n PA
le
vel a
nd b
ody
imag
e; A
chr
onic
illn
ess d
id n
ot in
fluen
ce
body
imag
e in
the
activ
e gr
oup.
30 Chapter 2
Low
ther
et
al. (
2002
) [73
]2
15;
Y/N
15/0
; (1
9-28
)N
N/N
NCS
Rela
tions
hip
betw
een
athl
etic
perf
orm
ance
, se
lf-effi
cacy
and
psy
cho-
logi
cal s
kills
High
self-
effica
cy w
as a
ssoc
iate
d w
ith su
cces
sful
ath
letic
pe
rfor
man
ce; T
he u
sage
of a
ctiva
tionf
and
rela
xatio
n sk
ills w
as a
ssoc
iate
d w
ith h
igh
self-
effica
cy a
nd su
cces
s-fu
l ath
letic
per
form
ance
.
Spor
ner e
t al
. (20
09) [
32]
157
(1
32);
Y/N
115
/ 17
g;
47.4
g (±
13.4
)
NN
/NN
CSRe
latio
nshi
p be
twee
n pa
rtici
patio
n in
org
an-
ised
spor
t eve
nts a
nd
psyc
hoso
cial
cha
rac-
teris
tics
Parti
cipa
tion
in o
rgan
ised
spor
ting
even
ts in
crea
sed
the
know
ledg
e of
spor
ting
equi
pmen
t (92
%),
mob
ility
skill
s (8
4%) a
nd d
isabi
lity
acce
ptan
ce (8
4%);
98%
felt
that
pa
rtici
patio
n in
org
anise
d sp
ortin
g ev
ents
impr
oved
thei
r liv
es; I
ncre
ased
num
bers
of f
riend
s, in
tera
ction
with
ot
her d
isabl
ed p
eopl
e an
d ab
ility
to b
e co
mpe
titive
wer
e se
en a
s ben
efits
of p
artic
ipati
on in
org
anise
d sp
ortin
g ev
ents
; Par
ticip
ants
in o
rgan
ised
spor
ting
even
ts h
ad
decr
ease
d co
gniti
ve a
nd p
hysic
al li
mita
tions
(CHA
RT)
com
pare
d to
non
-par
ticip
ants
; For
63%
of t
he p
artic
i-pa
nts,
taki
ng p
art i
n or
gani
sed
spor
t eve
nts r
epre
sent
s th
eir o
nly
spor
ting
activ
ity.
Cout
ure
et
al. (
2010
) [74
]7
15;
Y/N
8/7;
65
.1
(±13
.9)
11 T
T /
4 TF
PVD/
Y15
Uni
/ L
LLo
ngCh
arac
teris
tics o
f le
isure
acti
vitie
s of
indi
vidu
als w
ith L
L am
puta
tions
Parti
cipa
tion
in le
isure
acti
vitie
s dec
reas
ed fo
llow
ing
ampu
tatio
n; L
eisu
re sa
tisfa
ction
of i
ndiv
idua
ls w
ith L
L am
puta
tions
was
hig
her t
han
ILP
refe
renc
e va
lue;
Indi
-vi
dual
s with
LL
ampu
tatio
ns e
ncou
nter
mor
e co
nstr
aint
s th
an A
B in
term
s of f
uncti
onal
abi
lities
and
acc
essib
ility
w
hen
enga
ging
in le
isure
acti
vitie
s.
Tata
r Y.
(201
0) [3
1]6
37;
Y/N
25/1
2; N
18 T
T /
19 T
F4
PVD
/Y37
Uni
CSRe
latio
nshi
p be
twee
n pa
rtici
patio
n in
spor
ts
and
body
imag
e of
am
pute
es
Parti
cipa
tion
in sp
orts
incr
ease
s per
ceiv
ed b
ody
imag
e of
am
pute
es.
Spor
t Par
ticip
ation
and
Phy
sical
Fun
ction
ing
Kege
l et a
l. (1
977)
h,i
[75]
613
4;
Y/N
103/
31;
4787
TT
/ 27
TF
65 P
VD,
69 N
on-
PVD
/Y
114
Uni
/ 2
0Bil
/ LL
CSLe
vel o
f spo
rt p
artic
ipa-
tion,
pre
ferr
ed sp
orts
an
d pr
osth
etic
use
61%
wer
e ac
tive
in sp
orts
Fish
ing
and
swim
min
g w
ere
mos
t fre
quen
tly p
erfo
rmed
6%
use
d sp
ort p
rost
hese
s
Amputees and sports: a systematic review 31
Kege
l et a
l (1
978)
h,i [
76]
613
4;
Y/N
103/
31;
4781
TT
/ 3
KD /
19 T
F / 5
HD
65 P
VD,
69 N
on-
PVD
/Y
114
Uni
/ 2
0Bil
/ LL
CSFu
nctio
nal c
apab
ilitie
s an
d po
pula
tion
char
-ac
teris
tics o
f acti
ve
indi
vidu
als w
ith li
mb
ampu
tatio
ns
Youn
ger i
ndiv
idua
ls w
ith T
T am
puta
tions
wer
e m
ore
ac-
tive
than
old
er in
divi
dual
s with
TF
ampu
tatio
ns
Kege
l et a
l. (1
980)
i [38
]6
100;
Y/
N85
/15;
45
58 T
T /
25 T
F29
PVD
, 71
Non
-PV
D / Y
83 U
ni
/ 17
Bil
/ LL
CSCh
arac
teris
tics o
f spo
rt
parti
cipa
tion:
leve
l, ba
r-rie
rs, p
rost
hesis
use
and
co
mpl
aint
s
Youn
ger i
ndiv
idua
ls w
ith tr
aum
atic
limb
ampu
tatio
ns
wer
e m
ore
activ
e th
an o
lder
indi
vidu
als w
ith v
ascu
lar
limb
ampu
tatio
ns B
arrie
rs to
spor
ts p
artic
ipati
on: p
ain,
em
barr
assm
ent,
lack
of s
peci
al o
rgan
ised
prog
ram
s for
in
divi
dual
s with
lim
b am
puta
tions
, lac
k of
aw
aren
ess
of th
e ex
isting
spor
t fac
ilitie
s (93
%) P
rost
hetis
ts d
id n
ot
wan
t to
mod
ify th
e pr
osth
esis
acco
rdin
g to
the
sugg
es-
tions
of i
ndiv
idua
ls w
ith li
mb
ampu
tatio
ns in
45%
of
case
s
Med
hat e
t al
. (19
90) [
77]
413
1;
Y/N
122/
9;
58 (2
4-90
)
82 T
T/61
TF
47 P
VD,
84 N
on-
PVD
/Y
N/L
LCS
Fact
ors i
nflue
ncin
g AD
L an
d sp
ort p
artic
ipati
onIn
divi
dual
s with
TF
ampu
tatio
ns re
port
ed m
ore
prob
-le
ms i
n AD
L th
an d
id in
divi
dual
s with
TT
ampu
tatio
ns
Spor
t par
ticip
ation
was
pro
blem
atic
for i
ndiv
idua
ls w
ith
both
TT
and
TF a
mpu
tatio
ns; L
east
pro
blem
atic
spor
ts:
cano
eing
and
swim
min
g
Pohj
olai
nen
et a
l. (1
990)
[7
8]
717
5;
Y/N
127/
48;
62
(±15
.8)
93 T
T/62
TF
142
PVD,
33
Non
-PV
D / Y
155
Uni
/ 2
0Bil
/ LL
CSCh
arac
teris
tics o
f pr
osth
etic
use,
wal
king
ab
ility
and
fact
ors i
nflu-
enci
ng w
alki
ng
60%
use
d th
eir p
rost
hesis
>12
hou
rs/d
ay 1
5% c
ould
wal
k 2-
3 hr
s and
23%
cou
ld w
alk
mor
e th
an 1
km
Isch
emic
pa
in re
stric
ted
wal
king
Gaile
y R
. (1
992)
[82]
512
14;
Y/N
Nj;
Nj
Nj
242
PVD,
97
2 N
on-
PVD
/ Y
Nj
CSCh
arac
teris
tics o
f re
crea
tiona
l acti
vitie
s:
type
, ret
urn
to, a
mou
nt
and
barr
iers
Nj
Burg
er e
t al.
(199
7) [7
9]7
228;
Y/
N19
1/37
; 53
.3
(±15
.4)
114
TT
/2 K
D /
108
TF /
4 HD
Non
PVD
/ Y22
8 U
ni
/ LL
CSCh
ange
s in
spor
ts p
ar-
ticip
ation
and
pre
ferr
ed
recr
eatio
nal a
ctivi
ties
follo
win
g am
puta
tion
Spor
t par
ticip
ation
dec
reas
ed P
refe
rred
recr
eatio
nal
activ
ities
cha
nged
tow
ards
"mor
e en
ergy
effi
cien
t" o
nes
32 Chapter 2
Burg
er e
t al.
(199
7) [3
6]7
223;
Y/
N18
7/36
; 54
(±
15.4
)
115
TT /
102
TF /
2 KD
/ 4
HD
Non
PVD
/ Y20
3 U
ni
/ 20
Bil
/ LL
CSIn
fluen
ces o
f age
, am
puta
tion
leve
l and
tim
e sin
ce a
mpu
tatio
n on
wal
king
, cyc
ling
and
inde
pend
ence
leve
l
Youn
ger i
ndiv
idua
ls w
ith T
T am
puta
tions
wal
ked
long
er
and
wer
e m
ore
likel
y to
cyc
le th
an o
lder
indi
vidu
als w
ith
TF a
mpu
tatio
ns A
shor
ter ti
me
since
am
puta
tion
lead
to
a hi
gher
inde
pend
ence
leve
l
Legr
o et
al.
(200
1) [8
0]3
92;
Y/N
79/1
3;
54.9
5 (±
13.7
)
58 T
TN
/NN
/LL
CSPr
efer
red
recr
eatio
nal
activ
ities
and
fact
ors
influ
enci
ng th
e ch
oice
of
acti
vitie
s.
Fish
ing
was
the
mos
t fre
quen
tly p
refe
rred
recr
eatio
nal
activ
ity (n
=15)
Gen
der,
requ
ired
ener
gy le
vel,
Pros
L im
pact
load
and
age
influ
ence
d ch
oice
of r
ecre
ation
al
activ
ity
Rau
et a
l. (2
007)
[33]
858
; Y/Y
58/0
; 37
(±10
.9)
43 T
T/15
TF
Non
PVD
/ Y58
Uni
/ L
LRC
TCh
ange
s of w
alki
ng
char
acte
ristic
s afte
r sh
ort i
nten
sive
phys
i-ot
hera
py fo
r ind
ivid
uals
with
lim
b am
puta
tions
co
mpa
red
to c
ontr
ols
Trai
ning
pro
gram
was
effe
ctive
in in
crea
sing
wal
king
di
stan
ce a
nd sp
eed,
Pro
sL m
axim
al lo
ad a
nd P
CI
Yazic
iogl
u et
al.
(200
7)
[81]
824
; Y/Y
24/0
; 28
(±4.
6)24
TT
Non
PVD
/ Y24
Uni
/ L
LCS
Diffe
renc
es in
phy
siolo
g-ic
al a
nd Q
oL c
hara
cter
-isti
cs o
f soc
cer p
laye
rs
com
pare
d to
con
trol
s
A di
ffere
nce
in p
hysio
logi
cal c
hara
cter
istics
was
re-
cord
ed, f
avou
ring
play
ers Q
oL im
prov
ed fo
r pla
yers
with
re
gard
s to
pain
, em
otion
al ro
le a
nd fe
ar o
f fal
ling
Yari
et a
l. (2
008)
[83]
846
; Y/Y
21/2
5;
55.8
(±
12.1
)
31
HD/1
5 HP
6 PV
D, 4
0 N
onPV
D / Y
46 U
ni
/ LL
CSAc
tivity
leve
l and
m
obili
ty li
mita
tions
of
indi
vidu
als w
ith H
D an
d HP
am
puta
tions
39%
par
ticip
ated
in sp
orts
Sw
imm
ing,
fitn
ess,
saili
ng a
nd
golf
wer
e th
e m
ost p
racti
ced
spor
ts
Wal
ker e
t al
. (20
09) [
84]
736
(62)
; Y/
Y21
/15;
32
.5k
36 T
TkN
onPV
D / Y
36 U
ni
/ LL
CSDi
ffere
nce
in o
utco
me
follo
win
g fib
ular
leng
th-
enin
g or
am
puta
tion
No
diffe
renc
e in
spor
t par
ticip
ation
bet
wee
n fib
ular
le
ngth
enin
g pa
tient
s and
pati
ents
with
am
puta
tion
No
diffe
renc
e in
spor
ts a
ctivi
ty b
etw
een
fibul
ar le
ngth
enin
g pa
tient
s, p
atien
ts w
ith a
mpu
tatio
n an
d co
ntro
l gro
up.
Patie
nts w
ith a
mpu
tatio
ns sc
ored
sign
ifica
ntly
bett
er
than
fibu
lar l
engt
heni
ng p
atien
ts o
n th
e jo
b sa
tisfie
rs
cont
ent s
cale
Amputees and sports: a systematic review 33
Karm
arka
r et
al.
(200
9)
[85]
742
; Y/Y
N; 4
2.11
(±
16)
1 AD
/ 20
TT
/ 3
KD /
14 T
F / 4
HD
13 P
VD,
27 N
on-
PVD
/ Y
28 U
ni
/ 10
Bil
/ 8 U
L /
34 L
L
CSPe
rson
al c
hara
cter
-isti
cs a
nd fu
nctio
nal
perf
orm
ance
rela
ted
to
mob
ility
dev
ice
in p
hysi-
cal a
ctive
vet
eran
s
Ampu
tatio
n le
vel a
nd d
egre
e of
diffi
culty
of t
he in
tend
ed
activ
ity w
ere
rela
ted
to p
artic
ipati
on in
spor
ts P
rost
hetic
us
ers w
ith a
mor
e pr
oxim
al a
mpu
tatio
n ha
d m
ore
prob
lem
s par
ticip
ating
in sp
orts
com
pare
d to
whe
elch
air
user
s of s
ame
ampu
tatio
n le
vel.
Kars
et a
l. (2
009)
[37]
810
5;
Y/Y
71/3
1;
58.7
1 AD
/ 58
TT
/ 13
KD
/ 27
TF
/ 5
HD /
1 HP
42 P
VD,
63 N
on-
PVD
/ Y
101
Uni
/ 4
Bil
/ LL
CSPa
rtici
patio
n in
spor
ts
of in
divi
dual
s with
LL
ampu
tatio
ns
32%
par
ticip
ated
in sp
orts
Par
ticip
ation
in sp
orts
bef
ore
the
ampu
tatio
n w
as re
late
d to
par
ticip
ation
in sp
orts
fo
llow
ing
the
ampu
tatio
n Sw
imm
ing,
fitn
ess a
nd c
yclin
g w
ere
the
mos
t pra
ctice
d sp
orts
42%
com
plai
ned
abou
t th
eir p
rost
hesis
or s
port
org
anisa
tion,
and
80%
of t
hem
fo
und
this
prob
lem
hin
derin
g th
eir p
artic
ipati
on in
spor
ts
van
den
Berg
-Em
ons
et a
l. (2
010)
[3
5]
818
(4
61);
Y/Y
17/1
; 56
(±13
.13)
18 T
T9
PVD,
9
Non
PVD
/ Y
18U
ni
/ LL
CSAc
tivity
leve
l of i
ndi-
vidu
als L
L am
puta
tions
Indi
vidu
als w
ith T
T am
puta
tions
are
40%
less
acti
ve th
an
AB R
ehab
ilita
tion
phys
icia
ns si
gnifi
cant
ly o
vere
stim
ate
the
activ
ity le
vels
of in
divi
dual
s with
lim
b am
puta
tions
Bekk
erin
g et
al.
(201
1)
[91]
743
(8
2);
Y/N
22/2
1;
16.1
(±
4.4)
4 TT
/ 11
KD
/ 12
TF
/ 16
RP
43 N
on-
PVD
/ Y43
Uni
/ L
LCS
Diffe
renc
e in
phy
sical
ac
tivity
bet
wee
n yo
ung
adul
ts u
nder
goin
g lim
b-sa
lvag
e or
abl
ative
su
rger
y
No
diffe
renc
e in
phy
sical
acti
vity
leve
l bet
wee
n yo
ung
adul
ts w
ho u
nder
wen
t lim
b-sa
lvag
e in
terv
entio
ns a
nd
the
ones
who
und
erw
ent a
blati
ve su
rger
y.
Spor
ts In
jurie
s
Kege
l et a
l (1
994)
[86]
375
; Y/
N72
/3; 2
9 (1
8-44
)N
17
PVD,
58
Non
-PV
D / N
N; 6
1LL
/ 14U
LCS
Inju
ry c
hara
cter
istics
of
ampu
tee
socc
er p
laye
rsPh
ysic
al in
jurie
s app
eare
d m
inor
com
pare
d w
ith e
mo-
tiona
l ben
efits
indu
ced
by sp
ort 5
2% o
f ind
ivid
uals
with
lim
b am
puta
tions
nev
er su
stai
ned
an in
jury
whi
le p
layi
ng
socc
er T
he in
jury
patt
ern
of in
divi
dual
s with
lim
b am
pu-
tatio
ns w
as si
mila
r to
AB
Mel
zer e
t al
. (2
001)
[8
9]
732
(5
6);
Y/N
32/0
; 42
.4N
Non
PVD
/ Y32
Uni
; LL
CSCo
ntra
late
ral k
nee
os-
teoa
rthr
itis p
reva
lenc
e in
indi
vidu
als w
ith li
mb
ampu
tatio
ns w
ho p
lay
or d
o no
t pla
y vo
lleyb
all
Cont
rala
tera
l kne
e os
teoa
rthr
itis w
as si
gnifi
cant
ly m
ore
com
mon
am
ong
indi
vidu
als w
ith li
mb
ampu
tatio
ns c
om-
pare
d to
con
trol
s (p<
0.05
) No
diffe
renc
e in
the
prev
a-le
nce
of c
ontr
alat
eral
kne
e os
teoa
rthr
itis w
as o
bser
ved
betw
een
indi
vidu
als w
ith li
mb
ampu
tatio
ns w
ho p
laye
d vo
lleyb
all a
nd th
e on
es w
ho d
id n
ot p
layl
34 Chapter 2
Ber
nard
i et
al.
(200
3)
[88]
128
(2
27);
Y/N
N; N
NN
/NN
CSPr
eval
ence
of S
RMP
75%
of i
ndiv
idua
ls w
ith li
mb
ampu
tatio
ns e
xhib
ited
SRM
P In
divi
dual
s with
lim
b am
puta
tions
are
mor
e lik
ely
to p
rese
nt S
RMP
than
any
oth
er d
isabl
ed g
roup
(O
R=15
.4) P
rese
nce
of S
RMP
was
ass
ocia
ted
with
a B
MI
betw
een
24.6
and
30.
9 (O
R=3.
4) a
nd m
ore
than
7 h
rs/
wee
k of
trai
ning
(OR=
3.8)
Desm
ond
et
al.[8
7] (2
008)
6
89;
Y/N
62/2
7;
≥60m
55 T
T /
30 T
F / 4
KD
16 P
VD,
73 N
on-
PVD
/ Y
89 U
ni;
LLCS
Asso
ciati
on b
etw
een
pain
, pro
sthe
sis sa
t-isf
actio
n an
d ac
tivity
re
stric
tion
Pain
was
ass
ocia
ted
with
pro
sthe
sis d
issati
sfac
tion
Pain
pr
esen
ce w
as n
ot a
ssoc
iate
d w
ith a
ctivi
ty re
stric
tion
a M
ean
or (r
ange
) or [
mea
n –
SD].
b Tr
aini
ng p
rogr
amm
e w
as n
ot st
anda
rdize
d an
d th
e m
easu
rem
ents
wer
e no
t dist
ribut
ed a
ccor
ding
to a
stan
dard
sche
dule
thro
ugho
ut th
e st
udy
dura
tion.
c Si
mila
r to
‘Nor
dic
wal
king
’.d
Valu
e fo
r the
tota
l sam
ple,
incl
udin
g in
divi
dual
s with
lim
b am
puta
tions
.e
A hi
gher
locu
s of c
ontr
ol re
pres
ents
a m
ore
exte
rnal
ized
pers
on. f
The
abi
lity
to in
crea
se e
nerg
y.g
Char
acte
ristic
s for
the
who
le p
opul
ation
(n =
132
).h
Poss
ibly
the
sam
e st
udy
popu
latio
n.i S
imila
r res
ults
repo
rted
by
the
thre
e st
udie
s for
spor
t par
ticip
ation
and
use
of s
peci
al sp
ort p
rost
hese
s.j I
ncon
siste
nt d
ata
pres
ente
d by
the
auth
or.
k Ch
arac
teris
tics f
or th
e w
hole
stud
y po
pula
tion.
l Aut
hors
stat
e th
at th
e po
pula
tion
sam
ple
was
too
smal
l to
sust
ain
a ‘st
atisti
cally
relia
ble
conc
lusio
n’.
m 6
5.2%
wer
e ov
er 6
0 ye
ars o
f age
.AB
= ab
le-b
odie
d; A
BIS
= Am
pute
e Bo
dy-Im
age
Scal
e; A
D= a
nkle
disa
rticu
latio
n; A
DL =
acti
vitie
s of d
aily
livi
ng; A
T =
anae
robi
c th
resh
old;
BM
I = b
ody
mas
s ind
ex; B
P =
bloo
d pr
essu
re; C
HART
= C
raig
Han
dica
p As
sess
men
t Rep
ortin
g Te
chni
que;
CS=
cro
ss-s
ectio
nal;
ED=
elbo
w d
isarti
cula
tion;
G/S
= g
ener
al c
ause
for a
mpu
tatio
n/sp
ecifi
c nu
mbe
rs
per c
ause
; HD=
hip
disa
rticu
latio
n; H
P =
hem
ipel
vect
omy;
HR=
hea
rt ra
te; H
R max
= m
axim
um H
R; IL
P =
indi
vidu
al le
isure
pro
file;
in/e
x =
incl
usio
n/ex
clus
ion
crite
ria re
port
ed;
KD=
knee
disa
rticu
latio
n; L
L =
low
er li
mb;
M=
men
; MBS
RQ=
Mul
tidim
ensio
nal B
ody-
Self
Rela
tions
Que
stion
naire
; N=
no, d
ata
miss
ing
or c
riter
ion
not f
ulfil
led;
non
-Pro
sL
= no
n-pr
osth
etic
limb;
non
-PVD
= a
ny c
ause
of a
mpu
tatio
n ot
her t
han
perip
hera
l vas
cula
r dise
ase,
incl
udin
g tr
aum
a, in
fecti
on o
r can
cer;
OR=
odd
s rati
o; P
A= p
hysic
al a
c-tiv
ity; P
CI =
phy
siolo
gica
l cos
t ind
ex c
alcu
late
d us
ing
the
valu
es o
btai
ned
from
the
2 m
in te
st a
s fol
low
s: [H
R fini
sh -
HRre
st]/
spee
d; P
rosL
= p
rost
hetic
lim
b; P
VD=
perip
hera
l vas
-cu
lar d
iseas
e; Q
oL =
qua
lity
of li
fe; Q
S= q
ualit
y sc
ore
of th
e st
udy;
RCT
= ra
ndom
ised
cont
rolle
d tr
ial;
RP=
rota
tionp
last
y; S
(n) =
num
ber o
f sub
ject
s with
lim
b am
puta
tions
(to
tal n
umbe
r of p
artic
ipan
ts);
SF =
stro
ke fr
eque
ncy;
SRM
P= sp
ort r
elat
ed m
uscl
e pa
in; T
F =
tran
s-fe
mor
al; T
T =
tran
s-tib
ial;
UL
= up
per l
imb;
VO
2max
= m
axim
al o
xyge
n up
take
vol
ume;
W=
wom
en; W
max
= m
axim
al p
ower
out
put;
Y =
yes,
dat
a pr
esen
t or c
riter
ion
fulfi
lled.
Amputees and sports: a systematic review 35
DISCUSSION
The aim of this study was to systematically review the literature on biomechanical characteristics, cardiopulmonary function, psychological wellbeing, sport participation and physical functioning and injury characteristics related to sports and/or physical activity among individuals with upper and/or lower limb amputations. Only 47 (1.3%) out of 3689 papers initially identified were selected for inclusion in this systematic review. Most of the included studies were older than 10 years, were observational, had cross-sectional designs and used convenience sampling from a single rehabilitation centre. In most studies, the mean age of the study participants was below 65 years, and the study samples consisted of a high percentage of individuals with non-vascular amputations. The general population of individuals with limb amputations has an average age above 65 years, and most of these individuals have vascular amputations.[92] Due to this difference, the results of the current review do not necessarily apply to the general populations of individuals with limb amputations.
Age, gender and amputation level were found to influence running and long jumping performance in athletes with limb amputations.[62-64;76] Participation in sports and physical activity positively influences their physical fitness, psychosocial well-being and physical functioning.[27-29;32;33;71;80] A more proximal amputation, older age and a vascular cause of amputation may lead to more problems in completing the activities of daily living among individuals with limb amputations.[77;79;85] Various studies have identified different factors influencing participation in sports among individuals with limb amputations without reaching overall agreement on a single one. In clinical practice, the type of sport or physical activity should be chosen according to each patient’s characteristics, needs and physical capabilities.
When young individuals with a trans-tibial amputation are able to run,[58] they can participate in a wide range of sports in which running is a basic component. Athletic performance was determined by the amputation level, with more proximal amputations leading to poorer performance as a result of more pronounced limb asymmetry.[60;64;65] For long jumpers with trans-tibial amputations, better results were recorded among individuals who used their prosthetic limb for take-off compared to those using their intact limb for take-
36 Chapter 2
off.[61] The findings of two studies, one[93;94] with a small sample size (n= 5 ) and a literature review[70] suggest that prosthesis characteristics influence running performance, therefore influencing also athletic performance. To clarify the influence of prosthesis characteristics on athletic performance, further research is needed in which athletes with limb amputations are repeatedly tested with different types of prostheses. Every athlete with a limb amputation should be assessed individually because each has a unique running style. Individual prosthesis modifications, special components or advice may be required.
One study investigated swimming technique among individuals with upper-limb amputations.[56] The authors concluded that when swimming at higher speeds (at least 75% of the individual’s maximum swimming speed), stroke frequency was more important than stroke length in gaining and maintaining speed. The similar results found for running[58] may indicate that for increasing speed in running or swimming, athletes with limb amputations rely more on increasing their pace than on the length of their stride or stroke. Because data regarding swimming characteristics are available only from a single study, further research on this topic is needed before drawing conclusions.
Cardiopulmonary function of individuals with limb amputations was better when a simple physical exercise program was included in their rehabilitation program. The intensity of the program should be based on each individual’s heart rate during AT and should not exceed 80% of the maximum peak value.[68] Individuals with limb amputations must be subjected to a maximal test to obtain a peak value. This is not always possible because vigorous physical activity may be contraindicated by underlying cardiac problems. Therefore, only individuals with limb amputations who are healthy enough to undergo a peak test should do so. If an individual cannot be subjected to a peak test, clinicians can adjust the value for able-bodied persons of the same age according to the individual’s physical condition. The rehabilitation programs may vary in duration, intensity, desired results and available rehabilitation time. An ergometer test can be used along with questionnaires (Medical Outcome Study 36-item short-form, SF-36,[95] and Prosthesis Evaluation Questionnaire, PEQ[96]) to assess the ability to walk. Individuals with lower limb amputations who are able to achieve an exercise intensity of 50% VO2max[72] or 60 watts can be expected to become successful prosthetic walkers.[66;72] When an individual’s walking prognosis is known, the
Amputees and sports: a systematic review 37
rehabilitation process can be adapted according to the expected outcome, therefore optimising the results.
The psychological impact of the disability on athletes with limb amputations was found to be smaller as compared to athletes with other disabilities, such as audio-visual impairment or spinal cord injury.[23] This is an interesting finding considering that an amputation is often perceived by the able-bodied as one of the worst physical disabilities.[97] Unfortunately, no similar comparison between different disabilities has been performed in non-sporting or inactive individuals. Therefore, we cannot say if this difference is due to selection bias. Participation in sports and physical activities has a positive influence on self-esteem, perceived body image and locus of control.[29;30;98] In general, the benefits of participation in sports outweigh the inconvenience of the disability. When individuals with limb amputations participate in sports and physical activities, they can set aside the concerns related to their disability. Because the majority of them have an underlying chronic disease, encouraging them to participate in sports may help them to overcome their disability by increasing their self-esteem. By taking part in organised sporting events, they can increase their knowledge of relevant sporting equipment and techniques to improve their performance. In addition, they improve their mobility skills, personal relationships and the acceptance of their own disability.[32] When surrounded by other individuals with physical disabilities, persons with limb amputations gain a sense of normality, and they may feel more comfortable with their disability.[99]
Participation in sports decreases following amputation.[74] In Europe, 11 to 39% of individuals with limb amputations participate in sports or regular physical activity, while in the United States this percentage is 61%.[37;38;75;76;79;83] This high percentage may be biased by sample characteristics in the United States studies, including an average age of 52 years and predominantly traumatic limb amputation in the study samples.[49-51] In general, individuals with limb amputations are older than 65, and more than 80% have a vascular cause for amputation.[92] The difference between European and North American studies may also be related to general differences in sports and physical activity habits between European and North American people.[100] The sports that individuals with limb amputations prefer to take part in are similar regardless of the continent: swimming, cycling, golf, fishing, fitness.[37;38;80;83] Most individuals with limb amputations do not use special sport prostheses because of high costs, lack
38 Chapter 2
of knowledge about such prostheses or the feeling that they are unnecessary.[37;38;80;83] A high percentage (42%) of all individuals with limb amputations reported at least one complaint about their prosthesis or about the sport organisation in which they participated.[37] Sport participation appears to be hindered to some extent by unavailability of a suitable prosthesis, poor performance or high cost of the prosthesis, inadequate facilities or insufficient information.[37;38] To increase sport participation, these factors have to be addressed. Individuals with limb amputations could be introduced to sports that do not require prosthesis use, like wheelchair or sitting sports. Professionals should encourage individuals with limb amputations to participate more in sports or physical activities and advise them in choosing appropriate sport prosthesis.
Several factors were associated with the physical functioning, mobility and activity level following amputation, including age,[38;76;79] aetiology,[38] amputation level and previous sport participation.[77;80;85] However, discrepancies were found concerning the importance of aetiology[37;78;79] and amputation level.[38;76] For example, two studies[78;79] using samples with different proportions of vascular and nonvascular amputations had similar main outcomes. This finding might lead to the conclusion that aetiology has no influence on sport participation and mobility outcomes. This statement contradicts other results on this topic[38;76;101] showing that individuals with non-vascular limb amputations are more active than individuals with vascular amputations. In some studies,[38;76;85] a more proximal amputation was found to lead to a decrease in sport participation. Other studies[37;83] have found similar rates of sport participation regardless of the amputation level. Less discrepancy exists concerning the influence of age on physical functioning, mobility and activity level following amputation.[38;76;79] Rehabilitation practitioners need to consider that a more proximal amputation, older age and the presence of comorbidity usually lead to a longer and more difficult rehabilitation.[102]
Sport-related muscle pain was more frequent amongst individuals with limb amputations than amongst individuals with other physical disabilities.[88] This difference is probably caused by the relatively limited amount of muscular tissue still available, which is subjected to more intense use as compared to individuals with other physical disabilities. Only one study of sport injuries was found that focused completely on individuals with limb amputations.[86] Other papers
Amputees and sports: a systematic review 39
assessed sport injuries in a mixed group of athletes with different locomotor disabilities.[103-106] Unfortunately, they did not address each disability as a separate category, making it impossible to identify disability-specific injury rates or patterns. Additionally, the sports in which individuals with limb amputations prefer to partake, such as fishing, swimming and golf,[23;38;77] were not investigated concerning injury rates or patterns.
LIMITATIONS OF THE CURRENT SYSTEMATIC REVIEW
The literature search used only the generic term “sports”, and no separate searches were conducted for studies involving individual sports. We assumed that studies relevant to the topic of this review would most likely have the word “sport” or “athlete” somewhere in their content or be registered under the Mesh terms “Sports” or “Physical Activity”. During the title assessment phase, papers were excluded if the title had no connection to the topic of the review. It is possible that some papers that did not include the word “sport” or were not included in the “Sports” Mesh category may have been incorrectly excluded. Therefore, a reference check of the included papers was performed, resulting in the identification of 29 additional studies. The minimum number of 10 participants was arbitrarily chosen to reduce the influence of outliers on outcome and to increase the possibility to generalise the results. Seventeen papers could not be retrieved due to unavailability or indexing errors. These papers included book chapters, dissertations and oral presentations. If, as in the main sample, only 1% of these missing papers could be included in this review, the effects on the main outcome would be negligible.
The findings of this review should be interpreted cautiously because only few studies had a high methodological value. Only one randomised controlled trial was identified. Conducting a randomised controlled trial on individuals with limb amputations may prove difficult because of the limited number of subjects available. Additionally, physical activity tests can only be performed on a healthier subgroup of individuals with limb amputations. Finally, only four st