University of Groningen Sports and amputation Bragaru, MihailM. Bragaru, R. Dekker, J.H.B. Geertzen & P.U. Dijkstra 16 Chapter 2 ABSTRACT Amputation of a limb may have a negative impact

University of Groningen

Sports and amputationBragaru, Mihail

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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 minimum 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


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


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


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.


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

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MikeTypewritten TextTable 1. Studies analyzing characteristics of individuals with limb amputations

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s with

TT

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with

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m

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st st

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(hip

, kne

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n al

l jum

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com

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s with

TT

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009)

[5

6]

413

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10;

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(±

3.1)

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DN

/ N

13 U

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imm

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char

acte

ris-

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f ind

ivid

uals

with

U

L am

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rela

ted

to th

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nthr

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etric

ch

arac

teris

tics

SF w

as re

late

d to

max

imum

swim

min

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(r=.

72);

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was

rela

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(r=.

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lder

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upp

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58).

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010)

[9

0]

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(±

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D / Y

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ni

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acte

ris-

tics o

f ind

ivid

uals

with

U

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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

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e re

late

d to

th

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natio

n of

the

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m.

Card

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Func

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Tom

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ska

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965)

b [5

2]

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; N

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6 TT

/ 11

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N /

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s of c

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y an

d m

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rce

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acte

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s aft

er tr

aini

ng

HR a

nd B

P de

crea

sed

in th

e m

ajor

ity o

f ind

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uals

with

lim

b am

puta

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afte

r 2 w

eeks

of i

ndoo

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g; In

spi-

ratio

n fr

eque

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and

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cle

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han

d, sh

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nd

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ority

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ndiv

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ls w

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mb

ampu

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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

.



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


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


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.


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


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


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

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University of Groningen Sports and amputation Bragaru, MihailM. Bragaru, R. Dekker, J.H.B. Geertzen & P.U. Dijkstra 16 Chapter 2 ABSTRACT Amputation of a limb may have a negative impact