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Exploring cycling and sports in people with a lower limb amputation: prosthetic aspects

Poonsiri, Jutamanee

DOI:

10.33612/diss.146256706

IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below.

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Publication date: 2020

Link to publication in University of Groningen/UMCG research database

Citation for published version (APA):

Poonsiri, J. (2020). Exploring cycling and sports in people with a lower limb amputation: prosthetic aspects. University of Groningen. https://doi.org/10.33612/diss.146256706

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CHAPTER 1

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PHYSICAL ACTIVITIES; EXERCISE, SPORTS, AND CYCLING

Physical activity (PA) is “any bodily movement produced by the skeletal muscles that uses energy” (1). Sports, exercise, working, active transportation fall under this definition hence considered as PA (1). Sports are played following the set of rules and usually aim for winning while people who exercise repetitively and plan their movements aiming to improve health (1). Physical activity intensities or how hard individuals exerting the efforts can be classified by measuring a person's working metabolic rate relative to their resting metabolic rate- Metabolic Equivalents (METs). Moderate PA is 3 to 6 METs, and vigorous PA is more than 6 METs (1), meaning these PA intensities cost at least 3 times higher energy than the energy at rest. For health benefits, World Health Organization (WHO) recommends adults to perform moderate PA at least 150 minutes/week, vigorous PA at least 75 minutes/week, or an equivalent combination of moderate and vigorous intensity PA (1). Individuals who perform insufficient amounts of moderate-to-vigorous physical activity are usually considered as physically inactive (2).

Physical inactivity could lead to non-communicable diseases such as diabetes, chronic kidney disease, or cancer (1). These non-communicable diseases may lead to a lower limb amputation (LLA), subsequent amputations or death (3,4). In persons with more comorbidities, the risk of amputations increases (4) and PA reduces (5). When compared to people without physical and sensory disabilities, people with disabilities including a LLA adhere less to the WHO’s recommendation (6). They spend less time participating in moderate to vigorous activities PA than people with no disabilities (6). At the same age as able-bodied individuals, people with diabetes are less physically active, which is even worse after a LLA (5). Their free time activities change after a LLA from more physically active like cycling or farming to be more sedentary like reading, watching television or listening to music (7). A review reveals that the percentage of people with a LLA that participate in sports range from as low as 11 % to as high as 60% (8).

People with a LLA can generate sufficient effort for health benefits by cycling. Most of the cycling can be considered as moderate PA (9). Energy costs due to general bicycling is about 7.5 METs and unicycling 5 METs (10). Bicycling with speed less than 10 mph (4 METs) cost fewer METs than uphill bicycling (14 METs) or racing (16 METs) (10). For people with a LLA who do not sport or exercise, they can still meet the recommended level of PA (11) with everyday PA through participating in commuting by cycling and through PA at work (12).

Cycling has many advantages; cycling can provide entertainment, socialization, cardiovascular fitness, increase muscle strength and keep active

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GENERAL INTRODUCTION

11 joint ranges beneficial for walking (9,13–15). People with a LLA may reduce PA if they experience walking problems (4). Because the saddle carries most of the weight, cycling minimizes load and impact on the lower limb. Furthermore, cycling is accessible and feasible for most people due to numerous types of bicycles and price ranges. Given the fact that many people started cycling since childhood (16) and many people commute 30 minutes or more a day, integrating cycling into daily routines provides a promising method to increase PA (9).

FACILITATORS AND BARRIERS

International Classification of Functioning, Disability and Health (ICF) classifies the factors influencing activity participation into environmental and personal factors (17). The ICF framework shows that health condition relates to body structure and function, activities, participation, and environmental and personal factors. Following the ICF framework, a LLA influences body functions/structure (amputation procedure, prosthetic function, residual limb health, cardiovascular endurance, muscle strength), activities (running, strengthening exercise), participation, personal factors (motivation, outcome expectations), and environmental factors (socialization, attention on amputation and post-operative care quality) (18).

Nine themes relating to PA barriers and facilitators constructed from veterans with a LLA are routine/purpose, social support, perceived benefit and costs, confidence/acceptance, lack of acceptance, active history, resources, health, self-efficacy and prosthesis issues (19). For sports, barriers and facilitators are classified into three categories: social, technical, and personal factors (20). Having social support and sport peers or increasing social contacts influence sports participation (20). Technical factors including transportation, infrastructure (sports facilities), information and prosthesis are experienced more as barriers than facilitators (20). To reduce the technical barriers, the focus should be toward improving transportation to facilities and accessibilities of facilities rather than aspects of the prostheses since many athletes sports without the prostheses (20).

People with a LLA reported activity limitations and participation restrictions to their desired PA preferences (18). A LLA itself can act as a barrier to PA participation due to the loss of anatomic structures of the limb. Condition-related factors such a low cardiorespiratory fitness or co-morbidities also act as PA barriers (5,18). In Dutch people with a LLA, age above 60 years, smoking and vascular-related cause of a LLA are predictors of not participating in sports (21). Since several factors can influence PA participation, and therefore cycling participation, the key to promote PA is to understand these factors and how they are related to each other (22).

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LOWER LIMB PROSTHESES

Lower limb prostheses are provided to people after a LLA for function and/or cosmesis. Given the same patient conditions, prosthetic prescription varies depending on clinicians expertise and knowledge (23,24). This knowledge is transmitted, developed and renewed by clinical training, clinical practice, guidelines, protocols (25,26), courses and symposia and lead to the prescription variations among the clinicians (23). For that reason, clinical guidelines or references should be used (23–25). Several books suggest that fitting of the lower limb prostheses for people with severe hip or knee contracture (≥ 25º) is difficult (27–29). Such a suggestion may limit the chance of prosthesis prescription and fabrication and as a result, limit the chance of prosthesis use and participating in PA in patients with a severe knee or hip contracture. Considering intention to walk or activity participation, clinicians have prescribed and fitted lower limb prostheses, bent prostheses, to people despite the presence of severe contractures of hip or knee (30–32). These persons thereafter walk and participate in vocational and recreational activities with the bent prostheses (32).

Besides the expertise of clinicians, financial accessibility could determine the choices of prosthesis prescription. Thai people with a LLA can receive prostheses for free from public hospitals (33), but the components are usually limited to a solid-ankle cushioned heel (SACH) foot and depending on amputation level, an exoskeletal shank, a safety knee unit, a socket, and belt suspensions (34) (Figures 1, 2). The mechanics and design of these components may not be suitable for sports and cause skin abrasion, pain or restrict hip or knee movements (35). In contrast, the prostheses prescriptions in the Netherlands have greater variations than in Thailand and primarily based on the local clinicians (23,24) rather than the finance. Consequently, the prescription variations can lead to underuse or overuse of prosthetic care (22).

Figure 1. A transtibial prosthesis consists of a SACH foot, an exoskeletal shank laminated with socket, and a cuff suspension.

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GENERAL INTRODUCTION

13 Figure 2. A transfemoral prosthesis consists of a SACH foot, an exoskeletal shank laminated with a weight-activated knee, an exoskeletal thigh laminated with a socket, and a Silesian belt.

For professional athletes, specially designed prostheses for sports may offer an increase in sports performance (36). A small number of athletes can limit clinician experience in prescribing or fitting sport prostheses. The selection of the prosthetic components may be primarily based on the input of prosthetic components manufacturers. For example, the prosthetic sports feet are classified and selected based on diverge foot stiffness categories from the manufacturers rather than standardized unit (37). This may not fit with an individual athlete’s desired performance and result in dissatisfactory.

Prostheses can be considered as both a barrier and a facilitator. Prosthetic problems can restrict PA (38) or sports participation (18,19). Special prostheses for cycling could facilitate cycling for professional athletes (39,40). In people who cannot walk longer than a few hundred meters with the prosthesis without blisters, the prosthesis can be a barrier to participate in sports (20). Poorly fitting prostheses may cause fear for the users (19). Heat and sweating in a well-fitting prosthesis may hinder people to sport (19). On the other hand, some people with a LLA sport without the prosthesis (19,20).

THESIS AIMS

It has been shown that people with a LLA participate in cycling (7,21,41–43), but those studies aimed to identify overall PA, sports or leisure activities participation rather than cycling participation. Before a LLA, many people cycle in daily life, but the information on cycling participation after a LLA is limited. Barriers and facilitators for sports in people with a LLA may not represent

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barriers and facilitators for cycling. Through an understanding of cycling participation and cycling factors, clinicians can help people to become more physically active by cycling. Cycling was often reported for sports that people participate in with prostheses (21) but specialized prostheses for cycling are not easily accessible for most people with a LLA. Knowledge about how the prostheses are used for cycling or sports and its satisfaction can help clinicians to improve prostheses.

This thesis aims to explore cycling participation after a LLA and factors predicting cycling, particularly towards the use of lower limb prostheses. For cycling participation, frequency, duration and reasons were evaluated. Prostheses used and their association with cycling were analyzed. Factors associated with cycling were analyzed as barriers or facilitators and predictors of cycling with a LLA. Satisfactions of the prosthesis and service were analyzed and identified as well as its association with cycling. Lastly, the satisfaction of athletes who used sports prostheses, particularly prosthetic sports feet, were evaluated, and factors influencing satisfaction in the prosthetic sports feet use and provision process were presented.

THESIS OUTLINE

Chapter 2, a systematic review, describes problems and solutions of prosthetic

fittings in people with a LLA who have a severe hip or knee contracture. Chapter 3, a scoping review, presents current evidence of cycling participation,

facilitators and barriers in people with a LLA. Chapter 4 is a survey study in Thai

people with a LLA reporting cycling participation, facilitator and barriers as well as cycling predictors. A similar study has been done in people with a LLA in the Netherlands and is presented in Chapter 5. Chapter 6 presents the satisfaction

of a daily prosthesis and its relationship with cycling in Thai people with a LLA.

Chapter 7, a mixed-methods study, presents the satisfaction of athletes with a

LLA with their prosthetic sports feet who use the feet in several sports including cycling. Chapter 8 presents a letter to editor written due to arisen questions in

the research methodology and statistical analysis of an included study in the

Chapter 3. Chapter 9, the general discussion, the findings of this thesis are

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GENERAL INTRODUCTION

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