Exploring cycling and sports in people with a lower limb amputation: prosthetic aspects
Poonsiri, Jutamanee
DOI:
10.33612/diss.146256706
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Publication date: 2020
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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
1
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).
12
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.
1
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
14
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
1
GENERAL INTRODUCTION
15
REFERENCES
1. World Health Organization. Global recommendations on physical activity for health. Geneva: World Health Organization. 2010. https://www.who.int/dietphysicalactivity/pa/en/
2. Tremblay MS, Aubert S, Barnes JD, Saunders TJ, Carson V, Latimer-Cheung AE, et al. Sedentary Behavior Research Network (SBRN) - Terminology Consensus Project process and outcome. Int J Behav Nutr Phys Act. 2017;14(1):1–17. https://doi.org/10.1186/s12966-017-0525-8
3. Unwin N. Epidemiology of lower extremity amputation in centres in Europe, North America and East Asia. Br J Surg. 2000;87(3):328–37. https://doi.org/10.1046/j.1365-2168.2000.01344.x
4. Varma P, Stineman MG, Dillingham TR. Epidemiology of Limb Loss. Phys Med Rehabil Clin N Am. 2014;25(1):1–8. https://doi.org/10.1016/j.pmr.2013.09.001
5. Paxton RJ, Murray AM, Stevens-Lapsley JE, Sherk KA, Christiansen CL. Physical activity, ambulation, and comorbidities in people with diabetes and lower-limb amputation. J Rehabil Res Dev. 2016;53(6): 1069–78. http://doi.org/10.1682/JRRD.2015.08.0161
6. de Hollander EL, Proper KI. Physical activity levels of adults with various physical disabilities. Prev Med Reports. 2018;10:370–6. https://doi.org/10.1016/j.pmedr.2018.04.017
7. Burger H, Marincek C. The life style of young persons after lower limb amputation caused by injury. Prosthet Orthot Int. 1997;21(1):35–9. https://doi.org/10.3109/03093649709164528
8. Bragaru M, Dekker R, Geertzen JHB, Dijkstra PU. Amputees and sports. Sport Med. 2011;41(9):721– 40. https://doi.org/10.2165/11590420-000000000-00000
9. Götschi T, Garrard J, Giles-Corti B. Cycling as a part of daily life: A review of health perspectives. Transp Rev. 2016;36(1):45–71. https://doi.org/10.1080/01441647.2015.1057877
10. Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, Bassett DR, Tudor-Locke C, et al. 2011 Compendium of physical activities: A second update of codes and MET values. Med Sci Sports Exerc. 2011;43(8):1575–81. https://doi.org/10.1249/MSS.0b013e31821ece12
11. Rodgers AB, editor. Physical Activity Guidelines for Americans . 2nd ed. U.S. Department of health and Human Services; 2008. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guide lines_2nd_edition.pdf
12. Geidl W, Semrau J, Pfeifer K. Health behaviour change theories: Contributions to an ICF-based behavioural exercise therapy for individuals with chronic diseases. Disabil Rehabil. 2014;36(24): 2091–100. https://doi.org/10.3109/09638288.2014.891056
13. Oja P, Manttari A, Heinonen A, Kukkonen-Harjula K, Laukkanen R, Pasanen M, et al. Physiological effects of walking and cycling to work. Scand J Med Sci Sport. 1991;1(3):151–7. https://doi.org/ 10.1111/j.1600-0838.1991.tb00288.x
14. Oja P, Titze S, Bauman A, de Geus B, Krenn P, Reger-Nash B, et al. Health benefits of cycling: A systematic review. Scand J Med Sci Sport. 2011;21(4):496–509. https://doi.org/10.1111/j.1600-0838.2011.01299.x
15. Nolan L. Lower limb strength in sports-active transtibial amputees. Prosthet Orthot Int. 2009 ;33(3): 230–41. https://doi.org/10.1080/03093640903082118
16. Jewett A, Beck LF, Taylor C, Baldwin G. Bicycle helmet use among persons 5 years and older in the United States, 2012. J Safety Res. 2016;59:1–7. https://doi.org/10.1016/j.jsr.2016.09.001
17. World Health Organization. A Practical Manual for using the International Classification of Functioning, Disability and Health (ICF). Exposure draft for comment. Geneva: WHO. 2013. https://www.who.int/classifications/icf/en/
18. Crawford DA, Hamilton TB, Dionne CP, Day JD. Barriers and facilitators to physical activity participation for men with transtibial osteomyoplastic amputation: A thematic analysis. J Prosthetics Orthot. 2016;28(4):165–72. https://doi.org/10.1097/JPO.0000000000000109
19. Littman AJ, Bouldin ED, Haselkorn JK. This is your new normal: A qualitative study of barriers and facilitators to physical activity in Veterans with lower extremity loss. Disabil Health J. 2017;10(4):600– 6. http://dx.doi.org/10.1016/j.dhjo.2017.03.004
16
20. Bragaru M, van Wilgen CP, Geertzen JHB, Ruijs SGJB, Dijkstra PU, Dekker R. Barriers and facilitators of participation in sports: a qualitative study on Dutch individuals with lower limb amputation. PLoS One. 2013;8(3):e59881. https://doi.org/10.1371/journal.pone.0059881
21. Bragaru M, Meulenbelt HEJ, Dijkstra PU, Geertzen JHB, Dekker R. Sports participation of Dutch lower limb amputees. Prosthet Orthot Int. 2013;37(6):454–8. https://doi.org/10.1177/0309364613476533 22. Rimmer JH. Use of the ICF in identifying factors that impact participation in physical
activity/rehabilitation among people with disabilities. Disabil Rehabil. 2006;28(17):1087–95. https://doi.org/10.1080/09638280500493860
23. Van Der Linde H, Geertzen JHB, Hofstad CJ, Van Limbeek J, Postema K. Prosthetic prescription in the Netherlands: an observational study. Prosthet Orthot Int. 2003;27:170–8. https://doi.org/10.1080/ 03093640308726679
24. Van Der Linde H, Geertzen JHB, Hofstad CJ, Van Limbeek J, Postema K. Prosthetic prescription in the Netherlands: An interview with clinical experts. Prosthet Orthot Int. 2004;28(2):98–104. https://doi.org/10.1080/03093640408726694
25. Prothesen P. Protocol verstrekkingsproces beenprothesen Stuurgroep PPP (Protocollering en Prijssystematiek Prothesen).2019. https://www.ispo.nl/protocol-verstrekkingsproces-beenprothesen
26. Niveau L. Protocol Prescriptie Prothese Beenprothese. Vol. 2019. 2019. https://www.ispo.nl/ protocol-verstrekkingsproces-beenprothesen
27. Bowker JH, Thomson RG. Management of musculoskeletal complications. In: Atlas of limb prosthetics: surgical, prosthetic, and rehabilitation principles. 1st ed. St. Louis, Toronto, London: American Academy of Orthopaedic Surgeons; 1981.
28. Bowker JH, Michael JW. Atlas of limb prosthetics: surgical, prosthetic and rehabilitation principles. 2nd ed. St. Louis: American Academy of Orthopaedic Surgeons; 1992.
29. Bowker JH. The art of prosthesis prescription. In: Atlas of limb prosthetics: surgical, prosthetic, and rehabilitation principles. 3rd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2004. 30. Alexander J. Irreversible contractures: an impediment to prosthetic rehabilitation. Am Acad
Orthotists Prosthetists. 1980;4(3):1–2. http://www.oandplibrary.org/cpo/1980_03_001.asp
31. Kim SB, Ko CY, Son J, Kang S, Ryu J, Mun M. Relief of knee flexion contracture and gait improvement following adaptive training for an assist device in a transtibial amputee: A case study. J Back Musculoskelet Rehabil. 2017;30(2):371–81. https://doi.org/10.3233/BMR-160736
32. Titner H. Fitting and fabrication of a prosthesis for a severe flexion contracture: case study. Bull Prosthet Res. 1973;10(19):84–7. https://pubmed.ncbi.nlm.nih.gov/4767332/
33. Prakongsai P, Limwattananon S, Tangcharoensathien V. The equity impact of the universal coverage policy: Lessons from Thailand. Adv Health Econ Health Serv Res. 2009;21:57–81. https://doi.org/10.1108/S0731-2199(2009)0000021006
34. Anannub K, Yotnuengnit P. Compliance and satisfaction of lower limb amputees toward basic prostheses. Chula Med J. 2016;60(6):603–15. https://he01.tci-thaijo.org/index.php/clmj/article/view/ 182224
35. Webster JB, Levy CE, Bryant PR, Prusakowski PE. Focused review: Sports and recreation for persons with limb deficiency. Arch Phys Med Rehabil. 2001;82(Suppl. 1):S38–44. https://doi.org/10.1053/ apmr.2001.22243
36. Childers WL, Kistenberg RS, Gregor RJ. The biomechanics of cycling with a transtibial amputation: Recommendations for prosthetic design and direction for future research. Prosthet Orthot Int. 2009;33(3):256–71. https://doi.org/10.1080/03093640903067234
37. Beck ON, Taboga P, Grabowski AM. Characterizing the mechanical properties of running-specific prostheses. PLoS One. 2016;11(12):1–16. https://doi.org/10.1371/journal.pone.0168298
38. Gallagher P, O’Donovan MA, Doyle A, Desmond D. Environmental barriers, activity limitations and participation restrictions experienced by people with major limb amputation. Prosthet Orthot Int. 2011;35(3):278–84. https://doi.org/10.1177/0309364611407108
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GENERAL INTRODUCTION
17
39. Bragaru M, Dekker R, Geertzen JHB. Sport prostheses and prosthetic adaptations for the upper and lower limb amputees: an overview of peer reviewed literature. Prosthet Orthot Int. 2012;36(3):290– 6. https://doi.org/10.1177/0309364612447093
40. Childers WL, Kistenberg RS, Gregor RJ. Pedaling asymmetries in cyclists with unilateral transtibial amputation: Effect of prosthetic foot stiffness. J Appl Biomech. 2011;27(4):314–21. https://doi.org/ 10.1123/jab.27.4.314
41. Kubińska Z, Bergier B, Bergier J. Usage of leisure time by disabled males and females from the Lublin region. Ann Agric Environ Med. 2013;20(2):341–5. https://pubmed.ncbi.nlm.nih.gov/23772588/ 42. Legro MW, Reiber GE, Czerniecki JM, Sangeorzan BJ. Recreational activities of lower-limb amputees
with prostheses. J Rehabil Res Dev. 2010;38(3):319–25. https://pubmed.ncbi.nlm.nih.gov/ 11440263
43. Gailey RS. Recreational pursuits for elders with amputation. Top Geriatr Rehabil. 1992;8(1):39–58. https://doi.org/10.1097/00013614-199209000-00007
