Amputation of a limb may cause permanent disability and decreases mobility temporarily or permanently.[1] 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.[2] These perceptions contribute to the relatively high depression and anxiety rates recorded amongst individuals with limb amputations, especially in the first 2 years after amputation.[3–5] 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 US, about 82% of all lower and upper limb amputations are due to vascular conditions, whereas 16% of amputations are due to trauma.[6] 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.[7]

In general, participation in sports or physical activities is important in maintaining physical fitness.[8,9] Lack of physical exercise is the most important determinant of a deteriorating physical state, often leading to coronary heart disease.[10] Health organizations recommend 30 minutes or more of moderately vigorous daily physical activity.[11] Because of the amputation and the underlying diseases persisting after amputation, individuals with limb amputations tend to be less active than the able-bodied.[12] 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.[13]

Publications focusing on sports participation among individuals with limb amputations are generally characterized by a limited number of participants, anecdotal reports and diverse outcome variables.[14–18] Even though there are a number of reviews[13,19,20] 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, such as 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 programme as part of a treatment programme for their patients, and to better understand the benefits and risks of sports participation for this group. Therefore, the aim of this article 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.

1. 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”.[21] Physical activity was defined as “any bodily movement produced by skeletal muscles that require energy expenditure”.[22]

Four databases were searched: 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 and the search was structured into two parts. One part concerned papers that related to amputations, while the second part concerned papers that 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 table S1 online in the Supplemental Digital Content (SDC) 1, http://links.adisonline.com/SMZ/A6. Sports were only searched as MeSH headings and as a general free text word, not by means of specific types of sports, such as running, cycling or basketball. All retrieved papers were combined in a single database and duplicates were removed. The most recent search date was 31 March 2010.Footnote 1

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.

2. 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).

Fig. 1
figure 1

Flow chart of the systematic review.

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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 S1 online in the SDC 1.

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.

2.1 Biomechanical Aspects and Athletic Performance

Ten studies analysed the biomechanical aspects of swimming,[23] running[24–26] and long jump,[27–32] 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 I.

Table I
figure Tab1

Studies analysing characteristics for individuals with limb amputations

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Young individuals with unilateral transtibial amputations who were provided with prostheses and were adequately trained were able to run.[24,25] Runners with lower limb amputations demonstrated a difference between the prosthetic and nonprosthetic limbs regarding step length and vertical, mediolateral and horizontal displacement of the centre of mass. The prosthetic and nonprosthetic limbs also differed in these variables from those of able-bodied individuals.[26,32] Long jumpers with transtibial amputations jumped further than those with transfemoral amputations.[27,31] Long jumpers with transtibial amputations who used their prosthetic limb for take-off had a shorter last step and a lower vertical velocity at touchdown than did those jumpers using their sound limb for take-off.[28] Runners with lower limb amputations[25,26] and swimmers with upper limb amputations[23] increase their speed by increasing their pace rather than their step or stroke length.

2.2 Cardiopulmonary Function

Twelve studies analysed cardiopulmonary function in relation to sports or physical activity among individuals with limb amputations.[1,17,34–43] 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 (V̇O2max), heart rate, blood pressure, anaerobic threshold, and maximum power output. An overview of these papers is presented in table I.

The general physical condition of individuals with limb amputations is worse than the reference values for able-bodied people of similar age.[1,34] Nevertheless, individuals with limb amputations have better aerobic and anaerobic power outputs than do individuals with other locomotor disabilities.[39] Participation in sports or physical activity has beneficial influences on the cardiopulmonary system, muscle force and body mass of individuals with limb amputations.[17,35,38,40] The rehabilitation time of individuals with limb amputations was shorter when physical training was part of their rehabilitation programme.[41]

2.3 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.[44–49] 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 I.

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.[44,47] 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.[48,49] Participation in sports and/or physical activity decreased following the amputation as a direct result of physical constraints and accessibility issues.[49]

2.4 Sport Participation and Physical Functioning

Fifteen studies analysed associations between sport participation and/or physical activity and physical functioning of individuals with limb amputations.[51–65] 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 programme. An overview of these papers is presented in table I.

From the included papers, it appears that between 11% and 61% of individuals with lower limb amputations participate in sports and/or physical activities.[51–53,57,62,65] The choice of which sports to take part in was influenced by gender, the specific energy requirement of the sport and the load on the prosthetic limb.[59,64] Fishing, swimming, golfing, walking and cycling were favoured sports. Younger individuals with unilateral transtibial amputations due to nonvascular causes were more active than older individuals with bilateral transfemoral amputations due to vascular causes.[53,57] A short but intensive physical training programme improved the walking distance and speed of individuals with traumatic lower limb amputations.[60]

2.5 Sports Injuries

Four studies analysed the sports injuries suffered by individuals with limb amputations.[68–71] 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 I.

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.[70] The emotional benefits of participating in sports outweighed the possible risk of injury.[68] The presence of pain did not influence perceived activity restrictions.[71]

3. Discussion

The aim of this study was to systematically review the literature on biomechanical characteristics, cardiopulmonary function, psychological well-being, 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%) 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 nonvascular amputations. The general population of individuals with limb amputations has an average age above 65 years, and most of these individuals have vascular amputations.[72] 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.[29–31,52] Participation in sports and physical activity positively influences their physical fitness, psychosocial well-being and physical functioning.[35,40,41,44,48,59,60] 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.[54,57,64] 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 transtibial amputation are able to run,[25] 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.[27,31,32] For long jumpers with trans-tibial amputations, better results were recorded among individuals who used their prosthetic limb for take-off compared with those using their intact limb for take-off.[28] The findings of two studies, one[73] with a small sample size (n = 5) and a literature review,[74] suggest that prosthesis characteristics influence running performance therefore also influence 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.[23] 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[25] 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 programme was included in their rehabilitation programme. The intensity of the programme should be based on each individual’s heart rate during anaerobic threshold and should not exceed 80% of the maximum peak value.[37] 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 programmes 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,[75] and Prosthesis Evaluation Questionnaire; PEQ[76]) to assess the ability to walk. Individuals with lower limb amputations who are able to achieve an exercise intensity of 50% V̇O2max[43] or 60 Watts can be expected to become successful prosthetic walkers.[34,43] When an individual’s walking prognosis is known, the rehabilitation process can be adapted according to the expected outcome, therefore optimizing the results.

The psychological impact of the disability on athletes with limb amputations was found to be smaller as compared with athletes with other disabilities, such as audio-visual impairment or spinal cord injury.[45] This is an interesting finding considering that an amputation is often perceived by the able-bodied as one of the worst physical disabilities.[77] Unfortunately, no similar comparison between different disabilities has been performed in nonsporting 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.[44,46,78] 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 organized 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.[48] 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.[79]

Participation in sports decreases following amputation.[49,58] In Europe, 11–39% of individuals with limb amputations participate in sports or regular physical activity, while in the US this percentage is 61%.[51–53,57,62,65] This high percentage may be biased by sample characteristics in the US studies, including an average age of 52 years and predominantly traumatic limb amputation in the study samples.[51–53] In general, individuals with limb amputations are older than 65, and more than 80% have a vascular cause for amputation.[72] 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.[80] The sports that individuals with limb amputations prefer to take part in are similar regardless of the continent: swimming, cycling, golf, fishing, fitness.[53,59,62,65] Most individuals with limb amputations do not use special sport prostheses because of high costs, lack of knowledge about such prostheses or the feeling that they are unnecessary.[53,59,62,65] A high percentage (42%) of all individuals with limb amputations reported at least one complaint about their prosthesis or about the sport organization in which they participated.[65] Sport participation appears to be hindered to some extent by the unavailability of a suitable prosthesis, poor performance or high cost of the prosthesis, inadequate facilities or insufficient information.[53,65] 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, such as wheelchair or sitting sports. Professionals should encourage individuals with limb amputations to participate more in sports or physical activities and advise them in choosing an appropriate sport prosthesis.

Several factors were associated with the physical functioning, mobility and activity level following amputation including age,[52,53,57] aetiology,[53] amputation level and previous sport participation.[54,59,64,65] However, discrepancies were found concerning the importance of aetiology[55,57,65] and amputation level.[52,53] For example, two studies[55,57] 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[52,53,81] showing that individuals with nonvascular limb amputations are more active than individuals with vascular amputations. In some studies,[52,53,64] a more proximal amputation was found to lead to a decrease in sport participation. Other studies[62,65] 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.[52,53,57] Rehabilitation practitioners need to consider that a more proximal amputation, older age and the presence of co-morbidity usually lead to a longer and more difficult rehabilitation.[82]

Sport-related muscle pain was more frequent amongst individuals with limb amputations than amongst individuals with other physical disabilities.[70] This difference is probably caused by the relatively limited amount of muscular tissue still available, which is subjected to more intense use as compared with individuals with other physical disabilities. Only one study of sport injuries was found that focused completely on individuals with limb amputations.[68] Other papers assessed sport injuries in a mixed group of athletes with different locomotor disabilities.[83–86] 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,[45,53,54] were not investigated concerning injury rates or patterns.

4. 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 ten participants was arbitrarily chosen to reduce the influence of outliers on outcome and to increase the possibility of generalizing 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 randomized controlled trial was identified. Conducting a randomized 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 studies included individuals with upper limb amputations in their study populations.

5. Conclusion

Participating in sports or physical activity is beneficial for individuals with lower limb amputations. The psychosocial benefits for these individuals are at least equal to those experienced by able-bodied persons.

Future research should focus on the inclusion of a larger variety of sports and individuals with upper limb amputations in the study population. The influence of prosthetic technical characteristics on athletic performance needs further clarification because only running, long jumping and swimming have been analysed so far. The influence of sports on quality of life needs to be more thoroughly investigated. The determinants of sport participation are controversial. Therefore, more studies investigating these determinants are needed. A physical training programme to improve cardiopulmonary function as part of the rehabilitation of individuals with limb amputations should be developed and tested for its efficacy.