Epidemiology and Pathophysiology of Amputation

Ken Pitetti, Ph.D., Professor, College of Health Professions, Wichita State University

Amputations are commonly divided into two major categories: upper-extremity (UE) and lower-extremity (LE) amputations. The majority (i.e., 80%) of LE amputations are caused by peripheral vascular disease and diabetes. Trauma due to vehicular accidents or job-related accidents is the second most common cause of LE amputations. Trauma due to vehicular accidents, severe lacerations from tools and machinery, and frostbite, is the major cause of UE amputations. Curative treatment of tumors is an additional cause of both types of amputations.

LE amputations are commonly classified into the following categories:

• toe and partial foot amputation (i.e., Symes);
• unilateral (i.e., involvement of only one leg) below-knee;
• unilateral above-knee;
• hip disarticulation and hemipelvectomy;
• bilateral (i.e., involving both legs) below-knee;
• bilateral above- and below-knee (i.e., one leg amputated above the knee, one leg amputated below the knee); and
• bilateral above-knee (i.e., both legs amputated above the knee).

Energy expenditure of ambulation is higher for LE amputees when compared to either non-disabled peers or UE amputees. Indeed, the energy cost of walking is directly related to the level of amputation. For instance, Huang and colleagues (1979) reported that even when LE amputees were allowed to choose their own comfortable walking speeds, the mean energy cost was 9% higher for unilateral below-knee amputees, 65% higher for unilateral above-knee amputees and 280% higher for bilateral above-knee amputees when compared to their non-disabled peers. The higher the energy cost of walking, the more work it takes to ambulate and, therefore, the less ambulation the LE amputee is likely to do. This contributes to a sedentary lifestyle. Studies have shown that non-vascular LE amputees have higher rates of cardiovascular disease, hypertension and adult-onset diabetes (Type II) (Hrubec and Ryder, 1979; Rose et al., 1987) when compared to the non-disabled population. Sedentary lifestyle was listed as the major contributing factor for the increase in these secondary diseases. These findings accentuate the importance for LE amputees to include physical exercise and activity in their lifestyles.

UE amputations are commonly categorized as below-elbow or above-elbow amputations and shoulder disarticulation. Because UE amputations have little effect on the individual's walking or running ability, UE amputees have no greater risk of cardiovascular disease, hypertension, obesity, or Type II diabetes than non-disabled individuals (Hrubec & Ryder, 1979; Rose et al., 1987).

Amputees and Exercise

The basic principles of exercise testing and exercise prescription stated in ACSM's Guidelines for Exercise Testing and Prescription (2006) and ACSM's Exercise Management of Persons with Chronic Diseases and Disabilities (1997) provide the foundation for this section. Special needs and situations created by amputation will be addressed.

Excellent resources which describe balance, agility, coordination, endurance, stretching, and strengthening exercises for LE amputees are found in the following texts: Strengthening and Stretching for Lower Extremity Amputees (Gailey & Gailey, 1994); Balance. Agility. Coordination and Endurance for Lower Extremity Amputees (Gailey & Gailey, 1994); and Home Exercise Guide for Lower Extremity Amputees (Gailey, Gailey & Sendelback, 1995.)

Another excellent resource for training LE amputees for sport or health is the publication by the Department of Veterans Affairs, Physical Fitness: A Guide for Individuals with Lower Limb Loss (Burgess and Rappoport, 1991). The publication represents a guide for prescribing exercises that will improve all aspects of physical fitness, including cardiovascular, flexibility, muscle strength and endurance and motor skills.

Research has established the benefits of exercise for LE amputees. In 1973, James reported that for healthy (i.e., non-vascular) unilateral above-knee amputees, one-legged (i.e., non-involved leg) bicycle ergometry training improved cardiovascular fitness and walking efficiency. Additionally, the asymmetry of the prosthetic gait was decreased. In 1987, it was reported (Pitetti et al., 1987) that when a combination of unilateral below-and above-knee, and bilateral below-and above-knee amputees trained on a Schwinn Air-Dyne ergometer (an apparatus that involves both upper- and lower-body musculature), they improved their cardiovascular fitness and walking efficiency. Following a treadmill training program, a 63-year-old bilateral below-knee amputee with cardiac status of Class IV and restrictive-obstructive pulmonary disease improved cardiovascular fitness, improved cardiac status from Class IV to Class II, and therapeutically improved from Class E (bed rest) to Class C (moderate exercise restriction). These studies established that LE amputees, whether healthy or suffering from secondary disabilities, can improve their fitness levels, but more importantly, can improve their quality of life by increasing their ability to perform activities of daily living.

It is important that a LE amputee has a comfortable prosthetic limb(s) that is suited for the activity or exercise of choice. Activities and exercises such as treadmill walking, bicycling, rowing, StairMaster, Body Trec and other aerobic machines do not require special adaptations to a standard artificial limb. Such activities and exercises as running, sprinting, and swimming do require special adaptations. It is recommended that the amputee work with a prosthetist in obtaining needed adaptations for prosthetic limbs.

Skin breakdown (i.e., blisters) or hair follicle infections can significantly affect the activity level of any amputee. Practicing proper hygiene will help prevent skin problems. It is important for the amputee to determine the right size of stump socks and the correct number of stump socks to be worn, to change stump socks daily and when they are damp or wet (e.g., following exercise). This is essential to help prevent skin irritations and blisters.

UE amputees, because of their healthy lower extremities, are not as limited in their modes of exercise as LE amputees. All activities and exercises involving the lower extremities that can be performed by non-disabled individuals are applicable to UE amputees. However, when performing upper-extremity exercises (i.e., weight training), the position of the UE amputee's feet and legs are paramount in order to obtain balance and stability. Therefore, UE amputees should perform upper-extremity exercises while standing and, if sitting, they should allow their feet to be in contact with the floor.

About the Author

Ken Pitetti, Ph.D., is Professor, College of Health Professions, Wichita State University. He received his B.S. degree in biology from the University of San Francisco, his M.S. in biology from Ft. Hays State University, and his doctorate in Human Physiology from the University of Texas Southwestern Medical School in Dallas. For the past 17 years, Dr. Pitetti's research has focused on exercise science and health concerns as they pertain to persons with chronic diseases and disabilities. For this paper, Dr. Pitetti also brings personal insight to exercise and amputation, as he lost his leg in combat operations during the Vietnam War.

Note

The information provided here is offered as a service only. The National Center on Physical Activity and Disability, University of Illinois at Chicago, the National Center on Accessibility, and the Rehabilitation Institute of Chicago do not formally recommend or endorse the equipment listed. As with any products or services, consumers should investigate and determine on their own which equipment best fits their needs and budget.

National Center on Physical Activity and Disability
http://www.ncpad.org
ncpad@uic.edu
(800) 900-8086 (voice and TTY)
(312) 355-4058 (facsimile)

Organizations

1. Amputee Coalition of America :
   Knoxville , Tennessee

Books

1. American College of Sports Medicine. (2005). ACSM's Guidelines for Exercise Testing and Prescription 7th Ed. Philadelphia, PA: Lea & Febiger / Lippincott Williams & Wilkins.
2. American College of Sports Medicine. (1997). ACSM's exercise management for persons with chronic diseases and disabilities. Champaign, Illinois: Human Kinetics Publishers.
3. Burgess, E.M., & Rappoport, A. (1991). Physical Fitness: A Guide for Individuals with Lower Limb. Washington, D.C: Department of Veterans Affairs.
4. Gailey, R. S., & Gailey, A.M. (1994). Stretching and Strengthening for Lower Extremity Amputees. Miami, FL: Advanced Rehabilitation Therapy, Inc.
5. Gailey, R.S., & Gailey, A.M. (1994). Balance, Agility, Coordination and Endurance for Lower Extremity Amputees. Miami, FL: Advanced Rehabilitation Therapy, Inc.
6. Gaily, R.S., Gailey, A.M., & Sendelbach, S.J. (1995). Home Exercise Guide for Lower Extremity Amputees. Miami, FL: Advanced Rehabilitation Therapy, Inc.

Journals

1. Hrubec, Z. & Ryder, R.A. (1978). Traumatic limb amputation and subsequent mortality from cardiovascular disease and other causes. Journal of Chronic Disease, 33, 239-250.
2. James, U. (1973). Effect of physical training in healthy male unilateral above-knee amputees. Journal of Rehabilitative Medicine, 5, 71-80.
3. Pitetti, K.H., Snell, P.G., Stray-Gunderson, J., & Gottschalk, F.A. (1987). Aerobic training exercise for individuals who had amputations of the lower limb. Journal of Bone and Joint Surgery, 69(A), 914-921.
4. Rose, H.C., Schweitzer, P., Charoenkul, V., & Schwartz, E. (1987). Cardiovascular disease risk factors in combat veteran after traumatic leg amputation. Archives of Physical Medicine and Rehabilitation, 68, 20-23.

This fact sheet was last updated on 03-01-2007.

Disclaimer