# Exercise as it relates to Disease/Enablers and Barriers to Physical Activity with the Lower Limb Amputee Population

This following is an analysis of the journal article of ‘Physical activity barriers and enablers in older Veterans with lower-limb amputation” by Littman, Edward, Thompson, Haselkorn, Sangeorzan and Arterburn.

### What is the background to this research?

Physical activity (PA) provides many physical and mental health benefits. Physical inactivity is the one of leading causes of associated with chronic diseases, poor health and obesity $^1$. Walking, however, is one of the most popular form of PA. This could be a different case for lower limb amputees. Lower limb amputation (LLA) would be considered a limitation to PA and walking. For the LLA population to walk, it requires additional skills, energy and strength $^2$. Lower limb amputees are reported to have poorer health related outcomes secondary to a decreased participation to PA $^3$. LLA itself can lead to depression, anxiety and a lower quality of life $^4$. PA in this population is more challenging as it may be because of chronic illness that may have led to their amputation; the need for prosthetics and equipment to walk is challenging as well as risk of skin ulceration in the residual limb $^{1,2}$. In Australia, there are around 8000 amputations per year, mainly due to peripheral vascular disease and diabetes related foot disease. PA in the LLA population is still required to prevent any further deterioration in the physical and psychological function, worsening chronic illnesses and weight gain $^5$. PA is known to have a positive contribution to individual’s health. Gaining awareness and finding alternative pathways to increase PA in this population would potentially improve individual’s quality of life and decrease the economic burden $^6$.

### Where is the research from?

This research by Littman et al. (2014) $^2$ is from the Seattle Epidemiologic Research and Information Centre in the Department of Veterans Affairs (VA) in Washington which included data gathered from 8 medical centres in Washington, Oregon, Alaska and Idaho and their community-based outpatient clinics.

### What kind of research was this?

It was a qualitative research study which used self-reported surveys from community population data.

### What did the research involve?

There was a 28-page questionnaire which asked about amputation characteristics, PA, diet, weight, health and well-being, demographic characteristics, walking ability, mental health and pain indicators. Barriers and enablers of PA were also assessed. This questionnaire was posted to 400 potential subjects that had either partial foot, below knee or above knee amputations from US Veterans electronic medical records. Out of the 400 subjects they were approached, 161 people completed the questionnaire, 3 people were ineligible for the study, leaving 158 for analyses. There were 155 men and 3 women that participated, the average age of participants were 65 years old and 15 years post amputation $^2$.

### What were the basic results?

Predominately, the study participants were male, older, non-employed (e.g. retired, disabled), lower wealth population. With their current activities, walking or wheeling were the most common forms of PA (64.6%), followed by strengthening exercises (42.4%), exercises prescribed by a physical or an occupational therapist (31.7%), gardening (30.7%) and yard work (29.4%). Individuals with above knee amputations were more likely to perform prescribed physical and occupational therapy exercises, strengthening exercises and bicycling $^2$. This research also found that the main barriers to PA were resource and pain related. Those with above knee amputations, reported they had fears of falling which was the main barrier to PA for this group $^2$. Conclusions made from self-reporting can have its limitations and can cause bias results $^2$. The research is also skewed towards older white males in the four northwestern states which under represents females, youth, rural areas and ethnic minorities. Therefore, only generalised conclusions should be made based on these results. As these individuals were Veterans, this population of this group could have been physically active prior to their amputation compared to the general population.

### What conclusions can we take from this research?

Individuals with LLA that were physically active had a higher chance of being physically healthy, less sedentary and have more interest and knowledge related to exercise. Key barriers should be addressed which would potentially increase PA with this population of people. The enablers for PA that were reported to facilitate PA was financial assistance to join a gym and support from family or spouses. The enablers of PA do not differentiate between the level of amputation $^1$. Personal factors including finances, motivation and pain related factors which should be considered when addressing this population’s barriers and enablers of PA. This could potentially reduce the sedentary behaviours through education and self-efficacy $^7$. The conclusions that can be taken from this research is that there is a relationship between increased PA with an improved quality of life. It also indicated that PA in the LLA population is important to promote physical and psychological well-being which would potentially reduce the risk of chronic diseases $^2$. However, this research requires a consideration of larger groups of amputees such as females, youths, a variety of ethnic minority groups and those living in rural areas.

### Practical advice

Health professionals should use these research results to develop and encourage practical measures to increase PA in the LLA population. Lack of PA negatively impacts their physical and psychological health and impacts their quality of life. Amputees have both physical and mental barriers to PA. In Australia, non-government and community-based organisations could provide individualised support involving social workers, recreational therapists to help with financial barriers that have limited access to the resources. They can also employ motivational interviewing techniques to encourage participants to set PA goals that could be achievable within their fitness level, functional capacity and financial means. When encouraging PA, family members and spouses should be included into their individualised plan which would be helpful in providing motivation and overcoming the barriers to PA.

### Further information/resources

National Disability Insurance Scheme (NDIS) – allows access to financial and service support. https://www.ndis.gov.au/about-us.html
Disability Sports Australia- connects people with physical disabilities through sports and recreational opportunities. http://www.sports.org.au/about-dsa/
Limbs 4 life- provides information and support for people who have had amputations, their families and all health care providers which also include sporting opportunities. http://limbs4life.org.au/links.html

### References

1. Deans S. (2012). Motivations and barriers to prosthesis users participation in physical activity, exercise and sport: A review of the literature. Prosthetics and Orthotics International. 36(3):260-9.
2. Littman A. (2014). Physical activity barriers and enablers in older veterans with lower-limb amputation. Journal of Rehabilitation Research and Development.51(6):895-906.
3. da Silva . (2011). Physical activity and quality of life of amputees in Southern Brazile. Prosthetics and Orthotics International. 35(4):432-8.
4. Sinha R. (2011). Factors affecting quality of life in lower limb amputees. Prosthetics and Orthotics International. 35(1):90-6.
5. Dillon M. (2014). Incidence of lower limb amputation in Australian hospitals from 2000-2010. Prosthetics and Orthotics International. 38(2):122-32.
6. World Health Organisation. (2015). Global Strategy on Diet, Physical Activity and Health; Available from: http://www.who.int/dietphysicalactivity/en/
7. Bragaru M. (2013). Sports participation of Dutch lower limb amputees. Prosthetics and Orthotics International. 37(6):454-8.