# Exercise as it relates to Disease/Physical activity barriers and enablers in lower limb amputees

This is an analysis of the journal article "Physical activity barriers and enablers in older Veterans with lower-limb amputation" by Littman, Edward, Thompson, Haselkorn, Sangeorzan and Arterburn (2014).

## What is the background to this research?

The World Health Organisation estimates one billion people globally live with some form of disability. This will only increase due to ageing populations, and increases in chronic health conditions such as diabetes, cancer and cardiovascular disease. People with a disability generally have poorer health outcomes, lower education, reduced economic opportunities and higher rates of poverty. They also experience formidable barriers including access to transport and health services.
Amputation is a leading cause of permanent disability and is associated with anxiety, isolation, depression and reduced quality of life. Lower limb amputees also have poor health related outcomes and behaviours and participate in less exercise,. Globally the incidence of amputation is between 2.8–43.9 cases per 100,000 people per year. Australia has one of the highest lower limb amputation rates in the developed world, with around 8000 amputations per annum, often associated with diabetes related foot disease or peripheral vascular disease.
Physical activity makes a positive contribution to overall health. Physical inactivity is the fourth leading cause of mortality globally and is associated with chronic disease, obesity and poor health outcomes. Amputees are generally less active and reduce physical activity levels post amputation. Understanding and finding pathways to increasing physical activity can potentially reduce the economic burden, and improve the quality of life in this population.

## Where is the research from?

Littman et al. (2014) from the Seattle Epidemiologic Research and Information Centre, Seattle, Washington, conducted the study targeting the Pacific Northwest urban regions of the USA.

## What kind of research was this?

This is a qualitative research study, relying on self-reported surveys to generate community population data.

## What did the research involve?

A random sample of 400 potential subjects was identified from US government electronic medical records. Subjects were US Veterans with either partial foot, below knee or above knee amputation. A 28-page questionnaire was posted to potential subjects. 161 questionnaires were completed and 3 excluded. A total of 158 completed questionnaires were assessed, 155 men and 3 women, with an average age of 65 years and 15 years post amputation. The questionnaire sought information on amputation and demographic characteristics, walking ability, physical activity levels, mental health and pain indicators. Barriers and enablers of physical activity were also assessed.

## What were the basic results?

Subjects were predominantly male, non-employed (retired, disabled) and had lower socio-economic status. Main forms of physical activity were walking or wheeling. Lower levels of physical activity were associated with more sedentary behaviour. The primary barriers to physical activity were lack of resources and pain. Primary factors that could increase physical activity included financial assistance and family or spousal support.

## Summary Table of Results

| Current Activities (per cent of subjects) | Barriers to Activity (per cent of subjects) | Enablers to Activity (per cent of subjects) |
| 1 Walking or wheeling (64.6) | 1 Resource related (55.1) | 1 Free or no cost membership to gym (43) |
| 2 Strengthening exercises (42.4) | 2 Pain related (53.2) | 2 Support from spouse or family (35.7) |
| 3 Therapist related exercises (31.7) | 3 Health related (30.1) | 3 Home exercise equipment (27.6) |
| 4 Gardening (30.7) | 4 Fatigue or sleepiness (26.1) | 4 Specialised equipment (26.9) |
| 5 Yard work (29.4) | 5 Knowledge related (25.5) | 5 Exercise buddy or partner (24.2) |
| 6 Sedentary behaviours ≥ 5 hours/day watching television (29) | 6 Lack of interest (24.2) | 6 Transportation to gym (22.8) |
| 7 Bicycling (12.1) | 7 Fear of falling (18.1) | 7 Group exercise classes at Veterans Affairs (20.3) |
| 8 Golfing (5.8) | 8 Lack of time (7.5) | 8 Group exercise classes in community (20.3) |
| 9 Swimming (3.2) | | 9 Periodic telephone calls that provide encouragement (9.6) |
| 10 Hydrotherapy (4) | | |

## How did the researchers interpret the results?

There was a strong association between current physical activity and pre-amputation physical activity level. Confirming the importance of maintaining physical activity throughout the life cycle. Physically active amputees were more likely to be physically healthy, be less sedentary, and have more exercise related knowledge and interest. Addressing key barriers and enablers could potentially increase physical activity within this population.
However, conclusions should be moderated due to the limitations of self-reporting, which can bias results. Also the research over-represents older white males in urban areas and under-represents females, youth, ethnic minorities and rural areas. Further, this population is likely to be more physically active pre-amputation compared to the general population. Therefore, only generalised conclusions can be made.

## What conclusions can we take from this research?

Physical activity can potentially improve the quality of life for lower limb amputees. To increase physical activity barriers and enablers need to be addressed, including, financial, family and social support. However personal factors including resource related, motivation, interest and pain interference factors as well as reducing sedentary behaviours through education also need to be considered. Ultimately, amputees need to demonstrate self-efficacy.
This study complements previous research findings indicating regular physical activity in lower limb amputees is important to maintaining physical and psychological function as well as reducing the risk of chronic disease,. Although other research suggest a weaker relationship between increased physical activity levels and improved quality of life. Indicating the need for further investigation into physical activity impacts, as well as broadening parameters to include females, ethnic minorities, rural areas and youth.

## What are the implications of this research?

Amputees are among the most disadvantaged and face considerable barriers. A lack of physical activity and dangerous sedentary behaviour levels can negatively impact physical and psychological function, and quality of life. Health professionals and health policy makers can use research results to develop and implement practical measures to increase physical activity participation. In the Australian context, this means ensuring non-government and community-based organisations have the ability to provide effective individualised support, physical activity related opportunities and access to financial resources as part of the National Disability Insurance Scheme.

## Further resources

For further information regarding physical activity and support for amputees; click on the links below.
* National Disability Insurance Scheme including access to financial and service support https://myplace.ndis.gov.au/ndisstorefront/index.html
* Disability Sports Australia assists people with a physical disability to develop and engage with the community through sports and recreational opportunities http://www.sports.org.au/
* Australian Paralympic Committee helps those with disabilities participate in sport and compete at the Paralympic Games https://www.paralympic.org.au/
* Information and support to amputees, families and health care providers including sporting opportunities http://www.limbs4life.org.au/

## References

* 1 2 3 4 Littman, A., Boyko, E., Thompson, M., Haselkorn, J., Sangeorzan, B., & Arterburn, D. (2014). Physical activity barriers and enablers in older veterans with lower-limb amputation. Journal of Rehabilitation Research and Development, 51(6), 895-906. doi:10.1682/JRRD.2013.06.0152
* 1 2 World Health Organisation & the World Bank. (2011). World Report on Disability. Geneva, Switzerland: World Health Organisation.
* 1 2 Deans, S. A., McFadyen, A. K., & Rowe, P. J. (2008). Physical activity and quality of life: A study of a lower-limb amputee population. Prosthetics and Orthotics International, 32(2), 186-200. doi:10.1080/03093640802016514
* ↑ Sinha, R., Van Den Heuvel, Wim J.A, & Arokiasamy, P. (2011). Factors affecting quality of life in lower limb amputees. Prosthetics and Orthotics International, 35(1), 90-96. doi:10.1177/0309364610397087
* ↑ Group, T. S. (2000). Epidemiology of lower extremity amputation in centres in Europe, North America and East Asia. British Journal Of Surgery, 87(3), 328-337. doi:10.1046/j.1365-2168.2000.01344.x
* ↑ Dillon, M. P., Kohler, F., & Peeva, V. (2014). Incidence of lower limb amputation in Australian hospitals from 2000 to 2010. Prosthetics and Orthotics International, 38(2), 122-132. doi:10.1177/0309364613490441
* ↑ AIHW 2014. Cardiovascular disease, diabetes and chronic kidney disease: Australian facts: morbidity—hospital care. Cardiovascular, diabetes and chronic kidney disease series no. 3. Cat. no. CDK 3. Canberra: AIHW
* ↑ World Health Organisation. (2015). Global strategy on Diet, Physical activity and Health. Retrieved from World Health Organisation website: http://www.who.int/dietphysicalactivity/en/
* ↑ Australian Bureau of Statistics. (2013). Australian Health Survey: Physical Activity, 2011-12 (Cat.no. 4364.0.55.004). Canberra, Australia: ABS.
* ↑ Deans, S., Burns, D., McGarry, A., Murray, K., & Mutrie, N. (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), 260-269. doi:10.1177/0309364612437905
* ↑ Allen, F. (2010). Health Psychology and Behaviour in Australia. North Ryde, NSW: McGraw-Hill.
* ↑ Bragaru, M., Meulenbelt, H., Dijkstra, P. U., Geertzen, J. H. B., & Dekker, R. (2013). Sports participation of Dutch lower limb amputees. Prosthetics and Orthotics International, 37(6), 454-458. doi:10.1177/0309364613476533
* ↑ da Silva, R., Rizzo, J. G., Gutierres Filho, Paulo José Barbosa, Ramos, V., & Deans, S. (2011). Physical activity and quality of life of amputees in Southern Brazil. Prosthetics and Orthotics International, 35(4), 432-438. doi:10.1177/0309364611425093