Ex Rx Tips for Trainers Working with Amputees
By Jennifer Green, B.S.
|Jennifer Green, NCHPAD Visiting Information Specialist
There are two major categories of amputation: upper-extremity (UE) and lower-extremity (LE). Upper-extremity amputations typically occur due to vehicular accidents, severe lacerations, or frostbite. These types of amputees are classified into two groups: below the elbow and above the elbow. Because UE amputations have little impact on the individuals' walking or running ability, exercise guidelines for this population will be similar to those individuals without an amputation. However, as personal trainers, it is important to be creative and be able to provide adaptations for upper-body exercises for these persons.
The majority of lower-extremity amputations are due to vascular and circulatory diseases such as type 2 diabetes and peripheral vascular disease. Other causes include trauma, treatments for tumors, and congenital deformities. Determining the specific classification for an LE amputee is important because the purpose of exercise differs between these classifications. The two classifications of LE amputations are vascular amputees and non-vascular amputees. The purpose of exercise of vascular amputees is to "abate or preclude the pathogenesis of vascular disease." For non-vascular amputees, the purpose of exercise is similar to that of individuals without an amputation. It helps to reduce the chance of developing secondary disabilities such as cardiovascular disease, high blood pressure, and obesity.
When prescribing exercise for amputees, the modality of physical activity is important to consider and depends upon the level of amputation in the lower limb(s). Levels of lower-extremity amputation include:
- Symes: amputation of the forefoot or mid-foot, usually leaving the heel bone intact
- Transtibial: Below the knee
- Transfemoral: Above the knee
- Hip Disarticulation: Removal at the femoral hip joint
- Unilateral: Involving one limb
- Bilateral: Involving two limbs
The appropriate exercise modality for nonvascular unilateral amputation above or below the knee, unilateral hip disarticulation, bilateral amputation below the knee, or bilateral amputation above and below the knee should incorporate a sufficient amount of muscle mass to elicit exercise responses similar to those persons without an amputation. These modalities could include a one-leg bicycle ergometer, combined arm-leg ergometer, rowing, and upper-body ergometry. However, for bilateral above-knee amputation or bilateral hip disarticulation, individual responses will be limited by the muscle mass and work capacity of the upper-body musculature (arms, shoulder, chest, and trunk), similar to the situation of persons with paraplegia. For example, a unilateral below-knee, above-knee, or hip disarticulation amputee will involve enough muscle mass exercising on a sitting arm-leg ergometer to see an improvement in cardiovascular fitness similar in magnitude to that of a nondisabled person on the same modality.
However, a bilateral above-knee amputee, limited to modalities such as arm ergometer or swimming that incorporate a smaller muscle mass, will elicit cardiovascular improvements but of a smaller magnitude than obtained by the unilateral amputee exercising on an arm-leg ergometer.
According to the American College of Sports Medicine, the goal of aerobic physical activity for amputees is to increase cardiovascular fitness and endurance of both the involved and uninvolved limbs as well as increase efficiency of ambulation and activities of daily living. Lower-extremity amputees should be exercising aerobically 4 to 7 days per week at 40-80% HRR or an RPE of 11-16 for 30 to 60 minutes. However, due to the level of amputation or physical fitness it may be appropriate to begin with 10 to 20 minutes of activity and gradually build-up to 30 to 60 minutes to avoid exhaustion.
Strength training is important in this population to increase strength in the trunk, hips, and uninvolved limb as well as increase efficiency of ambulation and efficiency of activities of daily living. Weight training should be performed 2 to 3 days per week at 60-80% 1 RM or at a weight allowing for 8 repetitions. These individuals should be performing at least 2 upper-body, 1 core, and 2 lower body exercises per session. Flexibility should be performed at the end of every exercise session to maintain range of motion.
As with any population, there are special considerations that must be taken into account when creating an exercise prescription. Energy expenditure for lower-extremity amputees is much higher and directly related to the level of amputation. For example, the energy costs for a unilateral transfemoral amputee is much higher than a unilateral transtibial amputee. Skin breakdowns or infections can also further exacerbate a disability, limiting all exercise as well as recreational activities, work-related activities, or activities of daily living. Avoid these injuries by checking the fit of the prosthetic and avoid activities that promote friction between the amputated limb and prosthetic. Finally, avoid overuse injuries of both the injured and uninjured limbs.
As personal trainers, the knowledge to work with any population is important to increasing your clientele. The ability to be creative with your exercise prescriptions and accommodate individuals with disabilities will give you a step above the rest. Amputees are a growing population, especially vascular amputees due to the rise in diabetes within the United States. By increasing your knowledge of this population and having the skills that can help them abate the pathogenesis of disease, you can be an important part of the rehabilitation process and help your clients further avoid complications.
American College of Sports Medicine. (2005). ACSM's guidelines for exercise testing and prescription 7th ed. Philadelphia, PA: Lea & Febiger/Lippincott Williams & Wilkins.
American College of Sports Medicine. (1997). ACSM's exercise management for persons with chronic diseases and disabilities. Champaign, IL: Human Kinetics Publishers.
Please send any questions or comments to Jennifer Green at Jennifer Green.