Research
Effects of including core strengthening exercise as
part of a comprehensive rehabilitation programmes
on people with lower-limb amputation: a pilot study
Sofía Mosteiro-Losada1
Silvia Varela2
Oscar García-García2
Iván Martínez-Lemos3
Carlos Ayán3
Author details can be found
at the end of this article
Correspondence to:
Silvia Varela;
silviavm@uvigo.es
How to cite this article:
Mosteiro-Losada S,
Varela S, García-García O,
Martínez‑Lemos I, Ayán C.
Effects of including core
strengthening exercise as
part of a comprehensive
rehabilitation programmes
on people with lower-limb
amputation: a pilot study. Int J
Ther Rehabil. 2021. https://doi.
org/10.12968/ijtr.2019.0141
1
Abstract
Background/Aims Exercise can be a useful rehabilitation approach for people with
lower-limb amputation. However, there is a lack of research in this regard. The aim of
this study was to analyse functional mobility, walking speed, range of motion and quality
of life changes experienced by people with lower-limb amputation after taking part in a
comprehensive exercise programme that included core strengthening exercises.
Methods This was a pilot study including six individuals who carried out a
comprehensive exercise programme, which was performed once a week for 5 months.
During the first 2 weeks, the participants attended 1-hour sessions that focused on
the execution of diaphragmatic breathing and body scheme exercises. From the fourth
week until the end of the intervention, the sessions were much longer, and included a
warm-up phase, two circuit training workouts for core strength and balance, and a final
stretching routine.
Results Significant improvements were found in the participants’ functional mobility
(P=0.007) and walking speed (P=0.001). The exercise intervention did not have a
significant impact on the participants’ range of motion and quality of life.
Conclusions In a group of people with lower-limb amputation, the performance of a
comprehensive exercise programme that included core strengthening, was found to be
beneficial for functional mobility and walking speed, although no significant effect was
observed for range of motion and quality of life measures.
Key words: Amputees; Core training; Exercise; Lower limb; Rehabilitation
Submitted: 17 November 2019; accepted following double-blind peer review: 10 August 2020
Introduction
People with lower-limb amputation usually exhibit abnormal gait patterns when walking
with a prosthetic (Vanicek et al, 2009), and so regaining the ability to walk without gait
issues has become one of the major goals to be attained in their rehabilitation process.
Taking this into account, it has been suggested that a certain level of fitness must be
achieved by lower-limb amputees before becoming successful prosthetic users (Chin et al,
2006). In spite of this, interventional studies about the effects of gait training exercises
on this population are scarce, and have generally focused on combined aerobic, muscular
strengthening and functional interventions aimed at improving lower-body performance
(Highsmith et al, 2016; Wong et al, 2016).
From a biomechanical point of view, it seems interesting to propose other training
interventions such as those that include exercises focused on trunk stability, in order to
improve walking ability in this population. This is because of the functional involvement
that the core has in aspects as basic as dynamic stability and distal mobility, which are
essential for developing a correct gait. Trunk function is important for standing balance and
© 2021 MA Healthcare Ltd
mobility, and therefore, adding trunk exercises to gait rehabilitation programmes has been
suggested as an alternative physical therapy option in different populations (Freeman et al,
2012; Van Criekinge et al, 2017). Core training could represent an effective rehabilitation
approach, as it includes a range of exercises aimed at strengthening the musculature of the
lumbopelvic-hip region, which plays a role in controlling both torso position and motion
over the pelvis. Core training has become widely used to restore kinetic function by means
International Journal of Therapy and Rehabilitation | 2021 | https://doi.org/10.12968/ijtr.2019.0141
Downloaded from magonlinelibrary.com by 129.100.058.076 on January 8, 2024.
 Research

of allowing the transfer of torque and momentum between the lower and upper extremities
(Huxel and Anderson, 2013). Previous research has shown that core training has resulted
in balance improvements in people with impaired mobility (Freeman et al, 2010). This
is an important finding, since balance is a key factor that influences the development and
regaining of walking ability in lower-limb amputees (van Velzen et al, 2006).
The strengthening of the core musculature could also be helpful for lower-limb amputees,
given its effects on other features frequently present, such as decreased range of motion
(Yeung et al, 2012), and lower quality of life (Grzebień et al, 2017). As previously observed,
an increase in range of motion could be achieved through reductions in muscular stiffness
(Kuszewski et al, 2018), while improvements in mobility and gait would lead to a better
quality of life (Wurdeman et al, 2018).

Aim
To the best of the authors’ knowledge, no study has been published so far regarding the
effects of including core exercises as part of a physical rehabilitation programme in people
with lower-limb amputation. Under these circumstances, the aim of this pilot study was
to analyse walking ability, walking speed, range of motion and quality of life changes
experienced by people with lower-limb amputation after taking part in a comprehensive
exercise programme that included core strengthening exercises.

Methods
Participants
The participants included in this study were recruited by means of an invitation letter sent
through an orthopaedic clinic located in a city of the northwest of Spain.
To be eligible for the study, participants had to:
■ Be over 18 years of age
■ Use their prosthesis on a daily basis
■ Be able to walk independently with the use of their current prosthesis.
Individuals were excluded from the study if they experienced prosthetic or medical
issues (ie residual limb ulcer, hip-flexion contracture, cognitive decline) that would prevent
completion of the intervention.

Ethical approval
The participants were well informed of the purpose of this study and possible risk, and
informed written consent was obtained. In addition, ethical approval was given by the
local ethics committee (approval number: 2017-000053-39). The person in the images
presented in the article is one of the authors and gave their consent to be photographed.

Measurements
One of the co-authors of this manuscript, who is a specialist in physical exercise and
rehabilitation administered the following tests 1 week before the intervention started and
1 week after its completion.

L-test of functional mobility

This test was used to assess the effects of the intervention on the participants’ functional
mobility (Deathe and Miller, 2005). The participants were instructed to stand up from a
chair, walk at self-selected speed for 3 metres, make a 90° turn and walk for 7 metres, then
turn 180° and return to the chair. The time (in seconds, to the nearest tenth of a second)
that it took for the subject to complete this test was recorded.
© 2021 MA Healthcare Ltd

10-metre walk test

The 10-metre walk test (10MWT) was administered to identify the effects of the intervention
on the participants’ walking speed (Roffman et al, 2016). The participants were asked to
walk as fast as they could along a 14-metre walking track. The first and the last 2 metres
of the walking track were used for acceleration and deceleration, and the time for covering

2 International Journal of Therapy and Rehabilitation | 2021 | https://doi.org/10.12968/ijtr.2019.0141

Downloaded from magonlinelibrary.com by 129.100.058.076 on January 8, 2024.

 Research

the middle 10 metres was recorded. Walking speed was calculated by dividing distance
by time and recording speed as metres per second.

Range of motion
Passive range of motion of the hip joint of the residual limb for flexion, extension, abduction
and adduction was assessed without the leg prosthesis by using a digital goniometer
(Baseline® 12-1027), following standard procedure (Nussbaumer et al, 2010).

36-Item Short Form Health Survey

The Spanish validated version of the 36-Item Short Form Health Survey (SF-36) (Vilagut
et al, 2005) was used to identify the effects of the intervention on the quality of life of
the participants. The SF-36 measures eight health attributes across eight domains, which
are both physically based (physical functioning, role limitations resulting from physical
health problems, bodily pain and general health) and emotionally based (mental health,
role limitations resulting from emotional problems, social functioning and vitality). The
SF-36 provides physical and health summary scores ranging from 0 to 100, with higher
scores indicating more positive health states.

Intervention
Initially, the primary intention of this study was that the participants followed a standard
core training programme. However, during baseline evaluations, and after having observed
how the participants performed a series of random tasks (ie unipodal balance, swinging
one leg over the other, sitting or kneeling on the floor), it became clear that they showed
a lack of balance, poor postural control and difficulties in bending over and standing up.
Therefore, a comprehensive programme using selective exercises customised for lower-
limb amputees was specifically designed. The exercise intervention was structured with
the aim of helping the participants to build up overall fitness, with particular emphasis on
balance and muscle strength. The training programme took place in the modern fitness
room at the Absolute Wellness Center, Pontevedra, Spain, for one session a week over a
5-month period and it was monitored by the person who was in charge of the evaluation.
During the first 2 weeks, the participants received a 1-hour session that focused on the
execution of diaphragmatic breathing exercises performed while lying on the floor, as well
as body awareness exercises aimed at improving postural control. By the third week, the
core training exercise known as the supine bridge was included as part of the training.
This exercise was performed with the help of a Pilates ring (Figure 1). At this stage, the
participants had learned how to get up and lie down by themselves. Nevertheless, differences
in their own muscular strength levels were observed, especially in the core musculature.
Consequently, some of the participants had to perform individualised isometric exercises,
aimed at toning up the transverse abdominis muscle (ie forearm isometric push-up hold)
before taking part in the second phase of the programme (circuit training sessions). The
participant who presented with a vascular amputation showed a higher balance impairment
than the rest of the patients, since the small size of his stump usually caused problems
when fitting in the prosthesis. Therefore, individual balance exercises (single-leg balance
and step-ups (stepping up and down on a bench)) were prescribed for him.
From the fourth week until the end of the intervention, participants kept exercising
once a week, for longer sessions (2 hours) including a variety of exercises, aimed at trunk
stability, and both upper and lower musculature. At this stage, all sessions were carried
out following the same schedule: a 15-minute warm-up phase focused on diaphragmatic
and range motion exercises; a main part consisting of circuit training workouts for core
strength and balance; and a final 10-minute static stretching routine. The main part of the
sessions were focused on the performance of circuit training workouts for core strength
© 2021 MA Healthcare Ltd

and balance.
Initially, those participants with lower fitness levels were instructed to perform 10
repetitions for each exercise, with a rest interval of 20 seconds between them, while those
who showed greater muscular strength executed 12 repetitions. In addition, every week,
a repetition per exercise was increased for the fittest participants, while for those with
lower muscular strength it was incremented every 2 weeks.

3 International Journal of Therapy and Rehabilitation | 2021 | https://doi.org/10.12968/ijtr.2019.0141

Downloaded from magonlinelibrary.com by 129.100.058.076 on January 8, 2024.

 Research

Figure 1. Supine bridge with Pilates ring.

Once all the participants were able to perform 15 repetitions of the proposed exercises,
two circuit training workout were proposed, including six exercises for 30 seconds each
one and a rest interval of 30 seconds between them (Table 1). The participants performed
three sets, rested for 2 minutes and performed another three sets. Blue resistance bands
(medium resistance) were used, while the weight load for pull-over and squat exercises
was increased by 1–2 kg every 2 weeks.
As the programme went on, the participants’ fitness level improved progressively so
that they were able to perform more complex and demanding exercises. Thus, two different
circuit training plans were organised (Table 2). Initially, the exercises were performed
following a 1:1 work/rest ratio (30 seconds/30 seconds), and then the participants progressed
to a 1:2 ratio (30 seconds/15 seconds). Two to four sets (depending on the fitness level
of the participants), were performed, with a rest interval of 2 minutes between them. The
weight load was increased as proposed in the first circuit training. Towards the end of the
training programme, some participants tried out the green resistance band (medium to
high resistance), but they were not able to accurately perform the exercises. Therefore,
the yellow band (light resistance) was used through this phase.
Attendance, as well as injuries or adverse effects related to the programme, were
registered by the person in charge of the sessions.

Statistical analyses
© 2021 MA Healthcare Ltd

The mean and standard deviation, as well as percentage of change, were registered for
the participants’ functional mobility, walking speed, quality of life and passive range of
motion. To assess the effects of the intervention, a paired sample t-test was performed to
determine the presence or absence of significant differences. All statistical analyses were
conducted using the Statistical Package for the Social Sciences (version 25.0), and the
criterion reference for statistical significance was set at P<0.05.

4 International Journal of Therapy and Rehabilitation | 2021 | https://doi.org/10.12968/ijtr.2019.0141

Downloaded from magonlinelibrary.com by 129.100.058.076 on January 8, 2024.

 Research

Table 1. Initial circuit training exercises

First circuit training

Stations Equipment Description

Step-up Aerobic step From a standing position, step up and down on the bench. Alternate legs for each
repetition

Transfer Cones From a standing position. Pick up the cone from the floor on the left-hand side of
you and transfer it 1.5 m to the right-hand side

Bicep curl Resistance band From a standing position, place the band under the feet, hold the handles, wrists
(yellow – light turned upwards and curl the forearms up toward the shoulders
resistance)

Pull-over Weight plate In a supine position, lift the feet off the floor and bend the knees at 90°. Take the
(2.5–10 kg) weight plate with the hands and hold it straight over the chest. Lower the weight
plate in an arc behind the head and return

Squat and lift Kettlebell (4–10 kg) From a standing position, hold the kettlebell with arms outstretched at chest level.
Lower into the squat while lifting the kettlebell in an arc. Keep your arms straight
and locked out over the head during the movement

Isometric Pilates ring Keep isometric squat position while holding the Pilates ring in the hands with
squat and straight arms at chest height. Press palms towards each other for 30 seconds
chest press

Second circuit training

Stations Equipment Description

Supine pelvic In a supine position with feet on the floor and flexed knees, contract abdominal
tilts muscles to flatten low back into the mat/floor. Relax abdominal muscles while
gently contracting low back muscles to increase the arch in your low back. Avoid
raising hips off the mat/floor

Roll-down From a seated position on the floor/mat, begin to roll spine backwards towards the
floor one vertebra at a time until lying. Return to the starting position

Seated rows Resistance band In a seated position on the floor with straight knees, place the band around the feet,
(yellow – light hold the handles, hands facing in towards each other, and pull the band towards
resistance) waist

Bridge In a supine position with feet on floor and flexed knees, keep the arms at the sides
of the trunk. Raise the hips so that body forms a straight line from shoulders to
knees

Bridge and Pilates ring Same position as the bridge exercise, but hold the ring between the knees.
ring Squeeze knees towards each other

Straight leg In a supine position, with one foot on the floor with flexed knee and one leg straight,
raise raise the straight leg about 30 cm off the floor
Note: All the exercises were carried out with careful breathing control.

Results
Out of the nine people initially invited, eight met the inclusion criteria, and six (aged
56.83 years ± 9.70 years) showed interest in taking in part in this study. They had a lower-
extremity amputation at the transtibial or transfemoral level. The cause of amputation was
trauma in five of six cases, and one cause was vascular. All participants were established
walkers and used their prosthesis daily (Table 3).
© 2021 MA Healthcare Ltd

All participants completed all the scheduled sessions and no injuries or adverse effects
were registered.
Once the intervention had ended, significant improvements were found in the participants’
functional mobility (P=0.007) and walking speed (P=0.01), as shown in Table 4. The
training programme did not have a significant impact on the participants’ range of motion
and quality of life (Table 5).

5 International Journal of Therapy and Rehabilitation | 2021 | https://doi.org/10.12968/ijtr.2019.0141

Downloaded from magonlinelibrary.com by 129.100.058.076 on January 8, 2024.

 Research

Table 2. Advanced circuit training exercises

First circuit training

Stations Equipment Description

Reverse lunge Aerobic step Stand on bench. Step down to the left side of the step with one leg and
off step perform a lunge. Step back up and repeat, alternating legs

Zigzag Cones Walk forward 2 m in a zigzag pattern between cones

Front raise Resistance band (blue) In a standing position, place the band under the feet, hold the handles in front
of the thighs, with hands facing in to body, and raise both arms to the front
until they are parallel to the floor

Arm swing Dumbbells (2.5–7.5 kg) In a seated position with straight knees, take the dumbbells and swing the
arms with the elbow flexed and move the arms from back to front as if you
are running, alternating arms, with core activation

Hip mobility Little hurdles In a standing position, walk forward facing the hurdle, passing over five
hurdles first with the sound limb and then with the amputated leg

Overhead squats Weight plate (2.5–5 kg) Stay in an isometric half-squat position while holding the weight plate
maintaining stretched arms in front of the chest. Lift the weight plate straight
up in an arc over the head and return

Second circuit training

Stations Equipment Description

Seated rows Resistance band (blue) In a seated position with straight knees, place the band around feet and cross
it into an ‘x’. Hold the handles with wrists facing inwards and pull the band
towards the body, keeping elbows close to the trunk

Seated leg raise Resistance band (blue) In a seated position with straight knees, place the band around a foot and
cross it into an ‘x’. Hold the band close to the foot and raise the leg, keeping
it straight. Alternate legs

Isometric row Resistance band (blue) In a seated position with straight knees, place the band around the feet and
and leg raise cross it into an ‘x’. Stay in an isometric row position while raising the leg,
keeping it straight. Alternate legs

Isometric row Resistance band (blue) In a seated position with straight knees, place the band around one foot and
and leg press cross it into an ‘x’. Stay in an isometric row position while raising the leg bent
at 90° and push it until it is fully extended but not locked.
Note: All exercises were carried out with careful breathing control.

Table 3. Participants’ characteristics, prosthetic mechanism and number of completed sessions.

Amputation Time
Age following Prosthetic Sessions
Participant Sex (years) Limb Level Reason amputation mechanism (months)

A Female 40 Right Transtibial Traumatic 3 years Pin-lock suction 20 (5)

suspension

B Male 60 Right Transfemoral Traumatic 11 years Microprocessor 20 (5)

(C-Leg 4)

C Male 63 Right Transtibial Traumatic 7 years Pin-lock suction 20 (5)

suspension

D Male 57 Right Transfemoral Traumatic 9 years Microprocessor 20 (5)

(Rheo Knee)
© 2021 MA Healthcare Ltd

E Male 53 Right Transfemoral Traumatic 22 years Hydraulic 20 (5)

(Knee 3R80)

F Male 68 Left Transfemoral Vascular 5 years Suspension with 20 (5)

belt

6 International Journal of Therapy and Rehabilitation | 2021 | https://doi.org/10.12968/ijtr.2019.0141

Downloaded from magonlinelibrary.com by 129.100.058.076 on January 8, 2024.

 Research

Table 4. Effects of the intervention on the participants’ functional mobility,

walking speed and quality of life
L-Test (seconds) 10-m Walk Test (m/s−1) SF-36 Quality of Life (score)

Participant Pre Post % Pre Post % Pre Post %

A 59.2 39.3 33.6 0.62 0.76 22.5 31.8 37.9 19.2

B 52.7 32.5 38.3 0.58 0.78 34.4 37.9 35.5 −6.3

C 60.4 54.2 10.3 0.49 0.54 10.2 41.2 41.8 1.5

D 46.2 26.4 42.9 0.71 0.88 23.9 54.2 49.1 −9.4

E 62.8 58.1 7.5 0.47 0.56 19.1 36.1 36.7 1.6

F 70.1 60.8 13.3 0.33 0.35 6.0 36.7 40.2 9.5

Mean ± SD 58.6 ± 8.3 45.2 ± 14.4 15.7 0.53 ± 0.13 0.64 ± 0.19 20.7 36.7 ± 7.7 40.2 ± 4.9 19.2

95% (5.6–21.1) (−0.18, −0.03) (−4.8, 3.7)

confidence
interval

Difference t=4.3; P=0.007 t=−3.89; P=0.01 t=−0.3; P=0.764

Paired sample t-test; SD: standard deviation; SF-36: Short-form 36.

Table 5. Effects of the intervention on the participants’ range of motion

Hip flexion (°) Hip extension (°) Hip adduction (°) Hip abduction (°)

Participant Pre Post % Pre Post % Pre Post % Pre Post %

A 68.8 69.0 0.3 166.0 167.0 0.6 62.0 63.0 1.6 131.4 132.0 0.5

B 92.6 93.0 0.4 160.00 160.50 0.3 69.00 69.50 0.7 112.00 112.50 0.4

C 105.0 105.5 0.5 168.00 168.50 0.3 73.50 74.00 0.7 126.00 126.50 0.4

D 75.5 77.0 2.0 146.00 147.00 0.7 59.20 60.00 1.3 126.10 126.50 -0.3

E 92.6 106.6 15.1 161.30 163.00 1.0 63.30 68.20 7.7 104.00 112.20 7.9

F 92.7 106.0 14.3 160.00 169.90 6.2 62.70 65.00 3.7 103.90 111.30 7.1

Mean ± SD 87.9 ± 92.8 5.4 160.2 ± 162.6 1.5 64.9 ± 66.6 2.6 117.2 ± 160.2 2.7
13.2 ± 7.7 ± 8.4 5.3 ± 5.0 12.1 ± 7.7
16.4

95% (−12.0–2.0) (−6.3–1.4) (−3.5–0.1) (−6.9–1.0)

confidence
interval

Difference t=−1.8; P=0.130 t=−1.6; P=0.167 t=−2.4; P=0.064 t=−1.9; P=0.116

Paired sample t-test; SD: standard deviation.

Discussion
This pilot study was conducted to provide information regarding the effects of a
comprehensive training programme that included core strengthening exercises for a group of
people with lower-limb amputation. The obtained results showed that the functional mobility
and the walking speed scores of the six participants improved between the baseline and the
© 2021 MA Healthcare Ltd

intervention. These findings, alongside the fact that programme compliance was high and
no dropouts or training-related injuries were reported, provide support for introducing core
strengthening exercises in those rehabilitation programmes aimed at addressing mobility
impairment in lower-limb amputees.
Several reasons could help to explain the gait improvements found in this research.
First, some of the proposed exercises were aimed at strengthening the musculature of

7 International Journal of Therapy and Rehabilitation | 2021 | https://doi.org/10.12968/ijtr.2019.0141

Downloaded from magonlinelibrary.com by 129.100.058.076 on January 8, 2024.

 Research

the trunk, which in turn could have resulted in balance improvements, as it has been
previously observed in elderly populations (Granacher et al, 2013). This is in line with
previous research suggesting that in lower-limb amputees, regaining walking ability is
influenced by balance level (van Velzen et al, 2006).

Core muscle activation

In relation to this, it has been observed that people with mobility impairments have
imbalanced core muscle activation while walking. Core muscles are more activated on the
less affected side (Ketelhut et al, 2015), which underlines the importance of strengthening
the trunk musculature to enable stable walking. Second, the proposed programme included
lower-body strengthening exercises in which the hip and the knee musculature were
involved. Previous studies in lower-limb amputees showed that increases in the muscular
strength of the hip and knee flexors and extensors resulted in greater stride length and step
cadence (Anjum et al, 2016). It is necessary to take into account that some of the performed
exercises also involved the hip abductors. In this regard, Pauley et al (2014) observed
significant changes in functional mobility and walking speed in a group of lower-limb
amputees who carried out a rehabilitation programme focused on the strengthening of this
muscle group. Thus, our participants’ locomotor capabilities could have been improved
through gains in lower-body muscular strength. Finally, as the programme went on, it was
noticed that the participants were progressively increasing their fitness level, which could
allow them to achieve a faster and more economical gait pattern, as previously observed
in this population (Wezenberg et al, 2013).

Flexibility training
Flexibility training has been recognised as an important factor in the rehabilitation process
following an amputation (Esquenazi and DiGiacomo, 2001). However, very few studies
have been focused on the effects of flexibility training on amputees. In the present research,
no significant changes were found in the hip range of motion of the participants, perhaps
because of the characteristics of the training programme carried out. Indeed, as judged by
other authors (Anaforoğlu et al, 2016), it seems that the low frequency of the programme
(1 day a week) and not including dynamic stretching exercises are some possible reasons
to explain the lack of improvements in flexibility. Moreover, no specific emphasis was
made to improve flexibility of the iliopsoas. This muscle is responsible for a decreased
hip extension range of motion resulting from excessive tightness, which those with a
lower-limb amputation have been noted to experience (Gailey, 2008).
The main purpose of the rehabilitation process following an amputation is to restore
function and to regain an acceptable level of functioning and participation, which in turn
leads to a better quality of life. Although improvements were observed in functional
mobility and walking speed, no significant effect of the programme on the participants’
quality of life was found. This could be because the performance of physical exercise
might not have a significant impact on a series of factors, such as employment status, the
use of a prosthesis, phantom limb pain or residual stump pain, which are strongly related
to the quality of life of lower-limb amputees (Sinha et al, 2011). The lack of research
regarding the effects of rehabilitation exercise programmes on the quality of life of this
population prevents further discussion.

Strengths and limitations

This pilot exploratory research has some strengths as well as marked constraints. On the
one hand, in addition to its originality, it provides preliminary evidence about the effects
of a comprehensive strengthening exercise programme on people with limb loss, supplying
valuable data to inform clinical practice and future trials. Additionally, it gives a detailed
© 2021 MA Healthcare Ltd

and in-depth description of the training programme carried out, which is worthy of note,
given that in this population, exercise protocols are usually complex and unclearly defined
(Wong et al, 2016). However, the small sample size and the lack of control group when
trying to justify the effects of the programme on the analysed variables are limitations.
Finally, it is necessary to consider that the sample was not homogeneous, since the
participants showed different levels of amputation and not all of them were traumatic.

8 International Journal of Therapy and Rehabilitation | 2021 | https://doi.org/10.12968/ijtr.2019.0141

Downloaded from magonlinelibrary.com by 129.100.058.076 on January 8, 2024.

 Research

Key points
■ Rehabilitation of functional mobility is one of the main objectives in people with lower
limb amputation.
■ Core training is a therapeutic exercise form that could restore kinetic function.
■ A comprehensive exercise programme that included core strengthening improves
significantly functional mobility and walking speed.

Transfemoral and transtibial amputees show a different gait pattern (Keklicek et al, 2019)
and differences in quality of life have also been noted (Knežević et al, 2015). Similarly,
people that have had a dysvascular amputation must face a series of comorbidities that have
a negative impact on their mobility and quality of life (Vogel et al, 2014). These limitations
warrant caution when interpreting and generalising the results of this study.

Conclusions
The development of a comprehensive exercise programme that included core strengthening
in a group of people with a lower-limb amputation showed that there were benefits for
walking ability and walking speed, although no significant effect was observed in range
of motion and quality of life. Further controlled studies with a greater sample size are
needed to confirm these findings.

Conflicts of interest
The authors declare that there are no conflicts of interest.

Funding
No funding was received for this work.

Author details
1Absolute Wellness Center, Pontevedra, Spain
2HealthyFitResearch Group, Galicia Sur Health Research Institute, Department of Special Didactics,
University of Vigo, Pontevedra, Spain
3WellMove Research Group, Galicia Sur Health Research Institute, Department of Special Didactics,
University of Vigo, Pontevedra, Spain

References
Anaforoğlu B, Erbahçeci F, Aksekili MAE. The effectiveness of a back school program in lowerlimb amputees: a
randomized controlled study. Turk J Med Sci. 2016;46(4):1122–1129. https://doi.org/10.3906/sag-1503-131
Anjum H, Amjad I, Malik AN. Effectiveness of proprioceptive neuromuscular facilitation techniques as
compared to traditional strength training in gait training among transtibial amputees. J Coll Physicians Surg
Pak. 2016;26(6):503–506
Chin T, Sawamura S, Shiba R. Effect of physical fitness on prosthetic ambulation in elderly amputees. Am J Phys
Med Rehab. 2006;85(12):992–996
Deathe AB, Miller WC. The L test of functional mobility: measurement properties of a modified version of the
timed “up and go” test designed for people with lower-limb amputations. Phys Ther. 2005;85(7):626–635.
https://doi.org/10.1093/ptj/85.7.626
Esquenazi A, DiGiacomo R. Rehabilitation after amputation. J Am Podiatr Med Assoc. 2001;91(1):13–22.
https://doi.org/10.7547/87507315-91-1-13
© 2021 MA Healthcare Ltd

Freeman JA, Gear M, Pauli A et al. The effect of core stability training on balance and mobility in ambulant
individuals with multiple sclerosis: a multi-centre series of single case studies. Mult Scler. 2010;16(11):1377–
1384. https://doi.org/10.1177/1352458510378126
Freeman J, Fox E, Gear M, Hough A. Pilates based core stability training in ambulant individuals with multiple
sclerosis: protocol for a multi-centre randomised controlled trial. BMC Neurol. 2012;12(1):19. https://doi.
org/10.1186/1471-2377-12-19

9 International Journal of Therapy and Rehabilitation | 2021 | https://doi.org/10.12968/ijtr.2019.0141

Downloaded from magonlinelibrary.com by 129.100.058.076 on January 8, 2024.

 Research

Gailey R. Review of secondary physical conditions associated with lower-limb amputation and long-term
prosthesis use. J Rehabil Res Dev. 2008;45(1):15–30. https://doi.org/10.1682/JRRD.2006.11.0147
Granacher U, Gollhofer A, Hortobágyi T, Kressig RW, Muehlbauer T. The importance of trunk muscle
strength for balance, functional performance, and fall prevention in seniors: a systematic review. Sports
Med. 2013;43(7):627–641. https://doi.org/10.1007/s40279-013-0041-1
Grzebień A, Chabowski M, Malinowski M et al. Analysis of selected factors determining quality of life in
patients after lower limb amputation-a review article. Pol Przegl Chir. 2017;89(2):57–61. https://doi.
org/10.5604/01.3001.0009.8980
Highsmith MJ, Andrews CR, Millman C et al. Gait training interventions for lower extremity amputees: a
systematic literature review. Technol Innov. 2016;18(2):99–113. https://doi.org/10.21300/18.2-3.2016.99
Huxel KC, Anderson BE. Core stability training for injury prevention. Sports Health. 2013;5(6):514–522.
https://doi.org/10.1177/1941738113481200
Keklicek H, Kirdi E, Yalcin A et al. Comparison of gait variability and symmetry in trained individuals
with transtibial and transfemoral limb loss. J Orthop Surg. 2019;27(1):2309499019832665. https://doi.
org/10.1177/2309499019832665
Ketelhut NB, Kindred JH, Manago MM et al. Core muscle characteristics during walking of patients with
multiple sclerosis. J Rehabil Res Dev. 2015;52(6):713–724. https://doi.org/10.1682/JRRD.2015.01.0006
Knežević A, Salamon T, Milankov M et al. Assessment of quality of life in patients after lower limb
amputation. Med Pregl. 2015;68(3-4):103–108. https://doi.org/10.2298/MPNS1504103K
Kuszewski MT, Gnat R, Gogola A. The impact of core muscles training on the range of anterior pelvic
tilt in subjects with increased stiffness of the hamstrings. Hum Mov Sci. 2018;57:32–39. https://doi.
org/10.1016/j.humov.2017.11.003
Nussbaumer S, Leunig M, Glatthorn JF et al. Validity and test-retest reliability of manual goniometers for
measuring passive hip range of motion in femoroacetabular impingement patients. BMC Musculoskelet
Disord. 2010;11(1):194. https://doi.org/10.1186/1471-2474-11-194
Pauley T, Devlin M, Madan-Sharma P. A single-blind, cross-over trial of hip abductor strength training to
improve timed up and go performance in patients with unilateral, transfemoral amputation. J Rehabil
Med. 2014;46(3):264–270. https://doi.org/10.2340/16501977-1270
Roffman CE, Buchanan J, Allison GT. Locomotor performance during rehabilitation of people with lower
limb amputation and prosthetic nonuse 12 months after discharge. Phys Ther. 2016;96(7):985–994.
https://doi.org/10.2522/ptj.20140164
Sinha R, van den Heuvel WJ, Arokiasamy P. Factors affecting quality of life in lower limb amputees.
Prosthet Orthot Int. 2011;35(1):90–96. https://doi.org/10.1177/0309364610397087
Vanicek N, Strike S, McNaughton L et al. Gait patterns in transtibial amputee fallers vs. non-fallers:
biomechanical differences during level walking. Gait Posture. 2009;29(3):415–420. https://doi.
org/10.1016/j.gaitpost.2008.10.062
Van Criekinge T, Saeys W, Hallemans A et al. Effectiveness of additional trunk exercises on gait
performance: study protocol for a randomized controlled trial. Trials. 2017;18(1):249. https://doi.
org/10.1186/s13063-017-1989-1
van Velzen JM, van Bennekom CA, Polomski W et al. Physical capacity and walking ability after
lower limb amputation: a systematic review. Clin Rehabil. 2006;20(11):999–1016. https://doi.
org/10.1177/0269215506070700
Vilagut G, Ferrer M, Rajmil L et al. The Spanish version of the Short Form 36 Health Survey: a decade of
experience and new developments. Gac Sanit. 2005;19(2):135–150. https://doi.org/10.1157/13074369
Vogel TR, Petroski GF, Kruse RL. Impact of amputation level and comorbidities on functional status of
elderly adults before and after lower extremity amputation. J Vasc Surg. 2013;58(5):1432. https://doi.
org/10.1016/j.jvs.2013.08.061
Wezenberg D, van der Woude LH, Faber WX et al. Relation between aerobic capacity and walking ability in
older adults with a lower-limb amputation. Arch Phys Med Rehabil. 2013;94(9):1714–1720. https://doi.
org/10.1016/j.apmr.2013.02.016
Wong CK, Ehrlich JE, Ersing JC et al. Exercise programs to improve gait performance in people with
lower limb amputation: a systematic review. Prosthet Orthot Int. 2016;40(1):8–17. https://doi.
org/10.1177/0309364614546926
© 2021 MA Healthcare Ltd

Wurdeman SR, Stevens PM, Campbell JH. Mobility Analysis of AmpuTees (MAAT I): quality of life and
satisfaction are strongly related to mobility for patients with a lower limb prosthesis. Prosthet Orthot
Int. 2018;42(5):498–503. https://doi.org/10.1177/0309364617736089
Yeung LF, Leung AKL, Zhang M et al. Long-distance walking effects on trans-tibial amputees
compensatory gait patterns and implications on prosthetic designs and training. Gait Posture.
2012;35(2):328–333. https://doi.org/10.1016/j.gaitpost.2011.10.004

10 International Journal of Therapy and Rehabilitation | 2021 | https://doi.org/10.12968/ijtr.2019.0141

Downloaded from magonlinelibrary.com by 129.100.058.076 on January 8, 2024.