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VOLUME 3, ISSUE 1 

 2020 

 

 

LITERATURE REVIEW 

Jamieson A.G, Murray L, Buis A. The use of physical activity outcomes in rehabilitation interventions for lower limb amputees: A systematic review. Canadian 

Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.2. https://doi.org/10.33137/cpoj.v3i1.33931 

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https://doi.org/10.33137/cpoj.v3i1.33931


 

1 

Jamieson A.G, Murray L, Buis A. The use of physical activity outcomes in rehabilitation interventions for lower limb amputees: A systematic review. Canadian 
Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.2. https://doi.org/10.33137/cpoj.v3i1.33931  

 

 

 
LITERATURE REVIEW 

 

THE USE OF PHYSICAL ACTIVITY OUTCOMES IN REHABILITATION INTERVENTIONS FOR 
LOWER LIMB AMPUTEES: A SYSTEMATIC REVIEW    

 
Jamieson A.G, Murray L, Buis A*         
 
Department of Biomedical Engineering, University of Strathclyde, Wolfson Centre, 106 Rottenrow, Glasgow, G4 0NW, Scotland, UK. 
 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

INTRODUCTION   

The Limb amputation is increasingly prevalent, and it is 

projected that the number of individuals with limb loss in the 

United States by 2050 will be 1 in 85, with 65% of all 

amputation cases being classified as a lower limb 

amputation.1 The primary causes of amputation are 

peripheral vascular disease and physical trauma, with the 

former cause representing 82% of amputation cases.2 

Lower-limb amputation can create physical, 

socioeconomical and psychological barriers towards the 

individual’s physical activity. These barriers include having 

a poorly fitted prosthesis, insufficient resources for physical 

activity, lack of motivation to participate in activities and a 

lack of self-efficacy.3 As such, Individuals with Lower Limb 

Amputation (ILLAs) are generally less physically active than 

individuals without limb loss.4 By maintaining sufficient 

levels of physical activity, ILLAs will over time see 

improvements in their heart and lung functionality and can 

improve perceptions of the individual’s quality of life, self-

esteem and body image.5-7 

Interventions which have focused on improving the physical 

activity of ILLAs can be broken down into two major 

categories; prosthetic interventions and behavioural 

interventions. In a prosthetic intervention, the subject is fit 

 
OPEN  ACCESS Volume 3, Issue 1, Article No.2. 2020 

 

 

Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index 

 

ABSTRACT 

 

BACKGROUND: Interventions which have focused on improving the physical activity of individuals with 

lower limb amputation can be mostly categorized into behavioural-based and prosthetic-based 

interventions. The aim of this review was to assess the quality of these interventions, and to identify the 

key gaps in research in this field.  

 

METHODOLOGY: The databases of Scopus, Pubmed, Embase, Medline and Web of Science were 

searched between September and December of 2019 for articles relating to physical activity, amputees 

and interventions. Articles were assessed quantitively based on internal validity, external validity and 

intervention intensity.    

FINDINGS: Sixteen articles (5 behavioural, 11 prosthetic) were assessed. Both approaches had 

comparable methodological quality and mixed efficacy for producing a significant change in physical 

activity outcomes. Almost all interventions used a simplistic measurement of activity as their outcome.  

CONCLUSIONS: There is an insufficient amount of studies to assess the overall efficacy of behavioural 

interventions in regard to how they impact on physical activity behaviour. However, the increase of quality 

of the methodology in the more recent studies could indicate that future interventions will retain similar 

levels of quality. Prosthetic interventions have shown no major improvement in efficacy compared to 

similar reviews and may need to utilise more advanced prosthetic components to attain significant 

changes in physical activity. Activity outcomes should expand into more complex activity measurements 

to properly understand the physical activity profile of people with lower limb amputation. 

ARTICLE INFO 

Received: April 2, 2020 

Accepted: May 11, 2020 

Published: May 19, 2020 

CITATION 

Jamieson A.G, Murray L, Buis A. 

The use of physical activity 

outcomes in rehabilitation 

interventions for lower limb 

amputees: A systematic review. 

Canadian Prosthetics & 

Orthotics Journal. 2020; 

Volume3, Issue1, No.2. 

https://doi.org/10.33137/cpoj.v3i

1.33931  

KEYWORDS 

Amputation, Rehabilitation, 

Amputee, Lower Limb 

Amputation, Physical Activity, 

Lower Limb Prosthetics, 

Exercise. 

 

*CORRESPONDING AUTHOR 

Dr. Arjan Buis,  
Department of Biomedical Engineering, University of Strathclyde, 

Wolfson Centre, 106 Rottenrow, Glasgow, G4 0NW, Scotland, UK. 

E-Mail: arjan.buis@strath.ac.uk 

ORCID: https://orcid.org/0000-0003-3947-293X 

 

https://doi.org/10.33137/cpoj.v3i1.33931
https://jps.library.utoronto.ca/index.php/cpoj/index
https://doi.org/10.33137/cpoj.v3i1.33931
https://doi.org/10.33137/cpoj.v3i1.33931
mailto:arjan.buis@strath.ac.uk
https://orcid.org/0000-0003-3947-293X


 

2 

Jamieson A.G, Murray L, Buis A. The use of physical activity outcomes in rehabilitation interventions for lower limb amputees: A systematic review. Canadian 
Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.2. https://doi.org/10.33137/cpoj.v3i1.33931  

ISSN: 2561-987X THE USE OF PHYSICAL ACTIVITY OUTCOMES IN REHABILITATION  
Jamieson et al. 2020 

 
CPOJ 

 
with a prosthetic component, and their physical activity is 

typically compared with subjects wearing a variant of that 

prosthetic component.8 Marked improvements in physical 

activity rates indicate that the prosthetic intervention has 

helped the patient carry out more physical activity, whether 

by making them feel more comfortable wearing the 

prosthesis, reducing the socket pain or wearing during gait, 

or any other number of potential physical or psychological 

factors. A behavioural intervention on the other hand will 

aim to employ behavioural change techniques such as goal 

setting, self-monitoring of behaviour and behaviour 

substitution to the subjects,9 which can then be measured 

in quantifiable activity, such as the number of steps taken 

per day.10 Other categories of physical activity interventions 

exist, such as massage interventions,11 however the paucity 

of these interventions makes them unsuitable for the scope 

of this review.  

The primary aim of this review was to assess the quality of 

prosthetic and behavioural interventions when they are 

used to modify physical activity behaviour or physical 

activity performance in ILLAs. Additionally, the review was 

also established to identify and address the key gaps in 

research in this field. 

METHODOLOGY 

Search Strategy and Screening Process 

Literature searches were conducted in a period spanning 

September – December 2019, using the electronic 

databases of Scopus, Pubmed, Web of Science, and the 

combined databases of Embase and Medline via OVID. 

Additional hand searched articles from previous research 

were also included. The search strategy used Medical 

Subject Heading terms relating to the ILLA population 

(“amputee”, “amputees”, “leg amputation”, “lower limb 

amputation”, “physical disability” or “disabled persons”), 

terms relating to physical activity ("fitness", "exercise", 

"physical activity" or "physical activities") and terms relating 

to an intervention (“intervention” or “interventions”).  

Inclusion criteria 

An outcome measure is any measurement that evaluates 

the activity (e.g step count or the  energy expenditure 

generated from performing physical activity) of an ILLA, 

whether through self-reported activity monitoring (e.g an 

activity diary), activity evaluation questionnaires12-14 or 

objective activity monitoring devices (e.g a pedometer). All 

levels of lower limb amputation were included , so long as 

the subjects utilised a prosthesis or other walking support 

devices and were not exclusively wheelchair bound. Only 

studies that were available in full text and in the English 

language were considered for inclusion.  

Each article went through three checks for eligibility when 

screening; whether the title was appropriate, whether the 

article was a duplicate of an already identified paper, and 

whether the abstract appeared to provide eligible content for 

the review.  

Exclusion Criteria 

Any multifaceted intervention that contained prosthetic or 

behavioural components were excluded, as it would not be 

possible to determine the individual efficacy of that 

component on the physical activity outcomes. Case studies 

were not included due to their lack of generalizability.  

Assessment of Methodology Quality 

Articles included for full review used an analysis structure 

devised from a combination of assessment methodologies. 

Internal validity, external validity and intervention intensity 

were used to determine the quality of each article’s 

methodology. Internal and external validity was assessed 

based on modified criteria by Salminen et al.,15 which itself 

was based on a modified version of internal validity criteria 

used in Borghouts et al.16 and by external validity used in 

Shekelle et al.17 Intervention intensity was used in Ma and 

Gini’s18  systematic review of physical activity interventions 

on the physically disabled, which was based on a criteria list 

created by Hendrie et al.19 A full explanation of how the 

assessment criteria was marked is contained in APPENDIX 

A. 

RESULTS 

Screening Process 

Figure (1) shows a visualisation of the screening process. A 

total of 7,584 articles were identified and screened through 

Scopus, PubMed, Web of Science, Embase and Medline. 

After removing duplicates and unsuitable articles, 17 

potentially eligible papers were identified. An additional 4 

articles were found from various sources that were 

researched prior to the inception of the review. Two of the 

eligible articles20,21 did not specify whether the participants 

with limb loss had upper or lower limb loss. After contacting 

the correspondents, it was ensured that ILLAs were 

included in both studies.  

Five studies were excluded in total. Miller et al.22 was 

excluded based on the fact that their intervention was 

ongoing. Gailey et al.23 and Ladlow et al.24 were both 

excluded as they described a multifaceted intervention, 

where it was not clear how each component individually 

affected physical activity behaviours. Van der Ploeg et al.25 

described the same intervention that was used in one of the 

other eligible articles (Van der Ploeg et al.21) but used 

different outcome measures. Likewise, the intervention 

originally described by Morgan et al.8 was repeated in 

McDonald et al.26 and did not provide a description of the 

intervention procedure. Thus, a total of 16 articles were 

used for full analysis.  

https://doi.org/10.33137/cpoj.v3i1.33931


 

3 

Jamieson A.G, Murray L, Buis A. The use of physical activity outcomes in rehabilitation interventions for lower limb amputees: A systematic review. Canadian 
Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.2. https://doi.org/10.33137/cpoj.v3i1.33931  

ISSN: 2561-987X THE USE OF PHYSICAL ACTIVITY OUTCOMES IN REHABILITATION  
Jamieson et al. 2020 

 
CPOJ 

 

 

 

Study Characteristics 

The study characteristics of each intervention is illustrated 

in APPENDIX (B). One of the included papers, Klute et al.27 

was approached differently; as the paper described two 

individual interventions, both interventions were assessed 

independently: Klute et al.27 [A] refers to the intervention 

that compared Shock-absorbing pylons and Rigid pylons, 

while Klute et al.27 [B] refers to the intervention that 

compared Mechanical-controlled and Microprocessor-

controlled prosthetic knees.  

• Behavioural Interventions 

Aside from Delehanty and Trachsel,28 the behavioural 

studies were randomized, controlled trials. Two studies 

used telephone communication as the primary means of 

delivering the intervention (Christiansen et al.29; Littman et 

al.30), while Kosma et al.,20 Delehanty and Trachsel,28 and 

Van der Ploeg et al.21 used e-mail, group meetings and 

counselling sessions respectively to communicate.  

A range of physical activity assessment techniques were 

applied across the studies. Kosma et al.20 and Van der 

Ploeg et al.21 used standardized questionnaires while the 

two most recent studies, Christiansen et al.29 and  

Littman et al.,30 used objective activity monitoring via 

accelerometers. Van der Ploeg et al.21 also used a non-

standardised customised questionnaire to measure sport 

related activities. Delehanty and Trachsel28 used a non-

standardised ‘Rehabilitation Status Questionnaire’ to 

measure their outcomes.  

Behavioural interventions produced at least one significant 

change in physical activity behaviour in 3 out of the 5 

studies. These positive significant effects were the increase 

in step count, the decrease of sedentary time, the increase 

in activity level for vacation, sport participation, and the 

ability to meet daily physical activity requirements. In Kosma 

et al.20 and Littman et al.,30 no significant outcomes could be 

identified.  

• Prosthetic Interventions 

With the exception of Buis et al.31 and Selles et al.,32 

prosthetic interventions followed a crossover trial design 

wherein participants would be randomly assigned with one 

type of prosthetic, go through a period of accommodation, 

have their physical activity monitored, and then be fitted with 

the other type of prosthetic and repeat the process. In Buis 

et al.31 and Selles et al.,32 participants only received the 

intervention or the control, not both.  

The range of the types of prosthetic interventions applied 

was diverse, with the most frequently occurring type of 

intervention being the prosthetic knee (n=4). Other 

prosthetic interventions analysed the pylon, socket (n =2 

each), liner, suspension, feet and adapter (n =1 each). All 

prosthetic knee interventions involved comparing a 

microprocessor-controlled knee to a mechanical-controlled 

knee.  Intervention periods ranged from <1 week to 18 

weeks, with the accommodation period often controlling 

how long the intervention lasted.  

A majority of the studies used identical or similar activity 

monitoring devices and outcomes; 66% (8/12) of the studies 

used the ankle based StepWatch Activity Monitor (SAM) 

(Orthocare Innovations, Mountlake Terrace, WA, USA) as 

their measuring device. Other measuring devices included 

the ActivPAL, Actigraph and the so-called “Activity Monitor” 

used in one of the reviews.32 They were all accelerometer-

based activity monitors.  The only study to not use an 

accelerometer was Kaufman et al.33 which used the Doubly-

Labelled Water (DLW) method to obtain estimated energy 

expenditure. All SAM studies measured stepping activity to 

some degree (daily step count, weekly step count, step 

distance). Other measurements taken were the time spent 

during bouts of activity and the number of body posture 

transitions.  

The efficacy of the prosthetic interventions was overall 

mixed, with 7/12 studies finding no significant differences in 

any activity measurements taken. Liner, suspension and 

adapter designs all had significant impact on the activity 

Articles 

found in 

Scopus        

(n = 2309) 

Id
e
n
ti
fi
c
a
ti
o

n
 

Articles found for 

General Assessment 

(n = 7584) 

Duplicate Articles 

(n = 3772) Articles Excluded 

based on Title or 

Abstract (n = 3795) 

Articles assessed for 

Eligibility (n = 17) 

Articles excluded 

based on Content         

(n = 5) 

Articles included 

for full analysis              

(n = 16)          

S
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In
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Articles 

found in 

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(n = 1340) 

Articles 

found in 

Web of 

Science     

(n = 1782) 

Articles found 

in Embase+ 

OVID Medline        

(n = 2153) 

Articles found in 

other Reviews    

(n = 4) 

Figure 1: Flowchart diagram of the screening process.  

https://doi.org/10.33137/cpoj.v3i1.33931


 

4 

Jamieson A.G, Murray L, Buis A. The use of physical activity outcomes in rehabilitation interventions for lower limb amputees: A systematic review. Canadian 
Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.2. https://doi.org/10.33137/cpoj.v3i1.33931  

ISSN: 2561-987X THE USE OF PHYSICAL ACTIVITY OUTCOMES IN REHABILITATION  
Jamieson et al. 2020 

 
CPOJ 

 
measurements, while Pylon and Feet designs had no 

significant impact. Prosthetic knees had mixed results; no 

significant differences were found when step activity was 

measured, but significant differences were found in the 

estimated energy expenditure and activity levels. Due to the 

small amount of studies available for each design 

component, a relationship between the type of component 

and physical activity outcomes could not be ascertained.    

Internal validity 

• Behavioural Interventions 

The internal validity of the 5 behavioural studies is 

demonstrated in Table 1. Christiansen et al.29 and Van der 

Ploeg et al.21 had the highest internal validity, obtaining 8 

out of a possible 11 points each, while Kosma et al.20 and 

Delehanty and Trachsel28 had the lowest with 5 points each. 

The only criteria which was successfully achieved by all 

behavioural studies was having the outcome measures and 

data presentation congruent with the study aims. No criteria 

were unmet completely.  

 

• Prosthetic Interventions 

After conducting a Student T-test on the means of the 

internal validity scores for the prosthetic and behavioural 

interventions, the difference in the means between the two 

kinds of interventions was found to be non-significant (p = 

0.31). The study with the highest internal validity was 

Kaufmen et al.33 with 9 points, while the lowest was Klute et 

al.36 (2011) with 4 points.  

All prosthetic interventions successfully gave a sufficient 

description of their drop-outs (or had no drop-outs) and in 

utilising objective physical activity outcome measurements. 

The follow-up time of prosthetic interventions was found to 

be insufficient in most prosthetic interventions, only 

Kaufmen et al.33 had a follow-up greater than 4 months. 

Prosthetic interventions also performed poorly in having 

sufficient study size, reporting adherence to the intervention 

and checking for confounding variables. 

 

 

  
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Segal et al.35 1 0 0 0 1 1 1 0 1 1 0 6 

Morgan et al.8 1 1 0 0 1 1 1 1 1 1 0 8 

Klute  et al.36 1 0 0 0 0 1 0 0 0 1 1 3 

Klute  et al. [B]27 1 1 0 0 0 1 1 0 1 1 0 6 

Klute  et al. [A]27 1 1 0 0 1 1 1 0 1 1 0 7 

Kaufman et al.33 1 1 1 1 1 1 1 0 1 1 0 9 

Hafner et al.37 1 1 1 0 1 1 1 1 0 1 0 8 

Coleman et al.38 0 0 0 0 1 1 1 0 1 1 1 5 

Buis et al.31 0 0 0 0 1 1 1 1 1 1 0 6 

Berge et al.39 1 1 0 0 1 1 1 1 0 1 0 7 

Van der Ploeg et al.21 0 1 1 1 1 1 1 1 0 0 1 7 

Littman et al.30 1 1 0 1 0 1 1 0 0 1 1 6 

Kosma et al.20 0 1 1 0 0 0 1 1 1 0 0 5 

Delehanty & Trachsel 28 1 0 0 1 0 0 1 0 1 0 1 4 

Christiansen et al.29 1 1 0 0 1 1 1 0 1 1 1 7 

 

Table 1: Internal validity scores. Blue boxes indicate Behavioural Interventions and white boxes indicate Prosthetic Interventions. 

Reference numbers are located in square brackets [ ]. 

 

https://doi.org/10.33137/cpoj.v3i1.33931


 

5 

Jamieson A.G, Murray L, Buis A. The use of physical activity outcomes in rehabilitation interventions for lower limb amputees: A systematic review. Canadian 
Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.2. https://doi.org/10.33137/cpoj.v3i1.33931  

ISSN: 2561-987X THE USE OF PHYSICAL ACTIVITY OUTCOMES IN REHABILITATION  
Jamieson et al. 2020 

 
CPOJ 

 
External validity 

• Behavioural Interventions 

External validity is displayed in Table 2A. Only one study 

(Christiansen et al.29) obtained the maximum score for 

external validity, three studies acquired half of the maximum 

score (Delehanty and Trachsel,28 Kosma et al.,20 Van der 

Ploeg et al.21). All studies described their intervention in 

detail. Delehanty and Trachsel28 was the only study that 

failed to describe clinically relevant outcome measures, 

which was due to their non-standardised activity monitoring 

assessment. The intervention used in Christiansen et al.29 

was the only intervention to show a clinically important effect 

in the outcome measures: there was a greater than 10% 

gain in daily step count between the control and intervention 

groups.  

• Prosthetic Interventions 

In comparison to behavioural interventions, prosthetic 

interventions had highly consistent performance in external 

validity, however their overall mean performances in a 

Student T-Test were nearly identical (p = 0.93). Coleman et 

al.38 was the only study to achieve the maximum external 

validity, and just two studies had less than three points. The 

weakest performing, Theeven et al.34 only obtained 1 point. 

The remaining studies all scored 3 points. There was a 

significant discrepancy between the size effect and the 

other 3 external validity criteria; only 2 studies had a 10% 

significant gain (i.e a clinically important gain) in outcomes 

relating to daily/fortnightly step count (Coleman et al.38 and 

Klute et al.36 (2011)), whereas between 10 and 11 studies 

were able to achieve the other 3 criteria.   

Intervention Intensity 

• Behavioural Interventions 

Table 2B shows the intervention intensity calculated for 

each study. The highest scoring intervention was Littman et 

al.,30 with the lowest being Delahanty and Trachsel.28 In 

general, the studies performed highly in terms of frequency 

of contact (every study contacted the participants on a 

weekly or bi-weekly basis) and type of contact (most were 

individual contact or group contact with an individual 

element). No study achieved a ‘4’ or higher in intervention 

duration (6 months or more), and all studies performed 

poorly in the reach category (only Littman et al.30 and Van 

der Ploeg et al.21 provided more than one contact setting).  

 

 External Validity 

 

Intervention Intensity 

Reference 

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Theeven et al.34 1 0 0 0 1 1 4 5 1 11 

Selles et al.32 1 1 1 0 3 1 3 5 1 10 

Segal et al.35 1 1 1 0 3 1 3 5 1 10 

Morgan et al.8 1 1 1 0 3 1 3 5 1 10 

Klute  et al.36 1 0 1 1 3 1 3 5 1 10 

Klute  et al. [B]27 1 1 1 0 3 3 3 5 1 12 

Klute  et al. [A]27 1 1 1 0 3 1 3 5 1 10 

Kaufman et al.33 1 1 1 0 3 4 2 5 1 12 

Hafner et al.37 1 1 1 0 3 5 3 5 1 14 

Coleman et al.38 1 1 1 1 4 4 3 5 3 15 

Buis et al.31 0 1 1 0 2 1 4 5 1 11 

Berge et al.39 1 1 1 0 3 1 3 5 1 10 

Van der Ploeg et.al.21 0 1 1 0 2 2 4 5 3 14 

Littman et al.30 1 1 1 0 3 3 4 5 3 15 

Kosma et al.20 0 1 1 0 2 1 4 4 1 10 

Delehanty & Trachsel 28 1 1 0 0 2 1 4 3 1 9 

Christiansen et al.29 1 1 1 1 4 3 4 5 1 13 

 

Table 2 (A,B): External Validity and Intervention Intensity. Blue boxes indicate Behavioural Interventions and white boxes indicate Prosthetic 

Interventions.  

 

 

 

 

 

 

 

A B 

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6 

Jamieson A.G, Murray L, Buis A. The use of physical activity outcomes in rehabilitation interventions for lower limb amputees: A systematic review. Canadian 
Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.2. https://doi.org/10.33137/cpoj.v3i1.33931  

ISSN: 2561-987X THE USE OF PHYSICAL ACTIVITY OUTCOMES IN REHABILITATION  
Jamieson et al. 2020 

 
CPOJ 

 
• Prosthetic Interventions 

The performance of the prosthetic interventions was once 

again comparable to the behavioural interventions (p = 

0.51). The highest scoring prosthetic intervention was 

Coleman et al.38 with 15 points, while multiple studies tied 

for the lowest score at 10 points. All studies achieved the 

maximum score for type of contact (all participants were 

interacted with individually). Only one study, Coleman et 

al.,38 had more than one method of interacting with the 

participants (the reach) via face-to-face and telephone 

communication. As most prosthetic interventions were 

carried out over a short time span, only 4 studies had an 

intervention length score of 2 or higher. 

DISCUSSION  

The research in this study was important to assess the 

current state of behavioural interventions and prosthetic 

interventions in how they modify the physical activity 

behaviour of ILLAs.  After all identified literature were 

assessed for their internal validity, external validity and 

intervention intensity, it was found that behavioural and 

prosthetic interventions had roughly equal efficacy when it 

came to generating a significant change in physical activity 

behaviours. Statistically, the mean scores of internal 

validity, external validity and intervention intensity were 

equal between the two groups. Therefore, this study has 

shown that neither intervention has proven to be more 

effective than the other. 

Main Findings 

• Behavioural Interventions 

Behavioural interventions had mixed efficacy when it came 

to moderating physical activity in ILLAs. Only two studies 

identified (Christiansen et al.29 and van der Ploeg et al.21) 

had significant positive increases in physical activity 

behaviour in regards to daily step count, sport participation 

and the ability to meet pre-defined physical activity 

requirements. It is also important to consider that the 

findings of van der Ploeg et al.21 have questionable impact 

on ILLAs, as they only report their intervention’s impact on 

the general disabled population. Delehanty and Trachsel28 

had a single positive result (increased holiday time) while 

the rest had no significant results. These findings 

differentiate from reviews which have looked at behavioural 

intervention studies for people with non-specific disabilities; 

Castro et al.40 and Lai et al.41 found significant positive 

increases in physical activity outcomes in 70% and 83% of 

identified studies respectively. The meta-analysis used in 

Ma and Ginis18 reported “small to medium sized effects” in 

the interventions towards physical activity outcomes. A 

possible explanation for these differing results is the lack of 

available studies relating specifically to ILLAs: compared to 

the five articles found in this review, 38, 132 and 24 studies 

were identified in Castro et al.,40 Lai et al.41 and Ma and 

Ginis’s18 studies respectively.  

Another possible explanation is that behavioural 

interventions may need to tailor the intervention around 

solving the ILLAs’ barriers to physical activity, such as those 

identified in Littman et al.3 Despite the lack of evidence and 

the mixed results, there is some optimism in these findings; 

by considering that the more modern interventions applied 

in Christiansen et al.29 and Littman et al.30 had higher 

methodological quality than the older interventions, it is 

possible that future studies will retain a similar high level of 

methodological quality, which could lead to a more 

conclusive idea of how effective behavioural interventions 

are on the physical activity of ILLAs in the future. 

• Prosthetic Interventions 

Prosthetic interventions also had mixed effects on the 

physical activity of ILLAs, with five out of twelve studies 

reporting significant effects. This finding is echoed by 

Samuelsson et al.42 and Pepin et al.43 who both reviewed 

the effects of prosthetic components on physical activity. In 

Samuelsson et al.42 and Pepin et al.43 five out of eight 

studies and five out of fourteen studies had significant 

impact on physical activity outcomes respectively. The 

findings of the review are highly comparable to Samuelsson 

et al.42 as they used the same reviewing criteria (internal 

and external validity) and some of the same articles. The 

external validity was found to be scored identically in each 

of the shared articles, however there were some minor 

disagreements with internal validity criteria and scoring. For 

example, in the assessment of Coleman et al.38 they scored 

0 for reporting psychometric properties of the measuring 

instrument, while this review scored a 1. These 

discrepancies can be explained by the differing objectives 

that the review by Samuelsson et al.42 had. In Coleman et 

al.,38 the psychometric properties of the physical activity 

measuring instrument were reported, but not the 

questionnaires. As these questionnaires report on the 

impact of quality of life and participation in the individual’s 

community, which were critical topics in the review by 

Samuelsson et al.,42 this likely explains why  Coleman et 

al.38 scored a 0 in their review for that particular element. 

The maximum discrepancy in internal validity scoring was 

±1, so overall both reviews had a similar assessment of the 

shared articles.  

Only one prosthetic intervention to moderate physical 

activity had been developed in the time between the review 

by Pepin et al.43 and this review. Considering this finding, it 

appears that the development of prosthetic interventions to 

moderate physical activity outcomes has stagnated. At best, 

they appear to have mixed efficacy, and even within the 

intervention type, results are inconsistent. For instance, all 

identified prosthetic knee interventions compared a 

microprocessor knee to a mechanical knee, and multiple 

outcomes were found; two papers reported no significant 

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7 

Jamieson A.G, Murray L, Buis A. The use of physical activity outcomes in rehabilitation interventions for lower limb amputees: A systematic review. Canadian 
Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.2. https://doi.org/10.33137/cpoj.v3i1.33931  

ISSN: 2561-987X THE USE OF PHYSICAL ACTIVITY OUTCOMES IN REHABILITATION  
Jamieson et al. 2020 

 
CPOJ 

 
results in activity outcomes,27,37 one reported significant 

improvement in favour of wearing the microprocessor 

knee,33 and one reported significant improvements in favour 

of wearing the mechanical knee.34 The review therefore 

concludes that prosthetic interventions are, in their current 

state, an unreliable method of improving physical activity 

outcomes. Some promising developments in prosthetic 

technology could be incorporated into the design of future 

prosthetic interventions. For example, powered knees are a 

recently developed type of prosthetic knee that, compared 

to the more traditional microprocessor and mechanical 

knees, provide greater output in energy assistance and can 

help perform more demanding walking movements like 

climbing stairs.44 These inventions may be critical to 

obtaining definitive improvements in physical activity 

behaviour in ILLAs.  

Outcome measures in physical activity  

In the behavioural approach, two interventions used 

objective activity monitoring measurements,29,30 two 

interventions used subjective questionnaires,20,21 and two 

interventions used non-standardized questionnaires.21,28 By 

contrast, all prosthetic interventions used objective activity 

measurements. Delehanty and Trachsel28 used outcome 

measures that were the least effective and least informative; 

their Rehabilitation Status Questionnaire prior to the study 

had not been found reliable or validated in any way, aside 

from piloting the questionnaire with some patients prior to 

the study. Their outcome measures - which included 

“Church”, “Shopping” and “Banking” – are outdated by 

modern standards. In Van der Ploeg et al.,21 sport score and 

sport participation were assessed by a custom 

questionnaire which took into account the number of hours 

spent on the sport and the designated intensity of the sport 

in Metabolic Equivalent of Tasks (METs) from a physical 

activity compendium.45 The authors did not provide further 

details of which sports were carried out and for how long, so 

it was impossible to identify which activities the ILLA 

population were participating in. These non-standardised 

forms of evaluation make it difficult to compare results 

across different studies and should be avoided in future 

investigations.  

Van der Ploeg et al.21 and Kosma et al.20 made use of the 

“Physical Activity Scale for Individuals with Physical 

Disabilities” (PASIPD) questionnaire to evaluate their 

programs.14 PASIPD is a widely used and validated 

questionnaire.46 The questionnaire assesses physical 

activity by combining the number of hours spent performing 

a particular activity with the activity’s MET equivalent. 

Despite the questionnaire’s popularity, the PASIPD has 

been found to show poor correlation with objective physical 

activity measurements,47 and so in future studies these 

questionnaires should also be avoided where possible, 

especially when the accuracy of the measurements is an 

important factor.  

Christiansen et al.,29 Littman et al.30 and all prosthetic 

studies used objective activity monitoring. By far the most 

common approach was to utilise the Step Activity Monitor 

and then analyse the intervention by changes in some 

measurement of step activity. Other devices such as the 

ActivPAL and ActiGraph were also used but only to 

measure step count or vaguely defined ‘activity bouts’. 

While objective activity monitoring is much more reliable 

than self-report questionnaires in terms of accuracy,48 

monitoring devices are over-reliant on stepping. Stepping 

has strong associations with positive health outcomes such 

as a decrease in the risk of cardiometabolic adverse 

events,49 however it only gives a surface-level insight into 

the person’s activity – for instance, an ILLA who performs 

stationary exercises and stretches will appear to be inactive 

when monitored by an ordinary pedometer. Kaufman et al.33 

was the only study to measure energy expenditure via the 

Doubly-Labelled Water Effect. While its high precision 

makes the this method the gold standard for measuring 

energy expenditure,50 the primary limitation of this method 

is its complexity – the method requires ingesting an isotope 

which is then expunged through urination and analysed 

using mass spectroscopy. Analysis must be carried out by 

a specialist, making it impractical to use for large sample 

sizes. Another problematic issue is that there is no 

standardisation of energy readings applicable to amputees 

like METs are to non-amputees. Using standard METs to 

assess non-amputees gives an unfair comparison due to 

lower energy expenditures51 and bodies such as the 

American College of Sports Medicine have yet to establish 

an equivalent system for ILLAs. Likewise, while there are 

government funded documents such the UK Chief Medical 

Officers' Physical Activity Guidelines to help set standards 

of physical activity for the general population,52 there is no 

equivalent document for ILLAs.  

Future interventions for physical activity monitoring should 

consider incorporating more complex measurements of 

activity. Step count measurements could be expanded upon 

by being able to distinguish between uphill/downhill and 

upstairs/downstairs movement, and the associated energy 

expended from performing such motions. In addition, the 

interventions should break down the analysed data into a 

simple, digestible format such that the end user (i.e the 

ILLA) can sufficiently understand their data and know what 

they need to improve upon.   

Limitation   

The selection of chosen articles for review was limited by 

the number of databases used for the literature search, and 

the authors’ English language bias. There is a reasonable 

possibility that the authors may have failed to identify more 

studies such as Kosma et al.20 and Van der Ploeg et al.21 

which do not mention an ILLA population within their 

abstract. This review may contain some reporting bias for 

the internal validity evaluation as the authors added two 

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8 

Jamieson A.G, Murray L, Buis A. The use of physical activity outcomes in rehabilitation interventions for lower limb amputees: A systematic review. Canadian 
Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.2. https://doi.org/10.33137/cpoj.v3i1.33931  

ISSN: 2561-987X THE USE OF PHYSICAL ACTIVITY OUTCOMES IN REHABILITATION  
Jamieson et al. 2020 

 
CPOJ 

 
additional criteria. To minimize this risk of bias, the authors 

conceived of these criteria before conducting the literature 

search. Some reporting bias may come from the fact that 

only one author carried out the assessment of 

methodological quality, and so is limited to one individual’s 

perspective. 

CONCLUSION 

After conducting a systematic review on Scopus, Pubmed, 

Embase, Medline and Web of Science, 16 studies were 

identified which assessed the physical activity of ILLAs after 

the application of a prosthetic or behavioural intervention. 

Ultimately, the lack of available studies makes it difficult to 

comment on the overall efficacy of behavioural interventions 

on ILLAs, but the increase of quality of the methodology in 

the most recent studies identified give an optimistic 

indication that future interventions will have similar levels of 

methodological quality. There are a substantial amount of 

prosthetic interventions with good methodological quality, 

however the efficacy of these prosthetic interventions has 

stagnated, and may require implementing more 

technologically advanced prosthetic components to obtain 

a significant change in activity. Future interventions should 

incorporate more sophisticated forms of activity 

measurement to give a more in-depth assessment of 

physical activity. 

ACKNOWLEDGEMENTS 

The author of this article would to thank the University of 

Strathclyde for providing the electronic resources required to 

access the reviewed papers for this research. 

DECLARATION OF CONFLICTING 

INTERESTS 

Mr. Jamieson receives grants from PAL Technologies Ltd as part 

of his PhD funding, PAL Technologies manufactures the ActivPAL 

which is one of the devices included in this review; co-author Dr. 

Arjan Buis is an associate editor at the Canadian Prosthetics & 

Orthotics Journal. Dr. Arjan Buis is also the main author of one of 

the reviewed articles.  

AUTHOR CONTRIBUTION 

• Alexander G. Jamieson: responsible for researching and 

reviewing all included articles and writing the main body of the 

review.  

• Laura Murray: responsible for editing , supervision. 

• Arjan Buis: responsible for editing , supervision. 

 

SOURCES OF SUPPORT 

This research was funded indirectly as part of the author Mr. 

Jamieson’s PhD sponsorship. The sponsorship is jointly 

funded by the EPSRC and PAL Technologies Ltd. 

 

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Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.2. https://doi.org/10.33137/cpoj.v3i1.33931  

ISSN: 2561-987X THE USE OF PHYSICAL ACTIVITY OUTCOMES IN REHABILITATION  
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Health. 2007;4(1):96-100. DOI: 10.1123/jpah.4.1.96 

47.Van Den Berg-Emons RJ, L'Ortye AA, Buffart LM, 

Nieuwenhuijsen C, Nooijen CF, Bergen MP, et al. Validation of the 

Physical Activity Scale for Individuals With Physical Disabilities. 

Arch Phys Med Rehabil. 2011;92(6):923-8. DOI: 

10.1016/j.apmr.2010.12.006 

48.Stepien JM, Cavenett S, Taylor L, Crotty M. Activity Levels 

Among Lower-Limb Amputees: Self-Report Versus Step Activity 

Monitor. Arch Phys Med Rehabil. 2007;88(7):896-900. DOI: 

10.1016/j.apmr.2007.03.016 

49.Schmidt MD, Cleland VJ, Shaw K, Dwyer T, Venn AJ. 

Cardiometabolic risk in younger and older adults across an index 

of ambulatory activity. Am. J. Prev. Med. 2009;37(4):278-84. DOI: 

10.1016/j.amepre.2009.05.020 

50.Berman E, Swibas T, Kohrt W, Catenacci V, Creasy S, 

Melanson E, et al. Maximizing precision and accuracy of the doubly 

labeled water method via optimal sampling protocol, calculation 

choices, and incorporation of 17O measurements. Eur. J. Clin. 

Nutr. 2019. DOI: 10.1038/s41430-019-0492-z 

51.Littman AJ, Boyko EJ, Thompson ML, Haselkorn JK, 

Sangeorzan BJ, Arterburn DE. Physical activity barriers and 

enablers in older Veterans with lower-limb amputation.  J 

Rehabil Res Dev. 2014;51(6):895-906. DOI: 10.1682/ 

jrrd.2013.06.0152 

52.UK Chief Medical Officers' Physical Activity Guidelines. In: Care 

DoHS, editor. 2019. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

https://doi.org/10.33137/cpoj.v3i1.33931


 

11 

Jamieson A.G, Murray L, Buis A. The use of physical activity outcomes in rehabilitation interventions for lower limb amputees: A systematic review. Canadian 
Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.2. https://doi.org/10.33137/cpoj.v3i1.33931  

ISSN: 2561-987X THE USE OF PHYSICAL ACTIVITY OUTCOMES IN REHABILITATION  
Jamieson et al. 2020 

 
CPOJ 

 

 

APPENDIX (A): DESCRIPTIONS OF THE RATING 

CRITERIA 

 

• INTERNAL VALIDITY 

An ideal study with the maximum internal validity should 

have a sufficient description of the study population 

selection and the inclusion and exclusion criteria. The study 

size (the product of the number of patients by the 

intervention length) should be greater than 10 patient years. 

The number of dropouts should be less than 20% of the total 

number included in the study, and the reasoning for 

dropouts should be sufficiently described (if there were no 

dropouts, both criteria were met by default). The follow-up 

time of the intervention should be at least 4 months. The 

study should check for confounding variables and report on 

the psychometric properties of the measuring instruments 

used - for this criterion only instruments measuring physical 

activity were assessed.  The outcome measures and data 

presented in the article should be in alignment with the 

study’s aims. 

Two additional criteria were created and used for this study: 

“whether the activity monitoring was carried out with 

objective measuring devices” and “whether participant 

adherence to the intervention was recorded”. The former 

criterion was added because an objective measurement of 

physical activity gives an unbiased, quantitative response to 

the intervention. The latter criterion, which asks whether 

participants managed to fully participate in the intervention, 

was added because adhesion to the intervention can be a 

factor in the outcome of the study. Each criterion was scored 

with a 1 (criteria was met) or a 0 (criteria was not met), 

making the maximum score for internal validity 11 points.  

• EXTERNAL VALIDITY 

The criteria used were as follows: Whether the participants 

in the study and the intervention itself were described in 

sufficient detail, whether clinically relevant outcomes were 

used, and whether the size of effect on the outcomes were 

clinically important, having a gain greater than or equal to 

10%. As with internal validity, each criterion was scored with 

a binomial outcome of 1 or 0, making the maximum score 4 

points.  

 

 

 

 

 

 

• INTERVENTION INTENSITY 

The intervention intensity score was calculated using four 

criteria which had a maximum score of 5 points each. The 

criteria were: the intervention’s duration (1 = <6 weeks, 2 = 

6 to 11 weeks, 3 = 12 weeks to 5 months, 4 = 6 to 12 

months, 5 = >12 months), frequency of contact between the 

intervention provider and the participant, (1 = annually, 2 = 

bimonthly to quarterly, 3 = monthly, 4 = weekly, 5 = daily) 

the type of contact, (1 = environmental at a physical, policy 

or legislative level, 2 = environmental with a small group or 

educational component involved, 3 = group contact, 4 = 

group contact with an individual component such as goal 

setting, 5 = individual) and the ‘reach’ - how many ways the 

intervention interacts with the participant (1 = one setting, 3 

= two settings, 5 = three or more settings). The total 

intervention intensity was calculated by the sum of the four 

factors, making the maximum score achievable 20 points.  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPENDIX 

(A) 

https://doi.org/10.33137/cpoj.v3i1.33931


 

12 

Jamieson A.G, Murray L, Buis A. The use of physical activity outcomes in rehabilitation interventions for lower limb amputees: A systematic review. Canadian 
Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.2. https://doi.org/10.33137/cpoj.v3i1.33931  

ISSN: 2561-987X THE USE OF PHYSICAL ACTIVITY OUTCOMES IN REHABILITATION  
Jamieson et al. 2020 

 
CPOJ 

 

 

APPENDIX (B): CHARACTERISTICS OF THE INCLUDED 

STUDIES 

Key summary: 

Appendix B summarizes the characteristics of all included 

studies. The key findings of this appendix were: 

• Behavioural interventions primarily employed 

randomized controlled study design, while nearly 

prosthetic interventions used crossover trial design. 

• Interventions lasted on average 15 weeks, had 23 

participants with an average age of 52 years. The 

participants primarily had unilateral amputation. 

• Most interventions used step count or a derivation of 

step count as their activity outcome metric. 

• When activity monitoring was used, the most popular 

device for carrying out this task was the Step Activity 

Monitor.  

• Interventions had mixed efficacy when it came to 

improving physical activity behaviours, this was true 

for both behavioural and prosthetic based 

interventions.  

Blue boxes indicate behavioural interventions, white boxes 

indicate prosthetic interventions.  

 

Abbreviations:  

PASIPD (Physical Activity Scale for Individuals with 

Physical Disabilities); SAM (Step Activity Monitor); ILLA 

(Individual(s) with Lower Extremity Amputation). 

  

1: One ILLA received intervention while 3 others received 

control. ILLAs made up 5% of the total population (n = 75).

  

2: 18 ILLAs received the ‘Rehabilitation and Sport’ 

intervention, another 18 had the combined ‘Rehabilitation 

and Sport’ + ‘Active after Rehabilitation’ intervention, and 28 

ILLAs were in the control group. ILLAs made up 6% of the 

total population (n = 993). 

 3: Age was not specified for ILLAs so the average age for 

all disability types was used. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPENDIX 

(B) 

https://doi.org/10.33137/cpoj.v3i1.33931


 

13 

Jamieson A.G, Murray L, Buis A. The use of physical activity outcomes in rehabilitation interventions for lower limb amputees: A systematic review. Canadian 
Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.2. https://doi.org/10.33137/cpoj.v3i1.33931  

ISSN: 2561-987X THE USE OF PHYSICAL ACTIVITY OUTCOMES IN REHABILITATION  
Jamieson et al. 2020 

 
CPOJ 

 
APPENDIX (B): CHARACTERISTICS OF THE INCLUDED STUDIES 

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https://doi.org/10.33137/cpoj.v3i1.33931


 

14 

Jamieson A.G, Murray L, Buis A. The use of physical activity outcomes in rehabilitation interventions for lower limb amputees: A systematic review. Canadian 
Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.2. https://doi.org/10.33137/cpoj.v3i1.33931  

ISSN: 2561-987X THE USE OF PHYSICAL ACTIVITY OUTCOMES IN REHABILITATION  
Jamieson et al. 2020 

 
CPOJ 

 
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https://doi.org/10.33137/cpoj.v3i1.33931


 

15 

Jamieson A.G, Murray L, Buis A. The use of physical activity outcomes in rehabilitation interventions for lower limb amputees: A systematic review. Canadian 
Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.2. https://doi.org/10.33137/cpoj.v3i1.33931  

ISSN: 2561-987X THE USE OF PHYSICAL ACTIVITY OUTCOMES IN REHABILITATION  
Jamieson et al. 2020 

 
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https://doi.org/10.33137/cpoj.v3i1.33931

