







































All articles are permanently available online to the public without restrictions or subscription fees. They are free to be used, cited, 

and distributed, provided that appropriate acknowledgment is included. Authors retain the copyright of their original contributions 

and grant the Canadian Online Publication Group (COPG) a license to publish the article and identify itself as the original 

publisher. CPOJ articles are licensed under the Creative Commons Attribution 4.0 International License. 

 

CPOJ Website: https://jps.library.utoronto.ca/index.php/cpoj/index 

Editorial Office: cpoj@online-publication.com    

ISSN: 2561-987X 

CPOJ is a member of, and subscribes to the principles of, the Committee on Publication Ethics (COPE).   

 

 

VOLUME 7, ISSUE 2 

 2024 
 

RESEARCH ARTICLE 

de Laat F.A, Kühne S.W.M, de Vos W.C.A.J, Geertzen J.H.B. Overcoming barriers to cycling for knee disarticulation and transfemoral prosthesis users: A pilot 

study in The Netherlands. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 2, No.4. https://doi.org/10.33137/cpoj.v7i2.44191  

 

https://jps.library.utoronto.ca/index.php/cpoj/index
mailto:cpoj@online-publication.com
https://publicationethics.org/about/our-organisation
https://publicationethics.org/members/canadian-prosthetics-orthotics-journal
https://doi.org/10.33137/cpoj.v7i2.44191


 

1 

de Laat F.A, Kühne S.W.M, de Vos W.C.A.J, Geertzen J.H.B. Overcoming barriers to cycling for knee disarticulation and transfemoral prosthesis users: A pilot 
study in The Netherlands. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 2, No.4. https://doi.org/10.33137/cpoj.v7i2.44191 

 

 

RESEARCH ARTICLE 

 

OVERCOMING BARRIERS TO CYCLING FOR KNEE DISARTICULATION AND TRANSFEMORAL 

PROSTHESIS USERS: A PILOT STUDY IN THE NETHERLANDS 

de Laat F.A1*, Kühne S.W.M2, de Vos W.C.A.J.2, Geertzen J.H.B.3 

1 Rehabilitation Centre Leijpark, Libra Rehabilitation Medicine & Audiology, Tilburg, The Netherlands. 
2 Livit Ottobock Care, ‘s Hertogenbosch and Dordrecht, The Netherlands. 
3 University of Groningen, University Medical Centre Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands. 

 
  
 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

INTRODUCTION   

 

Cycling is an activity with a number of benefits. It can be 

done as a recreational activity and is a cheap and eco-

friendly way of transportation, especially in flat countries like 

The Netherlands.1 For rehabilitation purposes, cycling is  

 

 

 

 

a good way to train the cardiovascular system and 

strengthening the leg muscles.2 

Persons with a lower limb amputation (LLA) can also benefit 

from cycling. Cycling is joint friendly, as the majority of body 

weight is supported by the bicycle seat, thereby reducing 

the load on the residual limb,3 but cycling requires more 

degrees of flexion at the hip, knee and ankle than walking.4 

Especially in persons with a LLA due to diabetes, limited 

joint mobility is common, affecting the range of motion of hip 

and knee.5 To address these limitations in range of motion, 

adaptations can be made to either the prosthesis or the 

bicycle.6 

 
OPEN  ACCESS 

ABSTRACT 

BACKGROUND: Cycling has a number of benefits, especially for individuals with a knee disarticulation or 

transfemoral prosthesis. However, the barriers they face in cycling are not well understood. 

OBJECTIVES: To explore the barriers in cycling experienced by users with a knee disarticulation or 

transfemoral prosthesis, and to gather solutions to overcome these barriers. 

METHODOLOGY: A qualitative research approach was used. In-depth, semi-structured, self-developed 

interviews were conducted with experienced prosthetic users (N=8) and an adapted version was used for 

certified prosthetists/orthotists (CPOs) (N=3). The interview included physical, psychological, prosthetic, and 

bicycle-related items. 

FINDINGS: Based on the findings from the interviews, the following barriers and corresponding 

recommendations were identified: 

• Physical barriers: Exertion, skin damage in the groin area and discomfort in the back and hip. 

o Recommendation: Use of an electric bicycle and use of a crank shortener or saddle adjustment to 

overcome asymmetry in cycling. 

• Psychological barriers: Fear of falling or fear of balance disturbances. 

o Recommendation: Task- and context-specific training, or graded exposure to cycling during prosthetic 

training, along with potentially using a more advanced bike with improved balance.  

• Prosthetic barriers: Problems with switching the knee prosthesis mode for cycling; challenges with 

prosthetic suspension; and discomfort caused by the socket brim design. 

o Recommendation: Manufacturers should integrate automatic detection of cycling in microprocessor 

prosthetic knee joints; use of a total elastic suspension belt (TES-belt); and lowering the ventral edge of 

the socket. 

• Bicycle-related barriers: Slipping of the prosthetic foot off the pedal. 

o Recommendation: Use of anti-slip pedals or a block heel under the shoe. 

CONCLUSION: By addressing the challenges and barriers, we aim to promote greater engagement in 

cycling, which offers significant physical and psychological benefits for persons with knee disarticulation or 

transfemoral amputation. Eventually, this can enhance their quality of life and foster greater independence. 

 

 

 

ARTICLE INFO 

Received: October 23, 2024 

Accepted: December 9, 2024 

Published: December 12, 2024 
 

CITATION 

de Laat F.A, Kühne S.W.M, de 

Vos W.C.A.J, Geertzen J.H.B. 

Overcoming barriers to cycling 

for knee disarticulation and 

transfemoral prosthesis users: A 

pilot study in The Netherlands. 

Canadian Prosthetics & 

Orthotics Journal. 2024; Volume 

7, Issue 2, No.4. 

https://doi.org/10.33137/cpoj.v7i

2.44191  

KEYWORDS 

Amputation, Cycling, Prosthesis, 

Mobility, knee Disarticulation, 

Transfemoral Amputation, 

Bicycle, Netherlands, Interview, 

Rehabilitation, Prosthetic Foot 

 

* CORRESPONDING AUTHOR: 

Fred A. de Laat, MD, PhD, 

Affiliation: Libra Rehabilitation Medicine & Audiology, Tilburg/Eindhoven, 
The Netherlands. 

E-Mail: f.delaat@libranet.nl 

ORCID ID: https://orcid.org/0000-0002-4348-5998 

 

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

Volume 7, Issue 2, Article No.4. 2024 

 

 

https://doi.org/10.33137/cpoj.v7i2.44191
https://doi.org/10.33137/cpoj.v7i2.44191
https://doi.org/10.33137/cpoj.v7i2.44191
mailto:f.delaat@libranet.nl
https://orcid.org/0000-0003-3947-293X
https://jps.library.utoronto.ca/index.php/cpoj/index


 

2 

de Laat F.A, Kühne S.W.M, de Vos W.C.A.J, Geertzen J.H.B. Overcoming barriers to cycling for knee disarticulation and transfemoral prosthesis users: A pilot 
study in The Netherlands. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 2, No.4. https://doi.org/10.33137/cpoj.v7i2.44191 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X OVERCOMING CYCLING BARRIERS FOR PROSTHESIS USERS 

de Laat et al., 2024 

There are several studies assessing the influence of 

facilitators and barriers in cycling with a knee disarticulation 

or transfemoral prosthesis.7-9 In an older study in Slovenia, 

persons with a transtibial amputation cycled more than 

persons with a transfemoral amputation.7 In a Thai study, 

persons with a transtibial amputation were 4.5 times more 

likely to cycle than persons with a knee disarticulation or 

transfemoral amputation.8 The components of the knee 

disarticulation and transfemoral prosthesis did not influence 

the chance in cycling after an LLA, although limited knee 

flexion ability was mentioned as a barrier. Participants also 

reported the prosthetic foot slipping off the pedal as a 

barrier. In that study, almost all participants used their daily 

prosthesis and shoes while cycling and reported that the 

prosthetic foot slipping off the pedal was a barrier.8 The 

circumstances in Thailand, however, differ considerably 

from those in Western countries like The Netherlands, 

particularly in terms of income and traffic. In a recent study 

in The Netherlands9 an overview was given of facilitators 

and barriers related to cycling participation in people with an 

LLA. A dynamic foot positively predicted cycling, whereas 

adjuvant comorbidity negatively predicted cycling. However, 

in that study, specific physical and emotional barriers were 

not mentioned, nor specific factors related to prosthesis or 

bicycle.9 

The objective of this pilot study was to explore barriers to 

cycling and identify solutions by interviewing experienced 

users of knee disarticulation or transfemoral prostheses, as 

well as prosthetists working with lower limb amputee 

cyclists. 

METHODOLOGY 

Participants 

Participants were recruited from two orthopedic services in 

the region of Dordrecht and Eindhoven, The Netherlands. 
All participants gave informed consent. A waiver from the 

local Medical Ethical committee was obtained for this study 

(METC Brabant nr NW2020-41). Inclusion criteria required 

participants to be regular cyclists with a knee disarticulation 

or transfemoral amputation. One of the authors (SK) 

contacted eligible participants, all of whom agreed to 

participate in the study. 

In addition to user opinions, it is important to include the 

perspectives of certified prosthetists/orthotists (CPOs). 

Therefore, CPOs with substantial experience (>7 years and 

working with 10–40 patients who cycle with knee 

disarticulation or above-the-knee prostheses) were also 

recruited. 

Procedure 

Participants with a knee disarticulation or a transfemoral 

amputation were asked to participate in an in-depth semi-

structured interview with one of the assessors (SK). This 

interview was self-developed, as no validated interview 

scheme or questionnaire was available on assessing 

cycling with a lower limb prosthesis. The interview (in Dutch) 

comprised open questions about experiences in cycling, 

barriers in the interaction between prosthesis and bicycle, 

and recommendations for diminishing these barriers. 

Characteristics of the participants (age, gender, amputation 

level, amputation side, type of prosthetic knee and foot, kind 

of bicycle (motorized or not)) were recorded. The interview 

framework is provided in Appendix A. 

For the CPO’s, an adapted interview instrument (Appendix 

B) was developed to assess risks associated with cycling 

using a prosthesis, and barriers related to the interaction 

between the prosthesis and the bicycle, and possible 

recommendations and their consequences. The 

characteristics of the CPOs (years of experience, number of 

treated persons with an LLA who cycle) were recorded. 

Data analysis 

All answers to the interview questions were recorded 

verbatim, resulting in detailed descriptions of the barriers 

and recommendations. To ensure the original meaning was 

preserved, the participants’ quotes were translated faithfully 

in English afterwards by an independent native English-

speaking CPO, working in The Netherlands. 

These barriers and recommendations were clustered by two 

independent assessors (FdL and WdV) in 4 categories, 

based on the global components of the framework of the 

International Classification of Functioning, Disability and 

Health (ICF):10  

1: Physical barriers affecting individuals with an LLA, 

especially skin damage and pain in the back and hips 

(body functions and structures in the ICF model) 

2: Psychological barriers affecting individuals with an 

LLA, especially fear of balance disturbances (personal 

factors in the ICF model) 

3: Prosthetic barriers affecting individuals with an LLA, 

especially the cycle mode in microprocessor knees 

(MPK’s) (environmental factors, [body-related] in the 

ICF model) 

4: Bicycle barriers affecting individuals with an LLA, 

especially the interaction between prosthetic foot and 

the pedal (environmental factors, [not body-related] in 

the ICF model). 

Differences in clustering between assessors were 

discussed until consensus was reached.  

RESULTS 

Characteristics of the participants 

We approached eight individuals with an LLA (6 with a 

transfemoral amputation, 2 with a knee disarticulation, 

numbers 1-8), fulfilling the inclusion criteria, and all agreed 

https://doi.org/10.33137/cpoj.v7i2.44191


 

3 

de Laat F.A, Kühne S.W.M, de Vos W.C.A.J, Geertzen J.H.B. Overcoming barriers to cycling for knee disarticulation and transfemoral prosthesis users: A pilot 
study in The Netherlands. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 2, No.4. https://doi.org/10.33137/cpoj.v7i2.44191 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X OVERCOMING CYCLING BARRIERS FOR PROSTHESIS USERS 

de Laat et al., 2024 

to participate. The characteristics of these participants are 

presented in Table 1. 

We also recruited three CPOs (numbers 9-11). They had on 

average 15 years of experience, and the average number 

of treated persons with an LLA who cycle was 10-40 per 

year per CPO. 

Barriers and recommendations in cycling 

All barriers, reported more than once, are clustered and 

presented in Table 2. 

    1 ) Physical barriers 

Skin damage and exertion were the most frequently 

reported barriers among all the barriers mentioned (82%). 

Answers of two participants and two CPOs were 

representative of the physical barriers mentioned: 

1: “Pedaling with just one leg is tiring.” 

5: “Especially the skin that rubs open. In particular in the 

groin and the top in my hip, where the edges of the 

prosthesis are located, that presses most on the skin.” 

8: “I had chafing spots with the previous socket, mostly 

on the hip, because you have more friction there. That 

socket was quite high and when you make the cycling 

movement, you continuously get a kind of rubbing effect. 

The socket connects higher than when walking and, 

because the cycling motion is greater, it irritated me.” 

9 (CPO): “You can get adhesions in the groin region. 

These adhesions are between the skin and the socket. 

While cycling, your movements become viscous, 

causing a lot of friction, and then the skin eventually 

breaks... Usually the socket chafes against the skin. In 

fact, the problems are always in the groin region. Or that 

they are really starting to get pressure ventrally proximal 

because the socket is pressing there when cycling.” 

10 (CPO): “Pressure spots ... Depends a bit on the 

position. The socket can start to push in the front and 

into the groin.” 

A recommendation to overcome exertion was to use an 

electric bicycle. The interaction between the skin and the 

socket brim during cycling, caused by the constant 

movement of the thigh, generates shear forces in the groin 

area. A recommendation was the use of a crank arm 

shortener, which was unknown for several participants with 

an LLA. Another recommendation to prevent skin problems 

is to adjust the saddle or remove the outer part of the saddle 

on the prosthetic side. In addition, it is recommended to 

lower the socket and use it in combination with a liner. A 

socket with soft material on the proximal side (soft-brim 

socket) is also recommended to reduce problems, if the 

residual limb is long enough. 

Participants reported that back pain was primarily caused 

by asymmetry during cycling. This asymmetry during 

cycling has two main causes: First, force application to the 

pedal is significantly limited with the prosthetic limb, 

resulting in the majority of the force being generated by the 

sound limb, which leads to an asymmetrical movement and 

posture on the saddle. Second, the shape of the socket brim 

can exert pressure on the groin due to the increased hip 

flexion required during cycling, which also can lead to an 

asymmetrical posture on the saddle or cause the upper 

body to compensate (by leaning backward) in order to avoid 

discomfort. For this item, the use of a crank arm shortener 

was proposed again. 

Table 1: Participant demographics and prosthetic characteristics.  
Abbreviations: TF, transfemoral; KD, knee disarticulation; MPK, microprocessor knee; IRC socket, transfemoral socket standard with ischial ramus containment 

(IRC) design. 

 Gender 
(F/M) 

Age 
(y) 

Amputation 
side (R/L) 

Amputation 
level 

Type of 
prosthetic 

knee 

Mechanic 
(M)/MPK 

type of 
prosthetic 

foot 

Type of 
prosthetic 

socket 
Liner 

Cycling 
level per 

week (km) 

e-bike 
(yes/no) 

1 F 56 R TF C-leg MPK Triton IRC socket No 0,5-30 no 

2 M 52 L KD Genium MPK Triton HD 
Knee 

disarticulation 
socket 

Yes 0,5-1 no 

3 F 71 R TF 
3R106 
PRO 

M Trias Soft brim socket Yes 0,5-3 yes 

4 M 35 R TF Rheo Knee MPK 
Variflex 
Rotate 

IRC socket No 0,5-30 yes 

5 M 78 L TF VGK M Triton IRC socket Yes 15 no 

6 F 46 L KD Genium MPK Triton 

Knee 
disarticulation 

socket (volume 
adjustable) 

Yes 20 no 

7 M 66 L TF 
RHEO 
Knee 

MPK Talux IRC socket Yes 25-50 yes 

8 F 25 L TF Genium MPK Trias Soft brim socket No 0,5-10 no 

 

https://doi.org/10.33137/cpoj.v7i2.44191


 

4 

de Laat F.A, Kühne S.W.M, de Vos W.C.A.J, Geertzen J.H.B. Overcoming barriers to cycling for knee disarticulation and transfemoral prosthesis users: A pilot 
study in The Netherlands. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 2, No.4. https://doi.org/10.33137/cpoj.v7i2.44191 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X OVERCOMING CYCLING BARRIERS FOR PROSTHESIS USERS 

de Laat et al., 2024 

Table 2: Clustered barriers reported by the person with an LLA and 

their CPO. Abbreviation: CPO, certified prosthetists/orthotists; LLA, 

lower-limb amputation. 

Barriers Item 

Person 

with an 

LLA 

(n=8) 

CPO 

(n=3) 

Total 

(n=11) 

  n n n 

Physical items 

Skin damage 6 3 9 

Back pain 4 1 5 

exertion 6 0 6 

     

Psychological 

items 

Fear of falling 4 2 6 

Fear of balance 

disturbances 
3 1 4 

     

Prosthetic items 

Knee prosthesis 

cycling mode 
6 2 8 

Fitting of the 

socket/suspensi

on/socket trim 

line 

5 2 7 

     

Bicycle items 

Prosthetic foot 

slipping off the 

pedal 

6 3 9 

 

2) Psychological barriers 

Fear of falling and concerns about balance disturbances 

were mentioned as psychological barriers. Fear was 

experienced when stepping on and off the bike, as well as 

when navigating busy roads. Answers of two participants 

were representative of the psychological barriers 

mentioned: 

5: “I have trouble balancing, I am getting older and more 

anxious… I am afraid I will fall on the prosthetic side.” 

9 (CPO): “Often prosthetic users are afraid of cycling.” 

    3) Prosthetic barriers 

The majority of the participants with an LLA (using a MPK) 

were dissatisfied with the knee's cycling mode. This is 

because of the necessity of using a cell phone to 

activate/deactivate the cycling mode. Some participants 

with an LLA forgot to switch off the cycling mode after use, 

which led to dangerous situations. 

1: “It is too cumbersome, it takes too much time. First 

you have to take your phone, unlock and open the 

application and connect to the prosthesis, which also 

takes a while. I think it takes 30 seconds to a minute to 

activate the bike mode. I do not think it is customer 

friendly.” 

1: “Apart from that when you get off, you have to take it 

off bike mode again, otherwise there is a risk of falling.” 

6: “I often forgot to change the knee-setting after 

cycling.” 

8: “So you have to start it, wait a while ... then it can 

connect. I often have my Bluetooth switched off, 

because otherwise my battery will drain quickly, so it is 

frustrating that Bluetooth is still on.” 

10 (CPO): “Attention must be paid to the knee-settings, 

which have to be changed when getting on and off.” 

All participants suggested implementing an automatic 

detection feature for the cycling mode of the MPK, if not 

already present. If this is not possible, a second best 

solution is a switch on the prosthesis (like the Very Good 

Knee (VGK) knee) instead of using a cell phone. 

The fitting of the socket was frequently mentioned as a 

barrier, due to too much sweating and loosening of the 

vacuum during cycling. 

8: “When you cycle, there is no vacuum anymore, 

because air is not anymore pumped out of the socket. If 

you sweat while doing this, there is also the chance that 

your socket will slide off your stump. Because you are 

cycling you do not have the effect that the air is blown or 

pushed out of the socket.” 

10 (CPO): “The constant rotating movement pushes the 

socket against the saddle. The socket comes loose from 

the saddle... which leads to failure of the prosthesis. 

Constant friction and perspiration can also cause the 

socket to detach from the stump more quickly.” 

To overcome fitting problems of the socket, a Total Elastic 

Suspension (TES) belt was recommended (Figure 1). 

 

Figure 1: TES-belt. Picture, made by one of the co-authors, with 

permission. 

   4) Bicycle barriers 

The interaction between prosthetic foot/shoe and the pedal, 

especially the prosthetic foot slipping off the pedal was most 

frequently reported. 

2: “I really have to pay attention. Checking whether the 

foot is properly on the pedal while cycling. Check every 

time, keep an eye on the foot each time to see if it needs 

to be repositioned.” 

https://doi.org/10.33137/cpoj.v7i2.44191


 

5 

de Laat F.A, Kühne S.W.M, de Vos W.C.A.J, Geertzen J.H.B. Overcoming barriers to cycling for knee disarticulation and transfemoral prosthesis users: A pilot 
study in The Netherlands. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 2, No.4. https://doi.org/10.33137/cpoj.v7i2.44191 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X OVERCOMING CYCLING BARRIERS FOR PROSTHESIS USERS 

de Laat et al., 2024 

5: “I adjust the position of my foot and make use of the 

height of the heel. I then press my heel on the pedal.” 

6: “To prevent the prosthesis from slipping away I had a 

strap but that is not easy to use. I couldn't get my foot 

out of it and could not get off my bike in traffic. Also, I 

had to put the pedal in a straight position before I put my 

foot in it and then my foot slid in so deep, I could not get 

it out again. That does not work and is very dangerous.” 

7: “I make sure I put my foot on the pedal correctly, heel 

behind the pedal, so on good roads nothing dangerous 

happens.” 

8: “We also bought a click system. But because one had 

to put shoes on again to cycle, we bought expensive 

shoes which we never used because I found it too 

impractical.” 

10 (CPO): “Yes, depending on what type of knee you 

have. The moment you have a knee that wants to push 

the knee to extend it slowly moves forward, if it is not 

locked. Then you have to secure it to the pedal.” 

To overcome the problem of the prosthetic foot slipping off 

the pedal, participants with an LLA tried a lot of solutions to 

click the shoe on the pedal, but frequently unlocking the 

shoe was dangerous. Two participants recommended a 

block heel (Figure 2) to prevent the prosthetic foot slipping 

off the pedal and were satisfied with it. 

 

Figure 2: Block heel under the shoe. Picture of one of the co-

authors. 

DISCUSSION 

In this study, we assessed barriers to cycling for individuals 

with a knee disarticulation or transfemoral amputation. We 

gathered and clustered barriers and recommendations in 

order to expand the possibilities for cycling. The most 

commonly mentioned barriers were exertion, residual limb 

skin damage and the prosthetic foot slipping off the pedal. 

Additionally, the method of switching the cycling mode on 

and off in the MPK using a cell phone was mentioned as a 

problem. Fear of falling, or fear of balance disturbances 

were the most mentioned psychological items. 

In a former Thai study,8 the most commonly mentioned 

barriers were pain and discomfort during cycling. However, 

in that study, most participants had a transtibial amputation, 

and none of the participants with a knee disarticulation or 

transfemoral amputation used an MPK. 

To overcome physical problems like skin damage or back 

pain, a crank arm shortener is proposed. Another option is 

lowering the edge of the socket, but most of the cyclists use 

the same prosthesis for cycling as for walking.8 Therefore, 

this solution can disturb the way of walking with the 

prosthesis and is only possible if the residual limb is long 

enough. To overcome exertion, an electric bicycle was 

recommended. 

In terms of psychological barriers, fear can be diminished 

by enlarging self-confidence. The literature suggests that 

task- and context-specific training, along with graded 

exposure to cycling, should be initiated as soon as possible 

to address this issue effectively.11 For adults with poor 

performance and a fear of falling or balance disturbances, 

the literature suggests that bike adaptations can help, such 

as a lower frame and automatic saddle height adjustment. 

These modifications can make it easier to step on and off 

the bike and ensure that the feet are flat on the ground when 

standing.12  

The prosthetic barriers mentioned by the participants were 

activating and deactivating the cycling mode of the knee and 

the fitting of the socket. The first item should be addressed 

by the manufacturers of the microprocessor prosthetic 

knees by integrating automatic cycling detection. 

Participants rejected solutions that rely on cell phone 

operation for mode switching. The fitting of the socket can 

be improved by using a TES-belt (Figure 1). The literature 

describes an open socket technique for individuals with 

knee disarticulation, which could be a solution.13 

The bicycle-related issue that was most frequently 

mentioned was the prosthetic foot slipping off the pedal. 

Most of the participants had made adaptations of the pedal, 

such as larger pedals with anti-slip, or a rubber strip on the 

lateral side of the pedal, to prevent the shoe from slipping 

off to the lateral side. These adaptations were satisfactory 

for the cyclists who made them. Two participants 

recommended a shoe with a block heel to prevent the 

prosthetic foot slipping off the pedal (Figure 2). Other tried 

adaptations, such as a toe clip or shoe cleat were not 

recommended, due to dangerous situations when 

unlocking. 

In summary, individuals with knee disarticulation or 

transfemoral amputation have the potential to regain their 

ability to cycle. Prerequisites include a rehabilitation team 

with the necessary resources, such as an adapted bicycle 

https://doi.org/10.33137/cpoj.v7i2.44191


 

6 

de Laat F.A, Kühne S.W.M, de Vos W.C.A.J, Geertzen J.H.B. Overcoming barriers to cycling for knee disarticulation and transfemoral prosthesis users: A pilot 
study in The Netherlands. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 2, No.4. https://doi.org/10.33137/cpoj.v7i2.44191 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X OVERCOMING CYCLING BARRIERS FOR PROSTHESIS USERS 

de Laat et al., 2024 

and/or saddle, expertise in cycle training, and a CPO with 

experience and interest in cycling, capable of creating an 

appropriate socket and suspension system.  

Study strengths and limitations 

A strength of the study is the broad experience and 

expertise of the participants, so a lot of barriers and 

recommendations could be gathered. We included 

individuals with an LLA ensuring diversity in age, gender, 

cycling distance levels, and types of prosthetic knees used. 

It could be seen as a limitation that all participants were 

recruited in two orthopedic services, so a selection bias 

could not be excluded. A further limitation of our study was 

the use of a self-developed interview scheme that was not 

validated. However, no validated tool existed, nor was there 

any information from scientific studies to base development 

of such a tool. This may have had an influence on the 

outcomes, although the questions asked were as broad as 

possible, to provide the participants with adequate room for 

their interpretation. At last it is questionable if saturation 

occurred in this pilot study. In general, saturation can be 

achieved in a narrow range (up to 9–17) of interviews, 

particularly in studies with relatively homogenous study 

populations and narrowly defined objectives.14 During our 

study, the penultimate participant (a CPO) gave a 

recommendation to prevent skin damage, whereas the last 

participant had no new barriers in cycling. Therefore, we 

think that lack of saturation has at most a minor influence in 

our results. 

CONCLUSION 

There are several barriers in cycling experienced by users 

with knee disarticulation or transfemoral prosthesis. 

Addressing these challenges and barriers aims to increase 

engagement in cycling, thereby providing substantial 

physical and psychological benefits for this population. 

Eventually, this can enhance their quality of life and foster 

greater independence. Future research could focus on 

multicenter, larger-scale studies with interventions for better 

cycling, such as an improved socket, or adjustment of the 

saddle or crank. 

 

ACKNOWLEDGEMENTS 

We wish to thank all patients and CPOs that participated in the 

study. 

DECLARATION OF CONFLICTING INTERESTS 

• Fred de Laat: Nothing to be declared. 

• Sabine Kuhne: Employee of Livit Ottobock Care. 

• Wouter de Vos: Employee of Livit Ottobock Care. 

• Jan Geertzen: Nothing to be declared. 

 

 

AUTHORS’ CONTRIBUTION 

• Fred de Laat: Research design, analysis and interpretation of 

the data, first draft of the manuscript, manuscript preparation. 

• Sabine Kuhne: Research design, data-acquisition, analysis 

and interpretation of the data, manuscript preparation. 

• Wouter de Vos: Research design, analysis and interpretation 

of the data, manuscript preparation. 

• Jan Geertzen: Analysis and interpretation of the data, 

manuscript preparation. 

 

All authors have read and approved the final version of the 

manuscript. 

 

SOURCES OF SUPPORT 

None. 

REFERENCES 

1.Poonsiri J, Dekker R, Dijkstra PU, Hijmans JM, Geertzen JHB. 

Bicycling participation in people with a lower limb amputation: A 

scoping review. BMC Musculoskelet Disord. 2018;19(1):398. DOI: 

10.1186/s12891-018-2313-2  

2.Oja P, Titze S, Bauman A, de Geus B, Krenn P, Reger-Nash B, et 

al. Health benefits of cycling: A systematic review. Scand J Med Sci 

Sports. 2011;21(4):496-509. DOI: 10.1111/j.1600-0838.2011.01299 

.x 

3.Ericson MO, Bratt A, Nisell R, Németh G, Ekholm J. Load 

moments about the hip and knee joints during ergometer cycling. 

Scand J Rehabil Med. 1986;18(4):165-72.  

4.Ericson MO, Nisell R, Nemeth G. Joint motions of the lower limb 

during ergometer cycling. J Orthop Sports Phys Ther. 

1988;9(8):273-8. DOI: 10.2519/jospt.1988.9.8.273 

5.Francia P, Anichini R, Seghieri G, De Bellis A, Gulisano M. 

History, Prevalence and Assessment of Limited Joint Mobility, from 

Stiff Hand Syndrome to Diabetic Foot Ulcer Prevention: A Narrative 

Review of the Literature. Curr Diabetes Rev. 2017; 14(5):411-26.  

6.Childers WL, Kistenberg RS, Gregor RJ. The biomechanics of 

cycling with a transtibial amputation: Recommendations for 

prosthetic design and direction for future research. Prosthet Orthot 

Int. 2009;33(3):256-71. DOI: 10.1080/03093640903067234 

7.Burger H, Marinček Č, Isakov E. Mobility of persons after 

traumatic lower limb amputation. Disabil Rehabil. 1997;19(7):272-

7. DOI: 10.3109/09638289709166538 

8.Poonsiri J, Dekker R, Dijkstra PU, Nutchamlong Y, 

Dismanopnarong C, Puttipaisan C, et al. Cycling of people with a 

lower limb amputation in Thailand. PLoS One. 

2019;14(8):e0220649. DOI: 10.1371/journal.pone.0220649 

9.Poonsiri J, Dekker R, Dijkstra PU, Hijmans JM, Geertzen JHB. 

Cycling in people with a lower limb amputation. BMC Sports Sci 

Med Rehabil. 2021;13(1):75. DOI: 10.1186/s13102-021-00302-3 

10.International classification of functioning, disability and health 

(ICF) [Internet]. WHO, Geneva. 2001; [cited 2024, October 23]. 

Available from: 

https://www.who.int/standards/classifications/international-

classification-of-functioning-disability-and-health 

https://doi.org/10.33137/cpoj.v7i2.44191
https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health
https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health


 

7 

de Laat F.A, Kühne S.W.M, de Vos W.C.A.J, Geertzen J.H.B. Overcoming barriers to cycling for knee disarticulation and transfemoral prosthesis users: A pilot 
study in The Netherlands. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 2, No.4. https://doi.org/10.33137/cpoj.v7i2.44191 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X OVERCOMING CYCLING BARRIERS FOR PROSTHESIS USERS 

de Laat et al., 2024 

11.van Twillert S, Postema K, Geertzen JHB, Hemminga T, Lettinga 

AT. Improving rehabilitation treatment in a local setting: A case 

study of prosthetic rehabilitation. Clin Rehabil. 2009;23:938-47. 

DOI: DOI: 10.1177/0269215509338125 

12.Dubbeldam R, Baten C, Buurke JH, Rietman JS. SOFIE, a 

bicycle that supports older cyclists? Accid Anal Prev. 2017; 

105:117-23. DOI: 10.1016/j.aap.2016.09.006 

13.Otter N, Postema K, Rijken RAJ, van Limbeek J. An open socket 

technique for through-knee amputations in relation to skin problems 

of the stump: an explorative study. Clin Rehabil. 1999;13:34-43. 
DOI: 10.1177/026921559901300105 

14.Hennink M, Kaiser BN. Sample sizes for saturation in qualitative 

research: A systematic review of empirical tests. Soc Sci Med. 

2022;292:114523. DOI: 10.1016/j.socscimed.2021.114523 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

https://doi.org/10.33137/cpoj.v7i2.44191


 

8 

de Laat F.A, Kühne S.W.M, de Vos W.C.A.J, Geertzen J.H.B. Overcoming barriers to cycling for knee disarticulation and transfemoral prosthesis users: A pilot 
study in The Netherlands. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 2, No.4. https://doi.org/10.33137/cpoj.v7i2.44191 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X OVERCOMING CYCLING BARRIERS FOR PROSTHESIS USERS 

de Laat et al., 2024 

 

Appendix A: Interview Framework for Cycling with a Knee-Disarticulation or Transfemoral Prosthesis. 
 

Demographics 

Sex:   
Age:  
Amputation level: 
Amputation side:   
Type of prosthetic knee:  
Type of prosthetic foot:  
Type of prosthetic socket:  
Type of liner:  
Weekly cycling distance (in kilometers) 
Type of bike (e-bike or regular bike) 

Reasons for 
Cycling 

Initial Question Follow up Questions 

Could you tell us the reasons you 
cycle? 

- How often do you cycle? 

- With whom do you cycle? 

- How do you feel after cycling? 

- What kind of feeling do you have after cycling? 

Benefits of cycling 

Initial Question Follow up Questions 

In what ways does cycling benefit 
you? 

- Impact on physical health? 
- Impact on mental health? 
- Impact on social life? 
- Impact on independence? 
- New life possibilities from cycling? 

Barriers to Cycling 

Initial Question Follow up Questions 

How was your experience cycling for 
the first time? 

- Why did you want to cycle? 
- What type of bicycle did you use? 
- How did it feel to get on and off the bicycle? 
- How did you manage switching the mode of the MPK knee 

between cycling and walking? 
- Was the saddle height comfortable? 
- Did you feel symmetry in movement between your left and right 

sides? 

How would you describe your cycling 
experience? 

- Long distance 
- Short distance 
- With stopovers 

What barriers do you experience 
while cycling? 

- Socket discomfort 
- Stump issues, sweating 
- Prosthetic knee limitations 
- Prosthetic foot limitations 
- Movement restrictions (e.g., difficulty bending or    extending the 
hip) 
- Muscle strength 
- Pain 
- Maximum cycling distance 
- Getting on and off the bike 

Have you ever experienced a 
dangerous situation in traffic? 

- Have you ever fallen off the bike? 

Modifications to 
the bike 

Initial Question Follow up Questions 

Do you have any modifications to 
your bike? 

Typical characteristics of the bike: 

• Backpedal brake 

• Gears 

• Frame height 

• Saddle 

• Click system 
Adaptations to the bike: 

• Prosthetic or shoe adaptations 
What do you do to make cycling 
easier? 

 

What do you think of a solution to 
make cycling easier? 

 

 

https://doi.org/10.33137/cpoj.v7i2.44191


 

9 

de Laat F.A, Kühne S.W.M, de Vos W.C.A.J, Geertzen J.H.B. Overcoming barriers to cycling for knee disarticulation and transfemoral prosthesis users: A pilot 
study in The Netherlands. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 2, No.4. https://doi.org/10.33137/cpoj.v7i2.44191 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X OVERCOMING CYCLING BARRIERS FOR PROSTHESIS USERS 

de Laat et al., 2024 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Demographics  
- Years of work experience: 
- Number of patients you have treated who cycle:  

What bike-related barriers do individuals 
with lower-limb prostheses face when 
cycling? 

- Stepping on or off the bike 
- Balance and stability 
- Type or model of the bike 
- Other challenges or barriers? 

What prosthesis-related barriers do 
individuals with lower-limb prostheses face 
when cycling? 

- Fit of the prosthesis 
- Prosthesis length 
- Socket model 
- Foot stiffness 
- Other challenges or barriers? 

What solutions have you implemented to 
address these issues? 

- Adaptation:  
Problem: 

 
- Adaptation: 

Problem: 
 
- Adaptation: 

Problem: 

What risks or dangers are associated with 
cycling using a lower-limb prosthesis?" 

- Traffic-related risks 
- Risks involving other people 
- Risks related to the bike 

 

Appendix B: CPOs' Insights on Cycling with Knee-Disarticulation or Transfemoral Prostheses. 
 

https://doi.org/10.33137/cpoj.v7i2.44191

