The Journal of International Medical Research

2009; 37: 1921 – 1927

Factors Affecting Prosthetic Rehabilitation

Outcomes in Amputees of Age 60 Years
and Over
S HAMAMURA1,3, T CHIN1,3, R KURODA2, T AKISUE2, T IGUCHI1,3, H KOHNO3,
A KITAGAWA3, N TSUMURA3 AND M KUROSAKA2
1
Department of Rehabilitation Science, Kobe University Graduate School of Medicine in
Hyogo Rehabilitation Center, Kobe, Japan; 2Department of Orthopaedic Surgery, Kobe
University Graduate School of Medicine, Kobe, Japan; 3Department of Orthopaedic Surgery,
Hyogo Rehabilitation Center Hospital, Kobe, Japan

This retrospective, observational study was
designed to investigate factors affecting
successful prosthetic ambulation in elderly
amputees aged ≥ 60 years. The study
included 64 unilateral transfemoral or hip
disarticulation amputees. Patients who
were able to walk ≥ 100 m with prosthesis
were classified as successful and those who
could walk < 100 m as failures. Age,
comorbidities, cause of amputation, ability
to stand on one leg, patient’s motivation for
walking and maximum oxygen uptake as a
proportion of predicted maximum oxygen
uptake (%VO2max) during an exercise load
test were examined as indicators of physical
fitness. Significant differences were noted
between the two groups in the number of
comorbidities, ability to stand on one leg,
patient’s motivation for walking and mean
%VO2max. A low number of comorbidities,
the ability to stand on one leg, motivation
for walking and adequate physical fitness
allowing an exercise intensity of ≥ 50%
VO2max were considered to be predictive
factors for successful prosthetic
rehabilitation.

KEY WORDS: ELDERLY AMPUTEE; PHYSICAL FITNESS; PROSTHETIC REHABILITATION; MAXIMUM

OXYGEN UPTAKE

Introduction for walking with a prosthesis, there have

Increases in the numbers of patients with
diabetes mellitus and arteriosclerotic
vascular disease of the leg have led to an
increase in the frequency of leg
amputations.1,2 As a result, orthopaedic
surgeons and others concerned with
prosthetic rehabilitation, have become
increasingly interested in predicting the
ambulatory outcomes for patients requiring
prosthesis. Although several researchers
have investigated the prognosis of amputees
been a number of problems and weaknesses
in their research. First, there is no standard
definition for successful prosthetic
rehabilitation, 3,4
which has led many
authors to set their own criteria. For
example, Dove et al.5 set the criterion of
walking at least 100 feet with or without a
cane, while Munin et al.6 permitted the use of
a cane or walker and a walking distance of
≥ 45 m. The second problem is that most
previous reports have studied patients with

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 S Hamamura, T Chin, R Kuroda et al.
Factors affecting prosthetic rehabilitation outcomes
varying levels of leg amputation4,7 – 9 and a
wide age range, from the young to the
elderly.3,4,8,9 Finally, previous research has
not included an evaluation of the physical
fitness of the amputees,3,4,7 – 9 despite the fact
that the energy required for walking with a
prosthesis increases in relation to the height
at which the leg is amputated.10,11
This study aimed to overcome these
weaknesses by clarifying the definition of
successful prosthetic rehabilitation and, due
to improved outcomes in lower leg
amputees, limiting the study participants to
unilateral transfemoral amputees and hip
disarticulation amputees. The physical
fitness of amputees was evaluated by
measuring maximum oxygen uptake as a
proportion of predicted maximum oxygen
uptake (%VO2max) during an exercise load
test. Various other factors that influence the
prognosis for walking with a prosthesis were
also examined.
Patients and methods
PATIENTS
This retrospective, observational study
included unilateral lower limb amputees
(unilateral transfemoral amputees and hip
disarticulation amputees) who were
hospitalized for prosthetic walking training
at the Hyogo Rehabilitation Center, Kobe,
Japan, and who had not previously been
fitted with a prosthesis. Patients with any
Steinberg factors12 that impeded prosthetic
walking, such as mental deterioration,
advanced neurological disorders, congestive
cardiac failure, advanced obstructive
pulmonary disease, or advanced hip flexion
contracture were excluded from entry to the
study. All included patients were required to
be ≥ 60 years of age. The patients were
informed of the purpose of this study and the
associated risks, and verbal and written
consent for their participation was obtained.
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The study protocol and methods were
approved by the institutional review board of
Hyogo Rehabilitation Center Hospital.
DEFINITION OF SUCCESSFUL
PROSTHETIC REHABILITATION
After completion of a rehabilitation
programme, patients were permitted to use
any necessary ambulatory aids (cane,
crutch, or walker) and were asked to walk at
their most comfortable walking speed on a
level surface. Patients who could walk ≥ 100
m without ambulatory aids or with only one
cane were classified as successful prosthetic
users. All others were classified as failed
prosthetic users.
INVESTIGATION OF CLINICAL
INFORMATION
Information about each patient before the
prosthesis was fitted was collected
retrospectively from clinical charts prepared
during admission. This information included
the cause of amputation (vascular or non-
vascular), the number of comorbidities, the
ability to maintain standing on the non-
amputated leg (possible or impossible) and
the patient’s motivation for walking with a
prosthesis (yes or no). Standing was assessed
and categorized as ‘possible’ if patients could
stand either unsupported or supported by
one hand on a desk.
EVALUATION OF PHYSICAL FITNESS
The amputees performed one-leg cycling
tests13 with the non-amputated leg before
they began prosthetic rehabilitation. A cycle
ergometer (Lode Angio WLP-300ST,
Groningen, The Netherlands) that could be
manipulated in a supine position was used.
The test was conducted with the patients
seated and their upper bodies reclining at an
angle of approximately 45°. This
incremental exercise test was begun with 3
 S Hamamura, T Chin, R Kuroda et al.
Factors affecting prosthetic rehabilitation outcomes
min of unloaded pedalling, followed by
increments of 5 – 15 W/min, until each
patient had reached their individual self-
assessed maximum load. Each patient was
directed to turn the pedals 60 times/min with
their non-amputated leg. During the
exercise, respiratory gas was monitored with
a respiromonitor (Minato RM-300; Minato
Medical Science, Osaka, Japan) to measure
oxygen uptake (VO2). At the same time,
electrocardiograms and heart rate were
monitored by a stress test system (ML-5000,
Fukuda Denshi, Tokyo, Japan), and cuff
blood pressure was determined every minute
with an autoelectrocardiometer (STBP-780;
Nippon Colin, Komaki, Japan).
As an indicator of physical fitness,
%VO2max during exercise was calculated in
terms of maximum oxygen uptake (ml/kg
per min) as a proportion of predicted
maximum oxygen uptake (ml/kg per min).
A previous study showed that ≥ 50% VO2max
was a good indicator for successful prosthetic
rehabilitation in transfemoral amputees.14
Thus, in the present study, the %VO2max was
divided into two categories, ≥ 50% VO2max
and < 50% VO2max, and walking ability with
a prosthesis was examined for each.
STATISTICAL ANALYSIS
The StatView® 5.0 (SAS Institute Inc., Cary,
NC, USA) statistical software package was
used to analyse the data. Fisher’s exact test
was used to determine differences in gender,
cause of amputation, level (height) of
amputation, ability to stand on the
remaining leg and the patient’s motivation
for walking. The non-parametric Mann–
Whitney U-test was used to determine if there
were differences in the number of
comorbidities between the two groups. A
non-paired t-test was used to compare mean
ages and %VO2max values. A P-value of < 0.05
was considered to be statistically significant.
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Results
In total, 64 unilateral lower limb amputees
(40 men and 24 women) aged 60 – 81 years
were included in the study. Of these, 53
patients were transfemoral amputees and 11
had hip disarticulation. None of the patients
included in the study had any Steinberg
factors12 impeding prosthetic walking, such
as mental deterioration, advanced
neurological disorders, congestive cardiac
failure, advanced obstructive pulmonary
disease, or advanced hip flexion contracture.
Comorbidities were common and included
hypertension, diabetes mellitus, end-stage
renal disease, hepatic disorders, cerebral
vascular disturbance, ischaemic heart
disease, degenerative joint disease, visual
disorder, endocrine disease, malignant
disorder such as metastasis, and
inflammatory disease such as chronic
osteomyelitis.
In the evaluation of prosthetic
ambulation ability, 44 patients were
successful prosthetic users (28 men and 16
women), of whom 10 were hip
disarticulation amputees. The mean ± SD
age of the successful prosthetic users was
66.7 ± 5.1 years. There were 20 failed
prosthetic users (12 men and eight women),
one being a hip disarticulation amputee.
The mean ± SD age of the failure group was
68.7 ± 5.6 years. There was a significant
difference between the two groups in the
number of comorbidities (P < 0.01), the
ability to stand on one-leg (P < 0.05) and
motivation to walk with a prosthesis (P <
0.05). No significant difference was observed
between the two groups in terms of age or
cause of amputation. In the successful
group, the mean ± SD %VO2max was
significantly higher (65.0 ± 14.0%)
compared with the failure group (45.2 ±
9.4%) (P < 0.01) (Table 1). When the two
groups were evaluated by whether they fell
 S Hamamura, T Chin, R Kuroda et al.
Factors affecting prosthetic rehabilitation outcomes

TABLE 1:
Comparison of the patient characteristics in the success and the failure prosthetic user
groups
Success Failure Statistical
Characteristics (n = 44) (n = 20) significance
Age (years), mean ± SD 66.7 ± 5.1 68.7 ± 5.6 NSa
%VO2max, mean ± SD 65.0 ± 14.0 45.2 ± 9.4 P < 0.01a
Gender, n
Male 28 12 NSb
Female 16 8
Cause of amputation, n
Vascular 12 11 NSb
Non-vascular 32 9
Level of amputation, n
Transfemoral 34 19 NSb
Hip disarticulation 10 1
No. of comorbidities, n
≤1 34 7 P < 0.01c
2 10 7
≥3 0 6
Ability to stand on unaffected limb, n
Possible 42 11 P < 0.05b
Impossible 2 9
Motivation for walking, n
Yes 44 7 P < 0.05b
No 0 13
Success group, patients who could walk ≥ 100 m without ambulatory aids or with only one cane following
completion of a rehabilitation programme. Failure group, all other patients.
a
Non-paired t-test; bFisher’s exact test; cNon-parametric Mann–Whitney U-test.
%VO2max, maximum oxygen uptake as a proportion of predicted maximum oxygen uptake; NS, not
statistically significant (P > 0.05).

into the ≥ 50 or < 50% VO2max categories, 38 VO2max category, whereas in the failed user
of the successful users were in the ≥ 50% group the numbers were four and 16,
VO2max category and six were in the < 50% respectively (Table 2). Thus, 90.4% of the

TABLE 2:
Numbers of successful and failed prosthetic users in the ≥ 50 or < 50 %VO2max categories

Success Failure Statistical

%VO2max (n = 44) (n = 20) significance
≥ 50 38 4
P < 0.001a
< 50 6 16
Success group, patients who could walk ≥ 100 m without ambulatory aids or with only one cane following
completion of a rehabilitation programme. Failure group, all other patients.
a
Fisher’s exact test.
%VO2max, maximum oxygen uptake as a proportion of predicted maximum oxygen uptake.

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 S Hamamura, T Chin, R Kuroda et al.
Factors affecting prosthetic rehabilitation outcomes
amputees with ≥ 50% VO2max values were in
the success group compared with only 27.3%
of amputees with < 50% VO2max (P < 0.001).
Discussion
For major lower-limb amputees, walking
with a prosthetic limb is an important
element for preserving independent status.
Thus, being able to predict a patient’s ability
to walk with a prosthesis is essential, both in
gaining appropriate informed consent to
carry out necessary amputations and in
aiding medical staff who work in
rehabilitation, particularly with respect to
elderly amputees.
In previous reports, increased age,
increased level (height) of leg amputation
and a large number of comorbidities have
been identified as important factors that
influence prosthetic rehabilitation.1,3 – 9,12,14 – 18
Some authors have claimed that old age in
itself makes prosthetic rehabilitation
unlikely,3,8,19 while others have stated that
geriatric amputees cannot be excluded as
candidates for prosthesis based solely on
their age.20,21 The results from the present
study did not demonstrate any significant
age difference between the success and
failure groups, and support the position that
age is not an important factor for
determining candidacy for prosthesis. The
discrepancy in terms of the importance of
various factors in prosthetic rehabilitation
arises because there is no standard definition
of what constitutes successful prosthetic
rehabilitation and because previous studies
have not been consistent in terms of the
types of patients that have been evaluated,
including patients with varying levels of leg
amputation and a wide age range. To
address these issues in the present study,
successful prosthetic rehabilitation was
clearly defined in advance and only
amputees ≥ 60 years of age who had either
1925
unilateral transfemoral or hip
disarticulation amputations were included.
Sufficient physical fitness has also been
identified as a requirement in geriatric lower-
limb amputees, to ensure that they are
capable of the energy expenditure required
for successful prosthetic ambulation.12,22,23
Previous studies identified ≥ 50% VO2max as an
initial guideline level for sufficient physical
fitness for successful walking with a prosthesis
in geriatric amputees.14,24 Using %VO2max as
an indicator of the physical fitness of
amputees, the present study showed that
90.4% (38/42) of the amputees with physical
fitness levels of ≥ 50% VO2max were successful
users of their prosthesis, whereas only 27.3%
(6/22) of those with < 50% VO2max were
successful. Based on these data it is suggested
that ≥ 50% VO2max is a valid guideline level
for the physical fitness required for successful
prosthetic rehabilitation of geriatric lower
limb amputees.
In addition to sufficient physical fitness
(i.e. the ability to sustain an exercise
intensity of ≥ 50% VO2max), it was also shown
that a low number of comorbidities, a good
ability to stand on one leg and the patient’s
motivation to walk with a prosthesis were
factors for the successful prosthetic
rehabilitation. Burger and Marincek25 and
Schoppen et al.26 previously demonstrated
that functional prosthetic use was intimately
related to the ability to stand without
support on one leg, and that the ability to
balance on one leg on the unaffected limb
was the most important factor for
ambulatory success. Other factors, including
age and cause of amputation (vascular or
non-vascular), were found to be of low
importance in predicting outcomes in
selected patients in the present study.
Although the results from the present
study are limited due to its retrospective
design and the relatively small number of
 S Hamamura, T Chin, R Kuroda et al.
Factors affecting prosthetic rehabilitation outcomes
patients included, it may be concluded that a
low number of comorbidities, the patient’s
motivation to walk, and a good ability to
stand on one leg on the non-amputated limb
are potentially the most valuable factors
contributing to successful prosthetic
ambulation in geriatric amputees. In
addition, ≥ 50% VO2max can be regarded as a
valid initial guideline level for the physical
• Received for publication 24 June 2009 • Accepted subject to revision 3 July 2009
• Revised accepted 18 November 2009
Copyright © 2009 Field House Publishing LLP
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Author’s address for correspondence

Dr Takaaki Chin
Department of Rehabilitation Science, Kobe University Graduate School of Medicine in
Hyogo Rehabilitation Center, 1070 Akebono-Cho, Nishi-Ku, Kobe 651-2181, Japan.
E-mail: t-chin@pure.ne.jp

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