More than two-thirds of the participants cycled after the LLA. The majority of cyclists already cycled before the LLA. Most of participants were amputated due to a trauma related cause and had a LLA level below the knee joint. None of amputation characteristics; however, were a predictor of cycling.
Cycling participation rate was similar to those reported in a previous study on sport and recreational activities participation in general [4]. Nevertheless, Dutch people with a LLA from this study reported a higher cycling rate than the rate found among people with a LLA in a review (48%) [7] or a survey in Thailand [5]. This difference might be explained by the popularity of bicycle use in the Netherlands [10]. The Netherlands is known as the cycling nation, with more bicycles than inhabitants (23 million bicycles and 17 million inhabitants) [10]. Further people with a LLA cycled for the same reasons as able-bodied people in the Netherlands [10].
Similar to most Thai cyclists who had undergone a LLA, the participants in the current study also initiated cycling themselves and did not rely on healthcare professionals or others for motivation or instruction [5]. Healthcare professionals may not prioritize cycling in the same way as people with a LLA [20]. Many cyclists had a positive attitude toward cycling; they considered it to be fun and good for their health. Another study found that high expectations of the benefits of physical activities were needed to initiate physical activities and that experiencing benefits kept people with a LLA engaged in the activity [21]. Moreover, fun has been reported as an essential factor for maintaining physical activity and was the discriminating factor between older adults who adhere to exercise and those who did not [22].
The majority of cyclists used their walking prosthesis and shoes. Approximately 46% of them used an electric bicycle. Considering that recreation was the main reason for cycling, daily prostheses were likely to provide sufficient function during cycling. Surprisingly, half of the cyclists with a mean age of 59 years cycled longer than 14 km per ride. This is quite a long distance, especially when considering that trips involving distances ranging from 7.5 to 15 km account for only 15% of all bicycle trips [10]. This result can partly be explained by the use of an electric bicycle [23]. Electric bicycles have become increasingly popular in the Netherlands and are mostly used by older adults [10]. The second most popular bicycle among the participants was the women’s bicycle, even though the majority of cyclists in this study were male. Similar to the utility bicycle or grandma bicycle (Dutch: omafiets) that is widely used by Thai cyclists with a LLA [5], “women’s bicycles” have a diagonal frame bar, creating a low instep. Consequently, cyclists do not need to lift their limb over a high horizontal bar, and this can help them get on and off the bicycle with their prosthesis more easily.
Dynamic foot
A dynamic foot increases the likelihood of cycling, in contrast to a SACH foot [5]. After a LLA, people who have the potential to walk with varying speeds and on various terrains are recommended to use a dynamic foot rather than a SACH foot [24]. This suggests that cyclists may already have a higher functional level in general. In addition, non-cyclists reported more rheumatoid arthritis and diabetes than cyclists. This higher functional level may also explain why non-electric bicycle users were able to cycle further than 40 km per ride.
Total number of facilitators
Increasing the number of facilitators is important for increasing the likelihood of cycling with a LLA. Cyclists reported a more positive attitude toward cycling and more perceived health benefits than non-cyclists. Although non-cyclists reported fewer facilitators, health benefits and a positive attitude toward cycling were still the most often reported facilitators. These findings suggest that non-cyclists are aware of cycling benefits, but these benefits do not motivate them enough to cycle. Interestingly, although cyclists also reported barriers to cycling such as lack of energy, pain, and discomfort, they continued cycling despite these complaints.
A previous study suggested that lower limb prosthesis users experience more barriers than facilitators when trying to adapt or maintain a physically active lifestyle [25]. In line with that study, non-cyclists in this study also reported more barriers than facilitators, for instance, a lack of skills or knowledge related to cycling or being afraid of getting injured. Most of these barriers hindered them from initiating cycling in the first place. Finding the desire to cycle after a LLA can help tailor the rehabilitation program to the specific needs and physical conditions of the individuals. Consequently, a sense of mastery or accomplishment from the training may facilitate them to continue cycling [25].
Practical factors related to work, built environment, weather, safety, and distance to destination were frequently reported by cyclists. For example, good quality streets, adequate cycling paths, good traffic safety, and good weather. In general, these external factors were frequently reported by cyclists as facilitators and less frequently reported as barriers. This contrasts with the study conducted in Thailand, where these factors were more frequently reported as barriers [2]. These findings suggest that the infrastructure in the Netherlands is quite accommodating to cyclists, with and without a LLA [26].
Presence of other underlying diseases in addition to the cause of LLA.
The presence of underlying diseases predicts that people with a LLA are less likely to cycle. Underlying diseases in addition to a LLA such as rheumatoid arthritis and diabetes can reduce physical activity performance [27, 28]. A study found that, on average, people with diabetes walked less (4603 steps/day) than able-bodied people (7817 steps/day), and people with both diabetes and a transtibial amputation walked even less than people with diabetes (1721 steps/day) [27]. A LLA due to vascular disease negatively associated with sport participation [6]. Another study found that the presence of three or more clinical conditions predicted a worse physical performance in gait speed, chair stand, and balance tests [28]. Consistent with the use of a SACH foot and the reduction in the likelihood of cycling, a negative association between having other underlying diseases and cycling may reflect the lower mobility of the non-cyclist group.
