Helping Patients Optimize Sports Performance and Avoid Injury Through Fitness Training

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Photograph courtesy of USF.

While not all of your patients with amputations will aspire to become elite athletes, those who participate in a sport and want to take their performance to the next level may find the maze of training and fitness information difficult to navigate. Although sports training, exercise, and fitness are highly complex, multifactorial subjects with varying approaches and viewpoints, this overview may help you sort through the sometimes conflicting information and help you guide your patient to the starting line. Ideally, designing a sports training program for this population should involve a multidisciplinary team that includes a physical therapist, athletic trainer or coach, primary care physician, and physical medicine and rehabilitation (PM&R) physician, in addition to a prosthetist. Although the information presented here is directed toward individuals with lower-limb amputations, much of it will benefit those with upper-limb amputations as well.

While sport-specific training is essential for improvement, cross-training (training in one or more other sports), a general understanding of exercise physiology, core training, and stretching can enhance performance and help prevent injury by working to correct muscle imbalance and promote general fitness, according to several experts.

Sport-Specific Training

The best training for a sport is the sport itself, most experts concur; the “practice makes perfect” adage largely holds true. As the athlete practices, therapists or trainers can use the opportunity to observe and help correct movement inefficiencies, postural errors, and other weaknesses for better performance.

“It’s pretty obvious that, to get better in any activity, you must precisely practice the skill that you wish to develop,” writes running coach Roy Benson. (www.runnersworld.com/race-training/bensons-law-specificity) “A concert cellist like Yo-Yo Ma certainly doesn’t improve by playing the guitar.”

When All Is SAID and Done

In sports performance, the principle of SAID (specific adaptation to imposed demand) comes into play, explains Associate Professor M. Jason Highsmith, PT, DPT, PhD, CP, FAAOP, codirector of the University of South Florida (USF) Center for Neuromusculoskeletal Research, Tampa. “According to the SAID principle, people should immerse themselves in the activity they want to excel in, rather than becoming overly involved in other types of training. [However,] cross-training [is considered to] provide carryover benefits which enhance performance in the primary sport.”

According to fitness expert Kristy Lee Wilson, “The SAID principle states that the body will adapt to the specific demands placed upon it. In other words, you get what you train for.” (www.sharecare.com/health/types-exercise/what-is-the-said-principle)

The brain likewise adapts to repeated movement patterns, forming new neural communication pathways for faster, more efficient communication with muscles and recruitment of muscle fibers for movement. Repetitively practicing a skill, such as riding a bicycle, can create motor learning or “muscle memories” that are almost permanently stored in the cerebellum and utilized without conscious thought.

Cross-Training’s Complementary Role

“The goal of most athletes is to become stronger, improve performance, and avoid injuries,” writes Paul Krause, MD, a former team physician with the U.S. Nordic Ski Team and sports medicine expert. (www.americanrunning.org/w/article/the-benefits-of-crosstraining) “It is difficult to achieve all of these goals by training in one sport alone; cross-training can add the missing link.” Cross-training can increase power, add flexibility, build stability, sharpen reflexes, and increase motivation. “If ‘variety is the spice of life,’ then cross-training is the ‘spice of exercise.’”

Krause lists the following sports and their benefits to help create a workout plan.

  • Skate skiing: Quadriceps strength and balance.
  • Classic skiing (striding): Gluteus and triceps strength.
  • Snowshoeing: Hip flexor and gluteus strength.
  • Inline skating: Lower-back strength and balance.
  • Rowing: Upper-back and quadriceps strength.
  • Cycling: Quadriceps and anterior tibialis strength.
  • Pilates: Core strength and power.
  • Elliptical trainer: Leg and arm strength at low impact.
  • Circuit weights: Functional strength wherever it’s needed.
  • Rock climbing: Upper-body and core strength.

Alex Hetherington, CP, program director, Amputee Comprehensive Training (ACT) Program, University of California, San Francisco (UCSF), uses running as an example. “Alongside proper running technique, integrating cross-training builds your anaerobic and aerobic capacity. To me, that often includes swimming and stationary bike exercise to improve overall physiology without additional stress on the joints. Swimming and biking, along with proper stretching and strength training in the gym, will lead to a better race, a better time, and a better runner.”

“If someone enjoys running—and especially if they are interested in an occasional competition, such as a 10K or 15K—they would be amazed at how much they can benefit from doing some mid-distance and sprint work,” Highsmith says. “Don’t just do long-distance running; do some sprint work if you want to see speed gains.”

Where Does the Energy Come From?

A brief explanation of how the body produces energy helps in understanding how various sports and training programs affect physiology and sports performance.

amputee runners

ACT program participants train to improve their running form and fitness. Photograph courtesy of the Department of Orthopaedic Surgery, University of California, San Francisco.

The body converts fuel, or nutrients, into energy by first producing adenosine triphosphate (ATP), which, when broken down into other substances, releases energy for muscle contractions. The body uses three ATP-producing systems: one aerobic (oxygen is used) and two anaerobic (oxygen is not used). The aerobic system enables the body to continue low- to moderate-intensity sports, such as distance running and cycling, over a prolonged time period and builds endurance and cardiovascular strength.

However, when the sport or activity requires short, intense bursts of energy at maximum or near-maximum capacity, such as weight lifting or sprinting, the aerobic system simply can’t produce sufficient ATP fast enough. Then the anaerobic systems, which produce considerable ATP very quickly but only for a short time, take over. Anaerobic exercise builds power, or strength, increases muscle mass and bone strength, tones the body, and helps control weight.

Some sports include both aerobic and anaerobic elements. For instance, soccer and basketball involve sprinting and dodging, which use anaerobic energy, and jogging, which uses aerobic energy.

Confused about Muscle Confusion?

Often considered a marketing term coined by noted fitness trainer Tony Horton, developer of the P90X® (Power 90 Extreme) home fitness programs, the muscle confusion concept centers on variety in workouts. The goal is to avoid a plateau effect in which the body and brain become so efficient in performing repeated routines that progress stops. Of course, muscles do not actually become confused, but they should be challenged in order to avoid a decrease in performance and/or strength gains, explains the National Academy of Sports Medicine (NASM).

The Core of the Matter

According to some experts, a key piece of improving performance is core training. Comprising the abdominal muscles, the spinal musculature, and the hip musculature, the body’s core is vital for staying strong, staying flexible, and improving sports performance, points out Harvard Medical School Assistant Professor Edward Phillips, MD, in the school’s blog.

“A little-known fact for many people is how involved your core is in movement, including basic sitting posture and walking,” Highsmith says. “Think of it this way—any time you’re on one foot, you’re definitely engaging your core. Core stability is key.”

“Since persons with amputation are now lacking certain muscles they used for eccentric, concentric, and isometric contractions throughout their range of motion, they’re relying much more on their prosthetic device which puts a lot of stress on remaining musculature. In turn, this increases stress on the core musculature,” says Justin Z. Laferrier, PhD, MSPT, OCS, SCS, ATP, CSCS, assistant professor, Physical Therapy Program, University of Connecticut, Storrs. Without a strong core foundation, moving the prosthesis and residual limb away from the body’s midline is much more difficult, he says. “We do a lot of lumbar stabilization and core-training exercises because, as the old theory says, ‘distal mobility comes from proximal stability.’”

amputee martial arts fighter

An ACT athletic trainer works with a mixed martial arts fighter on his kicking technique. Photograph courtesy of the Department of Orthopaedic Surgery, University of California, San Francisco.

For a runner with an amputation, core training helps optimize proper, biomechanically efficient form, Laferrier adds. “Some people focus so much on increasing running distance and speed that they don’t spend enough time optimizing their form. Taking time to strengthen your core can pay huge dividends down the road.”

Balancing Act

“Balance is a crucial precursor to movement,” writes physical therapist and conditioning coach Elo Heinaste, and involves the vestibular system, vision, proprioceptors, and muscles. “Balance helps to keep the movements more coordinated and efficient; it ensures better awareness about the body and strengthens proprioceptive abilities.”
(allaboutperformance.wordpress.com/2012/05/01/balance-not-just-a-simple-skill-9)

An ideal fitness program will challenge both static and dynamic balance with a focus on coordination, according to the College Sports Scholarships network. (www.collegesportsscholarships.com/balance-training-athletes.htm)

It’s a Stretch

Stretching increases joint range of motion and thus flexibility, improves muscular coordination, increases blood circulation, and reduces stress. Surprisingly though, recent research findings contradict some conventional wisdom on the benefits of stretching for injury prevention and reducing post-exercise muscle soreness. Results are mixed about whether or not stretching helps prevent injuries. According to two systematic literature reviews published in 2011, research indicates that stretching does not produce clinically important reductions in delayed-onset muscle soreness in healthy adults. (bjsm.bmj.com/content/45/15/1249.extract; www.ncbi.nlm.nih.gov/pubmed/21735398) The Mayo Clinic recommends replacing stretching with light aerobic activity for warm-ups since stretching cold muscles can cause injury. It also recommends focusing any stretching on major muscle groups. Stretching exercises should include those specific to the sport in which the individual engages. For example, since soccer players are vulnerable to hamstring injuries, they should opt for moves that help stretch the hamstrings.

“It’s important to note that poor stretching or lack of stretching can lead to tight muscles and limited range of motion,” Hetherington says. “Optimal range of motion can lead to improvements in technique and performance, such as proper stride length in walking and running.”

In addition to proper training and stretching, the experts we consulted also stressed that good nutrition and sufficient rest and recovery time following intensive activity, along with adequate sleep, play an essential role in health and performance.

Injury Prevention

A plethora of repetitive strain injuries (RSIs) and other sports-related injuries can plague athletes, including patellofemoral pain syndrome, knee compartment syndrome, Achilles heel tendinitis, iliotibial band syndrome, and stress fractures, among others. People with amputations are at even higher risk for injury due to the lost muscle and bone. They have a higher risk of muscle imbalances and weaknesses, and of overuse injuries to the sound side limb. Good prosthetic fit, comfort, alignment, gait training, and cross-training can encourage prosthetic device users to distribute weight and force more evenly across both limbs.

To prevent training injuries, Highsmith, Laferrier, and others recommend small, incremental increases in the length of activities, the number of repetitions in a training session, and in the intensity of training. “Sometimes the problem is that someone is so excited about their new running prosthesis that they run so long and intensely and become so sore and injured that they are shut down for two or three weeks while the limb heals,” Highsmith says. “That’s not only injurious but demotivating as well.”

Also, according to various sources, cross-training can help prevent injuries by correcting muscle imbalance and preventing the stronger muscles from pulling the body out of alignment and causing tears and pulls in weaker muscles.

Innovative Programs

The following programs highlight some of the advances and innovations that are helping individuals with amputations increase function, fitness, and performance. One model uses technology; another relies on comprehensive care, which requires the resources of a large institution; and one uses a model that could be launched by rehabilitation hospitals and larger O&P practices.

Virtual World Meets Real World

Individuals with amputations, stroke patients, and others can step into a virtual world to hike up a mountain, walk through a combat zone, pilot a boat, or other 3D simulations of real-life gait, balance, and cognition-challenging scenarios in USF’s Computerized Augmented Rehabilitation Environment (CAREN) system.

subject in CAREN system

A subject uses the CAREN system, which simulates 3D real-world scenarios challenging patients’ balance, coordination, and mobility. Photograph courtesy of USF Health.

Using a split-belt treadmill and safety harness in an immersive, interactive gaming environment, which includes avatars, users can learn new strategies in balance, coordination, and mobility, according to a USF press release. With several technologies integrated into the CAREN system, it provides a new resource to advance research and treatment of musculoskeletal and neurological disorders.

“The CAREN system is capable of doing both assessment and training,” Highsmith says. “The system can simulate real-world scenarios the individual may function in as well as a clinic setting. There is continuous walking while the person is being both posturally perturbed and visually and cognitively challenged.”

Running Club Promotes Fitness, Camaraderie

Recently started by Mary Free Bed Rehabilitation Hospital, Grand Rapids, Michigan, the Amputee Running Club helps people with amputations improve cardiovascular health, get fit, and improve function while enjoying fun and camaraderie. The club focuses on stretching and cardiovascular exercise; members are also encouraged to share health tips and exercise ideas. “This club is a great way for beginners to train together in a supportive community,” notes the Mary Free Bed website. (www.maryfreebed.com/amputee-running-club)

The club is the newest addition to the hospital’s initiatives to promote sports and health for individuals with disabilities. A major initiative, the Wheelchair and Adaptive Sports Program, began more than 40 years ago with a single tennis team. Now about 400 children and 300 adults participate in various team sports.

Civilians Get an Introduction to a Comprehensive Military-Care Model

Inspired by patients with a keen interest in returning to active lifestyles, including competitive runners, cyclists, climbers, martial artists, and soccer players, Matthew Garibaldi, CPO, and his colleagues developed UCSF’s ACT program, the first comprehensive rehabilitation program for civilians modeled after the renowned military medical program at Walter Reed National Military Medical Center, Bethesda, Maryland, in conjunction with the Center for the Intrepid, San Antonio, Texas. Prior to the introduction of this program, these types of comprehensive training programs did not exist for the civilian amputee population.

“There are approximately 1,600 military-related amputees as a result of efforts in Iraq and Afghanistan, but there are roughly 1.7 million civilian amputees in the United States,” says Garibaldi, assistant professor in the Department of Orthopaedic Surgery and director of the university’s Orthotics and Prosthetics Center. “I highlight this point not to marginalize the efforts of the brave men and women who have defended and continue to defend our country, but to draw attention to a glaring healthcare disparity that exists in our profession and that has been broadly overlooked for years. Unfortunately, the current civilian rehabilitation protocol is as follows: patient suffers an amputation, undergoes one or two months of physical therapy, and is then set out into the world without any further assistance or specialized training. Our team at UCSF views this level of post-prosthetic training as wholly inadequate. We know that our patients and those throughout the country demand and deserve more.”

The program incorporates a diverse series of training modalities, advanced gait analysis equipment, and a comprehensive multidisciplinary team. The program’s mission is to assist those affected by limb loss in maximizing their physical potential. Additionally, the program aims to “optimize clinical outcomes, provide verifiable evidence for component selection, and to assist with the creation of best practices within our profession,” Garibaldi says.

The program hosts several clinics throughout the year and one large annual event. ACT assessments often include evaluations by physical therapists, prosthetists, athletic trainers, sports medicine physicians, and nutritionists. It also introduces participants to a variety of athletic and fitness activities, such as basketball, rock climbing, cycling, swimming, surfing, and yoga.

“The ACT program provides both the tools and the community to make a full recovery following amputation,” Hetherington says. “We help our athletes return to the sports they enjoyed prior to amputation and encourage newcomers to improve health and mobility through fitness.”

At the time this article was written, two national ACT events had been held. “I cannot begin to convey the impact they have had on the lives of each participant; the apparent tears of joy on the faces of many who perhaps thought they would never walk, run, or climb again. This confirms for me the timeliness of this new venture,” Garibaldi says.

Miki Fairley is a freelance writer based in southwest Colorado. She can be contacted via e-mail at

This article is for informational and educational purposes. Individuals should consult a healthcare provider before beginning any exercise or fitness program.

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