Case Studies
International Journal of Sports Physiology and Performance, 2012, 7, 290-294
© 2012 Human Kinetics, Inc.
Physical Fitness and Performances of an Amputee
Cycling World Champion: A Case Study
Paolo Menaspà, Ermanno Rampinini, Lara Tonetti, and Andrea Bosio
Purpose: To describe the physical fitness of a top-level lower limb amputee (LLA) cyclist and paracycling
time-trial (TT) race demands. Methods: The 40-y-old male unilateral transfemoral amputee TT World Champion was tested in a laboratory for peak oxygen uptake (VO2peak), ventilatory threshold (VT2), power output
(PO), and hemoglobin mass (Hb-mass). Moreover, several measures (eg, PO, heart rate [HR], cadence) were
collected during 4 international TT competitions in the same season. The races’ intensity was evaluated as
time spent below, at, or above VT2. Results: The cyclist (1.73 m, 55.0 kg) had a VO2peak of 3.372 L/min (61.3
mL ∙ kg–1 ∙ min–1). The laboratory peak PO was 315 W (5.7 W/kg). The maximal HR was 208 beats/min, and
his Hb-mass was 744 g (13.5 g/kg). The TTs were meanly 18 ± 4.5 km in length, and the mean PO was 248
± 8 W with a cadence of 92 ± 1 rpm. During the TTs, the cyclist spent 23% ± 9% of total time at VT2, 59%
± 10% below, and 18% ± 5% above this intensity. Conclusions: The subject’s relative VO2peak is higher than
previously published data on LLA, and surprisingly it is even higher than “good” ACSM normative data for
nondisabled people. The intensity of the races was found to be similar to cycling TTs of the same duration
in elite female cyclists. These results might be useful to develop specific training schedules and enhance
performance of LLA cyclists.
Keywords: lower limb amputee, amputation, transfemoral, paracycling, single-leg
Paracycling racing events include road races and
time trials (TT) both at the World Championships and
at the Paralympic Games. Paracycling has been a Paralympic sport since 1988, and it will schedule 50 medal
events in the 2012 London Paralympic Games program.
Paracyclists are classified according to the extent of
activity limitation resulting from their impairment, and,
according to the Union Cycliste Internationale rules,
unilateral lower limb amputees (LLAs) are categorized
in cycling class C2.
Studies on LLAs have shown that their lifestyle is
less dynamic than that of a nonamputee control group1
and more sedentary than before amputation.2 In fact,
before amputation their most frequent leisure activities
were dynamic (eg, cycling, team ball games), while after
amputation they became sedentary (eg, reading, watching
television). Inactivity has been indicated as a risk factor
for cardiovascular disease in an amputee population.3
It has been shown that LLAs have increased risk and
mortality rates for cardiovascular diseases.4,5
The physical fitness of LLAs has been found lower
than that of able-bodied subjects.6 However, 1-leg cycling
endurance training has been shown to be useful in improv-
The authors are with the Human Performance Laboratory, Sport
Service MAPEI, Castellanza, Italy.
290
ing LLA’s physical fitness.6–8 Chin et al6 also suggested
that the enhancement in fitness seems to be relevant to
functional outcomes (ie, prosthetic ambulatory capacity).
Moreover, participation in physical activity and sports
provides benefits to disabled people from a physiological,
psychological, and social point of view.9–12
Due to the positive effect of physical activity and
sport participation for LLAs, researchers have focused
on training exercises6–8 and on laboratory testing protocols.13,14 To date, no studies have described the physiological characteristics of LLA cyclists or their cycling
performance.
We had the unique opportunity to test a top-level
LLA cyclist at the peak of his outstanding cycling career.
The first aim of this study was to describe the subject’s
physical fitness, measured in a laboratory environment.
The second aim was to provide an insight into the exercise
intensities sustained during international TT races, using
direct power-output (PO) and heart-rate (HR) measurements. The knowledge of the physiological demands of
these cycling events could be useful for specific training
development.
It is noteworthy, from an exercise management
viewpoint, that cancer amputees are classified by ACSM
in the nonvascular group (together with trauma and warrelated amputees),15 and for this reason the data presented
here could represent high-level reference data for all
nonvascular LLAs.
One-Leg Cycling Top-Level Performances 291
Methods
The subject is a male cancer survivor (40 y old, 1.73 m,
and 55.0 kg), diagnosed with osteosarcoma at the age of
13. During the 3 years that followed the diagnosis, he had
20 chemotherapy cycles and 17 surgeries, ending with
a transfemoral amputation and a lung lobectomy due to
metastasis. Since then he has been competing internationally in 3 different sports as an LLA, and at the time of the
study, he was paracycling TT World Champion. His clinical and sport histories are described in detail in Table 1.
The subject provided written informed consent to
participate in this study, which was approved by the
institutional review board in the spirit of the Helsinki
Declaration. The current research is a laboratory and field
descriptive case study.
The subject performed 2 evaluation sessions during
the competitive season, and the only data that are reported
are those related to the test in which he reached the highest
peak oxygen uptake (VO2peak).16,17 He was asked not to eat
within 3 hours of testing or to drink beverages containing
caffeine for at least 8 hours before testing and to avoid
intense exercise for 24 hours before testing. The laboratory evaluations were completed in controlled environmental conditions (20–23°C, 40–70% relative humidity)
on the subject’s racing bicycle with the rear wheel braked
by a custom-made Monark-type pendulum system.
After a 15-minute warm-up at 75 W, the maximal
incremental test to determine VO2peak and peak PO (PPO)
started, and resistance was augmented by 25 W every
30 seconds until volitional exhaustion. The cyclist was
instructed to ride at a constant cadence freely chosen
between 85 and 100 rpm throughout the test. When the
last workload was not completed, the PPO was calculated
using the formula of Kuipers et al18:
PPO = WL + (t/d) × WWL
in which WL is the value of the last complete workload
(W), t is the time the last workload was maintained (s),
d is the duration of each workload (60 s), and WWL is the
PO difference between the workloads (25 W).
PO data were collected at 1 Hz through a dynamically calibrated SRM crank set mounted on the subject’s
bike, which has also been used during competitions
(SRM Training System, Jülich, Germany). The power
meters were “zeroed” by the athlete, in accordance with
the manufacturer’s instructions, before the start of each
test and race. Respiratory parameters were measured
using a breath-by-breath automated gas-analysis system
(VMAX29, Sensormedics, Yorba Linda, CA). Achievement of VO2peak was considered the attainment of at least
2 of the following criteria: a plateau in VO2 with increasing power output (<80 mL · kg–1 · min–1), a respiratoryexchange ratio above 1.10, or a heart rate ±10 beats/
min of age-predicted maximum (220 – age).19
The ventilatory threshold (VT2) was identified by
experienced technicians,20 and the workload corresponding to VT2 ± 10 W was used as the VT2 range. Based on
Table 1 Highlights of the Subject’s Medical and Sport History
Year
1983
1983–86
Age (y)
13
13–16
1988–90
1993–95
1996
1997
1998
2000
2002
18–20
23–25
26
27
28
30
32
2004
34
2006
36
2007
2008
2009–10
2011
37
38
39–40
41
Event
Diagnosed with osteosarcoma.
In 3 y, he had 20 chemotherapy cycles and 17 surgeries. He had a left transfemoral amputation.
Due to metastasis, he had a lobectomy of the right lung.
1st place New York City Marathon (best time 5 h, 50 min).
1st place long and high jump Athletic National Championship.
Practiced Alpine skiing.
3rd place Para-Rowing World Championship.
1-h 1-leg cycling world record 37.499 km.
5th place individual pursuit Paralympic Games, Sydney.
2nd place 1-km standing start World Championship.
3rd place individual pursuit World Championship.
3rd place individual pursuit Paralympic Games, Athens.
6th place 1-km standing start Paralympic Games, Athens.
2nd place 1-km standing start World Championship.
3rd place individual pursuit World Championship.
3rd place time trial World Championship.
2nd place time trial World Championship.
Paralympic Games, Beijing.
1st place time trial World Championship.
2nd place individual pursuit World Championship.
292 Menaspà et al
the VT2 established in the laboratory evaluation, 3 PO
ranges were described: <VT2, VT2, and >VT2.
The maximal HR was reported both in laboratory and
in field conditions (Polar T31 transmitter, Polar Electro
Oy, Kempele, Finland). Moreover, the subject was evaluated for total hemoglobin mass (Hb-mass), which was
measured with the CO-rebreathing method.21
Race data were collected during 4 international
TTs, part of the 2010 Union Cycliste Internationale
paracycling calendar. PO, HR, cadence, speed, distance,
and altitude were continuously measured during races.
Race data were analyzed using the open source Golden
Cheetah software (http://www.goldencheetah.org). Data
are presented as absolute (W) and relative (W/kg) values.
The percentage of total time spent below, at, and above
the VT2 range has been reported. Moreover, race POs
were analyzed and presented as a set of maximal mean
power (MMP) data22 for time periods of 5, 15, 30, 60, 240,
300, and 600 seconds. Data of 4 races were analyzed, and
only the highest MMP for each of the assessed durations
is reported.23 Data are reported as means (± SD) unless
otherwise specified.
Results
The absolute and relative VO2peak were 3.372 L/min and
61.3 mL ∙ kg–1 ∙ min–1, respectively. The PPO reached in
the incremental maximal test was 315 W (5.7 W/kg), and
the PO at VT2 was 255 W (4.6 W/kg). The maximal HR
in laboratory condition was 208 beats/min, while during
races it was recorded at 206 beats/min. The Hb-mass was
744 g (13.5 g/kg).
Descriptive data (eg, cadence, speed) collected
during the races are summarized in Table 2. During the
4 TTs, the subject spent meanly 59% ± 10%, 23% ± 9%,
and 18% ± 5% of the total time below, at, and above the
VT2 range, respectively.
MMPs for periods of 5, 15, 30, 60, 240, 300, and 600
seconds were 450, 415, 387, 371, 290, 285, and 271 W.
The relative MMP for each period is shown in Figure 1.
Table 2 Time-Trial-Competition Data and Race Characteristics, Mean ± SD
Event, date
P1, May 30,
2010
P1, June 4,
2010
CDM, June 13,
2010
WCh, August
20, 2010
Mean power
(W)
256 ± 50
Mean power
per kg
4.7 ± 0.9
Mean heart rate
(beats/min)
188 ± 10
Mean cadence
(rpm)
93 ± 13
Rank
2
252 ± 64
4.6 ± 1.2
192 ± 8
92 ± 15
1
244 ± 47
4.4 ± 0.8
190 ± 9
91 ± 12
2
239 ± 64
4.4 ± 1.2
196 ± 9
93 ± 17
1
Race characteristicsa
12.8 km, 18 min 24 s,
41.7 km/h, 16 m
16.0 km, 23 min 28 s,
40.9 km/h, 65 m
20.6 km, 29 min 21 s,
42.1 km/h, 60 m
22.7 km, 36 min 1 s,
37.8 km/h, 230 m
Abbreviations: PI, paracycling races; CDM, World Cup; WCh, World Championships.
a Total length, total duration, mean speed, total positive altitude difference.
Figure 1 — Maximal mean power, expressed as relative values, of the lower limb amputee (LLA) subject compared with values
of female and male cyclists, derived from the publications of Ebert et al22 and Quod et al.23
One-Leg Cycling Top-Level Performances 293
Discussion
This case study describes for the first time the physical
fitness of a top-level LLA cyclist, and it shows the paracycling TT race demands through field data collected
during competitions.
As for the first aim, the main finding is that the subject’s relative VO2peak is considerably higher than other
data previously published on LLAs. Chin et al6 reported
a VO2max of 20 mL ∙ kg–1 ∙ min–1 in 51 LLAs13 and a value
of 25 mL ∙ kg–1 ∙ min–1 after 6 weeks of training. Pitetti et
al8 showed values of 29 mL ∙ kg–1 ∙ min–1 after aerobicconditioning training based on the ACSM guidelines.
From an exercise management viewpoint our subject’s
outstanding values could represent a peak reference value
for all nonvascular (ie, cancer, trauma, and war-related)
LLAs. His VO2peak is even higher than the ACSM normative “good” values for age-matched able-bodied people
(about 45 mL ∙ kg–1 ∙ min–1).24
Concerning other descriptive physiological data, the
cyclist’s maximal HR was noticeably higher (Δ 28 beats/
min) than the expected value for age-matched people, as
the 220 – age formula has been previously used even in
LLA.8,25 The subject’s relative Hb-mass was similar to
values of competitive endurance athletes (13.8 ± 0.9 g/
kg).26
In regard to the TT race demands, Table 2 shows that
mean PO decreases as the duration of the TT increases.
The cadence was similar among the different competitions, at values similar to the one freely chosen by elite
cyclists.27 To the best of our knowledge, there are no
published data of PO measured during professional male
TT competitions. Thus, concerning the exercise-intensity
distribution, in our opinion the only comparison possible
is with the data published by Abbiss et al28; in fact, duration and length of the TT described for the elite female
cyclists were similar to those of the LLA World Championship described in this study (24.2 km, 34.5 min and 22.7
km, 36.0 min, respectively). The female cyclists spent,
respectively, about 60%, 20%, and 20% of the total race
time below, at, and above VT2. Similarly, during the TT
World Championship our subject spent about 65%, 15%,
and 20% of the race time at those intensities.
Due to the lack of research on TT PO, there are no
data on MMP recorded during such competitions. Thus,
in Figure 1 the relative MMP of the subject is compared
with the ones previously published on road races by
women cyclists of the Australian national team22 and
experienced male cyclists.23
It is remarkable how the differences among diverse
categories of cyclists (ie, LLA cyclists, female and male
cyclists) change in relation to the duration of efforts.
Indeed, for very short effort of 5 seconds, the MMP of
the LLA cyclist is about 50% and 33% less than the ones
sustainable by male and female cyclists, respectively.
This important issue could be explained by the amputation itself. In able-bodied cyclists the PO during short
sprints have been shown to be highly correlated to lower
limb and thigh muscle volumes,29 so in an LLA cyclist a
limited PO is likely for very short effort. Due to the lack
of research on LLA cyclists, it is not possible to know
whether the matter is related more to torque or to cadence
(eg, half the number of strokes for identical cadences).
The gap in the MMP decreases while the time
increases. From the time of 60 seconds onward, the difference from female cyclists becomes smaller than 5%
and from male cyclists becomes smaller than 10% for
the time period of 240 seconds and longer. In this regard,
the smaller differences in MMP for the longest (hence,
more aerobic) periods could be explained by the closer
aerobic-fitness levels presented. In fact, the subject has
a VO2peak of 61.3 mL ∙ kg–1 ∙ min–1, and the female and
male cyclists presented in Figure 1 showed VO2max of
63.6 and 72.7 mL ∙ kg–1 ∙ min–1, respectively.
Practical Applications
The physiological parameters shown in this research
should represent reference data for LLA cyclists aspiring
to perform at high level. In addition, they could serve as
peak reference data for all nonvascular LLA. Moreover,
the original observation presented in this study should be
taken into account by professionals, coaches, researchers,
and anybody who works with LLA cyclists and cycling
in general.
Conclusions
In conclusion, these data prove that the physical fitness
of a transfemoral amputee trained cyclist can exceed that
of age-matched able-bodied people. Furthermore, LLA
cyclists may sustain aerobic-exercise intensities (ie, time
spent above, at, or below VT2) very similar to those of
able-bodied cyclists.
Acknowledgments
The authors would like to thank the athlete for his kind availability. A further mention goes to Caterina Cazzola for the
English revision of the manuscript.
The results of the current study do not constitute endorsement of the product by the authors or the journal.
References
1.Bussmann JB, Schrauwen HJ, Stam HJ. Daily physical
activity and heart rate response in people with a unilateral traumatic transtibial amputation. Arch Phys Med
Rehabil. 2008;89(3):430–434. PubMed doi:10.1016/j.
apmr.2007.11.012
2. Burger H, Marincek C. The life style of young persons
after lower limb amputation caused by injury. Prosthet
Orthot Int. 1997;21(1):35–39. PubMed
3.Frugoli AB, Guion WK, Joyner BA, McMillan JL.
Cardiovascular disease risk factors in an amputee
population. J Prosthet Orthot. 2000;12(3):80–87.
doi:10.1097/00008526-200012030-00004
4.Naschitz JE, Lenger R. Why traumatic leg amputees
are at increased risk for cardiovascular diseases. QJM.
294 Menaspà et al
2008;101(4):251–259. PubMed doi:10.1093/qjmed/
hcm131
5. Modan M, Peles E, Halkin H, et al. Increased cardiovascular disease mortality rates in traumatic lower limb amputees. Am J Cardiol. 1998;82(10):1242–1247. PubMed
doi:10.1016/S0002-9149(98)00601-8
6.Chin T, Sawamura S, Fujita H, et al. Physical fitness
of lower limb amputees. Am J Phys Med Rehabil.
2002;81(5):321–325. PubMed doi:10.1097/00002060200205000-00001
7. Chin T, Sawamura S, Fujita H, et al. Effect of endurance
training program based on anaerobic threshold (AT) for
lower limb amputees. J Rehabil Res Dev. 2001;38(1):7–11.
PubMed
8.Pitetti KH, Snell PG, Stray-Gundersen J, Gottschalk
FA. Aerobic training exercises for individuals who had
amputation of the lower limb. J Bone Joint Surg Am.
1987;69(6):914–921. PubMed
9.Hutzter Y, Bar-Eli M. Psychological benefits of sports
for disabled people: a review. Scand J Med Sci Sports.
1993;3(4):217–228. doi:10.1111/j.1600-0838.1993.
tb00386.x
10. Webster JB, Levy CE, Bryant PR, Prusakowski PE. Sports
and recreation for persons with limb deficiency. Arch Phys
Med Rehabil. 2001;82(3, Suppl 1):S38–S44. PubMed
doi:10.1016/S0003-9993(01)80036-8
11.Kars C, Hofman M, Geertzen JH, Pepping GJ,
Dekker R. Participation in sports by lower limb amputees in the Province of Drenthe, The Netherlands.
Prosthet Orthot Int. 2009;33(4):356–367. PubMed
doi:10.3109/03093640902984579
12. Wetterhahn KA, Hanson C, Levy CE. Effect of participation in physical activity on body image of amputees.
Am J Phys Med Rehabil. 2002;81(3):194–201. PubMed
doi:10.1097/00002060-200203000-00007
13. Chin T, Sawamura S, Fujita H, et al. The efficacy of the
one-leg cycling test for determining the anaerobic threshold (AT) of lower limb amputees. Prosthet Orthot Int.
1997;21(2):141–146. PubMed
14. Vestering MM, Schoppen T, Dekker R, Wempe J, Geertzen JH. Development of an exercise testing protocol for
patients with a lower limb amputation: results of a pilot
study. Int J Rehabil Res. 2005;28(3):237–244. PubMed
doi:10.1097/00004356-200509000-00006
15.Pitetti KH, Pedrotty MH. Lower limb amputation. In:
Durstine JL, Moore GE, Painter PL, Roberts SO, eds.
ACSM’S Exercise Management for Persons With Chronic
Diseases and Disabilities. 3rd ed. Champaign, IL: Human
Kinetics; 2009:280–284.
16.Martin DT, McLean B, Trewin C, Lee H, Victor J,
Hahn AG. Physiological characteristics of nationally
competitive female road cyclists and demands of competition. Sports Med. 2001;31(7):469–477. PubMed
doi:10.2165/00007256-200131070-00002
17.Menaspà P, Rampinini E, Bosio A, Carlomagno D,
Riggio M, Sassi A. Physiological and anthropometric
characteristics of junior cyclists of different specialties and performance levels. Scand J Med Sci Sports.
2012;22(3):392–398. PubMed
18.Kuipers H, Verstappen FT, Keizer HA, Geurten P, van
Kranenburg G. Variability of aerobic performance in the
laboratory and its physiologic correlates. Int J Sports Med.
1985;6(4):197–201. PubMed doi:10.1055/s-2008-1025839
19.Howley ET, Bassett DR, Jr, Welch HG. Criteria for
maximal oxygen uptake: review and commentary. Med
Sci Sports Exerc. 1995;27(9):1292–1301. PubMed
20. Lucia A, Hoyos J, Perez M, Chicharro JL. Heart rate and
performance parameters in elite cyclists: a longitudinal
study. Med Sci Sports Exerc. 2000;32(10):1777–1782.
PubMed doi:10.1097/00005768-200010000-00018
21. Schmidt W, Prommer N. The optimised CO-rebreathing
method: a new tool to determine total haemoglobin mass
routinely. Eur J Appl Physiol. 2005;95(5-6):486–495.
PubMed doi:10.1007/s00421-005-0050-3
22. Ebert TR, Martin DT, McDonald W, Victor J, Plummer J,
Withers RT. Power output during women’s World Cup road
cycle racing. Eur J Appl Physiol. 2005;95(5-6):529–536.
PubMed doi:10.1007/s00421-005-0039-y
23.Quod MJ, Martin DT, Martin JC, Laursen PB.
The power profile predicts road cycling MMP.
Int J Sports Med. 2010;31(6):397–401. PubMed
doi:10.1055/s-0030-1247528
24. Heyward VH. Advanced Fitness Assessment and Exercise
Prescription. 5th ed. Champaign, IL: Human Kinetics;
2006.
25. Macfarlane PA, Nielson DH, Shurr DG, et al. Transfemoral
amputee physiological requirements: comparisons between
SACH foot walking and Flex-Foot walking. J Prosthet
Orthot. 1997;9(4):138–143. doi:10.1097/00008526199700940-00003
26.Prommer N, Sottas PE, Schoch C, Schumacher
YO, Schmidt W. Total hemoglobin mass—a new
parameter to detect blood doping? Med Sci Sports
Exerc. 2008;40(12):2112–2118. PubMed doi:10.1249/
MSS.0b013e3181820942
27.Foss O, Hallen J. Cadence and performance in elite
cyclists. Eur J Appl Physiol. 2005;93(4):453–462. PubMed
doi:10.1007/s00421-004-1226-y
28.Abbiss CR, Straker L, Quod MJ, Martin DT, Laursen
PB. Examining pacing profiles in elite female road
cyclists using exposure variation analysis. Br J Sports
Med. 2010;44(6):437–442. PubMed doi:10.1136/
bjsm.2008.047787
29.Martin JC, Davidson CJ, Pardyjak ER. Understanding
sprint-cycling performance: the integration of muscle
power, resistance, and modeling. Int J Sports Physiol
Perform. 2007;2(1):5–21. PubMed