Learning to ride a bike can be a rite of passage for any child. It also provides exercise, enhances one’s sense of balance, develops decision-making skills and promotes healthy interaction with family and friends. Because bike riding has so much to offer, the Area Child Amputee Center (ACAC) in Grand Rapids, Michigan, conducted a survey to determine if this activity was accessible to children with limb differences. This survey also aimed at finding answers to questions that parents of children with limb differences might have about bike riding, such as –

• Should their child begin riding at the same age as other children?
• Should their child wear a prosthesis while riding?
• What, if any, adaptive equipment and techniques could help their child ride?
• How many children ride specialty bikes, and what is the level of their limb loss?
• Do children with limb differences have more accidents on bikes than other children?

The results from the ACAC survey are provided below; they are organized alphabetically by specific limb difference conditions.

Above-Knee Amputation
Thirteen out of 14 above-knee amputees surveyed rode bicycles while wearing a prosthesis. The average age of the beginner was 6.7 years. Tricycle riding usually began at the age of 3.5 years. These children found one or more of the following strategies helpful in bike riding: wearing foot straps and/or stirrup pedals on both prosthetic and non-prosthetic legs, using a riding peg in the place of the prosthetic leg and/or the assistance of another person in getting started riding.

One child, who underwent an amputation at age nine, rides a hand-cranked three-wheeler from “Top End” by Action. Another parent purchased the Adam’s Trail-A-Bike for $180, which she says has improved her child’s sense of balance. Using the Trail-A-Bike, the child’s bike is actually attached behind an adult cycle.

The price of specialty bikes can be a problem, but most respondents reported that their children ride standard bikes with inexpensive adaptations such as training wheels and/or toe clips for added assistance.

Arm Length/Hand Difference
This group was comprised of 18 children who had arm or hand length difference. None of these children required a prosthesis. The average age that these children began riding tricycles was 2.75 years, and bikes, 5.6 years.

Simple adjustments were made to standard bicycles to make them accessible for these children, i.e., reversing or adjusting the handlebars, putting blocks on the pedals, replacing the regular bike handle with a 10-speed handle bar, or moving the hand brake to the side of the bike that the child found to be more stabilizing. Problems with balance were also addressed by having the child put his palm or wrist on the handlebar, or by having him wrap his wrist around the handlebar. Another possible solution was to put a belt around the child’s chest so that an adult could hold on to the strap for stability.

Seven of the children in this group believed that their limb differences primarily affected their sense of balance. As far as bicycle accidents were concerned, seven members of this group believed that their limb differences contributed to these incidents.

Below-Knee Amputation
Of the 25 unilateral and 5 bilateral respondents, the average age of the tricycle rider was 2.8 years, while the average age of the bike rider was 5.5 years. Parents commented that bike riding came to these children as naturally as it did to other kids, and that these
children felt that they were equal to their friends when
bike riding. All but one of the cyclists preferred wearing a prosthesis while riding. Overall, the age of the child, rather than the limb difference, appeared to determine the kind of bike selected. Younger children usually rode standard bikes with pedal brakes, while older children rode bikes with multiple speeds and hand brakes. One child, who is a bilateral below knee amputee, rides a 10-speed three-wheeler with a “wheelie” bar.
The cyclists surveyed found one or more of the following strategies helpful: blocks on pedals, foot straps, using the curb to get started and/or pedaling primarily with the non-prosthetic leg. Three of the children in this group believed that their ability to balance on the bike was affected by their limb difference, while two believed that their limb differences caused them to have bike accidents.

Hip Disarticulation
Only three of those polled had hip disarticulation. Of those in this category, the average bike rider was 5.5 years old, and the tricycle-rider was 3.5 years old. Only one child wore a prosthesis while riding, but did not use it in cycling. Another child had been using a hand-pedaled, child-size Chariot Bike since the age of three.
Toe clips on the non-prosthetic leg and the use of a curb to get started riding were reported as being helpful in alleviating certain problems for these riders. One biker blamed a bicycle accident on his limb difference.

Lower Limb Difference
This category was comprised of six children who could not be classified in any of the other categories — three children with arthrogryposis and three with PFFD. The average age of these young cyclists was consistent with that of the other riders. The approximate age of the beginner tricyclist was 2.8 years, and the bicyclist, four years.

Bike riding was not as common in this category as in previous ones. Only one child rode a toddler bicycle with training wheels. A preschool pushbike or a hand-pedaled bicycle worked well for these children. A child whose knees were fused started riding a Chariot hand-pedaled bike at age 10 and at age 13 switched to a Shadow Mock II racing bike. The parent of a child in this group noted, “Riding his hand-pedaled bike makes him feel that he fits in with the other children.”

Weakness and balance problems contributed to the bike accidents of two children.

Tri/QuadMembral
This group of three respondents used specialty tricycles and bicycles. These children started tricycling at the early age of about 2.5 years, and bicycling around age of 10 years. Bikes used by the respondents included a three-wheeler with alternate crank handlebars, similar to the Shadow by Quickie. Also used were a hand-pedaled four-wheeler by Chariot and an upper-extremity-propelled Tri-Aid bike with sockets attached to the handlebar for the upper extremity.

“Bikes can’t be too big, or they are not effective,” a parent in this group stressed. Compatibility between the child and the bike in terms of size can pose a financial problem for parents any time the child grows even an inch or two. Certain specialty bike companies do manufacture bikes that adapt to the users size; see this issue’s Gear Guide for more information about these companies. Two of the families polled were able to get financial assistance for purchasing specialty bikes for their children. If cost is a barrier, for exercise purposes an alternative to a bike might be a manual wheelchair.

Unilateral Below or Above Elbow
Of the 26 children with an unilateral amputation below or above the elbow, most began riding tricycles around the age of 2.4 years, and started on bikes at the age of 4.9 years.

Fourteen of the children in this group did not use any type of prosthesis while riding a bicycle, and none of the cyclists required a specialty bike. One child who does not wear a prosthesis had a socket attached to the handlebar by a prosthetist. She rests her affected arm in the socket to help with steering while riding. The other members of this group used standard bikes that had been inexpensively modified. The list of adaptations was as follows: changing the back brake to the same side as the front hand brake, letting some air out of the tires to prevent rocking, attaching a wooden dowel to the handle bar or using a straight handlebar so that either an ADEPT prosthesis or a hook prosthesis could grip it.

Important Bike Riding Principles
As far as bike riding is concerned, the parents of children with limb differences should always keep in mind the following principles:

1. No bike riding should be done without a helmet.
2. Prior to purchase, its a good idea to have the bike evaluated for user suitability by an occupational or recreation therapist.
3. The bike should be of the size appropriate to the child.
4. The beginner’s bike should be of one speed only and should be equipped with both training wheels and brakes.

Be sure to check out the Gear Guide in this issue (pg. 49) if you are interested in purchasing a specialty bike or bike accessories. The Gear Guide has information about a number of companies that manufacture and sell specialty bikes and accessories.

About the Author

Mary VanderHoek is now a nurse at St. Cloud Hospital in Minnesota.

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