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Effect of balance exercise on balance control in unilateral lower limb amputees.

  • National Institute for Locomotor Disabilities
IJOT : Vol. XLI : No. 3 September 2009 - December 2009
* Damayanti Sethy, M. O.T., Co-Authors : ** Eva Snehlata Kujur, M.O.T.; *** Kaushik Sau, M.O.T.
Abstract :
OBJECTIVES- 1. To study the effect of balance exercise on balance control of unilateral lower limb amputees.
2. To study the difference in balance control in Trans Femoral and Trans Tibial amputees.
METHODOLOGY-Thirty unilateral Trans-femoral and Trans-tibial amputees were selected and divided into two groups of 15
each. Control group received conventional training and Experimental group received conventional training along with
Phyaction balance exercise. Duration of treatment was 30 minutes, five days a week for four weeks. Pre and Post training
evaluation of functional reach, and Global balance performance was done for both the groups. Statistical analysis was done
by t test.
RESULT: Statistically significant improvement was seen in all the outcome measures in experimental group and no significant
improvement was seen in case of control group which shows that balance exercise is effective in controlling balance in
unilateral lower limb amputees.
CONCLUSION: Early phase balance exercise is effective in controlling balance of unilateral lower limb amputees. Area
covered by the non-affected limb was more in comparison to the prosthetic limb, so strengthening of the non-affected limb
should be incorporated in the rehabilitation of unilateral lower limb amputees.
Keywords: Balance training, Amputees, perturbation, Prosthesis.
Postural stability is essential to the performance of most daily
activities and is necessary to lead an independent life. Gait
and balance impairments may increase the risk of falls, the
leading cause of accidental death. Fall related injuries
constitute a serious public health problem associated with
high costs for society as well as human suffering1.
In able-bodied individuals the ankle joint and leg musculature
play an important role in maintaining balance by appropriately
shifting the center of pressure 2.
The reorganization of standing balance after a lower limb
amputation is considered, with emphasis on persons with an
acquired unilateral amputation above the ankle and below
the hip joint. In the first section, three major peripheral motor
The Indian Journal of Occupational Therapy : Vol. XLI : No. 3 (September 2009 - December 2009)
* Occupational Therapist
** Sr. Occupational Therapist
*** Jr. Lecturer
Place of Study : National Institute for the Orthopaedically
Handicapped, Kolkata
Period of Study : August 2007 - December 2008
Correspondence :
Dr. Damayanti Sethy
Occupational Therapist, National Institute for the Orthopaedically
Handicapped, B.T. Road, Bonhoogly, Kolkata-90, W.B.
Tel. : 09831318686
E-mail :
and sensory impairments are discussed: (a) a lack of ankle
torque generation to restore equilibrium in the sagittal plane,
(b) a lack of weight-shifting capacity to control posture in
the frontal plane and (c) a distorted somato-sensory input
from the side of amputation 3.
Falling is an important clinical problem in amputee population.
Balance confidence was the only factor associated with
mobility capability and performance and social activity. 4
Miller WC et al 20015 in their study with 435 unilateral below
knee and above knee lower limb amputees found that exactly
52.4% subjects reported falling in the past year, whereas
49.2% reported a fear of falling and concluded that Falling
and fear of falling are pervasive among amputees.
Hof AL et al (2007)6 studied control of lateral balance in
walking of Trans femoral amputees and their study found
that amputees showed asymmetric gait with shorter stance
(60%) at the prosthetic side versus 68% at the non-prosthetic
Backley JG et al (2002)7 studied balance performance of
lower limb amputees during quiet standing and under dynamic
conditions. They used a single axis stabilimeter to assess the
center of pressure (COP) excursions in both the situations
and found that Amputees had a greater problem controlling
dynamic balance in the antero -posterior direction than medio-
lateral direction.
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IJOT : Vol. XLI : No. 3 September 2009 - December 2009
A.H. Vrieling et al (2008)8 in their study with unilateral trans
femoral and trans tibial amputees studied that the ability to
cope with balance perturbations is limited in prosthetic limb
due to absence of ankle strategy.
Chiari, L.; et al 200511 in their study used prototype audio-
biofeedback system for balance improvement through the
sonification using trunk kinematic information and found that
it is effective in controlling balance.
Nicholas et al 1997 12in their study used force platform using
audio and visual feed back for balance control in hemiplegic
stroke patients and found that feedback can be used to
improve balance.
Several studies have mentioned static balance tests and few
studies mentioned regarding dynamic balance tests. Most of
the studies have used weight-bearing training for unilateral
lower limb amputees, which may not be sufficient for
maintaining balance in daily activities since balance control
is often required during ambulation which is a dynamic
activity. Falls regularly occur when balance control is hindered
by an external perturbation .
So It is important to train
balance by using perturbations. In this study an attempt has
been made to see the effect of early phase balance training
by support surface perturbations in unilateral lower limb
1. To study the effect of balance training on balance
control of unilateral lower limb amputees in their early
phase of rehabilitation.
2. To find out the difference in the improvement of
balance in unilateral Trans- Femoral and Trans-Tibial
Thirty patients with unilateral lower limb amputees both
Trans-femoral(TF) and Trans-tibial(TB) attending outpatient
Occupational Therapy department, outpatient Prosthetic and
Orthotic department and Inpatient Rehabilitation ward, NIOH
were selected for the study and divided into two groups of
fifteen each. Group A was the Experimental group and
Group-B was the control group. Evaluation of the entire
outcome measures, both pre and post training were done by
an Occupational therapist unaware of the study results.
§Age-18-55 years
§Amputation at least two months earlier
§Early phase of prosthetic training
§Ability to stand with a prosthesis without walking aids
for at least 30 minutes
§Ability to perform Balance exercise level -2 in the
balance exercise equipment.
§Impaired hearing and vision
§Having medical conditions that could affect their ability
or balance
§Reduced sensation of the non-affected limb.
§Pain at the stump and fitting problems of the prosthesis
Phyaction balance exercise is an apparatus having a balance
exercise soft ware installed in the personal computer/Laptop
and a hard ware (Proprioceptive board/tablet) attached to it
with a connecting cable. The apparatus is fitted with an
internal electrical supply. The Board is of moving fulcrum
type. The fulcrum changes with the changes in the board
position. The board rolls on the balancing shapes that have a
suitable diameter. Three pairs of interchangeable shapes are
available. The board is attached with an encoder that detects
its position. The encoder is operated through a lever that is
in contact with the floor. The encoder is connected to an
electronic card that reads the angle of the board top surface
with respect to the floor on which the board rests and sends
the reading to the PC through a USB port. The interface
graphics of the tablet were designed by using the interactive
graphic controls that are typical of the Windows operating
Dimensions: 420x430x65mm
Weight 2.5Kg
Maximum patients weight: 100Kg
Movement range:- -15,+15degrees
The equipment provides perturbation along with auditory and
visual feedback.
Measuring tape for functional reach measurement.
Phyaction balance exercise version 2.0, October 2005.
Laptop and connecting cables.
Functional reach, Balance exercise parameter (Total area
covered by both the feet) and the Global performance of
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IJOT : Vol. XLI : No. 3 September 2009 - December 2009
30 minutes a day, five times a week for four weeks
The amputee patients who fit the inclusion criteria were
allotted to two groups by convenient sampling method after
getting informed consent. All the amputees were using
conventional TF and TT prosthesis. A general history was
taken from the patient and individual patient demographics
along with date of accident were saved in the data sheet
provided by the balance exercise soft ware. Baseline
measurement of Functional Reach, and balance exercise
performance, total area covered by both prosthetic limb and
the non affected limb, Global for both antero-posterior(AP)
stability control and medio-lateral(ML) stability control for
both trans-femoral and trans-tibial amputees were taken.
Global performance is weighed average (a number from 0
to 100) of the 8 calculated parameters. The parameters are
total area covered within the profile, Extra area outside the
profile, Extra time taken and Recovery time. A score of 100
is the worst case and zero is the best. Experimental group
received Phyaction balance exercise with conventional
training and control group received conventional training only,
which consisted of parallel bar training in front of a full-
length mirror.
On the first day of training level of balance exercise
performance of the patients was evaluated. Patients stood
erect on the moving Board with their hands along side their
bodies. Patients were instructed to stand with both feet on
the floor as motionless as possible to maintain balance while
the board sways over a diameter of 40 centimeter both in
medio-lateral and antero-posterior direction .For safety
purpose one therapist stood near by the patient. The
movement of the board was set in the exercise program for
individual patients. Feet position selected for the patient was
bilateral, position of the patient was standing, Board heading
was straight for medio-lateral balance control exercise and
transversal for antero-posterior balance exercise. Graphic
presentation of the exercise was set complete which will
show the board and the graphic presentations on the screen.
Each patient got both visual and auditory feed back from the
screen. The amplitude and frequency of movement was set
to be 3 degrees and 3 cycles/min resectively. Patient was
asked to stand on the Proprioceptive board and the program
was set starting from level one exercise. If the patient could
do level-1 without any error then the next level of exercise
was done. Initially most of the patients could do balance
level two, so the exercise was set starting from balance level-
3 and progressed to the next levels as the patients ability to
control balance progressed without covering extra area. With
the improvement of the patients ability the level of difficulty
was increased. All the patients in the Experimental group
received 15 minutes of medio-lateral balance control exercise
and 15 minutes of antero-posterior balance control exercise.
Each 15 minutes were divided into 5 sets of exercise of 3
minutes each set. After each three minutes of exercise
patients received 1 minute rest. Each patient received antero-
postero balance control exercise after completing 15 minutes
of medio-lateral exercise in the same manner. Exercise
performance was noted on initial evaluation and after 4 weeks
of training.
Paired t- test was used to analyze that data within each group
and Un-paired t test was used to analyze the data between
the two groups. Result was considered significant at p<0.05.
Data was analyzed by using SPSS software version 10.0
Table 1
Comparing pre and post FUNCTIONAL REACH
within each group
Graph 1
As seen in Table and Graph-1, there is a statistically
significant improvement in functional reach post training in
experimental group and no significant improvement in control
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IJOT : Vol. XLI : No. 3 September 2009 - December 2009
Table 2
Comparing Medio-lateral (ML) global balance
performance within each group
Graph 2
The Table and Graph-2 shows statistically significant
improvement (p=0.005) in Medio-lateral global balance
performance post training in experimental group and no
significant improvement (p=0.077) in control group.
Table 3
Comparing Antero-Posterior(A-P) global balance
performance within each group.
Graph 3
Table and Graph-3 shows statistically significant improvement
(p=0.002) in AnteroPosterior global balance performance
post training in experimental group and no significant
improvement (p=0.065) in control group.
Table 4
Comparing Mean Differences between both the
Graph 4
The Table and Graph-4 shows statistically significant
improvement in all the four-outcome measure in experimental
group in comparison to control group
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IJOT : Vol. XLI : No. 3 September 2009 - December 2009
Table 5
Comparing Area covered by prosthetic and non-
affected limb in all patients.
Graph 5
As shown in Table and Graph-5, all the patients both pre and
post balance training, covered more area by the non- affected
limb in comparison to the prosthetic limb.
Table 6
Comparing Global Balance improvement in Trans-
femoral and Trans-tibial amputees
Graph 6
The result shows that the Trans-tibial amputees improved
better than the Trans femoral amputees.
The result of the study showed that there is a significant
improvement in Functional Reach and the global balance
performance in the experimental group and no significant
improvement in these outcome measures in the control group.
This suggests that post Phyaction Balance training, balance
control improved in the unilateral lower limb amputees which
is similar to the findings of a study by Laessoe et al 200813
who concluded that both young and elderly use anticipatory
postural control strategies to minimize the impact of
predictable perturbations and perturbation training by using
a moving board improves balance control. Along with
perturbation, all the patients got both visual and auditory
feedback during the training and thus experimental group
showed improvement in balance control. The result of the
study is supported by Van Ootegham et all 20089 .In their
study they used continuous variable amplitude oscillations
evoked by translating platform and the result showed that
with repeated trials participants reduced their magnitude of
center of mass (COM) displacements. These findings provide
important insight into the generalizability of improved
compensatory balance control with training.
A study by A Gupta and R Sharma (2006)10 found that visual
feedback is important in training symmetrical weight bearing
in unilateral amputees and the result of their study showed
significant improvement after training with visual feedback.
In our study amputees covered more area on the non-
amputed limb than the prosthetic limb and the result
corroborates with the study of A.H Veiring et al 20088 which
says that, compared to quiet standing, loading on non affected
limb is more than the prosthetic limb when balance is
perturbed. Various causes have been cited in many studies
for the asymmetric weight bearing like a lack of ankle torque
generation to restore equilibrium in the sagittal plane, a lack
of weight-shifting capacity to control posture in the frontal
plane and a distorted somato-sensory input from the side of
amputation. In this study it was seen that improvement in
Medio-lateral balance control is better than anterior-posterior
balance control. The poor improvement in the anterior-
posterior balance control may be attributed to lack of ankle
strategy in both amputee groups which could not be used
when balance was perturbed in antero-posterior direction.The
better improvement in balance performance seen in Trans-
tibial amputees than the trans femoral amputees may be
attributed to the presence of hip abductors/adductors and
knee extensors/flexors in the former group for the use of hip
strategy when balance was perturbed and the absence of
adequate strength and length of hip and knee muscles in the
trans-femoral amputees.
Comparing the area covered by non-
affected limb and the prosthetic limb
Comparing the balance improvement in trans femoral and
trans tibial amputees
pre training
post training
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IJOT : Vol. XLI : No. 3 September 2009 - December 2009
The present study showed the effect of perturbation on
balance control of unilateral lower limb amputees and thus
gives evidence that during early prosthetic training, balance
training should be incorporated in the rehabilitation program
of amputees for their better participation in community life.
As the amputees covered more area in the non- affected
limb than the prosthetic limb, which suggests that amputees
bear most of their body weight on the non affected side. The
result suggests that strength training of the non affected limb
is important in the rehabilitation of the unilateral lower limb
amputees. Future studies can be conducted to see the
effectiveness of Medio-lateral balance control and Antero-
posterior balance control in amputees with respect to residual
limb length.
We take this opportunity to thank Dr.Ratnesh Kumar,
Director, NIOH for granting us the permission to carryout
our study.
Our special thanks to Dr. S.P Mokashi, Asso.Prof &Head,
Department of Occupational Therapy, SVNIRTAR, Cuttack,
Orissa. and Dr. Pankaj Bajpai,Asst. Prof& Head,
Department of Occupational Therapy, NIOH, Kolkata for
their blessings, encouragement and guidance throughout the
We also thank to Dr Mrinmoy Karmokar, Occupational
Therapist, Leprosy Mission, Kolkata for helping us with the
We are thankful to all the staff, Dept. of occupational therapy
for their valuable suggestion through out the study.
We thank Mr.S.D Berman,Prosthetist, Gauri, Wanphylla
(students) for their help.
Finally we thank all our patients for trusting us during the
course of the study.
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... Research findings show that exercise may function as an intervening therapy to improve balance control and posture among the amputee and thus could be considered as a therapeutic tool by experts and occupational therapists. In this regard, Damayanti-Sethy et al. (2009) have investigated the effect of balance exercises on controlling balance among people with unilateral lower limb amputation [8]. In doing so, thirty people with lower limbs amputation (above knee and below knee) were selected and put into two groups of 15. ...
... The program last four weeks and five days a week, 30 minutes each day. The results showed that the intervention of balance exercises was effective in promoting balance ability in people with unilateral lower limb amputation [8]. In another study, Barnett et al. (2013) have studied the adaptive responses in postural control among transtibial amputee after discharge from rehabilitation program. ...
... In exercise sessions stage, the examinee in balance exercise group performed their exercises program for 1 month (4 weeks, 5 sessions per week, 30 minutes each session) [8]. The exercise schedule was designed in a way as to add 5 minutes to the sessions in each week. ...
Full-text available
Objectives. The aim of the present study was to compare the effect of a selected balance program with and without using mirror on balance of individual with amputee. Methods. Twenty-one lower limb amputees (with age range between 25 to 60 years) participated in this study and randomly were recruited into three groups: control, balance program, and mirror balance program. The participants took part in pretest after one month. Experimental groups performed their balancing program for 1 month (4 weeks, 5 sessions per week, 30 minutes each session). To asses postural control, Computerized Dynamic Posturography was used Using sensory organization test, balance was measured in six conditions (first: existence of sight, hearing and proprioception; second: elimination of sight; third: manipulation of vestibular system; fourth: manipulation of proprioception; fifth: elimination of sight and manipulation of proprioception and sixth: manipulation of vestibular system and proprioception). Results. The results indicated that the stability score in both balance and mirror balance groups have improved compare to the control group. Furthermore, in the first and second conditions, both experimental groups have obtained a higher stability score and a less displacement in the center of gravity compare to the control. In the sixth condition, the stability score was lower and displacement score was higher. Also, the amputee in the balance exercise using mirror group had a better balance in all the six conditions. Conclusion. Finally, we can conclude that undergoing a series of balance exercises with and without mirror improves balance and postural stability in lower limb amputee.
... In rehabilitation programs after LLA, the usual focus is on independent walking with the prostheses (Fortington et al, 2012). In recent years, rehabilitation programs for people with amputations have included strengthening exercises, walking training, video games, cycling ergometer training, weight-bearing exercises, coordination exercises, gait training, and functional activities in daily life (e.g., carrying a glass of water without spilling) (Andrysek et al, 2012;Darter, Nielsen, Yack, and Janz, 2013;Nolan, 2012;Rau and Bonvin, 2007;Sethy, Kujur, and Sau, 2009;Van de Meent, Hopman, and Frölke, 2013;VanRoss, Johnson, and Abbott, 2009). ...
... Van De Meent, Hopman, and Frölke (2013) also used weight-bearing exercises, but focused on patients with osseointegration. Andrysek et al. (2012) used video games for postural control and balance, while Sethy, Kujur, and Sau (2009) also focused on balance using balance exercises (i.e., conventional training) comparing two Table 2. Classification of study design, described by Jovell and Navarro-Rubio (1995), which was used to assess the methodological quality of included papers. groups with and without Phyaction software. ...
... Rau and Bonvin (2007) used the 2-min walk test, while Van de Meent, Hopman, and Frölke (2013) used the 6-min walk test. In another study, the functional reach test, balance exercise parameters, and global performance of balance were used (Sethy, Kujur, and Sau, 2009). VanRoss, Johnson, and Abbott (2009) examined stump wound healing, time required to achieve healing, and resting transcutaneous oxygen pressure before and after physiotherapy. ...
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Background: Successful use of prostheses after lower-limb amputation (LLA) depends on undergoing physiotherapy and rehabilitation both physically and psychologically. The aim of this systematic literature review is to systematically review the scientific evidence regarding prosthetic rehabilitation and physiotherapy after LLA. Methods: A systematic literature search was conducted using PubMed, Web of Science, Cochrane, CINAHL, EMBASE, SCOPUS, and EMB Reviews databases on December 31, 2015. Studies with the search keywords were identified and independently assessed by reviewers. The search yielded 403 potentially relevant articles after the removal of duplicates. Of these, only nine articles met the inclusion criteria. All studies were original articles, one of which was a randomized controlled study. Different measurement methods were used and positive results in terms of functional status, weight-lifting capacity with prosthesis, walking and balance ability, and acute care process were gained with a physiotherapy program. Conventional methods still possess high importance; however, it is safe to say that virtual reality and software-based programs for rehabilitation are increasingly being developed and getting more and more support. Discussion: LLA rehabilitation is a topic that requires the focus of current and future studies; evidence-based studies are required on the approaches to rehabilitation for specific LLA groups.
... Reach Test measures the maximum distance an individual can reach forward while standing in a fixed position (Duncan et al., 1990) and has been used to assess balance ability after balance training over four weeks (Damayanti Sethy et al., 2009). As such, clinical assessments can identify general balance capability and confidence, and gauge the effect of rehabilitation interventions on standing balance. ...
People with a unilateral transtibial amputation (TTA) complete functional tasks asymmetrically, using compensatory strategies to accommodate for the lost ankle muscle function. These strategies may contribute the greater intact limb joint pain, low-back pain, and greater risk of falling commonly reported in this population. Prosthetists attempt to reduce asymmetries during the prosthetic alignment process. However, this process, which focuses on straight-line walking, may not capture the effect of prosthetic alignment on other functional tasks. The purpose of this dissertation was to determine how people with TTA maintain dynamic balance during turning and seat transfers and to quantify the effects of prosthetic alignment during seat transfers. The first aim was to determine how balance regulation during turning is affected by the side the prosthesis is on and quantify how people with TTA maintain dynamic balance during a 90-degree turn. Participants with TTA had greater range of whole-body angular momentum when turning with the prosthesis on the inside compared to outside of the turn. There were altered head/trunk and legs interactions between turns and groups. The observed differences when turning with the prosthesis on the inside of a turn may suggest people with TTA have a greater risk of balance loss during turning. The second aim was to quantify the effect of prosthetic alignment on dynamic balance during functional tasks. We compared the range and number of adjustments of whole-body angular momentum during walking, sit-to-stand, stand-to-sit, sit-to-walk, and walk-to-sit between different alignments. Sit-to-stand was the only task where alignment significantly affected angular momentum, although differences in magnitudes were small. Participants with TTA had less balance control compared to non-amputees, across alignments. These results suggest that acute changes in prosthetic alignment likely do not affect balance control during seat transfers. The third aim was to determine the effects of anterior-posterior alignment shifts on movement strategies during sit-to-stand. We compared 3D ground reaction force impulses, sagittal-plane knee moments, anterior/posterior center of pressure position, and 3D trunk range of motion between alignments. The posterior alignment reduced braking impulse asymmetry and axial trunk range of motion compared to other alignments. These results suggest that prosthetic alignment may affect the movement strategies used during sit-to-stand which may have implications for asymmetric and altered movement patterns found in people with TTA. The fourth aim was to determine the effect of prosthetic alignment on hip and low-back joint contact forces during sit-to-stand in people with a unilateral transtibial amputation. Using a musculoskeletal simulation framework, there were no differences in hip and L4-L5 joint contact forces between alignments. Participants with TTA had a greater peak hip joint contact force on the intact side hip compared to the amputated side across all alignments. This result may have important implications as greater cumulative intact hip loading throughout daily life may increase the risk of hip joint pain and degeneration in people with TTA. Together, these studies support the idea that even highly functional individuals with a lower limb amputation have decreased balance control and altered joint loading across a range of functional tasks. Results from these studies also suggest that people with TTA develop compensatory strategies in response to acute changes in prosthetic alignment do not affect balance or joint loading during seat transfers. Future work should explore whether these findings extend to long-term changes in alignment or to lower functioning individuals.
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Objectives To investigate the effects of dual task balance training on static and dynamic balance, functional mobility, cognitive level, and sleep quality in individuals with transfemoral amputation. Design Randomised controlled clinical trial. Participants Transfemoral amputees (n=20). Interventions Participants were randomly assigned to the single task gait and balance training group (n=10) or the dual task task gait and balance training group (n=10). Training was given in sessions of 60 min/day, 3 days/wk for 4 weeks. The single task training group performed traditional gait and balance exercises, and the dual task training group practised cognitive and motor tasks while performing gait and balance exercises. Main Outcome Measures The one leg stance test and the four-square step test were used for balance assessment. The Timed Up and Go test, and 10-meter walk test were used for gait assessment. Three test conditions to evaluate the training effects were single walking, walking while performing a cognitive task (serial subtraction), and walking while performing a motor task (tray-carrying). The Montreal Cognitive Assessment scale was used for cognitive assessment and the Pittsburgh Sleep Quality Index for sleep quality assessment. Results Balance and mobility improved in both groups. Dual task balance performance, functional mobility and gait speed improved more in the dual task training group after training (p <0.05). Cognitive status and sleep quality improved significantly in the dual task group (p <0.05). Conclusions Dual-task training was more effective than single task training in the improvement of dual task performance and cognitive status. The inclusion of dual task exercises in the rehabilitation program of transfemoral amputees will provide a different perspective due to increased task automation.
The need for rehabilitation expertise within the emergency humanitarian response team is increasingly recognised. Early rehabilitation allows patients to recover faster and to regain a better function following trauma. Patient rehabilitation requires teamwork. The medical staff and the patient’s relatives must be involved from the beginning, and communication is paramount, setting functional goals together and providing continuity of care. The physiotherapy treatment plan is designed considering the possible secondary complications as well as the expected disabilities resulting from the trauma. The role of the physiotherapist includes educating and encouraging the patient to be active in his own rehabilitation, prevent complications and help regain function and autonomy, improving the patient’s reintegration into society.
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The reorganisation of standing balance after a lower limb amputation is considered, with emphasis on persons with an acquired unilateral amputation above the ankle and below the hip joint. In the first section, three major peripheral motor and sensory impairments are discussed: (a) a lack of ankle torque generation to restore equilibrium in the sagittal plane, (b) a lack of weight-shifting capacity to control posture in the frontal plane and (c) a distorted somatosensory input from the side of amputation. In the second part of die paper, it is argued that a lower limb amputation, as any other serious peripheral lesion, also affects the highest levels of the sensorimotor system, because the functional recovery after amputation requires a central adaptation to the alterations of peripheral motor and sensory conditions. A reduction in the cognitive regulation of posture as well as a decrease in visual dependency are proposed as two of the most critical parameters of the long-term central adaptation process and as relevant indicators of the restoration of (the safe performance of) gross motor skills. In the final section, some implications for the management, balance assessment and training of persons with a lower limb amputation are mentioned.
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Gait and balance impairments may increase the risk of falls, the leading cause of accidental death in the elderly population. Fall-related injuries constitute a serious public health problem associated with high costs for society as well as human suffering. A rapid step is the most important protective postural strategy, acting to recover equilibrium and prevent a fall from initiating. It can arise from large perturbations, but also frequently as a consequence of volitional movements. We propose to use a novel water-based training program which includes specific perturbation exercises that will target the stepping responses that could potentially have a profound effect in reducing risk of falling. We describe the water-based balance training program and a study protocol to evaluate its efficacy (Trial registration number #NCT00708136). The proposed water-based training program involves use of unpredictable, multi-directional perturbations in a group setting to evoke compensatory and volitional stepping responses. Perturbations are made by pushing slightly the subjects and by water turbulence, in 24 training sessions conducted over 12 weeks. Concurrent cognitive tasks during movement tasks are included. Principles of physical training and exercise including awareness, continuity, motivation, overload, periodicity, progression and specificity were used in the development of this novel program. Specific goals are to increase the speed of stepping responses and improve the postural control mechanism and physical functioning. A prospective, randomized, cross-over trial with concealed allocation, assessor blinding and intention-to-treat analysis will be performed to evaluate the efficacy of the water-based training program. A total of 36 community-dwelling adults (age 65-88) with no recent history of instability or falling will be assigned to either the perturbation-based training or a control group (no training). Voluntary step reaction times and postural stability using stabiliogram diffusion analysis will be tested before and after the 12 weeks of training. This study will determine whether a water-based balance training program that includes perturbation exercises, in a group setting, can improve speed of voluntary stepping responses and improve balance control. Results will help guide the development of more cost-effective interventions that can prevent the occurrence of falls in the elderly.
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Postural control in persons with lower limb amputation was studied using a cognitive approach to motor learning. The aim of this study was to show that an important characteristic of the central reorganization process after a lower limb amputation is the gradually decreasing need of attentional resources to perform a motor task. A dual-task procedure was developed to estimate the level of automaticity of a quiet, upright standing task. The effect of a concurrent attention-demanding task (Stroop task) on the efficiency of balance control was determined using force-platform measurements at the start and the end of the rehabilitation process. In contrast with a control group, the amputation group showed interference effects on body sway caused by the concurrent task both at the start (p less than .05) and, less severe, at the end of rehabilitation (p less than .05). Improvement of balance control was significant only for the dual-task condition (p less than .05). The results corroborated the hypothesis that dual tasks give information about the restoration of automaticity of postural control as an essential characteristic of the central reorganization process in persons with lower limb amputation. The role of dual-task procedures as a useful approach to skill assessment is discussed.
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To assess in amputee patients the relationship between having fallen in the past 12 months, fear of falling, and balance confidence on mobility capability, mobility performance, and social activity. Population-based survey and chart review. Two university-affiliated outpatient amputee programs in southwestern Ontario. Community-living individuals (n = 435) with a unilateral lower limb amputation. Patient chart review and a survey questionnaire. Self-report assessment of prosthetic capability and performance and social activity participation was assessed with the Prosthetic Evaluation Questionnaire mobility subscale, the Houghton Scale, and the Frenchay Activities Index. Falling experiences in the past 12 months were not significantly associated with any outcomes. Fear of falling was important in univariate relationships in all 3 outcomes, but not when balance confidence was included in multivariable modeling. Balance confidence was statistically significant with each of the outcomes and remained significant with inclusion of the covariates. There was statistical interaction (balance confidence x automatism; balance confidence x medication count) in modeling mobility capability and in modeling mobility performance (balance confidence x pain + balance confidence x amputation level). The final models accounted for 70%, 60%, and 55% of the variation in mobility capability, mobility performance, and social activity, respectively. Balance confidence was the only factor associated with mobility capability and performance and social activity in the final adjusted models. Clinicians and researchers should consider this variable in the rehabilitation of amputee patients.
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In this study we assessed whether balance confidence scores changed over a 2-year follow up period, and identified predictors of balance confidence and predictors of change in balance confidence among lower limb amputees. A prospective follow-up survey of 245 community living adults with unilateral below and above knee lower limb amputation who used their prosthetic limb daily was conducted. Balance confidence, assessed using the 16-item Activity-specific Balance Confidence (ABC) Scale, socio-demographic, health and amputation related variables were collected at baseline and 2 years later. ABC scores were similar at baseline (mean = 67.6; SD = 25.7) and follow up (mean = 68.0; SD = 25.8). Lower balance confidence scores at follow up were predicted by older age, being female, use of a mobility device, poor perceived health, increased symptoms of depression, having to concentrate while walking, and fear of falling (all p < 0.05). Predictors of change in balance confidence included gender and perceived health (all p < 0.05). Balance confidence appears to be a persistent problem in the amputee population. Health professionals are encouraged to consider balance confidence as a potentially important variable that may influence function in this clinically unique group of individuals. The identified predictor variables may be useful to clinicians in targeting individuals who require attention to improve balance confidence.
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This paper introduces a prototype audio-biofeedback system for balance improvement through the sonification using trunk kinematic information. In tests of this system, normal healthy subjects performed several trials in which they stood quietly in three sensory conditions while wearing an accelerometric sensory unit and headphones. The audio-biofeedback system converted in real-time the two-dimensional horizontal trunk accelerations into a stereo sound by modulating its frequency, level, and left/right balance. Preliminary results showed that subjects improved balance using this audio-biofeedback system and that this improvement was greater the more that balance was challenged by absent or unreliable sensory cues. In addition, high correlations were found between the center of pressure displacement and trunk acceleration, suggesting accelerometers may be useful for quantifying standing balance.
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In walking the human body is never in balance. Most of the time the trunk is supported by one leg and the centre of mass (CoM) 'falls' to the contralateral side. In dynamical situations the velocity of the CoM should be acknowledged as well in the 'extrapolated centre of mass' (XcoM). Centre of pressure (CoP) position was recorded by a treadmill with built-in force transducers. Lateral CoM and XcoM position were computed by filtering the CoP data. Subjects were six above-knee amputees and six matched healthy controls. They walked at approximately 0.75, 1, and 1.25m/s for 2min. Amputees showed asymmetric gait with shorter stance (60%) at the prosthetic side versus 68% at the non-prosthetic side and a wider stride (13+/-4cm, mean+/-S.D.) compared to controls (9+/-3cm). At foot placement CoP was just lateral to the XcoM. The margin between average CoP and XcoM at foot contact was only 1.6+/-0.7cm in controls, 2.7+/-0.5cm in amputees at the prosthetic side and 1.9+/-0.6cm at the non-prosthetic side. Next to this 'stepping strategy', CoP position was corrected after initial contact by modulating the lateral foot roll-off ('lateral ankle strategy') in non-prosthetic legs up to about 2cm. A simple mechanical model, the inverted pendulum model, can explain that: (1) a less precise foot placement (greater CoP-XcoM margin) results in a wider stride, (2) this effect can be reduced by walking with a higher cadence, and (3) a greater margin at one side, as with a leg prosthesis, should be compensated by a shorter stance duration at the same side to achieve a straight path. This suggests that not in all cases symmetric gait should be an aim of rehabilitation.
The purpose of this investigation was to compare the results in weight distribution between the two lower extremities of a group of unilateral below-knee (BK) amputee adults trained by conventional methods and another group trained by using visual feedback techniques through dynamic posturography imparted using a dual force plate system. Two sets of BK amputees were taken. One set of fifteen old BK amputees (>1 yr) using the PTB prosthesis and trained conventionally with parallel bars and mirror. Second set of fifteen recent amputees (3 months to 1 year) fitted with prostheses recently and they were given weight bearing training for equalized weight distribution by dynamic posturography using force plate systems. They were further sent to the parallel bar system for gait training. The results of our study indicated that weight bearing was more on the normal foot. The discrepancy was to the order of 65:35 percentage of Total Body Weight (%TBW). This data was then compared with normal individuals for the dominant and non-dominant phenomenon where the difference was 52:48%TBW. The difference in the second test group after training was much less, to the order of 55:45%TBW. This difference is believed to significantly improve the gait, reduce the static sway of the patient and thereby increase the overall acceptability of the prosthesis.
To determine the balance performance of active lower-limb amputees during quiet standing and under dynamic conditions. Center-of-pressure excursions during quiet standing and the standing balance performance on a single axis stabilimeter was assessed in six unilateral lower-limb amputees and six able-bodied controls. Stabilimeter trials were repeated with subjects standing so that pivoting occurred either in the anteroposterior or mediolateral direction or in the mediolateral direction but with vision occluded. Center-of-pressure excursions were significantly greater (P < 0.05) for amputees in both the mediolateral and anteroposterior directions. During all stabilimeter tests, amputees spent significantly less time in balance than able-bodied controls (P < 0.05), and this was attributed to a nonsignificant increase in the average time the stabilimeter spent in contact with the ground. Group differences in the average time of contact in the anteroposterior test condition were meaningful (effect size, 1.19). Amputees had poorer static and dynamic balance than able-bodied controls. Amputees had a greater problem controlling dynamic balance in the anteroposterior direction than the mediolateral direction. Findings highlight the importance of the ankle in maintaining balance in situations that involve body movements in the sagittal plane.
To study balance control on a moving platform in lower limb amputees. Observational cohort study. Unilateral transfemoral and transtibial amputees and able-bodied control subjects. Balance control on a platform that moved in the anteroposterior direction was tested with eyes open, blindfolded and while performing a dual task. Weight bearing symmetry, anteroposterior ground reaction force and centre of pressure shift. Compared to able-bodied subjects, in amputees the anteroposterior ground reaction force was larger in the prosthetic and non-affected limb, and the centre of pressure displacement was increased in the non-affected limb and decreased in the prosthetic limb. In amputees body weight was loaded more on the non-affected limb. Blindfolding or adding a dual task did not influence the outcome measures importantly. The results of this study indicate that experienced unilateral amputees with a high activity level compensate for the loss of ankle strategy by increasing movements and loading in the non-affected limb. The ability to cope with balance perturbations is limited in the prosthetic limb. To enable amputees to manage all possible balance disturbances in real life in a safe manner, we recommend to improve muscle strength and control in the non-affected limb and to train complex balance tasks in challenging environments during rehabilitation.