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

Full text

IJOT : Vol. XLI : No. 3 September 2009 - December 2009
63
EFFECT OF BALANCE EXERCISE ON BALANCE CONTROL IN
UNILATERAL LOWER LIMB AMPUTEES
* 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.
INTRODUCTION:
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 : damayanti.sethy@gmail.com
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
side.
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.
PDF created with pdfFactory trial version www.pdffactory.com

IJOT : Vol. XLI : No. 3 September 2009 - December 2009
64
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 .
5
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
amputees.
AIMS& OBJECTIVES:
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
amputees.
MATERIAL & METHOD
SUBJECTS:
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.
INCLUSION CRITERIA-
§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.
EXCLUSION CRITERIA
§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
APPARATUS:
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
systems.
•Dimensions: 420x430x65mm
•Weight 2.5Kg
•Maximum patient’s weight: 100Kg
•Movement range:- -15,+15degrees
The equipment provides perturbation along with auditory and
visual feedback.
MATERIALS:
Measuring tape for functional reach measurement.
Phyaction balance exercise version 2.0, October 2005.
Laptop and connecting cables.
OUT COME MEASURES:-
Functional reach, Balance exercise parameter (Total area
covered by both the feet) and the Global performance of
balance.
PDF created with pdfFactory trial version www.pdffactory.com

IJOT : Vol. XLI : No. 3 September 2009 - December 2009
65
DURATION OF BALANCE TRAINING:
30 minutes a day, five times a week for four weeks
PROCEDURE:
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.
PHYACTION BALANCE EXERCISE:
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 patient’s ability to
control balance progressed without covering extra area. With
the improvement of the patient’s 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.
DATA ANALYSIS AND RESULTS
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
group
0
2
4
6
8
10
12
14
EXP GROUP
COMPARING FUNCTIONAL REACH
REACH
-1
REACH
-2
CONTROL GROUP
PDF created with pdfFactory trial version www.pdffactory.com

IJOT : Vol. XLI : No. 3 September 2009 - December 2009
66
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 Antero—Posterior 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
groups
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
COMPARING M-L GLOBAL(BALANCE
PERFORMANCE)
0
10
20
30
40
50
60
70
EXP GROUP CONTROL GROUP
PRE GBP
POST GBP
COMPARING A-P GLOBAL(BALANCE
PERFORMANCE)
0
20
40
60
80
EXP GROUP CONTROL GROUP
PRE GBP
POST GBP
0
10
20
30
40
50
60
FR MLB APB 2MWT
COMPARING THE RESULT BETWEEN
THE GROUPS
EXP GROUP
CONTROL
GROUP
PDF created with pdfFactory trial version www.pdffactory.com

IJOT : Vol. XLI : No. 3 September 2009 - December 2009
67
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.
DISCUSSION
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
0
100
200
300
400
500
PRE TRAINING POST TRAINING
nonaffected
limb
prosthetic
limb
0
10
20
30
40
50
60
70
80
T-FEMORAL 1 T-TIBIAL 2
Comparing the balance improvement in trans femoral and
trans tibial amputees
pre training
post training
PDF created with pdfFactory trial version www.pdffactory.com

IJOT : Vol. XLI : No. 3 September 2009 - December 2009
68
CONCLUSION
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.
ACKNOWLEDGEMENT
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
study.
We also thank to Dr Mrinmoy Karmokar, Occupational
Therapist, Leprosy Mission, Kolkata for helping us with the
statistics.
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.
REFERENCES
1. Melzer I,Elbar O,Tsedek I,Oddsson Lie.A water based training
program that include perturbation exercises to improve stepping
responses in older adults.BMC Geriatrics 2008 Aug 17;8:19
2. Geurts ACH,Mulder TW,Nienhuis B,Rijken RAJ.Dual task
assessment of reorganization of postural control in persons with
lower limb amputation.Arch Phys Med Rehabil 1991:72:1095-64.
3. Alexander C. H. Geurts a; Theo W. Mulder bc Reorganization of
Postural Control Following Lower Limb Amputation: Theoretical
Considerations and Implications for Rehabilitation. Physiotherapy
Theory and Practice, Volume 8, Issue 3 1992.
4. Miller WC, Deathe AB, Speechley M, Koval J. The influence of
falling, fear of falling, and balance confidence on prosthetic
mobility and social activity among individuals with a lower
extremity amputation. Arch Phys Med Rehabil 2001;82:1238-44
5. Miller Wc ,Deathe AB . A prospective study examining balance
confidence among individuals with lower limb amputation. Disabil
Rehabil. 2004 Jul 22-Aug 5;26(14-15):875-81.
6. Hof AL, et al. Control of lateral balance in walking. Experimental
findings in normal Subjects and above-knee amputees. 2007
Feb;25(2):250-8
7. Buckley JG, O’Driscoll D, Bennett SJ.Postural sway and active
balance performance in highly active lower-limb amputees. Am J
Phys Med Rehabil. 2002, Jan;81(1):13-20
8. A.H Vrieling,H.G vn Keeken.Balance control on a moving plat
form in lower limb amputees. Gait posture.28 (2008)222-228.
9. Van Ootegham,Frank JS,BuchannnJJ.Compensatory postural
adaptations during continuous,variable amplitude perturbations
reveal generalized rather that sequence specific ;earning.Exp
Brain Research.2008 jun,187(4),603-11.
10. Gupta A,Sharma R.Comparision of static sway and static weight
bearing in below knee amputees trained by conventional versus
visual feedback techniques using dynamic posturography. Ind J.
of PMR April 2006,17(1),14-17
11. Chiari, L.; Dozza, M.; Cappello, A.; Horak, F.B.; Macellari, V.;
Giansanti, D. Audio-biofeedback for balance improvement: an
accelerometry-based system. Biomedical Engineering, Volume
52, Issue 12, Dec. 2005
12. DS Nicholas.Balance training after stroke using force platform
biofeedback.Physical Therapy Vol.77,No-5,May 1997,pp.553-558
13. Lasseo U,Voigt M.Anticipatory postural control strategies related
to predictive perturbations.Gait posture jul:28(1).62-8.
•
PDF created with pdfFactory trial version www.pdffactory.com