Review of Balance /Falls

and Recent studies in

Amputee Rehab.

By Nerissa Grebert

Westmead Hospital

Falls in Amputee Population

• Falls pose significant risk in amputee population

• 20% of people with lower limb amputation fall while in inpatient rehabilitation (Pauley et al, 2006)

• Greater than 50% of people in the community with LLA fall in previous 12 mths with or without wearing prosthesis (Miller et al, 2001; Kulkarni et al, 1996)

• Significant injuries post fall. 20-57% sustain a significant injury post fall including hemorrhage, lacerations, head trauma and fractures.(Pauley; Kulkarni; Miller)

• 49% of community dwellers with LLA report fear of falling, resulting in activity avoidance.

• Need to identify people who have lower balance and therefore are at high risk of falling.

• The Berg Balance test has been used in several studies to assess balance but never has been validated for the amputee population.

From

our

last

A

ust

PAR

meeti

ng:

Our most routinely used outcome measures for amputees:• 10m walk test

• 2min walk test

• 6min walk test

• TUG test

• AMP-PRO

Some discussion on:

• The use of Berg Balance Test to assess falls risk and improvement in balance

• Whether the ‘L-test’ would be a more appropriate assessment measure for Amputees.

• Appropriate exercises to perform in an Amputee exercise group to improve balance, health and mobility.

Revi

ew

of

3 a

rtic

les

1.Study by Major et al, 2013.

Validity and Reliability of the Berg Balance

Scale for Community-Dwelling Persons with

Lower-Limb Amputation.

2.Barry Deathe & William C

Miller, 2005.The L Test of Functional Mobility:

Measurement Properties of a Modified

Version of the Timed “Up & Go” Test

Designed for People With Lower-Limb

Amputations.3.Lamberg et al. 2014.Harness-Supported Versus

Conventional Training for people

with Lower-Limb Amputation: A

Preliminary Report.

New study by Major et al, 2013.

‘Validity and Reliability of the Berg Balance Scale for

Community-Dwelling Persons with Lower-Limb Amputation’

Berg

Bala

nce

Te

st

• 14 item scale to measure balance

• Total score out of 56

• 41-56=low falls risk

• 21-40= medium falls risk

• 1-20 = high falls risk

• Authors support a cut off score of 45 for Independent safe ambulation in non-amputee population.

MethodInclusion criteria

• Unilateral or bilateral lower-limb loss at or proximal to ankle

• Used a prosthesis for ambulation

• +\- mobility aid

• Nil UL amputation

• Residual limb in good condition

Information collected on:

• age,

• sex,

• height,

• mass,

• number of LLA,

• amputation level,

• amputation etiology,

• time since amputation

• frequency of prosthetic use,

• experience in using a prosthetic,

• number of falls in last 12 months,

• fear of falling,

• type of mobility aids

• Convergent validity for BBS was evaluated by collection of information on several clinical outcome measures that assess constructs related to balance and mobility.

• Participants completed:• Activities –specific Balance confidence

scale (ABC)– Perceived balance and confidence in 16 ADLs

• Prosthesis Evaluation Questionnaire –mobility subscale (PEQ-MS)– Mobility ability in ADLs while wearing a

prosthesis over last 4wks

• Frenchay Activities Index (FAI)– Frequency of ADLs over past 3mth and 6mth

• BBS x2 with different assessors

• The L-Test– Mobility/balance performance

– Rise from chair, walk 3m forward, turn ®, walk 7m, walk around a floor marker, retrace path to chair, sit down.

• 2min walk test

Results Is it a good test for us to use?????

• Results

• 30 participants

• Correlations between the BBS and other measures were stat sig.

• 10% achieved max points on BBS

• 70% achieved >50 –skewed distribution to higher scores

• BBS -high inter-relater reliability and internal consistency

• Performance tests showed stronger relationships with the BBS than questionnaires

• Participants scored worse on the BBS if classified as:

– fear of falling * }Stat. sig.

– Using mobility aid* }

– Unilat. AKA

– Dysvascular amputation

– 2+ falls in 12 months.*only 2 stat. sig.

• Differences minimal and not sig. b/w retrospective fallers- unable to ID LLA with greater risk of falling.

• 33% of unilateral participants scored 0-3 for standing on one leg despite all standing on intact leg.

• Unknown whether BBS can identify changes in balance performance resulting from therapeutic interventions.

The L Test of Functional

Mobility: Measurement Properties

of a Modified Version of

the Timed “Up & Go”

Test Designed for People

With Lower-Limb Amputations.

Death

e &

Mill

er,

2005.

The ‘L-

test

’

• Designed in Canada to assess

lower limb inpatients and

outpatient’s mobility.• Wanted a test which was easy

to administer in a clinic setting

with minimal free space and

time, but didn’t have the ceiling

effects of TUG test when used

with younger patients.

• Combination of TUG, 10m, and

2min tests.• Retains rise from chair and

turns to L and R.• Stand up, walk 3m, turn 90°,

walk 7m, turn 180°, return

along same path (L shape)

• Study to assess reliability and

validity.

Method

Inclusion

• 102 consecutive subjects attending amputee clinic

• 19yrs +, unilateral TT or TF amp

• Prosthesis minimum 6mths

Exclusion

• Unable to speak/read English or follow instructions

• Did not complete all tests

• Medical or prosthetic problem which prevented participation

Procedure1.Demographic data completed

2.Walk tests (1)

3.Self-report questionnaires (ABC, FAI, PEQ-MS)

4.Walk tests 2 (Different assessor)

5.Re-test 2 weeks later (optional)

Minimum 2mins rest between each test.

Walk test order

• TUG, 10m walk test, the L-Test, 2 min walk test

Resu

lts

• 93 subjects completed all preliminary

tests• 27 subjects returned for retesting

• Mean time for L test 32.6 sec

(TT=29.5s, TF=41.7)• Excellent Intra-rater reliability and

Inter-rater reliability proven

• Validity-Correlated well with other

measures• Highest correlations with other walk

tests. Followed by FAI, ABC, PEQ-MS.

• Higher mean times shown for subjects

who1.Were Older (39.7s)2.Used walking aid (43.3s)

3.Had to concentrate on each step

(44.5s)4.Vascular amputation (42.0s)

5.TF amputation (41.7s)

Resu

lts

cont.

• 10 subjects had ceiling effect for

TUG and L Test• 14 subjects had ceiling effect for

TUG but not L-Test• 3 subjects had ceiling for L-test

but not TUG (younger men with

TT due to trauma, > 8yrs)Responsiveness to training (Initial

results)• 68% sure a true change occurred with

2.6 sec shift• 95% sure with a 6.2 sec shift

Lam

berg

et

al.

2014

.

Harness-Supported Versus

Conventional Training for

people with Lower-Limb

Amputation:A Preliminary Report.Research questions1.Can continued gait training for

community based TTA with

>1yr have functional

improvements?2.Would the use of a harness for

support in treadmill training

lead to greater improvements

in gait symmetry and

endurance than no support?

Meth

ods

Participants :• Recruited through fliers/advertising

• 21-70 yrs• Unilateral TTA,TFA or knee disartic.

• >1 yr• Ability to walk with prosthesis >6mths

• Tolerate mod intensity exercise

• No current gait physio• Exclusion• Cardiac or pulmonary disease limiting

exercise• Discomfort which restricts ability to

walk• Active wounds on either leg

Inte

rventi

on

• Assigned to Treadmill training with or without harness support

• 12 sessions (3x / wk for 4 wks)

• 30 mins walking on treadmill

• Started at comfortable unsupported walking speed

• Supported group started training with 30% body weight supported

• Support reduced by 5% increments with full weight baring at treatment session 10

• Speed increased in 0.1mph increments as tol

• Assessed at baseline, 1 and 4 wks after training

• 6min walk test, TUG, ABC (self reported balance measure)

• 8 participants (7men) with unilateral

TTA due to trauma

• 4 to each grp

• For all participants the distance walked

in 6MWT and time to complete TUG

improved

• Mode of training found no difference

• 6MWT increased by 25% at 1wk post

(89.6m )and 32% at 4wks post

Rx(112.4m)

• TUG improved by 13% at 1 and 4 wks

post Rx

• No change in ABC scores

Resu

lts

Dis

cuss

ion

Evidence that treadmill

training helps increase

velocity and endurance of

walking in 1+ years post

amputation and benefits

are maintained a month

post exercise periodSmall study numbers, only

traumatic- may not be

generalisable to all LL

amputees ? Same benefit for acute

rehab phase

Concl

usi

on Is there a test

we as a group could all agree to perform on discharge?