BALANCE AND POSTURAL ADJUSTMENTS

1. BALANCE AND POSTURAL ADJUSTMENTS Implications for Amputee Rehabilitation NSWPAR, March 2007

2. SEARCH STRATEGY • Searched Medline, Cinahl, Embase • Keywords • amputee (816) • rehabilitation (96126) • posture • balance • Limit to human, english = 17

3. DIFFERENCES BETWEEN AMPUTEES AND NORMALS • Loss of sensory feedback • Loss of proprioception • Altered postural sway (Buckley et al, 2002; Miller and Deathe, 2004)

4. DIFFERENCES BETWEEN AMPUTEES AND NORMALS • Biomechanical differences • GAIT • Heel contact – hip muscle activity in abductors, eccentric knee extensors (shock absorption) • Midstance – dynamic stability maintained by hip abductors • Push off – hip flexor activity for propulsion • Swing – normal muscle activity (Sadeghi et al, 2001) • BALANCE • ↓ WB’ing on prosthetic side • Greater problems maintaining dynamic balance esp. in the a-p direction • Lack of ‘ankle strategies’ are partially compensated by ‘hip strategies’ • More dependant on vision • More prone to interference from concurrent attention demanding tasks (Buckley et al, 2002)

5. DIFFERENCES BETWEEN AMPUTEES AND NORMALS • STEPS • ↑ time taken to load prosthesis in stance • ↑ peak m-l and a-p CoP and CoM displacements and velocities at heel off and at foot contact • Differences were NOT between AK/BK amputees (Jones et al, 2004) • WEIGHT SHIFTING • ‘hip strategies’ rather than ‘ankle strategies’ in anticipatory postural adjustments (Mouchnino et al, 1998)

6. STATISTICS • 52% of unilateral AKA/BKA’s had a least one fall per year (Miller and Deathe, 2004) • Inpatient rehabilitation • 1 in 5 LL amputees fall • 18% sustaining an injury • Risk factors include age, LOS, comorbidities, cognitive impairment, >2 medications (benzo’s and opiates), bilateral amputation (Pauley et al, 2006) • Multiple falls predicted by: • TUG > 19 seconds • 180 degree turn > 3.7 seconds, > 6 steps • Four Stick Step Test > 24 seconds • Locomotion Capabilities Index < 15 (Dite et al 2007)

7. STATISTICS • Balance confidence related to; • Mobility devices used • Age • Fear of falling • Good perception of health • Automatic walking • Depression NOT Amputation cause or level of amputation?? (Miller and Deathe, 2004)

8. MEASUREMENT OF BALANCE • Activities-specific Balance Score (ABC scale) (Powell and Myers, 1995) • L-Test of Functional mobility (Deathe and Miller, 2005) • Step Test • Berg Balance Scale • Functional Reach • Frenchay Activities Index (FAI) • Prosthetic evaluation questionaire – mobility scale (PEQ-MS) • 4 stick step test

9. EFFICACY OF TRAINING • Matjacic and Burger, 2003 • Pilot study of balance training ‘BalanceReTrainer’ NOT RCT. • 3 outcome measures pre-post training; • Single leg balance on prosthesis • 3 (2.8) sec → 4.3 (4.5) sec, not significant. • TUG • 6.2 (1.9) sec → 5.4 (1.5) sec, not significant • 10m walk time • 5.5 (1.5) sec → 4.5 (0.9) sec, p<0.05 significant

10. EFFICACY OF TRAINING • Geurts et al, 1992, (Netherlands) • Not an RCT, pre-post rehab measures cf. age matched controls • Force platform measures (GRF and CoP) • Eyes open • Partial vision • Eyes closed • Conclusion “…a central reorganization of postural control takes place, in which sensory determinants of motor recovery may play a critical role…” • Isakov et al, 1992 (Israel) • V. similar study, no difference in postural sway eyes open or closed post 3-4 weeks rehab

11. EFFICACY OF TRAINING • Geurts et al, 1991(Netherlands) • Not an RCT, pre-post rehab measures cf. age matched controls • Force platform measures (GRF and CoP) • Concurrent cognitive task • Standing, no cognitive task • Conclusion; “…restoration of automaticity of postural control”

12. IMPLICATIONS FOR AMPUTEE REHABILITATION • Anticipatory postural adjustment strategies are unique for amputees and are task specific • Balance confidence is the biggest predictor for mobility outcomes in amputees – we need to train relevant ADL balance tasks for amputees to re-gain confidence

13. REFERENCES • Buckley JG, O’Driscoll D, Bennett S (2002): ‘ Postural Sway and Active Balance performance in Highly Active Lower-Limb Amputees’ American Journal Physical medicine and Rehabilitation 81(1):13-20. • Dite W, Connor HJ and Curtis HC (2007) Clinical Identification of Multiple Fall Risk After Unilateral Transtibial Amputation. Archives of Physical Medicine Rehabilitation 88: 109-114. • Evans WE, Hayes JP and Vermilion BD (1987): Rehabilitation of the bilateral amputee’ Journal of Vascular Surgery 5(4):589-93. • Geurts ACH, Milder TW, Neinhuis B and Rijken RAJ (1991): Dual-Task assessment of reorganization of posutal control in persons with lower limb amputation’ Archives Physical medicen and rehaibilaton 72, 1059-1064. • Geurts ACH, Milder TW, Nienhuis B and Rijken AJ (1992): ‘Postural reorganization following lower limb Amputation’ Scandinavian Journal of Rehabilitation Medicine 24:83-90. • Hoffman MD, Sheldahl LM, Buley KJ, Sandford PR (1997). Physiological Comparison of Walking among bilateral Above-Knee amputee and Able-bodied subjects and a model to account for the differences in metabolic cost’ Archives Physical medicine and rehabilitation 78, 385-92 • Isakov E, Mizrahi J, Ring H, susak Z and Hakim N (1992): ‘Standing Sway and weight bearing distribution in people with below knee amputations” Archives Physical Medicine and rehabilitation 73:174-178. • Jones SF, Twigg PC, Scally AJ, Buckley JG (2005): ‘The gait initiation process in unilateral lower-limb amputees when stepping up and stepping down to a new level’ Clinical Biomechanics 20(4): 405-13. • Majacic Z and Burger H (2003): ‘Dynamic balance training during standing in people with trans-tibial amputation: a pilot study’ Prosthetics and Orthotics International 27, 214-220. • Millar WC and Deathe AB (2004): ‘A prospective study examining balance confidence among individuals with lower limb amputation’. Disability and Rehabilitation 26:14/15;875-881.

14. Millar WC, Deathe AB, Speechley M., Koval J (2001): The influence of falling, fear of falling, and balance confidence on prosthetic mobility and social activity among individuals with a lower extremity amputation’ Archives of Physical medicine and rehabilitation 82:1238-44. • Mouchnino L, Mille ML, Cincera M, Bardot A, Delarque A, Pedotti A Massion J (1998): ‘ Postural reorganization of weight-shifting in below-knee amputees during leg raising’ Experimental Brain Research 121(2):205-14 • Nadollek H, Brauer S and Isles R (2002) Outcomes after trans-tibial amputation: the relationship between quiet stance ability, strength of hip abductor muscles and gait. Physiotherapy Research International 7(4) 203-214. • Pauley T, Devlin M, Heslin K (2006): ‘Falls Sustained during inpatient Rehabilitation After Lower limb amputation: Prevalence and Predictors’ American Journal Physical medicine and rehabilitation, 85(6):521-532. • Powell L ad Myers A (1995): ‘The Activities-specific Balance confidence (ABC) scale’ Journal of Gerontology, 50: M28-M34. • Sadegi H, Allard P and Dunhaime M (2001): Muscle Power Compensatory Mechanisms in Below-Knee Amputee Gait. American Journal of Physical Medicine 80 (1): 25-32. • Viton JM, Mouchnino L, Mille ML, Cincera M, Delarque A, Pedotti A, Bardot A and Massion J (2000): Equilibrium and movement control strategies in trans-tibial amputees’ Prosthetics and Orthotics International, 24:108-116

15. Questions for panel • Upper limb support – acute and training phases • Core stability training • Balance training v’s mobility training • Measurement of balance in the clinical setting