Transcript Review of Balance /Falls and new studies in Amputee Rehab.

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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)
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Significant injuries post fall. 20-57% sustain a
significant injury post fall including hemorrhage,
lacerations, head trauma and fractures.(Pauley;
Kulkarni; Miller)
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49% of community dwellers with LLA report fear of
falling, resulting in activity avoidance.
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Need to identify people who have lower balance
and therefore are at high risk of falling.
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The Berg Balance test has been used in several
studies to assess balance but never has been
validated for the amputee population.
Our most routinely used outcome
measures for amputees:
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10m walk test
2min walk test
6min walk test
TUG test
AMP-PRO
Some discussion on:
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The use of Berg Balance Test to assess falls
risk and improvement in balance
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Whether the ‘L-test’ would be a more
appropriate assessment measure for
Amputees.
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Appropriate exercises to perform in an
Amputee exercise group to improve
balance, health and mobility.
New study by Major et al, 2013.
‘Validity and Reliability of the
Berg Balance Scale for
Community-Dwelling Persons
with Lower-Limb Amputation’
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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 nonamputee population.
Method
Inclusion 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:
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• age,
• sex,
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• height,
• mass,
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• number of LLA,
• amputation level,
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• 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
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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:
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Activities –specific Balance confidence scale
(ABC)
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Perceived balance and confidence in 16 ADLs
Prosthesis Evaluation Questionnaire –mobility
subscale (PEQ-MS)
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Mobility ability in ADLs while wearing a prosthesis
over last 4wks
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Frenchay Activities Index (FAI)
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Frequency of ADLs over past 3mth and 6mth
BBS x2 with different assessors
The L-Test
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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
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BBS and other measures
were stat sig.
10% achieved max points
on BBS
70% achieved >50 –
skewed distribution to
higher scores
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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.
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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.
Method
Inclusion
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102 consecutive subjects attending
amputee clinic
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19yrs +, unilateral TT or TF amp
Prosthesis minimum 6mths
Exclusion
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Unable to speak/read English or follow
instructions
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Did not complete all tests
Medical or prosthetic problem which
prevented participation
Procedure
1.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
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TUG, 10m walk test, the L-Test, 2 min walk test
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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)