Transcript BALANCE AND POSTURAL ADJUSTMENTS

BALANCE AND
POSTURAL
ADJUSTMENTS
Implications for Amputee Rehabilitation
NSWPAR, March 2007
SEARCH STRATEGY
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Searched Medline, Cinahl, Embase
Keywords
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amputee (816)
rehabilitation (96126)
posture
balance
Limit to human, english = 17
DIFFERENCES BETWEEN
AMPUTEES AND NORMALS
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Loss of sensory feedback
Loss of proprioception
Altered postural sway
(Buckley et al, 2002; Miller and Deathe, 2004)
DIFFERENCES BETWEEN
AMPUTEES AND NORMALS
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Biomechanical differences
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GAIT
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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
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↓ 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)
DIFFERENCES BETWEEN
AMPUTEES AND NORMALS
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STEPS
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↑ 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)
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WEIGHT SHIFTING
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‘hip strategies’ rather than ‘ankle strategies’ in
anticipatory postural adjustments
(Mouchnino et al, 1998)
STATISTICS
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52% of unilateral AKA/BKA’s had a least one fall per year
(Miller and Deathe, 2004)
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Inpatient rehabilitation
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1 in 5 LL amputees fall
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18% sustaining an injury
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Risk factors include age, LOS, comorbidities, cognitive impairment,
>2 medications (benzo’s and opiates), bilateral amputation
(Pauley et al, 2006)
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Multiple falls predicted by:
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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)
STATISTICS
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Balance confidence related to;
1. Mobility devices used
2. Age
3. Fear of falling
 Good perception of health
 Automatic walking
 Depression
NOT Amputation cause or level of amputation??
(Miller and Deathe, 2004)
MEASUREMENT OF BALANCE
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Activities-specific Balance Score (ABC scale)
(Powell and Myers, 1995)
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L-Test of Functional mobility
(Deathe and Miller, 2005)
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Step Test
Berg Balance Scale
Functional Reach
Frenchay Activities Index (FAI)
Prosthetic evaluation questionaire – mobility scale
(PEQ-MS)
4 stick step test
EFFICACY OF TRAINING
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Matjacic and Burger, 2003
Pilot study of balance training ‘BalanceReTrainer’
NOT RCT.
3 outcome measures pre-post training;
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Single leg balance on prosthesis
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TUG
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3 (2.8) sec → 4.3 (4.5) sec, not significant.
6.2 (1.9) sec → 5.4 (1.5) sec, not significant
10m walk time
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5.5 (1.5) sec → 4.5 (0.9) sec, p<0.05 significant
EFFICACY OF TRAINING
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Geurts et al, 1992, (Netherlands)
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Not an RCT, pre-post rehab measures cf. age matched controls
Force platform measures (GRF and CoP)
 Eyes open
 Partial vision
 Eyes closed
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Conclusion
“…a central reorganization of postural control takes place, in which
sensory determinants of motor recovery may play a critical role…”
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Isakov et al, 1992 (Israel)
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V. similar study, no difference in postural sway eyes open or closed post 34 weeks rehab
EFFICACY OF TRAINING
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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”
IMPLICATIONS FOR AMPUTEE
REHABILITATION
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Anticipatory postural adjustment strategies
are unique for amputees and are task specific
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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
REFERENCES
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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 AboveKnee 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.
• 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
Questions for panel
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Upper limb support – acute and training phases
Core stability training
Balance training v’s mobility training
Measurement of balance in the clinical setting