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Review of Balance /Falls and Recent studies in Amputee Rehab. By Nerissa Grebert Westmead Hospital.

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Presentation on theme: "Review of Balance /Falls and Recent studies in Amputee Rehab. By Nerissa Grebert Westmead Hospital."— Presentation transcript:

1 Review of Balance /Falls and Recent studies in Amputee Rehab. By Nerissa Grebert Westmead Hospital

2 Falls in Amputee Population Falls pose significant risk 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) 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) 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)

3 Significant injuries post fall % sustain a significant injury post fall including hemorrhage, lacerations, head trauma and fractures.(Pauley; Kulkarni; Miller) Significant injuries post fall % 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. 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. 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. The Berg Balance test has been used in several studies to assess balance but never has been validated for the amputee population.

4 From our last AustPAR meeting: Our most routinely used outcome measures for amputees: 10m walk test 10m walk test 2min walk test 2min walk test 6min walk test 6min walk test TUG test TUG test AMP-PRO AMP-PRO Some discussion on: The use of Berg Balance Test to assess falls risk and improvement in balance 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. 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. Appropriate exercises to perform in an Amputee exercise group to improve balance, health and mobility.

5 Review of 3 articles 1. Study by Major et al, Validity and Reliability of the Berg Balance Scale for Community-Dwelling Persons with Lower-Limb Amputation. 2. Barry Deathe & William C Miller, 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 Harness-Supported Versus Conventional Training for people with Lower-Limb Amputation: A Preliminary Report.

6 New study by Major et al, Validity and Reliability of the Berg Balance Scale for Community-Dwelling Persons with Lower-Limb Amputation

7 Berg Balance Test 14 item scale to measure balance 14 item scale to measure balance Total score out of 56 Total score out of =low falls risk 41-56=low falls risk 21-40= medium falls risk 21-40= medium falls risk 1-20 = high falls risk 1-20 = high falls risk Authors support a cut off score of 45 for Independent safe ambulation in non- amputee population. Authors support a cut off score of 45 for Independent safe ambulation in non- amputee population.

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13 Method Inclusion criteria Unilateral or bilateral lower-limb loss at or proximal to ankle Unilateral or bilateral lower-limb loss at or proximal to ankle Used a prosthesis for ambulation Used a prosthesis for ambulation +\- mobility aid +\- mobility aid Nil UL amputation Nil UL amputation Residual limb in good condition Residual limb in good condition

14 Information collected on: age, age, sex, sex, height, height, mass, mass, number of LLA, number of LLA, amputation level, amputation level, amputation etiology, amputation etiology, time since amputation 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

15 Convergent validity for BBS was evaluated by collection of information on several clinical outcome measures that assess constructs related to balance and mobility. 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: Participants completed: Activities –specific Balance confidence scale (ABC) Activities –specific Balance confidence scale (ABC) – Perceived balance and confidence in 16 ADLs Prosthesis Evaluation Questionnaire –mobility subscale (PEQ-MS) Prosthesis Evaluation Questionnaire –mobility subscale (PEQ-MS) – Mobility ability in ADLs while wearing a prosthesis over last 4wks

16 Frenchay Activities Index (FAI) Frenchay Activities Index (FAI) – Frequency of ADLs over past 3mth and 6mth BBS x2 with different assessors BBS x2 with different assessors The L-Test 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 2min walk test

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

18 Results Results 30 participants 30 participants Correlations between the BBS and other measures were stat sig. Correlations between the BBS and other measures were stat sig. 10% achieved max points on BBS 10% achieved max points on BBS 70% achieved >50 – skewed distribution to higher scores 70% achieved >50 – skewed distribution to higher scores

19 BBS -high inter-relater reliability and internal consistency BBS -high inter-relater reliability and internal consistency Performance tests showed stronger relationships with the BBS than questionnaires Performance tests showed stronger relationships with the BBS than questionnaires Participants scored worse on the BBS if classified as: 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.

20 Differences minimal and not sig. b/w retrospective fallers- unable to ID LLA with greater risk of falling. 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. 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. Unknown whether BBS can identify changes in balance performance resulting from therapeutic interventions.

21 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. Deathe & Miller, 2005.

22 The L-test Designed in Canada to assess lower limb inpatients and outpatients mobility. Designed in Canada to assess lower limb inpatients and outpatients mobility. Wanted a test which was easy to administer in a clinic setting with minimal free space and time, but didnt have the ceiling effects of TUG test when used with younger patients. Wanted a test which was easy to administer in a clinic setting with minimal free space and time, but didnt have the ceiling effects of TUG test when used with younger patients. Combination of TUG, 10m, and 2min tests. Combination of TUG, 10m, and 2min tests. Retains rise from chair and turns to L and R. 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) Stand up, walk 3m, turn 90°, walk 7m, turn 180°, return along same path (L shape) Study to assess reliability and validity. Study to assess reliability and validity.

23 MethodInclusion 102 consecutive subjects attending amputee clinic 102 consecutive subjects attending amputee clinic 19yrs +, unilateral TT or TF amp 19yrs +, unilateral TT or TF amp Prosthesis minimum 6mths Prosthesis minimum 6mthsExclusion Unable to speak/read English or follow instructions Unable to speak/read English or follow instructions Did not complete all tests Did not complete all tests Medical or prosthetic problem which prevented participation Medical or prosthetic problem which prevented participation

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

25 Results 93 subjects completed all preliminary tests 93 subjects completed all preliminary tests 27 subjects returned for retesting 27 subjects returned for retesting Mean time for L test 32.6 sec (TT=29.5s, TF=41.7) Mean time for L test 32.6 sec (TT=29.5s, TF=41.7) Excellent Intra-rater reliability and Inter- rater reliability proven Excellent Intra-rater reliability and Inter- rater reliability proven Validity-Correlated well with other measures Validity-Correlated well with other measures Highest correlations with other walk tests. Followed by FAI, ABC, PEQ-MS. Highest correlations with other walk tests. Followed by FAI, ABC, PEQ-MS. Higher mean times shown for subjects who Higher mean times shown for subjects who 1. 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)

26 Results cont. 10 subjects had ceiling effect for TUG and L Test 10 subjects had ceiling effect for TUG and L Test 14 subjects had ceiling effect for TUG but not 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) 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 68% sure a true change occurred with 2.6 sec shift 95% sure with a 6.2 sec shift 95% sure with a 6.2 sec shift

27 Lamberg et al Harness-Supported Versus Conventional Training for people with Lower-Limb Amputation: A Preliminary Report. Research questions 1. 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?

28 Methods Participants : Recruited through fliers/advertising Recruited through fliers/advertising yrs yrs Unilateral TTA,TFA or knee disartic. Unilateral TTA,TFA or knee disartic. >1 yr >1 yr Ability to walk with prosthesis >6mths Ability to walk with prosthesis >6mths Tolerate mod intensity exercise Tolerate mod intensity exercise No current gait physio No current gait physio Exclusion Exclusion Cardiac or pulmonary disease limiting exercise Cardiac or pulmonary disease limiting exercise Discomfort which restricts ability to walk Discomfort which restricts ability to walk Active wounds on either leg Active wounds on either leg

29 Intervention Assigned to Treadmill training with or without harness support Assigned to Treadmill training with or without harness support 12 sessions (3x / wk for 4 wks) 12 sessions (3x / wk for 4 wks) 30 mins walking on treadmill 30 mins walking on treadmill Started at comfortable unsupported walking speed Started at comfortable unsupported walking speed Supported group started training with 30% body weight supported Supported group started training with 30% body weight supported Support reduced by 5% increments with full weight baring at treatment session 10 Support reduced by 5% increments with full weight baring at treatment session 10 Speed increased in 0.1mph increments as tol Speed increased in 0.1mph increments as tol Assessed at baseline, 1 and 4 wks after training Assessed at baseline, 1 and 4 wks after training 6min walk test, TUG, ABC (self reported balance measure) 6min walk test, TUG, ABC (self reported balance measure)

30 8 participants (7men) with unilateral TTA due to trauma 8 participants (7men) with unilateral TTA due to trauma 4 to each grp 4 to each grp For all participants the distance walked in 6MWT and time to complete TUG improved For all participants the distance walked in 6MWT and time to complete TUG improved Mode of training found no difference Mode of training found no difference 6MWT increased by 25% at 1wk post (89.6m )and 32% at 4wks post Rx(112.4m) 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 TUG improved by 13% at 1 and 4 wks post Rx No change in ABC scores No change in ABC scores Results

31 Discussion Evidence that treadmill training helps increase velocity and endurance of walking in 1+ years post amputation and benefits are maintained a month post exercise period Evidence that treadmill training helps increase velocity and endurance of walking in 1+ years post amputation and benefits are maintained a month post exercise period Small study numbers, only traumatic- may not be generalisable to all LL amputees Small study numbers, only traumatic- may not be generalisable to all LL amputees ? Same benefit for acute rehab phase ? Same benefit for acute rehab phase

32 Conclusion Is there a test we as a group could all agree to perform on discharge? Is there a test we as a group could all agree to perform on discharge?


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