Introduction
In 2005, it was estimated that one in 190 people living in America
were living with a loss of a limb, totaling 1.6 million Americans
(1). Dysvascular disease, trauma and cancer were the three primary
reasons that the amputations occurred (1). Of the 1.6 million
Americans with amputations, 1,027,000 had a lower limb amputation
(1). The article by Graham et. all estimates that by 2050, the
number of amputations will more than double to 3.6 million (1).
Amputations due to dysvascular reasons will grow from less than one
million to 2.3 million (1).
Fear of falling (FOF), a topic highly studied in the elderly
population, is now being studied more prevalently in people who have
had an amputation. Depending on the author, fear of falling has many
definitions including "a loss of a patient's confidence in his or
her balance abilities", a general concept that describes a low
fall-related efficacy (low confidence at avoiding falls) and being
afraid of falling, and "being worried about falling (2)." FOF has
been shown in the literature to be associated with a poorer health
status, functional decline, increase in activity restriction,
decreased quality of life, increased frailty, depression, and a
recent experience with falls, and therefore is an important issue to
address in all patients with FOF (2, 3). A key point from the study
performed by Vellas was that fear of falling should be addressed in
rehabilitation programs (4).
It has been shown in the current literature that the number of falls
in people who have below knee amputations is high. In a study by
Miller, 52.4% of people with amputations have reported falling in
the past 12 months, of which 55% reported a FOF. Of the people with
amputations, 43% of those who did not fall reported a FOF. In total,
49.2% subjects had a fear of falling and 76.2% of these people
avoided activities as a result of their fear. It is important to be
aware of FOF in the amputee population, and also to know the best
interventions to help increase confidence in order to best treat
this population. To date, little research has been performed on how
physical therapy interventions can affect confidence levels in
people who have had an amputation (5).
Current research shows conflicting results on whether strength
training does lead to improvements in balance in older adults. One
study by Chandler did not see balance improvements in
community-dwelling elders after a home exercise program (HEP)
consisting of strength training (6). However, other studies have
described positive effects in both balance and functional abilities
in older adults after a strength program (7, 8, 9). Elderly
participants in an 8 week weight training program focused on the
lower extremities noted that they were less afraid of falling, more
confident in leaving their homes, and more active (10). Currently
there is no literature investigating whether muscle strength gains
affect balance in a person who has had a lower extremity amputation.
Likewise, research addressing the best interventions that affect FOF
in the patient population that has had an amputation is scarce to
absent. The purpose of this case report is to describe the outcomes
of perceived fear of falling after a 5 week core and hip musculature
strengthening and gait training intervention in a 79 year old male
with a trans-tibial amputation.
Case Description
The patient was a 79 year old retired African American male who had
a left (L) below knee amputation (BKA) performed in April 2010 due
to vascular reasons. The patient had a lengthy hospital stay of
approximately two months after his amputation. He had to have a
revision of the residual limb secondary to infection in October of
2010. After his revision, he received therapy from a sub-acute
rehabilitation facility for strengthening, increasing activity
tolerance, transfer and gait training. November of 2010 he was
admitted to the hospital and had a right (R) lower extremity (LE)
popliteal bypass. Once receiving his prosthesis in January of 2011,
he presented to the same sub-acute rehabilitation facility as an
outpatient to receive therapy. His past medical history consisted of
Diabetes Mellitus Type II, Coronary Artery Disease, and a Deep Vein
Thrombosis. The patient reported no complaints of pain anywhere in
his body. The review of systems showed normal findings for all
systems.
The patient’s main mode of mobility was a power wheelchair and he
relied on the services of a transport company for community
integration. Currently the patient was residing at a hotel until he
was able to safely return to his single story home on a farm with
four steps to enter and no railing, where he planned to live with
his girlfriend. He also owned a walker but did not use it on a
regular basis. He was independent in transfers in and out of bed and
from his wheelchair to other surfaces, use of his power wheelchair,
and activities of daily living (ADLs). He was communicating with his
prosthetist regularly for concerns about his prosthesis fit. At this
point, he was not having therapy or treatment of any other kind and
therefore sought the care of a physical therapist for prosthetic
training. The patient’s goals for therapy were to walk without
needing an assistive device (AD) and to return to his home as soon
as possible.
The Falls Efficacy Scale (FES) is a ten item scale that asks the
patient to rate how confident they are in completing ADLs. A score
of one is very confident and a ten is not confident at all. The
lower the score, the smaller fear the patient has of falling. A
score of 70 or greater indicates that the person has a FOF. The
patient's initial score was a 24 (table 1). The Activities-specific
Balance Confidence Scale (ABC Scale) is a self-perceived scale
asking the patient to rate self-confidence in performing 16 tasks
(table 2). It has been shown to have reliability, with Cronbach
alpha for internal consistency of 0.93, and strong support for
validity for people who have had a lower limb amputation (11). His
initial score, found by adding his ratings from the 16 tasks and
dividing it by 16, was a 26.3 placing him in the low level of
functioning category. The patient rated himself with the use of his
prosthesis. This patient was chosen for this case report because of
the interest of the author in the treatment of patients with
amputations and the lack of literature on best interventions to
decrease fear of falling in this population.
Clinical Impression #1
This patient presented with a long and complicated medical history
related to his amputation. Since he does not have pain complaints,
his main concerns are related to his function as his goals are to
ambulate without an AD and to return home. His ABC scale scores
indicate that he is at a low level of functioning. At this point in
the examination, due to his frequent surgeries and hospitalizations
throughout the past year as well as his power wheelchair as his
primary mode of transportation, decreased muscle strength due to
atrophy is a likely impairment that may limit his ability in the
future to ambulate using his prosthesis without compensations in his
gait. Therefore extensive manual muscle testing in the patient’s
abdominals and throughout his bilateral (B) LE will be performed.
Due to the common balance impairment in this population, this will
also be something that is assessed during the objective portion of
the examination to help determine if FOF results are affected by
this impairment. As of this point in the examination, this patient
is a likely candidate for needing a core and LE strengthening
program in order to successfully ambulate with his prosthesis with
minimal gait compensations and to give him more confidence in his
ADLs, functional and community activities.
Examination
The examination began by observing the patient donning and doffing
his prosthesis. This skill is important to assess, as the patient
must apply the prosthesis correctly for even pressure and to prevent
sores from forming. The patient was independent in correctly donning
and doffing his gel liner, ply socks, and prosthesis. His residual
limb shape was conical and had good healing with no redness or sores
noted. When asked, the patient responded that he frequently checked
for any redness or sores between prosthesis usages. At this point,
he needed to wear 8 ply socks with the prosthesis and planned on
calling his prothetist for a re-fitting as his prosthesis was still
loose at times.
Goniometry was not performed, as per visual analysis his active
range of motion (ROM) was within functional limits for ambulation
and ADLs and equal bilaterally in his LE. Since a hand held
dynamometer was unavailable at this clinic, manual muscle testing
was performed. The patient had full active ROM in gravity minimized
positions. The patient had decreased muscle force production
bilaterally in his hip extensors, abductors and abdominals as noted
by his inability to actively move through the full ROM against
gravity (Table 3).
Sensation to light touch, assessed by performing a soft sweeping
motion on the skin of the face and then comparing the sensation to
the dermatomes of the LE, was intact on the right lower extremity
dermatomes L3-S1 and left (L) LE residual limb. It was slightly
impaired near the scar on the residual limb. Light touch is
important to note for this patient due to the effects of diabetes
distally on sensation. Sensation on the right leg is important to
note since he does not have a left ankle joint with functioning
sensory receptors or proprioception to help communicate where his
body is in space. If this patient had decreased or lack of sensation
on his right foot, his functional activities may be severely
impacted. Assessing sensation in the residual limb is important to
know if he can feel for even pressure distribution when wearing the
prosthesis.
Balance is important to test in a person with an amputation due to
distorted body schema and decreased number of joint and sensory
receptors available to communicate where the body is in space. This
patient has independent sitting balance without the use of his upper
extremities (UE). The patient had fair tolerance to light
perturbations in standing without UE support, and good tolerance
with UE support.
The patient was able to perform bed mobility and transfers supine to
and from sit independently. Contact guard assist (CGA) due to
unsteadiness for sit to/from stand and pivot transfers was needed.
Finally, gait observation with a two wheeled walker was performed.
CGA was provided due to instability. While ambulating with a two
wheeled walker the patient demonstrated a decreased weight shift to
the left, circumduction and external rotation of the L LE during
swing phase, increased stance time on right and increased step
length on the left, decreased L LE clearance, and forward and flexed
posture at the trunk.
Clinical Impression #2
The patient was independent with many of his ADLs, except for
ambulation and transfers. Based on the objective portion of the
examination, his gait pattern showed much compensation. Decreased
stance time on the left affects step length on the right and can
lead to a significantly altered gait pattern. The patient’s manual
muscle testing scores also indicated weakness in his abdominal
musculature, bilateral gluteal (maximus and medius) and hip abductor
muscles. Weakness in these muscles could be a large contributor to
the patient’s gait pattern. As the patient could only withstand
light perturbations in unsupported stance, his balance is also an
impairment that is affecting his ability to safety complete ADLs as
well as his confidence. After performing the subjective and
objective portion of the examination, this patient would benefit
from a strengthening program focusing on his abdominals and hip
musculature, specifically his gluteal and abductor muscles in order
to have sufficient strength and stability for single leg stance in
order to progress from a two wheeled walker to no AD. Gait training
with his prosthesis will also be a major focus of treatment.
Intervention
The patient’s frequency and duration was established at two times a
week for eight weeks. Given the patient’s long history with his
amputation, the need for a prosthesis re-fitting during this time,
and the high expectation of the patient to walk without an AD, eight
weeks was deemed as an appropriate time frame to reach these goals.
Interventions consisted of gait and prosthesis training, progressive
resistive exercises, transfer training, cardiovascular exercise, and
dynamic standing activities for balance and strength. Please see
tables five and six for weekly therapy interventions and operational
definitions.
Gait Training
Initially sessions began with gait training for approximately 15-25
minutes using the LE prosthesis and an AD based on the patient’s
daily presentation. If gait compensations were present, the parallel
bars were utilized. For example, if the patient was demonstrating
decreased single leg stance on the left leg, use of the parallel
bars for slow and controlled stepping with the right leg was
repetitively practiced. To correct decreased trunk rotation during
stepping, the SPTs hands were placed on the patients hips to help
facilitate the rotation. This was a normal practice throughout gait
training to continue to improve and normalize the patient’s gait
pattern.
Progressive Resistive Exercises
The patient presented with decreased muscle force production in
bilateral hip flexion, abduction (ABD), and extension and abdominals
per manual muscle testing. These outcomes may also contribute to the
patient’s self-rated high fear of falling grades. Single leg stance
(SLS) with opposite hip extension was performed at the parallel
bars. This exercise was prescribed to not only encourage gluteal
strengthening but for upright posture during stance and to increase
the periods of SLS on the prosthesis for a more equal step length
during gait. Side lying (SL) with hip ABD and clamshells, supine
abdominal isometric bracing, and bridging for hip extension
strengthening in weight bearing were prescribed to target weak
muscles in order to have a more normalized and steady gait pattern.
Changes in muscle strength for bridging and SL hip ABD were
monitored by ROM measurements as the patient was not able to perform
the exercises against gravity throughout the full ROM (see table 4
for goniometric measurements). Initially, due to time constraints in
the clinic these exercises were performed 10 times for 2 sets. In
order to have increased time for other activities in the clinic,
these exercises were prescribed for the patient’s home exercise
program (HEP). The exercises continued to be performed for at least
one set in the clinic, so as to monitor correct performance without
compensations.
Transfer Training
Sit to stand transfer training for body alignment and hand placement
was performed in the first couple of sessions to decrease fall risk
due to the hasty and unsafe technique of the patient. The patient
demonstrated pivoting when far away from the chair and poor
eccentric control. Verbal cues to turn completely in order to align
body with chair, back all the way to the chair, and reach back for
the chair were given to ensure that the patient had knowledge of the
chair’s location prior to sitting down.
Cardiovascular Training
Since it requires larger energy expenditure for the amputee to
perform activities compared to the typical person, the NuStep was
utilized for cardiovascular training, increasing activity tolerance,
performing a continuous B LE stepping motion similar to gait,
encouraging trunk rotation with UE movement opposite of LE, and LE
strengthening. Time increased from 10 to 15 minutes and from
resistance level 5 to level 7 over therapy sessions. Resistance was
changed based on patient perception of ease.
Dynamic standing activities for strength, weight shifting, and
balance
Varying exercises focusing on abdominal muscle strengthening were
performed at each session when time allowed. These exercises were
either performed on an unstable surface such as a theraball or in
stance to further challenge the activity. Stance activities also
allowed for practice in weight shifting and maintaining upright
posture with dynamic UE movements. One of these activities was
performed during most of the sessions. Each of the activities were
challenging for the patient, as he had to focus intently to prevent
LOB, at times needed verbal, manual, and visual cues to perform
exercises correctly, and needed close supervision and/or minimal
assist to prevent LOB.
Home Exercise Program
The original HEP consisted of isometric concentric abdominal
crunches, SL hip ABD, and SLS with opposite hip extension.
Initially, the patient needed frequent verbal and manual cueing to
perform the exercises correctly. For example, during standing hip
extension, the patient was facilitated at the shoulders and pelvis
to prevent forward trunk lean. During isometric concentric abdominal
exercises, the patient was frequently reminded to breathe throughout
the exercise. In sidelying the patient required moderate assist at
the pelvis to prevent a posterior lean, in order to ensure
activation of the abductor muscles versus the hip flexor muscles. SL
clamshells and bridging were added to the program. Per patient
report he was performing the exercises at home but had difficulty
remembering the exercises when asked to perform them in the clinic
without prompting. The patient also needed reminders at almost every
session on how to prevent compensations and perform the exercise
correctly.
Outcomes
Functionally, the patient improved in his ability to ambulate from a
two wheeled walker to a cane, although he did continue to show an
uneven stride length at times with a less stable AD. He ambulated
with improved upright posture and weight shift to the left,
increased trunk rotation and cadence without loss of balance, and
decreased circumduction of L LE during swing phase. He was able to
perform sit to stand transfers with increased safety and improved
eccentric control. Pre-intervention, the patient had fair standing
balance without UE support with minimal perturbations. Post
intervention, the patient was able to participate in dynamic UE
activities with weight shift and maintain his balance against
moderate perturbations.
Throughout the five weeks, the patient demonstrated increases in
abdominal strength as seen in manual muscle testing grades from a
2/5 to a 3/5. Although the patient's strength did not change enough
to reflect a difference in manual muscle testing grades for hip ABD
and extension, ROM values for exercises performed against gravity
indicate that his strength increased in his bilateral hip extensors
and abductors. Increases in strength were most evident through the
patient’s improved gait pattern.
Results from the ABC Scale showed that from the first to second
administration the patient’s confidence in 7 out of 16 activities
actually decreased. His confidence only improved in walking up a
ramp. From the second to third administration, his confidence
improved in 9 activities. Self-ratings from the first administration
to the last administration show that the patient had increased
confidence in the following five activities: walking up and down
stairs and bending over to pick a slipper up from the floor (0 to
50%), getting into or out of a car and walking across mall parking
lot (0 to 75%), and walking up or down a ramp (10 to 75%). The patient’s total
score increased from a 26.3 to a 44.1. Although his total score did
increase, both values indicate a low level of functioning.
According to patient self-ratings of confidence, the patient's
confidence gradually and progressively decreased for the FES
activities throughout the therapy sessions. From the first to last
administration confidence in the following activities decreased:
taking a bath or shower and walking around the house (3 to 5)
preparing meals and getting dressed and undressed (2 to 5), and
getting on and off toilet (2 to 4). The patient’s total score increased from a
23 to a 34, with both values reflecting that the patient does not
have a fear of falling, but that his confidence in performing the
activities decreased.
Discussion
Since a large number of patients with amputation report falling and
a fear of falling (5), it is important for physical therapists working
with this type of population to be aware of the treatments that make
the greatest impact on decreasing these complications. There have
been multiple studies that have shown that strength training does
lead to balance improvements in the elderly (7, 8, 9). This indicates
that a program focusing on strengthening may also be beneficial for
balance outcomes in a patient with an amputation, which may also
lead to increased confidence in performing ADLs without fear of
falling. To this author’s knowledge, there is limited available
literature on physical therapy treatments and their impact on fear
of falling scores in patients’ with an amputation. This case report
aimed to look at a strength program for the core and LE and describe
the outcomes on the ABC Scale and FES on balance confidence.
This patient demonstrated an improved gait pattern with the use of a
less restrictive assistive device, an increase in balance and
strength, and an increase in his functioning level in completion of
ADLs on the Activities specific Balance Confidence Scale after a
five week intervention consisting of gait training and strengthening
activities. Improvement in these functional activities may be due to
increased repetition and practice while in PT, but also may be
related to increases in abdominal and hip musculature strength and
balance. These functional gains not only allow the patient to have
increased independence but they allow for safer (by decreasing fall
risk) and more efficient performance of ADLs. Surprisingly, he
reported a decrease in confidence according to ratings on the Falls
Efficacy Scale over the five week intervention.
Overall, the patient’s self-reported scores did increase for the ABC
Scale when comparing the initial score to the end score, showing an
increase in confidence. However, it is interesting to note that
between the first and second self-ratings his confidence decreased
in performing 7 out of the 16 activities, with his total score
falling from a 26.3% to a 20.9%. With therapy services being
provided on a bi-weekly basis, the most likely expected outcome
would be that the patient’s confidence would increase as he became
stronger and more mobile. A hypothesis for this occurrence is that
since the patient was just beginning to become more mobile, it is
possible that he was noticing his unsteadiness or increased
difficulty with performing activities, leading to a decrease in his
confidence. Potentially with continued therapy and more repetition
of these activities, along with increased strength and balance, he
became more confident, explaining the rise in scores during the
third administration of the ABC Scale.
Another thought-provoking observation that arose when analyzing the
FES and ABC scale weekly scores is that the results were
contradictory. The FES results do not follow in a similar pattern to
the ABC Scale scores. Initial scores from the self-ranking on the
ABC Scale indicate a low level of functioning while self-rankings
from the FES scale indicate that the patient does not have a fear of
falling. The ABC Scale self-ranking of confidence showed a decline
and then a rise in reported confidence signifying that overall an
increase in confidence in performing ADLs occurred, while the FES
confidence ratings gradually increased, indicating that fear of
falling increased. A possible explanation may have been the
difference in rating for the two scales. The FES scale represents a
higher confidence level with a lower self-ranking, while the ABC
scale shows high confidence to be represented with a higher
self-ranking. Since the scales were administered directly after one
another, the patient may have been confused with the ranking system.
The scale questions are also phrased differently. The FES scale has
the patient report on how confident they feel in performing the
activity, while the ABC Scale has the patient rate their confidence
in the ability to not lose their balance or become unsteady while
performing the activity. Although these are similar ways of
presenting the same question, the phrasing may have caused a
different thought process in the patient and therefore a different
self- ranking. Since the scales were presented to the patient in a
subsequent manner, results from one scale may have affected the
other. Due to the contradictory results of the FES and ABC Scales,
it is difficult to determine if fear of falling was actually
influenced post intervention.
A limitation of this study was the manner in which the scales were
administered. Carryover effects from the first scale may have
affected the way that the patient ranked his confidence on the
second scale. Although the focus of this study was to describe
outcomes on perceived fear of falling changes throughout an
intervention focused on strengthening, another limitation is the
lack of objective data on whether improvements occurred in reliable
outcome measures. Due to the conflicting results of the scales, it
would have been beneficial to have pre and post-intervention scores
for outcome measures such as the Timed Up and Go Test or the Berg
Balance test to see if confidence changes had any correlation to
objective measurement changes. Another limitation of this study was
that pre-manual muscle testing scores were executed by the therapist
and post- manual muscle testing was performed by the student
physical therapist. Although there have been many studies performed
that show good inter-rate reliability for manual muscle testing,
inter-rater differences between testers may not reflect changes in
muscle strength as well as if the same tester had taken pre and post
measurements.
Due to the scant amount of literature on patients with amputations,
there are multiple avenues for future research in this area. One
suggestion is to perform research on the effect of a strengthening
program on fear of falling scores with patients that have other
types of amputations (ie: upper extremity, trans-femoral, Lisfranc).
Research on how to best assess and address fear of falling in a
patient with an amputation would be beneficial knowledge to the
professional community and the patient. In order to better assist
practitioners that are treating these types of patients, the best
interventions to decrease fear of falling should be researched.
Finally, in order to help with prognosis and plan of care, treatment
duration based on severity of fear of falling should be explored.
Conclusion
A 79 year old patient with a trans-tibial amputation exhibited an
improved gait pattern, use of a less resistive assistive device
during ambulation, increased balance, and increased strength in his
abdominal and bilateral hip extensors and abductors after a 5 week
intervention focusing on gait training and strengthening of the core
and hip musculature. According to the Activities Specific Balance
Scale, the patient had an increase in confidence that he would not
become unsteady or lose his balance when performing ADLs. In
contrast, the Falls Efficacy Scale showed the patient to have an
increase in fear of falling when performing ADLs.
Last revised: November 22, 2011
by Emily Husch, DPT
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