Feasibility of an Interdisciplinary Intervention to Promote Balance Confidence in Lower-Limb Prosthesis Users: A Case Study

Abstract

Introduction: Low confidence in ones' ability to maintain balance during daily activities is a prevalent issue for lower-limb prosthesis users (LLPUs) that negatively impacts psychosocial function but is not currently addressed in rehabilitation. The purpose of this case study was to demonstrate feasibility of an intervention that combines cognitive behavioral therapy techniques with physical therapy to increase balance confidence, reduce avoidance behaviors, and increase community participation in LLPU. Materials and Methods: A 58-year-old man with a unilateral transtibial amputation completed eight 120-minute intervention session, which included physical therapy in the form of virtual reality active gaming targeting balance and gait adaptability, followed by psychoeducation, cognitive restructuring, and a brief exposure exercise. The intervention was intended to improve balance and gait while addressing beliefs regarding physical abilities and their impact on behavior. All exercises were individually tailored to address real-world, subject-specific distress-inducing situations, identified jointly by a licensed physical therapist and behavioral counselor that were present throughout all intervention sessions. The primary outcome, balance confidence, was quantified before, during, immediately after, and 1 month after completion of the intervention. Additional measures of physical function and community participation were also assessed. Results: Objective balance measures (Berg Balance Scale) improved by 9 points from baseline to follow-up, and balance confidence improved from 48.5% at baseline to 91.9% at 1-month follow-up. Gains in gait self-efficacy and reductions in fear-avoidance behavior mirrored this change. Conclusions: This case study demonstrates that a multicomponent intervention is feasible and may provide a positive and helpful experience for LLPU to meaningfully improve balance confidence and reduce avoidance behavior. (

Key Modifiable Factors in Community Participation Among Adults With Lower Limb Amputation

“…27 After LLA, evidence is limited, but one case study suggests improvement in balance confidence with a multicomponent intervention including exercise, virtual realitybased activities, and cognitive behavioral therapy. 28 Prosthesis use, per the Houghton Scale, was a significant predictor of community participation after LLA. Hence, individuals with greater prosthesis utilization may be anticipated to participate in community activities to a greater extent than peers with limited prosthesis utilization.…”

“…More recently virtual reality has also been used to target balance confidence 27 . After LLA, evidence is limited, but one case study suggests improvement in balance confidence with a multicomponent intervention including exercise, virtual reality–based activities, and cognitive behavioral therapy 28 …”

Validating a fear‐of‐falling–related activity avoidance scale in lower limb prosthesis users

“…Information on FoFrelated activity avoidance may address the holistic needs of the prosthetics patient by informing targeted cognitive and physical therapies to minimize these behaviors and increase prosthesis use. 46,47 Although LLPUs who endorse FoF-related activity avoidance have significantly higher mSAFE scores than those who do not endorse these behaviors, the degree of avoidance cannot be determined from a simple yes/no question. For example, in the highest two levels of FoF where all participants endorsed activity avoidance, mSAFE scores ranged from 22 to 45 (on the 51 point scale; Figure 2), supporting the need for a validated continuous scale.…”

“…Although lower limb prosthetics practice in the United States is reasonably focused on performance outcomes and their relationship with functional mobility, psychological factors such as FoF that can meaningfully contribute to long‐term rehabilitation outcomes are often overlooked. Information on FoF‐related activity avoidance may address the holistic needs of the prosthetics patient by informing targeted cognitive and physical therapies to minimize these behaviors and increase prosthesis use 46,47 …”