Impact of a Four-Session Physical Therapy Program Emphasizing Manual Therapy and Exercise on the Balance and Prosthetic Walking Ability of People with Lower-Limb Amputation: A Pilot Study

Abstract

Purpose: No consensus exists regarding best practice for prosthetic rehabilitation programs after unilateral lower-limb amputation. A program integrating manual therapy with exercise for people using lower-limb prostheses has not been systematically investigated. The objectives of this pilot study were to determine whether a four-session physical therapy program of manual therapy, exercise, and functional training would (1) be feasible for people with lower-limb amputation and (2) produce medium to large effect size changes in balance and walking ability and self-reported prosthetic function. Methods: Five subjects were recruited for this pretest-posttest design pilot study. Outcome measures included self-report scales (Houghton Scale, Prosthetics Evaluation Questionnaire, fear of falling, and Activities-Specific Balance Confidence) and clinical performance assessments: Berg Balance Scale, 2-minute walk test, and timed up and go test. One week after the four-session manual therapy, exercise, and functional training program concluded, measures were reassessed. Effect size d and Wilcoxon P values were calculated. Results: Five subjects (average age, 54.0 years), with unilateral amputations of mixed etiology and level, completed the study without adverse event. Berg Balance Scale (d = 1.7, p < 0.05), timed up and go (d = 1.05, p > 0.05), and 2-minute walk test (d = 1.18, p < 0.05) had large effect size changes. Conclusions: A four-session program of manual therapy, exercise, and functional training proved feasible and increased balance and walking ability in people with lower-limb amputation. Controlled research to determine the effects of manual therapy and exercise in this population appears warranted. (J Prosthet Orthot. 2016;28:95-100.) KEY INDEXING TERMS:Berg balance scale, exercise, functional mobility, gait, limb loss, lower-limb, manual therapies, prosthesis, 2-minute walk test T he prevalence of people with amputations is expected to more than double to 3.6 million by 2050, with 40% having had major lower-limb loss. 1 After lower-limb amputation, a multitude of individual and clinical factors can impact community mobility and participation outcomes among users of prostheses. 2 In a review of 48 studies, balance impairment was identified as the most consistent clinical finding associated with decreased prosthetic function. 3 Gait dysfunction persists, with approximately half not achieving a satisfactory level of prosthetic use even after multiple years. 4,5 As hospital lengths of stay have decreased for individuals after amputations, 6 more prosthetic gait training occurs in outpatient settings. A recent systematic review found that few detailed outpatient rehabilitation programs for users of lower-limb prostheses have been researched. 7 Although no best practice consensus approach was determined, rehabilitation programs ranging from specific exercises, balance training, resisted gait training, and indoor and outdoor functional walking have been shown to improve gait performance as assessed by gait speed. 7 ...

Considering passive mechanical properties and patient user motor performance in lower limb prosthesis design optimization to enhance rehabilitation outcomes

“…Prior studies have proposed general training recommendations to allow the user to explore and engage the functional capabilities of themselves and the prosthesis 105, 131–134 . A review on therapeutic interventions to improve prosthetic gait performance identified five categories: supervised walking, specific muscle strengthening, balance training, (part-to-whole) gait training, and functional mobility training 132 .…”

Quantitative methods used to evaluate balance, postural control, and the fear of falling in lower limb prosthesis users: A systematic review

“…Looking at the protocols and tests, the most commonly found was the Berg Balance Scale, or selected items of the Berg Balance Scale (Figure 2). 14,31,73,80-82,93,94,103,107,118-120,138-140,144,147-168 Timed Up and Go 76,107,117,144,145,148,149,151,162,163,165,169-180 and Limits of Stability tests 12,13,20,25,30,37,42,46,47,59,71,72,74,83,84,89 were common (Figure 2). One leg stance test appeared with various names in about some studies.…”

“…Studies that explicitly stated limitations or confounders were just over two-thirds of the total (Table 2),. 13,14,19–22,24,28–56,71,74,76,77,80–95,108,109,115–132,140–145,147–165,169–180,182–184,188–191,193–198 The most commonly mentioned limitation was small sample size, 20,22,24,28,29,32,33,35,37,39,40,42,45,47,52,54-57,74,80,82,86,87,89,93,95,109,118,119,121,123,126,129,141,143,145,148,149,154-159,161,164,169,172,183,198 followed by generalizability issues, 14,19-21,34,38,41,42,44,52-56,80,81,87,89,109,127-130,142,148,151,155,156,162,171,175-177,184,188,189,191,193,196 recall bias, 14,148,150,157,171,173,182,184 heterogeneous groups, 29,42,54,89,142,174,176,177 homogenous groups, 21,38,39,44,45,91,164 and convenience samples. 14,161,176,177,196…”

Quantifying the risk of falls and injuries for amputees beyond annual fall rates—A longitudinal cohort analysis based on person-step exposure over time

“…Potential participants were excluded if they could not understand the study description for any reason; had diagnosed medical conditions affecting balance including blindness, vestibular disorders, traumatic brain injury, and hemiplegia; or had medical conditions making exercise dangerous such as uncontrolled hypertension or unstable angina. Planned sample size for the 1-year funding period was 10 participants, based on a past interventional study ( Wong et al, 2016 ), to allow for 50 data collection points.…”