This article was downloaded by: [Institut Za Rehabilitacijo]

On: 15 September 2009

Access details: Access Details: [subscription number 906397631]
Publisher Informa Healthcare
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,
37-41 Mortimer Street, London W1T 3JH, UK

Prosthetics and Orthotics International

Publication details, including instructions for authors and subscription information:
http://www.informaworld.com/smpp/title~content=t714595820

Dynamic balance training during standing in people with trans-tibial amputation:

A pilot study
Z. Matjaci a; H. Burger b
a
Institute for Rehabilitation, Ljubljana, Slovenia b Institute for Rehabilitation, Republic of Slovenia

Online Publication Date: 01 December 2003

To cite this Article Matjaci, Z. and Burger, H.(2003)'Dynamic balance training during standing in people with trans-tibial amputation: A
pilot study',Prosthetics and Orthotics International,27:3,214 — 220
To link to this Article: DOI: 10.1080/03093640308726684
URL: http://dx.doi.org/10.1080/03093640308726684

PLEASE SCROLL DOWN FOR ARTICLE

Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf

This article may be used for research, teaching and private study purposes. Any substantial or
systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or
distribution in any form to anyone is expressly forbidden.

The publisher does not give any warranty express or implied or make any representation that the contents
will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses
should be independently verified with primary sources. The publisher shall not be liable for any loss,
actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly
or indirectly in connection with or arising out of the use of this material.
 Prosthetics and Orthotics International, 2003, 27, 214-220
Dynamic balance training during standing in people with
trans-tibial amputation: a pilot study
Z. MATJA IĆ and H. BURGER
Institute for Rehabilitation, Republic of Slovenia
Abstract
Downloaded By: [Institut Za Rehabilitacijo] At: 07:46 15 September 2009
Falls and fear of falling are significant
problems arising from impaired balancing
abilities that affect people with lower limb
amputation during unassisted transfer
manoeuvres and ambulation. It is important to
develop and evaluate efficient therapeutic
interventions aimed at improving balancing and
coordination skills. A group of 14 persons after
trans-tibial amputation, fitted with trans-tibial
prostheses, were included in a balance-training
programme, consisting of approximately 20
minutes of balance training per day for five
consecutive days on BalanceReTrainer – a novel
balance-training, fall-safe mechanical apparatus.
Before and after the training period three
outcome measures were taken: duration of
standing only on the prosthetic leg, timed up and
go test and 10m walk. Each measurement was
repeated five times and the mean value was used
in the subsequent calculation of mean values and
standard deviations for the group. Before
training the group was able to stand on the
prosthetic leg for 2.98 ± 2.75s, they needed 6.15
± 1.9s for accomplishing timed up and go test
and they needed 5.51 ± 1.5s to cover the distance
of 10m. After the treatment period the values
were 4.3 ± 4.5s, 5.4 ± 1.5s and 4.5 ± 0.9s,
respectively. The results indicate improved
performance in all three measured tasks, thereby
indicating that the applied treatment programme
improves balancing and ambulation abilities in
people after trans-tibial amputation.
All correspondence to be addressed to Dr Zlatko
Matja ić, Institute for Rehabilitation, Republic of
Slovenia, Linhartova 51, SI-1000 Ljubljana Slovenia
Tel: (+ 386) 1 47 58 159 Fax: (+ 386) 1 43 72 070
E-mail: zlatko.matjacic@mail.ir-rs.si
214
Introduction
The ultimate goal of the rehabilitation of
people with lower limb amputations is to regain
functional walking ability, thereby regaining
also functional independence. Essential
components of smooth and energy-efficient
walking are good balancing abilities and
postural control (Geurts et al, 1992; Viton et al,
2000). It is therefore, the objective of post-
prosthesis-fitting therapy to help a person with
lower limb amputation to reorganise the
remaining physiological systems in order to re-
learn to efficiently balance and transfer weight
(Mensch and Ellis, 1986; Esquenazi and
DiGiacomo, 2001). It is very important that a
proper postural control following the loss of
distal proprioceptive sensory and motor systems
is established in such a way that inappropriate
compensation strategies are avoided; e.g.
displacement of centre of gravity by means of
lateral trunk bending instead of utilising hip
abductors.
The conventional therapeutic approach is to
exercise a set of balance training activities
during standing in the parallel bars (Mensch and
Ellis, 1986). The trainee is using the upper limbs
to assist the development of postural control
through balance and step position exercises,
which include antero-posterior weight shifting
with knees and hips extended, lateral weight
shifting, circular pelvic rotations over both legs
with shoulders remaining over the stance
position, raising both arms above the head,
alternate knee flexion and extension. The role of
a therapist is to guide the trainee and monitor
proper execution of activities. When the trainee
utilises inappropriate actions to accomplish a
given task the therapist has to take corrective
 Balance training after amputation 215
measures. Another important role of the
therapist is physically to prevent the patient from
falling during exercise. The common problem
with this described balance training approach is
that the subjects are at any given time exposed to
possible destabilisation and fall. Consequently,
the training sessions are rather static, the use of
upper limbs holding onto parallel bars excessive
and the outcome of training impeded by the
ever-present fear of falling.
A recent Canadian study (Miller et al, 2001)
examined prevalence and risk factors of falling
and fear of falling among lower limb amputees.
They included in the study 435 people with
lower limb amputation (75% trans-tibial
Downloaded By: [Institut Za Rehabilitacijo] At: 07:46 15 September 2009

amputations, 25% trans-femoral amputations).

The results have shown that approximately 50%
of subjects experienced falling and the same
percentage of subjects reported fear of falling. A
very common consequence of the fear of falling
is that people avoid carrying out activities that
could possibly lead to a fall, which in turn
further reduces their balancing and walking
abilities. Conversely, mastering balance abilities
improves the amputee's prosthetic skills and
provides confidence for gait and more
complicated tasks (Geurts et al, 1992). This
state of the art is calling for further research and
development of new, more efficient techniques
for balance training that would i) diminish the
incidence of falls and decrease fear of falling in
people with lower limb amputations and ii)
improve the rehabilitation outcome.
In the last two years the authors have
developed a mechanical apparatus and methods,
collectively named BalanceReTrainer, which
enables task-orientated balance training during
standing of neurological patients (Matjacic etal.,
2000; Matjacic et al, 2003). Training on
BalanceReTrainer is performed without support
of the upper limbs in a fall-safe environment.
Several case studies (Matjacic et al, 2000;
Matjacic et al, 2003) have indicated the efficacy
of the proposed methodology in stroke and
spinal cord injured individuals. The aim of this
pilot study was to explore whether
BalanceReTrainer could be a viable treatment
modality for practising balancing and postural
control skills in order to improve functional
ambulation skills in the population with lower
limb amputations.
Fig. 1. A photograph showing a subject fitted with trans-
tibial prosthesis standing on BalanceReTrainer and
exercising a computer task.
Methods
Subjects
Fourteen (14) individuals (aged 49 ± 1 0
years) with trans-tibial amputation (acquired
before 9 ± 1 years), fitted with trans-tibial
prostheses (patellar tendon supracondylar
suspension - PTS socket type) were included in
the pilot study. All subjects could ambulate
without the use of an assistive device. The
subjects were all mine victims, admitted to the
authors' clinic for replacement of prostheses.
The length of stay in the clinic was five days for
most of the subjects. Most of the time the
subjects were involved in the prosthesis-fitting
procedures, therefore during this five days they
were frequently donning and doffing the old and
the new prosthetic leg. Beside the experimental
treatment of balance training they were not
exposed to any other physiotherapy related to
standing and walking. All therapeutic
procedures as well as outcome measures
assessment related to the balancing pilot study
were done by subjects wearing their old
prostheses. Given the circumstances of the pilot
study the subjects represent a sample of
convenience. The data on subjects are given in
Table 1. The institutional ethics committee
 216 Z. Matjacic and H. Burger

Table 1. Data on subjects.

Subject Age , Time after Side No. of replaced Self-reported daily
- (yrs) amputation (yrs) prosthesis walked distance (km)
A • . .38 10 R 4 10
.58 7 L 2 5
• • c -• - 46 10 L 2 2
b 70 10 L 4 2
E 64 10 R 4 1
F 44 7 R 2 0.5
G 32 10 L 3 10
H 47 9 L 2 10
I 47 9 L 2 3
J 45 10 L 4 6
K 61 10 R 9 10
Downloaded By: [Institut Za Rehabilitacijo] At: 07:46 15 September 2009

L 48 7 L 3 5
M 43 10 R 3 5
N 48 10 R 2 15

approved the study and the subjects gave
informed consents.
BalanceReTrainer
Detailed and comprehensive information on
BalanceReTrainer and its predecessor device are
given in other publications (Matjacic et al.,
2000; Matjacic et al., 2003). Here only a short
description is provided.
BalanceReTrainer is a mechanical apparatus
that provides an impaired individual with a fall-
safe balancing environment (Fig. 1). The
balancing efforts of a standing individual are
augmented by stabilising forces acting at the
computer display is shown in Figure 2. The
opening scene (Fig. 2A) consists of 8
symmetrically placed target circles and the
tracker circle, which appears in the middle of the
screen. The task imposed on the standing subject
is first to move the mouse cursor (by changing
posture in sagittal and frontal planes) into the
tracker (step 1, Fig. 2B), which becomes locked
to the cursor. A further objective is then to move
A. a
o O
o Q
o o •RACKHl

level of the pelvis in the sagittal and frontal o •r o O o

* ^ \ MOUSE
planes of motion, assisting the balancing activity (~j CURSOI
of ankle muscles (sagittal plane) and ankle and o o o o o
hip muscles (frontal plane). The supporting •RRGEE

forces are generated entirely by passive, ...

compliant materials. The level of supporting c. D.

forces can be varied from zero up to the level
where no balancing activity is needed from the
standing subject. Additionally, movement in the
sagittal and frontal planes, measured by
transducers, is fed to an electronic interface
which transforms the current variations into
computer mouse signals, which are interfaced to
a personal computer (PC). Further, an advanced
balance training and evaluation programme was
developed to facilitate and test balancing in the
whole range of antero-posterior and medio-
lateral postural space in a gradual and systematic
way. The succession of scenes appearing at the
oo o 0 o o
o o o o
o o o o o o
Fig. 2. Computer based balance-training task. A. The initial
scene consists of eight symmetrically placed target circles,
the tracker circle and the mouse cursor, which is linked to
BalanceReTrainer movement. B. Standing subject
approaches the tracker. C. The tracker becomes attached to
mouse cursor and thereafter moves together with the mouse
cursor; one of the target circles becomes emboldened. D.
The subject steers the tracker into the emboldened target.
 Balance training after amputation
the tracker into the illuminated target (step 2,
Fig. 2C) and keep it in the target for a given
period of time (step 3, Fig. 2D). The total time
window given for completion of the task is
limited and can be varied as can the sizes of
target and tracker circles. In this way the
difficulty of the task can be varied. Successful
task completion is signaled by auditory feedback
- a short low-frequency beep. A short high-
frequency beep signals failure. One training
session consists of tracking each target for at
least three times where the order of appearance
of the targets is randomised.
Therapeutic intervention
Downloaded By: [Institut Za Rehabilitacijo] At: 07:46 15 September 2009
217
balance-training task, where the difficulty of the
task (bigger tracker and less time given for
accomplishing the task) was progressively
increased over the five training days. The
therapist who monitored postural activities and
corrected improper manoeuvres supervised each
training session.
Outcome measures and statistical analysis
Before the commencement and after the
completion of the training programme a set of
clinical outcome measures were recorded for
each subject. The three outcome measures were:
1) Duration of balancing on the prosthetic leg
only during stance, 2) Timed up and go test and

For five days in succession the subjects 3) 10m walking test. For all three-outcome
received therapy on BalanceReTrainer. Each of measures each measurement was repeated for
the training sessions lasted for approximately 20 each subject five times. The calculated mean
minutes. For the first 5-10 minutes the subjects value was used as a result for each individual
were instructed by the therapist to incline and was subsequently used to calculate the
forward, backward, left and right without using group mean. Two-tailed, paired t-test was used
hands for support and in such a way that enabled to compare the group means of each outcome
them safe excursion and return toward the measure before and after the treatment.
vertical posture. During this initial period of
training session the level of mechanical support Results
was determined. Generally, the level of support Table 2 presents results for each individual
was minimal for all the subjects. In the subject before and after the treatment for all
remaining period of the training session the three outcome measures where the mean values
subjects accomplished one computerised and standard deviations are given for each
Table 2. Results for each individual subject and for the group.
Subject Balancing on prosthesis (s) Timed up and go test (s) 10m walk test (s)
Before After Before After Before After
X±SD X±SD X±SD X±SD X±SD X±SD
A 1.2 + 0.4 2.1 ± 1.0 6.1 ± 0.3 5.9 ± 0.4 4.9 ± 0.4 4.7 ± 0.2
B 2.7 ± 0.6 3.3 ± 1.2 5.8 + 0.5 4.7 ±0.1 5.7 ± 0.4 3.7 ± 0.3
C 1.5 ± 0.5 2.3 + 1.3 5.8 ± 0.3 4.6 ± 0.4 6.1 ±0.3 4.1 ±0.6
D 1.3 ± 0.4 1.5 + 0.4 8.1 ±0.2 6.9 ±0.1 6.5 ± 0.3 5.5 ± 0.8
E 0.8 ± 0.1 1.3 ± 0.4 11.0 ± 1.1 8.5 ± 0.6 9.9 ± 0.2 6.8 ± 0.5
F 1.4 ± 0.9 3.2 ± 1.9 8.6 ± 0.2 7.8 ± 0.3 6.4 ± 0.7 5.6 ± 0.6
G 11.7 ±9.1 18.5 ±8.6 4.1 ±0.2 3.9 ± 0.1 4.6 ± 0.4 3.8 ± 0.3
H 2.8 ± 1.0 3.0 ± 0.7 4.6 ± 0.2 3.2 ± 0.1 4.8 ± 0.2 3.5 ± 0.3
I 3.2 ± 0.4 2.4 ± 0.5 4.6 ±0.1 4.7 ± 0.4 5.3 ± 0.2 4.5 ± 0.2
J 5.4 ±3.1 10.4 ± 3.8 5.0 ± 0.6 3.8 ± 0.2 4.8 ± 0.3 3.9 ± 0.6
K 2.2 ±1.3 3.6 ± 0.9 5.9 ± 0.7 5.0 ± 0.1 5.2 ± 0.2 4.9 ±0.1
L 2.6 ±1.1 3.4 ± 0.9 6.1 ± 0.3 5.6 ± 0.4 4.9 ±0.1 4.4 ± 0.7
M 2.4 ± 0.6 2.2 + 0.5 5.9 ± 0.1 5.5 ± 0.2 4.4 ±0.1 3.8 ±1.1
N 2.6 ± 1.3 3.2 ± 1.6 4.5 ± 0.2 5.2 ± 0.3 3.5 ± 0.3 3.5 ± 0.3

GROUP 3 + 2.8 4.3 ± 4.5 6.2 ± 1.9 5.4 ±1.5 5.5 ± 1.5 4.5 ± 0.9
*P<0.05
 218 Z. Matjacic and H. Burger
subject. Also the results for the group are
presented in Table 2. The general observation is
that in the majority of subjects the treatment
resulted in improved performance in all three
outcome measures. Standard deviations for the
first outcome measure are relatively high and
vary between subjects as well as when
comparing the results before and after treatment.
Standard deviations for the remaining two
outcome measures are relatively low and
comparable between subjects as well as when
comparing the results before and after treatment.
Before training the group of subjects was able
to stand on the prosthetic leg for 2.98 ± 2.75s,
while after the treatment the duration of standing
Downloaded By: [Institut Za Rehabilitacijo] At: 07:46 15 September 2009
on the prosthetic leg increased to 4.3 ± 4.5s.
With respect to the second outcome measure the
group of subjects needed 6.15 ± 1.9s to carry out
the timed up and go test. After the treatment this
time was to reduced to 5.4 ± 1.5s. For the third
outcome measure the group of subjects needed
at the start 5.51 ± 1.5s to cover the distance of
10m. After the treatment this time was reduced
to 4.5 ± 0.9s. This difference in walking
performance before and after the treatment was
statistically significant.
Discussion
The main purpose of the pilot study on
dynamic balance training in people with trans-
tibial amputations was to explore the potential
benefit of such training for improvement of
functional ambulation skills. The results are
encouraging as they indicate that Balance
ReTrainer based balance-training offers the
potential for improving locomotor skills in the
tested population.
Even though statistical analysis shows
statistically significant difference only in the
assessed performance for the third outcome
measure before and after the intervention, a
trend of improved performance can be seen in all
three evaluation tasks. Furthermore, there were
several methodological difficulties that
influenced the results. Firstly, throughout the
training period subjects were frequently
changing from the old, worn-out prosthesis and
the new prosthesis that were daily modified in
the process of fitting. These circumstances
clearly influence the sensory-motor integration
processes and it is fair to assume that they tend
to diminish the training effects. Secondly, the
extent of therapeutic intervention was limited as
only five training sessions were performed in
circumstances where the training conditions
were changing, as described above. The third
unfavorable aspect associated with the group of
subjects was that they were all "old" prosthesis
users. It is known that the best training results
with respect to balance training in a population
with lower limb amputations can be achieved in
a narrow time window soon after the amputation
and first prosthesis fitting (Mensch and Ellis,
1986; Esquenazi and DiGiacomo, 2001). In this
period alternative sensory-motor patterns are
developed (Geurts et al., 1992). Since all of the
subjects in this study were well beyond that
period the positive results of the study are very
encouraging and suggest that the developed
balance training programme on
BalanceReTrainer could be even more
successful if administered in the very early stage
of movement rehabilitation.
It appears from the results of the first outcome
measure that a great deal of intra- and inter-
subject variability is present when the subjects
attempted to maintain balance on the prosthetic
leg. This was expected as the imposed task is
challenging, comparable to the balancing of the
unimpaired population on long stilts. Not all
individuals are equally competent to carry out
either of the two demanding tasks. The authors'
findings are in line with those of Hermodsson et
al. (1994) who investigated and compared the
abilities to balance on the prosthetic leg in
vascular and traumatic trans-tibial amputees.
Their conclusion was that the required activity
posed a very difficult task for most of the tested
subjects. When standing on the prosthetic leg,
the subjects need to maintain their balance solely
by utilising hip and trunk strategies associated
with double inverted pendulum models of stance
where the centre of pressure excursions under
the prosthetic foot are small due to the loss of the
ankle joint (Viton et al, 2000). The important
aspect of the results associated with the first
outcome measure is that the majority of the
subjects improved the duration of their standing
after the treatment, which suggests that proper
hip and trunk controlled balancing patterns were
improved. The improved results after the
treatment in the remaining two outcome
measures, where the repeatability of subjects'
performance was high as judged from rather low
standard deviations, indicate that dynamic
standing-balance training importantly enhances
 Balance training after amputation
also locomotion abilities. Several studies have
highlighted a need for dynamic balance training,
possibly including cognitive feedback, that
facilitates development of proper sensory
substitution, which is crucial for confident
execution of transfers and walking in the
conditions where the significant portion of
proprioception as well as motor system is missing
after the amputation (Geurts et al, 1992; Viton et
al., 2000). It has been demonstrated that postural
control in the frontal plane is quite similar during
standing as well as during normal walking. It was
suggested that the postural control during walking
in the frontal plane is the most challenging
postural- and balance-associated task in healthy
Downloaded By: [Institut Za Rehabilitacijo] At: 07:46 15 September 2009
individuals (Bauby and Kuo, 2000), therefore it
seems reasonable to assume that improved
postural control during standing transfers also to
walking. It has been suggested that the 10m
walking test allows not only the assessment of
walking speed but also reflects improvement in
transfer and balancing abilities (Datta et al,
1996). The time needed to cover the 10m walk
distance decreased within the group by 20% in
only five days of training, which might be
considered as clinically relevant. As no other
training was undertaken during the five-days
treatment period the observed improvement must
be due to the balance-training programme.
Possible mechanisms related to improvement of
functional ambulation skills following treatment
on BalanceReTrainer are similar to those
suggested for neurological subjects that were
subjected to BalanceReTrainer treatment
(Matjacic et al, 2000; Matjacic et al, 2003).
When comparing conventional balance training
approaches in people with lower limb amputations
with BalanceReTrainer treatment it seems that the
more challenging training conditions provided by
the latter treatment modality, where the use of
arms is not possible but rather the gradual increase
of involvement of the residual sensory-motor
capabilities is facilitated, enable thorough
exploration and development of balancing skills.
Furthermore, it seems that such training that
incorporates cognitive feedback and repetitive
training conditions can bring about a better
awareness of functional capabilities and
achievable limits of postural movement, which
might reduce fear and the incidence of falling
when undertaking various activities of daily
living (Viton et al, 2000).
219
In the present pilot study the authors have
tested only a small sub-population of people
with lower limb amputations in the unfavourable
training conditions as discussed above. The
larger sub-population is the one of elderly
people with lower limb amputations due to
vascular reasons or diabetes, frequently
accompanied with polyneuropathies worsening
balancing abilities and postural control. The
promising results of the present study justify
launching a controlled clinical trial in the early
stages following amputation in the elderly
population.
Acknowledgements
The authors acknowledge financial support
from the Ministry of Education, Science and
Sport, Republic of Slovenia. The authors are
grateful to the subjects that participated in the
study. Special thanks go to Mr. Tomaz Bevetek,
PT who managed the treatment procedures.
REFERENCES
BAUBY CE, KUO AD (2000). Active control of lateral
balance in human walking. J Biomech 33, 1433-1440.
DATTA D, ARIYARATNAM R, HILTON S (1996). Timed
walking test – an all-embracing outcome measure for
lower-limb amputees? Clinical Rehabil 10, 227-232.
ESQUENAZI A, DIGIACOMO (2001). Rehabilitation after
amputation. J Am Podiatr Med Assoc 91, 13-22.
GEURTS ACH, MULDER TW, NIENHUIS B, RIJKEN RAJ
(1992). Postural reorganisation following lower limb
amputation. Scand J Rehabil Med 24, 83-90.
HERMODSSON Y, EKDAHL C, PERSSON BM, ROXENDAL G
(1994). Standing balance in trans-tibial amputees
following vascular disease or trauma: a comparative
study with healthy subjects. Prosthet Orthot Int 18,
150-158.
MATJA ić Z, HESSE S, SINKJAER T (2003).
BalanceReTrainer – a new standing-balance training
apparatus and methods applied to a chronic
hemiparetic subject with a neglect syndrome.
NeuroRehabilitation 18, 251-259.
MATJA ić Z, JOHANNESEN IL, SINKJAER T (2000). A
Multi-purpose Rehabilitation Frame: a novel apparatus
for balance training during standing of neurologically
impaired individuals. J Rehabil Res Dev 37, 681-691.
MENSCH G, ELLIS PM (1986). Physical therapy
management of lower extremity amputations.
-Rockville, MD: Aspen Publishers Inc.
 220 Z Matjacic and H. Burger
MILLER WC, SPEECHLEY M, DEATHE B (2001). The VITON J-M, MOUCHININO L, MILLE ML, CINCERA M,
prevalence and risk factors of falling and fear of falling DELARQUE A, PEDOTTI A, BARDOT A, MASSION J
among lower extremity amputees. Arch Phys Med (2000). Equilibrium and movement control strategies
Rehabil 82, 1031-1037. in trans-tibial amputees. Prosthet Orthot Int 24, 108-116.
Downloaded By: [Institut Za Rehabilitacijo] At: 07:46 15 September 2009