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Task-specific Fall Prevention Training Is Effective for Warfighters With Transtibial Amputations

  • Symposium: Recent Advances in Amputation Surgery and Rehabilitation
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Key factors limiting patients with lower extremity amputations to achieve maximal functional capabilities are falls and fear of falling. A task-specific fall prevention training program has successfully reduced prospectively recorded trip-related falls that occur in the community by the elderly. However, this program has not been tested in amputees.

Questions/purposes

In a cohort of unilateral transtibial amputees, we aimed to assess effectiveness of a falls prevention training program by (1) quantifying improvements in trunk control; (2) measuring responses to a standardized perturbation; and (3) demonstrating retention at 3 and 6 months after training. Second, we collected patient-reported outcomes for balance confidence and falls control.

Methods

Fourteen male military service members (26 ± 3 years) with unilateral transtibial amputations and who had been walking without an assistive device for a median of 10 months (range, 2–106 months) were recruited to participate in this prospective cohort study. The training program used a microprocessor-controlled treadmill designed to deliver task-specific postural perturbations that simulated a trip. The training consisted of six 30-minute sessions delivered over a 2-week period, during which task difficulty, including perturbation magnitude, increased as the patient’s ability progressed. Training effectiveness was assessed using a perturbation test in an immersive virtual environment. The key outcome variables were peak trunk flexion and velocity, because trunk kinematics at the recovery step have been shown to be a determinant of fall likelihood. The patient-reported outcomes were also collected using questionnaires. The effectiveness of the rehabilitation program was also assessed by collecting data before perturbation training and comparing the key outcome parameters with those measured immediately after perturbation training (0 months) as well as both 3 and 6 months posttraining.

Results

Mean trunk flexion angle and velocity significantly improved after participating in the training program. The prosthetic limb trunk flexion angle improved from pretraining (42°; 95% confidence interval [CI], 38°–47°) to after training (31°; 95% CI, 25°–37°; p < 0.001). Likewise, the trunk flexion velocity improved from pretraining (187°/sec; 95% CI, 166°–209°) to after training (143°/sec; 95% CI, 119°–167°; p < 0.004). The results display a significant side-to-side difference for peak trunk flexion angle (p = 0.01) with perturbations of the prosthetic limb resulting in higher peak angles. Prosthetic limb trips also exhibited significantly greater peak trunk flexion velocity compared with trips of the prosthetic limb (p = 0.005). These changes were maintained up to 6 months after the training. The peak trunk flexion angle of the subjects when the prosthetic limb was perturbed had a mean of 31° (95% CI, 25°–37°) at 0 month, 32° (95% CI, 28°–37°) at 3 months, and 30° (95% CI, 25°–34°) at 6 months. Likewise, the peak trunk flexion velocity for the prosthetic limb was a mean of 143°/sec (95% CI, 118°–167°) at 0 months, 143°/sec (95% CI, 126°–159°) at 3 months, and 132° (95% CI, 115°–149°) at 6 months. The peak trunk flexion angle when the nonprosthetic limb was perturbed had a mean of 22° (95% CI, 18°–24°) at 0 months, a mean of 26° (95% CI, 20°–32°) at 3 months, and a mean of 23° (95% CI, 19°–28°) at 6 months. The peak trunk flexion velocity for the nonprosthetic limb had a mean of 85°/sec (95% CI, 71°–98°) at 0 months, a mean of 96° (95% CI, 68°–124°) at 3 months, and 87°/sec (95% CI, 68°–105°) at 6 months. There were no significant changes in the peak trunk flexion angle (p = 0.16) or peak trunk flexion velocity (p = 0.35) over time after the training ended. The skill retention was present when either the prosthetic or nonprosthetic limb was perturbed. There were side-to-side differences in the trunk flexion angle (p = 0.038) and trunk flexion velocity (p = 0.004). Perturbations of the prosthetic side resulted in larger trunk flexion and higher trunk flexion velocities. Subjects prospectively reported decreased stumbles, semicontrolled falls, and uncontrolled falls.

Conclusions

These results indicate that task-specific fall prevention training is an effective rehabilitation method to reduce falls in persons with lower extremity transtibial amputations.

Level of Evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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Acknowledgments

We thank Jordan Sturdy, Trevor Kingsbury, Nancy Thesing, Katie Sharp, John-David Collins, Mandy Wong, Grant Myers, and Birgit Unfried for contributing to this research project.

Author information

Authors and Affiliations

  1. Department of Orthopedic Surgery, Biomechanics/Motion Analysis Laboratory, Mayo Clinic, Charlton North L-110L, 200 First Street SW, Rochester, MN, 55905, USA

    Kenton R. Kaufman PhD, PE

  2. Gait Analysis Laboratory, Naval Medical Center San Diego, San Diego, CA, USA

    Marilynn P. Wyatt MA, PT

  3. Naval Health Research Center San Diego, San Diego, CA, USA

    Pinata H. Sessoms PhD

  4. Department of Kinesiology and Nutrition, University of Illinois-Chicago, Chicago, IL, USA

    Mark D. Grabiner PhD

Authors
  1. Kenton R. Kaufman PhD, PE
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  2. Marilynn P. Wyatt MA, PT
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Corresponding author

Correspondence to Kenton R. Kaufman PhD, PE.

Additional information

This study was funded by the Department of Defense Grant Number W81X-WH-11-2-0058 (Log No. DM090896) and the Navy Bureau of Medicine and Surgery, Wounded, Ill, and Injured Program. Approved for public release; distribution is unlimited. This research was conducted in compliance with all applicable federal regulations governing the protection of human subjects (protocol NMCSD.2001.003 and Protocol NHRC.2001.0031). The institution of one or more of the authors (MDG) has a patent on technology (ActiveStep™; Symbex, Lebanon, NH, USA) noted in this manuscript. One of the authors (MDG) is an inventor of the ActiveStep™ system but has no conflicts of interest to declare with regard to the present study.

The views expressed are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the US Government.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research ® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

Patients were recruited from the Comprehensive Combat & Complex Casualty Care (C5) program at the Naval Medical Center San Diego, San Diego, CA, USA.

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Kaufman, K.R., Wyatt, M.P., Sessoms, P.H. et al. Task-specific Fall Prevention Training Is Effective for Warfighters With Transtibial Amputations. Clin Orthop Relat Res 472, 3076–3084 (2014). https://doi.org/10.1007/s11999-014-3664-0

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  • DOI: https://doi.org/10.1007/s11999-014-3664-0

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