PT Classroom - Outcomes Following a Core and Lower Extremity Strengthening Program on Fear of Falling in a 79 year old Male with a Trans-tibial Amputation: A Case Report ׀ by Emily Husch, DPT, Carrie Anderson, MPT & Amy McQuade, PT


Emily Husch, DPT, graduated with her Doctor of Physical Therapy degree from Carroll University in May of 2011. She also received her BS degree in exercise science from Carroll University in 2009 and is very interested in patients who have had amputations. Emily works as a physical therapist with United Hospital System in Kenosha where she works primarily in the outpatient PT setting.

 Outcomes Following a Core and Lower Extremity Strengthening Program on Fear of Falling in a 79 year old Male with a Trans-tibial Amputation: A Case Report


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.

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.

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.

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.

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.

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

1) Ziegler-Graham K, MacKenzie E, Ephraim P, Travison T, Brookmeyer R. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Archives of Physical Medicine & Rehabilitation. March 2008;89(3):422-429. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 16, 2011.
2) Legters K. Fear of falling. Physical Therapy [serial online]. March 2002;82(3):264-272. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 27, 2011.
3) Arfken C, Lach H, Birge S, Miller J. The prevalence and correlates of fear of falling in elderly persons living in the community. American Journal of Public Health. April 1994;84(4):565-570. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 16, 2011.
4) Vellas B, Wayne S, Romero L, Baumgartner R, Garry P. Fear of falling and restriction of mobility in elderly fallers. Age & Ageing. May 1997;26(3):189-193. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 16, 2011.
5) Miller W, Speechley M, Deathe B. The prevalence and risk factors of falling and fear of falling among lower extremity amputees. Archives of Physical Medicine & Rehabilitation. August 2001;82(8):1031-1037. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 16, 2011.
6) Chandler J, Duncan P, Kochersberger G, Studneski S. Is lower extremity strength gain associated with improvement in physical performance and disability in frail, community-dwelling elders? Archives of Physical Medicine & Rehabilitation. 1998, 79, 1, 24-30. Accessed April 27, 2011.
7) Holviala J, Sallinen J, Kraemer W, Alen M, Hakkinen K. Effects of strength training on muscle strength characteristics, functional capabilities, and balance in middle-aged and older women. Journal of Strength & Conditioning Research (Allen Press Publishing Services Inc.). May 2006;20(2):336-344. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 27, 2011.
8) Bird M, Hill K, Ball M, Williams A. Effects of resistance- and flexibility-exercise interventions on balance and related measures in older adults. Journal of Aging & Physical Activity. October 2009;17(4):444-454. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 27, 2011.
9) Mihay L, Boggs K, Breck A, Dokken E, NaThalang G. The effect of Tai Chi inspired exercise compared to strength training: a pilot study. Physical & Occupational Therapy in Geriatrics. 2006;24(3):13-26. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 27, 2011.
10) Kim S, Lockhart T, Roberto K. The effects of eight-week balance training or weight training: for the elderly on fear of falling measures and social activity levels. Quality in Ageing. December 2009;10(4):37-48. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 16, 2011.
11) Miller W, Deathe A, Speechley M. Psychometric properties of the Activities-Specific Balance Confidence Scale among individuals with a lower-limb amputation. Archives of Physical Medicine & Rehabilitation. May 2003;84(5):656-661. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 16, 2011.

Terms & Conditions

Please review our terms and conditions carefully before utilization of the Site. The information on this Site is for informational purposes only and should in no way replace a conventional visit to an actual live physical therapist or other healthcare professional. It is recommended that you seek professional and medical advise from your physical therapist or physician prior to any form of self treatment.

..="font-size: 2pt">.