Effects of Flexible Transfemoral Prostheses on Dynamic Balance in Unilateral Amputees: A Quasi-Experimental Within-Subject Study
DOI:
https://doi.org/10.55018/janh.v8i1.597Keywords:
Transfemoral Amputation, Prosthesis Design, Dynamic Balance, Postural Control, RehabilitationAbstract
Background: Dynamic balance impairment is a major functional challenge in individuals with transfemoral amputation and is closely associated with mobility limitations and increased fall risk. Flexible transfemoral prostheses are widely prescribed to improve ambulation. However, limited biomechanical evidence exists examining how flexible transfemoral prostheses influence dynamic balance performance using standardized functional clinical assessments. This study aimed to examine the effect of flexible transfemoral prosthesis use on dynamic balance in unilateral transfemoral amputees.
Methods: This quasi-experimental within-subject study followed the TREND reporting guideline. Thirty unilateral transfemoral amputees were recruited using purposive sampling from the Department of Prosthetics and Orthotics at Poltekkes Kemenkes Surakarta, Indonesia. Inclusion criteria were medical stability and ability to perform multidirectional stepping; exclusion criteria included bilateral amputation and neurological disorders. The independent variable was ambulation condition (axillary crutch ambulation versus flexible transfemoral prosthesis use), and the dependent variable was FSST completion time. Dynamic balance was assessed using the Four Square Step Test (FSST). Analyses were conducted using paired t-tests with 95% confidence intervals.
Results: Participants were predominantly male (76.7%) with a mean age of 33.6 ± 9.4 years and a mean post-amputation duration of 4.2 ± 2.1 years. FSST completion time significantly decreased during flexible transfemoral prosthesis use compared with axillary crutch ambulation (mean difference = 8.97 seconds; 95% CI, 7.72–10.22; p < 0.001), demonstrating a very large effect size (Cohen’s d = 2.68).
Conclusion: Flexible transfemoral prosthesis use significantly enhances dynamic balance in unilateral transfemoral amputees. Flexible transfemoral prostheses should be considered an essential component of function-oriented rehabilitation strategies to optimize postural control and safe mobility. Future longitudinal and instrumented biomechanical studies are warranted to further elucidate underlying adaptation mechanisms.
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Abou, L., Fliflet, A., Zhao, L., Du, Y., & Rice, L. (2022). The Effectiveness of Exercise Interventions to Improve Gait and Balance in Individuals with Lower Limb Amputations: A Systematic Review and Meta-analysis. Clinical Rehabilitation, 36(7), 857–872. https://doi.org/10.1177/02692155221086204
Aharoni, M. M. H., Lubetzky, A. V., Arie, L., & Krasovsky, T. (2021). Factors associated with dynamic balance in people with Persistent Postural Perceptual Dizziness (PPPD): a cross-sectional study using a virtual-reality Four Square Step Test. Journal of NeuroEngineering and Rehabilitation, 18(1), 55. https://doi.org/10.1186/s12984-021-00852-0
Andrysek, J., García, D., Rozbaczylo, C., Alvarez-Mitchell, C., Valdebenito, R., Rotter, K., & Wright, F. V. (2020). Biomechanical responses of young adults with unilateral transfemoral amputation using two types of mechanical stance control prosthetic knee joints. Prosthetics & Orthotics International, 44(5), 314–322. https://doi.org/10.1177/0309364620916385
Claret, C. R., Herget, G. W., Kouba, L., Wiest, D., Adler, J., von Tscharner, V., Stieglitz, T., & Pasluosta, C. (2019). Neuromuscular adaptations and sensorimotor integration following a unilateral transfemoral amputation. Journal of NeuroEngineering and Rehabilitation, 16(1), 115. https://doi.org/10.1186/s12984-019-0586-9
Dhariwal, A., Heitzmann, D., Barnett, C., Rusaw, D., Nilsson, P. V., Scheepers, L., Anderson, S., Berli, M. C., & Miller, W. C. (2025). Multilevel Meta-analysis of Therapeutic Interventions to Improve Fall-Related Outcomes in Individuals With Lower Limb Amputation. Archives of Physical Medicine and Rehabilitation. https://doi.org/10.1016/j.apmr.2025.11.033
Dupuis, F., Ginis, K. A. M., MacKay, C., Best, K. L., Blanchette, V., Cherif, A., Robert, M. T., Miller, W. C., Gee, C., Habra, N., Brousseau-Foley, M., & Zidarov, D. (2024). Do Exercise Programs Improve Fitness, Mobility, and Functional Capacity in Adults With Lower Limb Amputation? A Systematic Review on the Type and Minimal Dose Needed. Archives of Physical Medicine and Rehabilitation, 105(6), 1194–1211. https://doi.org/10.1016/j.apmr.2023.10.011
Eom, S.-Y., Choi, J.-E., & Park, D.-S. (2023). The Correlation of the Four Square Step Test and Fall Index in Healthy Adults. Physical Therapy Rehabilitation Science, 12(4), 481–485. https://doi.org/10.14474/ptrs.2023.12.4.481
Ettema, S., Kal, E., & Houdijk, H. (2021). General estimates of the energy cost of walking in people with different levels and causes of lower-limb amputation: a systematic review and meta-analysis. Prosthetics & Orthotics International, 45(5), 417–427. https://doi.org/10.1097/PXR.0000000000000035
Fuenzalida Squella, S. A., Kannenberg, A., & Brandão Benetti, Â. (2018). Enhancement of a prosthetic knee with a microprocessor-controlled gait phase switch reduces falls and improves balance confidence and gait speed in community ambulators with unilateral transfemoral amputation. Prosthetics & Orthotics International, 42(2), 228–235. https://doi.org/10.1177/0309364617716207
Gailey, R. S., Kristal, A., Al Muderis, M., Lučarević, J., Clemens, S., Applegate, E. B., Isaacson, B. M., Pasquina, P. F., Symsack, A., & Gaunaurd, I. A. (2023). Comparison of prosthetic mobility and balance in transfemoral amputees with bone-anchored prosthesis vs. socket prosthesis. Prosthetics and Orthotics International, 47(2), 130–136. https://doi.org/10.1097/PXR.0000000000000189
Johansson, R., Jensen, L., Barnett, C. T., & Rusaw, D. F. (2023). Quantitative methods used to evaluate balance, postural control, and the fear of falling in lower limb prosthesis users: A systematic review. Prosthetics & Orthotics International, 47(6), 586–598. https://doi.org/10.1097/PXR.0000000000000250
Kahle, J. T., Miro, R. M., Ho, L. T., Porter, M. R., Lura, D. J., Carey, S. L., Lunseth, P., Swanson, A. E., & Highsmith, M. J. (2021). Effect of transfemoral prosthetic socket interface design on gait, balance, mobility, and preference: A randomized clinical trial. Prosthetics & Orthotics International, 45(4), 304–312. https://doi.org/10.1097/PXR.0000000000000013
Liang, W., Qian, Z., Chen, W., Song, H., Cao, Y., Wei, G., Ren, L., Wang, K., & Ren, L. (2022). Mechanisms and component design of prosthetic knees: A review from a biomechanical function perspective. Frontiers in Bioengineering and Biotechnology, 10. https://doi.org/10.3389/fbioe.2022.950110
Moisan, G., Miramand, L., Younesian, H., & Turcot, K. (2022). Balance control deficits in individuals with a transtibial amputation with and without visual input. Prosthetics & Orthotics International, 46(2), 134–139. https://doi.org/10.1097/PXR.0000000000000086
Monaco, V., Aprigliano, F., Palmerini, L., Palumbo, P., Chiari, L., & Micera, S. (2022). Biomechanical Measures for Fall Risk Assessment and Fall Detection in People with Transfemoral Amputations for the Next-Generation Prostheses: A Scoping Review. JPO Journal of Prosthetics and Orthotics, 34(3), e144–e162. https://doi.org/10.1097/JPO.0000000000000393
Omana, H., Madou, E., Montero‐Odasso, M., Payne, M. W., Viana, R., & Hunter, S. W. (2023). The effect of dual‐task testing on the balance and gait of people with lower limb amputations: A systematic review. PM&R, 15(1), 94–128. https://doi.org/10.1002/pmrj.12702
Petrini, F. M., Bumbasirevic, M., Valle, G., Ilic, V., Mijović, P., Čvančara, P., Barberi, F., Katic, N., Bortolotti, D., Andreu, D., Lechler, K., Lesic, A., Mazic, S., Mijović, B., Guiraud, D., Stieglitz, T., Alexandersson, A., Micera, S., & Raspopovic, S. (2019). Sensory feedback restoration in leg amputees improves walking speed, metabolic cost and phantom pain. Nature Medicine, 25(9), 1356–1363. https://doi.org/10.1038/s41591-019-0567-3
Rash, I., Miller, W. C., Tao, G., & Payne, M. W. (2025). What are relevant predictors of physical activity in older adults with lower limb loss (LLL)? Results of a retrospective analysis. Prosthetics & Orthotics International, 49(1), 1–6. https://doi.org/10.1097/PXR.0000000000000336
Rosenblatt, N. J., Schneider, K. L., Miller, S. A., Hagopian, K., Hagg, S., Reddin, C., Churchill, R., Dams, G. M., Calamari, J. E., Stachowiak, A., & Major, M. J. (2025). Mixed methods analysis of an interdisciplinary intervention to promote balance confidence in lower limb prosthesis users. Frontiers in Rehabilitation Sciences, 6. https://doi.org/10.3389/fresc.2025.1626051
Silver-Thorn, M. B., Kempfer, J., Schnorenberg, A. J., & Slavens, B. A. (2018). Use of a Dynamic Balance System to Quantify Postural Steadiness and Stability of Individuals with Lower-Limb Amputation: A Pilot Study. JPO Journal of Prosthetics and Orthotics, 30(1), 31–38. https://doi.org/10.1097/JPO.0000000000000164
Valette, R., Gonzalez-Vargas, J., & Dosen, S. (2025). Development and assessment of vibrotactile feedback from the embedded sensors of a microprocessor-controlled knee prosthesis. Journal of NeuroEngineering and Rehabilitation, 23(1), 33. https://doi.org/10.1186/s12984-025-01793-8
Vu, K., Payne, M. W. C., Hunter, S. W., & Viana, R. (2019). Risk Factors for Falls in Individuals With Lower Extremity Amputations During the Pre‐Prosthetic Phase: A Retrospective Cohort Study. PM&R, 11(8), 828–833. https://doi.org/10.1002/pmrj.12046
Yazgan, A., Kutlutürk, S., & Lechler, K. (2021). Clinical Outcomes Comparing Two Prosthetic Knee Designs In Individuals With Unilateral Transfemoral Amputation In Turkey. Canadian Prosthetics & Orthotics Journal, 4(1). https://doi.org/10.33137/cpoj.v4i1.35297
Ziegler-Graham, K., MacKenzie, E. J., Ephraim, P. L., Travison, T. G., & Brookmeyer, R. (2008). Estimating the Prevalence of Limb Loss in the United States: 2005 to 2050. Archives of Physical Medicine and Rehabilitation. https://doi.org/10.1016/j.apmr.2007.11.005
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