J Rehabil Med 2014; 46: 264–270

ORIGINAL REPORT

A Single-Blind, Cross-Over Trial of Hip Abductor Strength

Training to Improve Timed Up & Go Performance in Patients
with Unilateral, Transfemoral Amputation

Tim Pauley, MSc1, Michael Devlin, MD, FRCPC2,3 and Pamela Madan-Sharma, BSc.PT3
From the 1Nathan Clinical Research Institute, West Park Healthcare Centre, 2Division of Physiatry,
Department of Medicine, University of Toronto, Toronto, and 3Amputee and Neurological Rehabilitation Services,
West Park Healthcare Centre, Toronto, Canada

Objective: To evaluate hip abductor strength-training for pa- through the amputated limb is obliterated distal to the site of
tients with unilateral transfemoral amputation. amputation, though factors such as muscular strength of the
Design: Single-blind, cross-over (AB/BA) trial with rand- intact musculature of the residual limb are modifiable with
omization. appropriate therapeutic exercise.
Subjects: Seventeen patients with transfemoral amputation. Lower limb amputation rehabilitation requires an extensive
Methods: Subjects completed 8-week programs of twice period of adjustment to the use of a prosthesis and is often
weekly hip abductor strength training or arm ergometry. accompanied by fear of falling (2) and reduced quality of life
Subjects were randomly assigned to receive either the exper- (3). Any or all of these factors may contribute to reduced ac-
imental or active control intervention first. A physiotherapist tivities of daily living (ADL) (4). ADL reduction in turn likely
blinded to group assignment conducted baseline and post-
contributes to detraining and atrophy which further restricts the
intervention assessments. The Timed Up & Go (TUG) test
ability to perform ADLs independently. Lower limb loss has
was selected as the primary outcome measure; secondary
been associated with muscle atrophy ranging from 40–60% in
measures included the 2 Minute Walk (2MW), hip abductor
the sectioned muscle groups as well as up to 30% for intact hip
strength, Activities Specific Balance Confidence Scale (ABC)
and prosthetic use. A two-way cross-over ANOVA was used stabilizers proximal to the amputation (5), the latter suggest-
for baseline and post-intervention treatment comparisons. ing that strength loss is not a direct result of the amputation
Results: There were no baseline differences between treat- surgery, but likely also affected by other contributing factors
ments for TUG, 2MW, ABC, Houghton scale, sitting or such as reduced activity. Patients with lower limb amputation
side-lying abductor strength (p > 0.05 for all), though su- also demonstrate structural changes to the proximal muscle
pine strength was greater for the experimental treatment groups, including lower thigh bone-free lean body mass and
(p < 0.05). After 8-weeks of hip abductor strength train- higher percent thigh fat (6), both of which have been linked
ing, there were significant treatment effects for TUG, ABC to poorer ambulation among able-bodied older adults (7),
(p < 0.01 for both), 2MW (p < 0.05), sitting and side-lying while atrophy of the hip-stabilizing muscles has been shown
abductor strength (p = 0.05 for both), but not for supine to contribute to greater gait asymmetry among patients with
strength, prosthetic use, nor thigh girth measures (p > 0.05 transfemoral amputation (TFA) (8). As a result, the capacity for
for all). isometric torque production by the abductors on the prosthetic
Conclusions: This study suggests that patients with unilat- side is as much as 30% less than the intact side (9), leading
eral transfemoral amputation can improve functional per- to an asymmetric stance, with 55% to 70% of body weight
formance and balance confidence following intense hip ab- distributed over the intact leg, and poor medio-lateral centre
ductor strength training. of pressure control (10). This loss of strength is also thought
Key words: amputation; amputees; hip abductor; resistance to be the main cause of Trendelenburg gait (11), commonly
training; functional performance; balance confidence. observed among patients with lower limb amputation. As leg
J Rehabil Med 2014; 46: 264–270 weakness has been causally linked to falls among older adults
(12), maintenance of lower limb strength is critical for patients
Correspondence address: Tim Pauley, West Park Healthcare with amputation.
Centre, 82 Buttonwood Ave. Toronto, ON, M6M 2J5 Canada.
Though lower limb musculature strength has been identified
E-mail: [email protected]
as a factor related to functional performance (13), a literature
Accepted Oct 10, 2013; Epub ahead of print Dec 19, 2013 search identified only a single trial investigating a 10-week,
twice weekly training program for patients with TFA (14) as
well as a single case study of strength training for a patient
INTRODUCTION
with a left unilateral upper and lower limb amputation (15).
Lower limb amputation results in neurophysiological and bio- While these studies were able to demonstrate improvements in
mechanical changes (1). For example, proprioceptive feedback hip strength and oxygen consumption, and leg press strength,

J Rehabil Med 46 © 2014 The Authors. doi: 10.2340/16501977-1270

Journal Compilation © 2014 Foundation of Rehabilitation Information. ISSN 1650-1977
 Hip abductor training in transfemoral amputees 265

Table I. Demographic and clinical data of study participants (n = 17) subjects had undergone unilateral, TFA secondary to diabetes or periph-
eral vascular disease, were 65 years or older, 6-months post-fitting with
Characteristic Subjects
a prosthesis, ambulatory prosthetic users, taking no medications that
Gender, male, n (%) 13 (76) may impair balance, able to complete all testing procedures, and not
Age, mean (SD) 67.8 (5.2) involved in a concurrent exercise program. This study was approved
Side of amputation, right, n (%) 6 (35) by the Research Ethics Boards at West Park Healthcare Centre and
Time since amputation, years, mean (SD) 7.3 (8.2) St. John’s Rehabilitation Hospital.
Residual limb length, cm, mean (SD) 31.6 (4.7)
Residual limb length, proportion ht, mean (SD) 0.19 (0.02) Procedures
SD: standard deviation. This study utilized a single-blind (evaluator), cross-over trial (AB/
BA) with randomization. Subjects were randomised using the random
numbers generator function in Microsoft Excel [i.e., = RAND()] by
respectively, neither evaluated the impact of training interven- the study Principal Investigator who was not involved in data col-
tions on functional outcomes typically utilized by clinicians lection or subject orientation/supervision. Group assignment was
to evaluate therapeutic progress. This study investigated an conducted by the study Research Assistant (RA). Subjects fitting
the study inclusion criteria were identified by clinical staff and sent
abductor strength training program designed to improve func- a letter with a description of the study and invitation to contact the
tional performance, as measured on the Timed Up & Go (TUG) study coordinator if interested in participating. Patients expressing an
primary outcome measure, as well as the secondary measures interest were invited to West Park Healthcare Centre where informed
of abductor strength, 2-Minute Walk (2MW) and prosthetic consent was obtained by the study coordinator. TFAs were randomly
use. Balance confidence was included to test for changes in assigned to receive either the experimental (EC group; n = 9) or con-
trol interventions first (CE group; n = 8). A Consolidated Standards
perception of postural control. The following null hypothesis of Reporting Trials (CONSORT) flow diagram describes recruitment
was tested: relative to the control treatment, subjects will and compliance (Fig. 1).
demonstrate no improvement in primary or secondary outcome Baseline and post-intervention assessments included the Timed Up
measures at the completion of the experimental intervention. and Go (TUG) (16), Two-Minute Walk (2MW) (17), and hip abduction
strength. For the TUG, upon the “Go” command, subjects rose from
a chair, walked forward for 3 m, turned, and returned to the seated
position. The 2MW was conducted in one direction only (i.e., no turn-
METHODS
ing) in an approximately 200-m corridor. The distance was measured
Subjects from the start position until 2 min had expired. Hip abductor strength
Six patients with right and 11 with left unilateral TFA (age 67.8 years measures were taken in accordance with the manufacturer’s instruc-
(standard deviation (SD) 5.2) were recruited. Subjects’ demographics tions for use of the microFET2 digital handheld muscle dynamometer.
and select clinical characteristics are included in Table I. Experimental Subjects were tested while sitting, side-lying and in a supine position

Assessed for
eligibility (n=237)

Excluded (n=220)
• Did not meet inclusion criteria
(n=20)
• Declined to participate (n=159)
• Invitation returned as undeliverable
(n=25)
• Unable to make phone contact
(n=16)

Randomized
(n=17)

Allocated to EC group (n=9) Allocated to CE group (n=8)

• Experimental phase of intervention (n=9) • Control phase of intervention (n=8)
o 67 + 7.0 days o 66 + 7.8 days
• Washout period • Washout period
o 55 + 9.6 days o 49 + 5.6 days
• Control phase of intervention (n=8) • Experimental phase of intervention (n=7)
o 69 + 6.8 days o 63 + 3.7 days

Analysed (n=17)

Fig. 1. Consolidated Standards of Reporting Trials (CONSORT) Flow Diagram.

EC group: experimental control intervention first; CE group: control intervention first.

J Rehabil Med 46
266 T. Pauley et al.

on a hospital plinth. Strength measures were repeated three times with ting, the patient was asked to carry out 10 repetitions. This continued
the mean utilized in the analysis. Thigh girth was measured 15% of until 10 repetitions could not be completed in one continuous set. The
height distal to the iliac crest. Secondary measures included the Activi- highest resistance at which the patient could successfully complete 10
ties Specific Balance Confidence Scale (ABC) (18) and the Houghton repetitions was considered the 10 RM.
scale of prosthetic use (19). Baseline and post-intervention assessments Subjects attended twice weekly supervised training sessions for
were conducted by a physiotherapist (PT) blinded to group assignment. 8 weeks. Each session included a 5-min warm-up on a stationary
Prior to assessment the study RA cautioned each subject not to reveal cycle ergometer at 60 cycles/min against an electronic metronome.
group assignment to the PT, if known. Upon completion of the baseline Resistance was titrated to achieve a target heart rate of 60% (using the
assessment subjects were oriented to, and instructed on the use of the Karvonen formula (21)) + 5 beats/min of age-predicted maximal heart
training equipment for the treatment to which they had initially been rate. Subjects then performed 3 sets of 10 RM bilaterally on the hip
assigned. Post intervention assessments were conducted on the next abductor with their prosthesis donned. Resistance was progressively
regularly scheduled visit following the final training session. increased by 5-pound increments each time the individual was able to
complete all 30 repetitions per training session. Each session lasted
Apparatus 15 to 20 min including the 5-min warm-up. The hip strengthening
This study utilized a commercially available Cybex Hip Abduction segment did not exceed 15 min for any subjects.
machine (Cybex International, Inc., Medway, Ma, USA). The pads,
Arm ergometry (control treatment)
against which force is typically applied by the lower femur to oper-
ate the machine, were elongated such that a laterally directed force Control subjects underwent supervised arm ergometry training twice
could be applied with proximal half of the femur without dislodging weekly for 8 weeks. Subjects exercised for 30 min/session at a 60
the prosthesis (see Figs 2a and 2b for anterior and posterior oblique cycles/min against an electronic metronome. Resistance was titrated to
views of the modified hip abductor). A Keiser M3 stationary cycle- achieve a target heart rate of 60% (using the formula by Karvonen et
ergometer (Keiser Corporation, Fresno, CA, USA) was used for al. (21)) + 5 beats/min of age-predicted maximal heart rate. Ergometer
warm-up purposes. This cycle ergometer was selected for its direct resistance was adjusted periodically to ensure a consistent target train-
drive mechanism (i.e., with no “coast” capability, pedals continued to ing zone throughout the duration of training. Arm ergometry training
rotate when pressure was no longer applied by the rider) and toe-clips, was selected as an intervention that was expected to have no effect on
thus allowing patients to cycle with the prosthesis donned without the primary and secondary measures selected for this study. The arm
fear of imbalance or dislodging the prosthesis. A table mounted arm ergometer was not calibrated throughout the trial.
ergometer (Accessible Fitness Systems, Model AFS 301, Safety Har- All subjects received compensation for expenses related travel/
bor, FL, USA ) was used during the control treatment. The microFET2 parking costs associated with attendance at all sessions as well as a
(Hoggan Health Industries, Salt Lake City, UT, USA) dynamometer modest honorarium scaled in accordance with program compliance.
was used to obtain abductor strength data.
Analysis
Hip abductor training (experimental treatment) Data were rank-transformed prior to inferential statistical analysis,
Though no specific recommendations for strength training of lower to avoid violating the underlying assumptions of the ANOVA (22).
limb amputees are available, the American College of Sports Medicine Two 2-way cross-over ANOVAs were used for baseline and post-
(ACSM) provides recommendations for older adults and the frail elderly intervention treatment comparisons, thus controlling for sequence and
(20). For these groups, the ACSM indicates high intensity strength train- period effects, where period 1 included the experimental and control
ing as a safe and effective means of improving functional and general treatments for the EC and CE groups, respectively, while period 2
health status and recommends resistance training at 80% 1 repetition max included the control and experimental treatments for the EC and CE
(1RM), 2–3 days/week, with 2–3 sets of each exercise. For purposes of groups, respectively. Means and SD reported herein reflect the untrans-
establishing a safe exercise program for patients with amputation, the formed data; significance values reflect the results of the analysis on the
ACSM guidelines for sets and frequency were adopted, while a 10RM transformed data. An intention-to-treat analysis using last observation
target was used in place of the 80% 1RM target. Subjects started their carried forward was used to account for two subjects (one each from the
initial hip abductor strength training session with no resistance followed CE and EC groups) who completed period 1, but opted not to transition
by incremental increases in 5-pound intervals. At each resistance set- to the alternative treatment condition. Minimal detectable difference
based on 90% confidence interval scores (MDD90) were calculated
from published data (16) for the primary outcome measure TUG to
determine the proportion of subjects who demonstrated improvement
in TUG scores which exceeded MDD during experimental and control
treatments. A priori sample size calculation (23) determined that a
minimum sample size of 17 subjects was required to achieve the ap-
propriate power to detect statistical significant differences at p < 0.05
on the identified outcome measures. SAS for Windows, version 9.1
was used to conduct the analyses.

RESULTS
Compliance with the experimental protocol was 100% for 15
subjects who completed period 1 and period 2. Two subjects
completed all 16 session of period 1 only. Eleven subjects
missed a mean of 2.4 sessions (11 during experimental treat-
ment, 15 during control treatment) due to inclement weather
Fig. 2. Modified hip abductor machine (Cybex International, Inc.), (n = 7), transportation issues (n = 7), or sickness (n = 12), though
indicating elongated hip abductor pads. Figs 2a and 2b show the anterior all missed sessions were made-up at a later date. There were no
and posterior oblique views, respectively, of the modified hip abductor. suspensions greater than two consecutive training days missed

J Rehabil Med 46
 Hip abductor training in transfemoral amputees 267

during either treatment for any subjects. The mean duration of The baseline and post-intervention measures for experimen-
treatments was 64.8 days (SD 5.6) for the experiment treatment tal and control treatments are provided in Table II. The results
and 66.5 days (SD 7.4) for the control treatment. There were of the cross-over ANOVA indicated few between-treatment
no adverse effects associated with participation in the trial. differences at baseline. The only exception was supine hip
Two subjects (one from the CE group, one from EC) opted abductor strength at the start of the experimental treatment
not to transition to the period 2 treatment upon completion of (10.1 kg (SD 3.1) vs 9.1 kg (SD 2.0), p < 0.05).
the period 1 treatment due to personal reasons. The CE sub- Analysis of post-treatment data indicated a number of sig-
ject was within one SD of the CE group mean on all baseline nificant improvements associated with hip abductor training
measures except the ABC (83.1 vs. 51.8 (SD 15.8)); at post- relative to arm ergometry. Hip abductor training resulted in
intervention this subject was within one SD of the CE group 17% faster TUG time (24.6 s (SD 11.4) vs. 29.6 s (SD 14.6),
means on all measures. The EC subject was within one SD of p < 0.01), 7% greater 2MW distance (60.9 m (SD 18.2) vs. 56.8 m
the EC group mean on all baseline measures except side-lying (SD 17.3), p < 0.05), 12% greater balance (59.2 (SD 17.9) vs.
strength (15.6 vs. 12.2 kg (SD 2.3)); at post-intervention this 52.8 (SD 21.3), p < 0.01), and 11% greater sitting strength
subject’s side-lying strength measure remained greater than one (11.4 kg (SD 2.9) vs. 10.3 kg (SD 2.7), p < 0.05). There were
SD relative to the EC group mean (14.8 vs. 12.2 kg (SD 2.7)), no differences detected for side-lying strength (12.4 kg (SD
though all other measures were within one SD of the group 2.4) vs. 10.6 kg (SD 3.2), p = 0.06), supine strength (p = 0.71),
mean. In consultation with the physiotherapist who conducted prosthetic use (p = 0.45), nor thigh girth (p = 0.42). The cross-
all baseline and post-intervention it was determined that there over ANOVA also indicated no significant sequence or period
was no reason to exclude these data from the analysis. Among effects for any of the outcome measures, indicating that the
the 15 subjects that completed both intervention treatments, outcome measures were affected by neither group assignment
two had a TUG time that exceeded two SDs of their respective (EC vs. CE) nor the ordering of treatment within each group.
sequence group mean, and one each had a 2MW walk distance, Utilizing published data (16), it was determined that an
sitting strength or side-lying strength measure that exceeded improvement of 5.7 s on the TUG met the MDD90 threshold.
two SDs of the respective group means. At post intervention While only two subjects achieved an improvement of at least
one subject each had a TUG time, side-lying or supine strength 5.7 s during the arm ergometry treatment, more than half (9/16)
measure that exceeded two SDs of the respective group means. were able to demonstrated improvements greater than 5.7 s
No outliers were consistently associated with any particular during the hip abductor treatment.
subjects. Once again, in consultation with the physiotherapist,
it was determined that there was no reason to exclude these
DISCUSSION
data from the analysis as all tests were carried out in accord-
ance with testing instructions. The outcome of this study resulted in the partial rejection
A target wash-out period of 8 weeks between study periods of the null hypotheses that there would be no treatment ef-
(actual mean 7.4 weeks (SD 1.16)) was utilized to eliminate fect on either the primary or secondary outcome measures.
carry-over effects from period 1 to period 2. The lack of sig- The results demonstrate that a twice weekly program of hip
nificant period effects associated with baseline (p > 0.14 for all) abductor strength training is effective in improving TUG and
or post-intervention measures (p > 0.24 for all) suggests that the 2MW performance, balance confidence and abductor strength.
wash-out period was sufficient to preclude contamination of pe- In addition, this 8-week program was well tolerated by all
riod 2 baseline measures by gains achieved during period 1. This subjects as indicted by the excellent compliance of nearly all
is particularly relevant for the EC group where the gains accrued study subjects.
during the experimental treatment during period 1 may have Interventions targeted at improving functional performance
improved control baseline measures at the beginning of period 2. are important for TFAs as they tend to ambulate less frequently

Table II. Results for baseline and post-intervention primary and secondary outcome measures for experimental and control treatment phases
Baseline Post-intervention
Control Experimental Control Experimental
Mean (SD) Mean (SD) Effect size (d) Mean (SD) Mean (SD) Effect size (d)
TUG, s 30.0 (14.3) 31.3 (13.4) 0.100 29.6 (14.6) 24.6 (11.4)** 0.358
2MW, m 57.1 (17.9) 54.0 (15.9) 0.182 56.8 (17.3) 60.9 (18.2)* 0.235
ABC 52.8 (20.9) 53.2 (21.0) 0.018 52.8 (21.3) 59.2 (17.9)** 0.324
Houghton 5.7 (2.7) 5.7 (2.8) 0.000 5.9 (2.8) 5.8 (2.8) 0.021
Strength, kg
Sitting 10.3 (2.3) 10.4 (2.8) 0.077 10.3 (2.7) 11.4 (2.9)* 0.382
Side-lying 10.9 (3.8) 11.5 (4.0) 0.144 10.9 (3.2) 12.2 (2.5) 0.436
Supine 9.1 (2.0) 10.1 (3.1)** 0.394 9.8 (2.3) 10.0 (2.4) 0.114
Girth, cm 48.3 (6.5) 47.9 (5.9) 0.071 48.5 (6.2) 48.1 (6.2) 0.066
*p < 0.05; **p < 0.01.
TUG: Timed Up & Go; 2MW: Two-Minute Walk; ABC: Activities Specific Balance Confidence Scale; Houghton: Houghton Scale of Prosthetic Use.

J Rehabil Med 46
268 T. Pauley et al.

than transtibial amputees (TTA) (24); demonstrate limited en- that subjects were able to observe progressive improvement
durance (25, 26); report a higher incidence of community falls in strength gains over time. This suggests that the observed
than TTAs (27, 28) and, as a result of greater bone density loss improvement in strength translated to a perceived improvement
compared to both able-bodied adults and patients with TTAs in balance, whereas in previous studies an improvement in
(29), are likely at a higher risk of hip fracture. The results of function (i.e., walking ability) was not readily evident to the
the current study suggest that hip abductor strength training subject, thus balance confidence remained unchanged.
may, through improvement in functional performance, mitigate
these factors. Strength measures
Hip abductor strength improved while seated or side-lying, but
Functional outcome measures not while lying supine. Given that baseline supine strength was
Outcomes commonly utilized in the rehabilitation of patients significantly different, it is unclear why this difference failed
with amputation were used in this study. Published values to remain at post-intervention, particularly as post-intervention
for the TUG for TFAs vary widely and are often difficult to sitting and side-lying strength differed significantly. This ap-
discriminate as data are often aggregated for TFAs and TTAs parent incongruence may reflect inherent differences in test-
(18, 30). A study evaluating the reliability and validity of the ing manoeuvres. Seated and side-lying abduction may allow
TUG for patients with lower limb amputation, which found more force generation to be directed toward the hand-held
TUG score of 28.3 s (SD 12.2) for TFAs (16), is comparable dynamometer, while supine abduction may result in force being
to the range of TUG scores found in the current study, which directed both as an abduction force toward the dynamometer
ranged from 31.9 s (SD 13.6) at baseline to 24.3 s (SD 11.6). and an extension force toward the bed, thus dissipating abduc-
In a study comparing two different mechanical knees and tion force. Alternatively, this observation may be partially
the patients’ original knee, the reported TUG time with the explained by the fact that strength training was conducted in
original knee was 10.4 s (SD 3.7) for a group of TFAs (31). the seated position. Further examination of the reliability and
While quite different from the results of the current study, validity of hand-held dynamometer for assessing hip abduction
the differences may be ascribed to the characteristics of that force generation among patients with TFA may be warranted.
group which tended to be younger (67.8 years (SD 5.2) vs. The observed increased in hip abductor strength is largely
58.8 years (SD 11.9)) and had experienced their amputation consistent with Nolan (14) who found that a 10-week home-
much earlier (7.3 years (SD 8.2) vs. 31.8 years (SD 17.3)); in based training program consisting of twice weekly balance,
addition, inclusion criteria included 6–8 h daily prosthetic use co-ordination and hip flexion/extension exercises resulted in
and ability to walk for a distance of 1 km. Nonetheless, as the significant increases in hip flexor/extensor strength in the re-
TUG has been established as a measure of functional walking sidual and intact limbs, while hip strength measures remained
speed related to physical mobility (16), a 17% improvement largely unchanged among the control group. However, where
in TUG time clearly suggests the effectiveness of hip abduc- Nolan was largely focused on improvements in muscular
tor strength training. Only 2/16 subjects were able to achieve strength and restoration of running ability, the current study
improvements in TUG score exceeding the 5.7s MDD90 score focused primarily on functional outcomes commonly used in
as a result of arm ergometry, while 9/16 subjects exceeded 5.7s the rehabilitation setting and suggestive of improved commu-
as a result of hip abductor strength training. nity ambulation. In addition, where Nolan utilized relatively
2MW times are also often not reported in a manner allowing young patients with amputation due to trauma, tumour or
discrimination between TFAs and TTAs (32, 33). In the current congenital problems, the patients included in the current study
study mean 2MW times at the beginning of both intervention were a mean of 26.7 years older with a history of diabetes and/
treatments, as well as the mean 2MW time at the completion or peripheral vascular disease.
of the control treatment, were comparable to a previously In spite of the exercise-related improvements in abductor
published report of TFAs when using a locked-knee prosthesis strength, the values obtained at the completion of the ex-
(34). Given that the 2MW test has been shown to be related to perimental treatment in the current study remain well below
ambulation performance in the community (32), an improve- reference values for able-bodied male (26.7 kg, non-dominant;
ment of 7% in 2MW performance is notable. 26.4 kg, dominant) and female adults aged 60–69 years (16.8
The significant improvement in perception of balance con- kg, non-dominant; 17.6 kg, dominant), as measured in the
fidence is a welcome result of this program, given the study supine position (38). In addition, the relatively short duration
group tended to report much lower balance confidence relative of the intervention treatment and the absence of significant
to non-vascular patients with amputation (35) and indeed has differences in girth measures suggest that the observed
been identified as a variable that should be closely considered improvement in hip abductor strength likely resulted from
by clinicians as it relates to functional performance (36). neurological adaptation to the strength training as opposed to
Though balance confidence at discharge from prosthetic reha- muscle hypertrophy (39). Given the gap that remains between
bilitation has been shown to be predictive of social activity, it strength measures seen in the current study and age-matched
tends not to change over time, in spite of improvement in walk- reference values as well as the absence for significant muscle
ing ability (37). In the current study, the significant improve- hypertrophy, it is possible that continued exercise training
ment in balance confidence may have resulted from the fact would allow additional strength gains to be achieved. Though

J Rehabil Med 46
 Hip abductor training in transfemoral amputees 269

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This project was funded by a research grant provided by the Canadian ability, validity, and responsiveness to change. Arch Phys Med
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