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Association Between Balance Ability and Functional Mobility in Transtibial Amputee Patients 
Olaitan Olabiyi1, Ayomide Ajibewa1, Bakhat Ali¹, Bushra Madad Malik², Noor Jan², Ayesha Rayyan3, Saba Memon², Salman Hyder², Waqar Ahmed3
Published online: December 2025
  © The Author(s) 
Abstract
Background: Transtibial amputation affects mobility and independence, often compromising balance and functional mobility. Physiotherapy interventions focusing on balance and functional training are essential to improve outcomes. This study evaluates the relationship between balance ability, measured by the Berg Balance Scale (BBS), and functional mobility, assessed using the Houghton Scale, in transtibial amputees in Pakistan.
Methods: This cross-sectional study included 30 transtibial amputees aged 20–72 years, recruited from the Sindh Institute of Physical Medicine and Rehabilitation between April and September 2024. Balance and functional mobility were assessed using three tasks from the BBS and the Houghton Scale. Data were analyzed with SPSS 23; descriptive statistics, Chi-square tests, and Spearman’s correlation were applied, with p<0.05 considered significant.
Results: Participants were predominantly male (80%), with half aged 20–35 years. Younger participants and those without diabetes demonstrated higher functional mobility. Most participants (96.7%) engaged in regular exercise, and 43.3% achieved independent community mobility. Older participants had lower balance (BBS: 10.4±1.5) and functional mobility (Houghton: 8.2±1.7) scores. A moderate positive correlation was observed between BBS and Houghton Scale scores (ρ=0.432, p=0.017).
Conclusions: Balance ability is positively associated with functional mobility in transtibial amputees. Targeted balance training improves independence and reduces fall risk. Diabetes and trauma were major causes of amputation. Structured rehabilitation programs are essential for optimizing functional outcomes.
Keywords: Berg Balance Scale, Houghton Scale, Transtibial Amputees, Pakistan


Corresponding Author:
Bushra Madad Ali Malik, MPHIL 
Email: bushramadadalimalik@gmail.com

Introduction
Amputation, defined as the surgical removal of a body part, significantly impacts an individual’s mobility, independence, and quality of life. Transtibial amputation (below-knee) is among the most common lower-limb amputations and presents challenges in balance, functional mobility, and prosthetic use. Comprehensive rehabilitation strategies are essential to restore mobility, enhance balance, and facilitate reintegration into daily and community activities.¹
The etiology of amputation varies globally. Peripheral vascular disease, diabetes mellitus, and trauma are major causes, with regional variations in prevalence.² Traumatic amputations, particularly resulting from road traffic accidents, account for a significant proportion of cases in Asia, with incidence rising between 1990 and 2019.³ In Pakistan, lower-limb amputations are frequently related to diabetes complications and trauma, with diabetic foot complications such as infections and ulcers contributing to 60–80% of cases.⁴ Inadequate diabetes management, delayed medical intervention, and poor adherence to treatment exacerbate the risk of limb loss.⁵
Rehabilitation following transtibial amputation requires a multidisciplinary approach, including physiotherapy, occupational therapy, prosthetic training, and psychological support. ⁶ Among the key rehabilitation objectives are improving balance, enhancing functional mobility, and reducing the risk of falls. Balance deficits negatively affect the ability to perform daily activities, leading to functional limitations and reduced quality of life.⁷
Validated tools such as the Berg Balance Scale (BBS) and the Houghton Scale are widely used to assess balance ability and functional mobility in amputee populations. ⁸,⁹ Prior studies have demonstrated that balance training and functional exercises improve prosthetic use, reduce fall risk, and support community reintegration.¹⁰
Despite the clinical significance of balance and mobility in transtibial amputees, data from Pakistan remain limited. This study aimed to investigate the relationship between balance ability and functional mobility in transtibial amputee patients, providing evidence to guide rehabilitation strategies tailored to this population.
Methods
Study Design and Setting
This cross-sectional, descriptive study was conducted between April and September 2024 at the Sindh Institute of Physical Medicine and Rehabilitation (SIPMR), a multidisciplinary center equipped for comprehensive amputee care. The study was designed to evaluate the relationship between balance ability and functional mobility in transtibial amputee patients.
Participants
A total of 30 participants with unilateral transtibial amputation, aged 20–72 years, were recruited using a convenience sampling method. Participants with cognitive impairments limiting their understanding of study procedures were excluded. The sample size was calculated based on a correlation coefficient of 0.69 between BBS and Houghton Scale scores, at α = 0.05 and 80% power (β = 0.2), exceeding the minimum required sample of 14 participants.


Ethical Considerations
The study was approved by the Institute’s Ethics Review Committee (ERC number: PGC-ERC/2024-03/03). The requirement for written informed consent was waived due to the observational nature of the study. All procedures adhered to the principles of the Declaration of Helsinki.
Data Collection
Demographics and Clinical Characteristics
Participants’ age, gender, body mass index (BMI), amputation etiology, comorbidities, duration of amputation, and exercise habits were recorded.
Outcome Measures
Balance and functional mobility were assessed using the following validated instruments:
1. Berg Balance Scale (BBS) – Three tasks were selected from the original 14-task scale, focusing on:
· Standing with eyes closed
· Looking behind over the shoulders
· Turning 360°
Each task was scored from 0 to 4, with higher scores indicating better balance ability.
2. Houghton Scale – Used to assess functional mobility and prosthetic use, scored from 0 to 12, with higher scores indicating greater independence.
Procedure
Observational assessments were conducted by trained physiotherapists. Participants performed the three selected BBS tasks and completed the Houghton Scale questionnaire regarding their functional mobility in household and community settings.
Statistical Analysis
Data were analyzed using SPSS version 23. Descriptive statistics (mean ± standard deviation, frequency, and percentages) were used to summarize participant characteristics. Associations between categorical variables (e.g., age, comorbidities) and functional outcomes were examined using the Chi-square test. The Spearman correlation coefficient (ρ) was calculated to assess the relationship between BBS scores and Houghton Scale scores. A p-value <0.05 was considered statistically significant.
Results
A total of 30 transtibial amputee patients participated in the study. Half of the participants (50%, 15/30) were aged 20–35 years. The majority were male (80%, 24/30), with a male-to-female ratio of 4:1 (Table 1).

Table 1. Frequency of Amputee Participants by Gender

	Gender
	
	

	Male
	24 (80.0%)
	

	Female
	6 (20.0%)
	








Participant Demographics and Clinical Characteristics
Table 2 presents the mean age, BMI, time since amputation, and duration of exercise. Age significantly impacted balance and functional ability (p = 0.001 and p = 0.043, respectively), whereas BMI, exercise duration, and time since amputation showed no significant association with BBS or Houghton Scale scores.
Table 2. Association of Clinical Characteristics with BBS and Houghton Scale Scores
	Clinical Characteristics
	Mean ± SD
	p-value (BBS)
	p-value (Houghton)

	Age (20–78 yr)
	45.5 ± 14.7
	0.001
	0.043

	BMI
	25.2 ± 3.3
	0.073
	0.567

	Time since amputation (yr)
	4.6 ± 4.6
	0.623
	0.445

	Duration of exercise (min)
	37.7 ± 22.4
	0.138
	0.208

	Effect of Exercise (Yes/No)
	–
	0.785
	0.278



Functional Outcomes by Community Independence
Table 3 shows the differences in BBS and Houghton Scale scores across different levels of community independence. Higher ability groups performed better, demonstrating the effectiveness of the scales in distinguishing functional independence.
Table 3. Significance of Differences in Outcome Measures Across Ability Categories
	Outcome Measures
	Independent Community
	Limited Community
	Household Limited
	F / t-Value
	p-Value

	Houghton Scale (0–12)
	13 (9–12)
	15 (6–8)
	2 (0–5)
	F=42.800
	<0.001

	3-Task Berg Balance
	11.3 ± 1.7
	8.5 ± 3.4
	5.4 ± 4.3
	F=33.090
	<0.001



Gender-Wise Distribution
Table 4 displays participant characteristics by gender, including age, time since amputation, BMI, and duration of exercise. The total row has been removed for clarity.
Table 4. Gender-Wise Distribution of Participants (ANOVA)
	Gender (N)
	Age (yr) Mean
	Min
	Max
	Time Since Amputation (yr) Mean
	Min
	Max
	BMI (kg/m²) Mean
	Min
	Max
	Duration of Exercise (min) Mean
	Min
	Max

	Male (24)
	48.21
	20
	72
	3.83
	0
	19
	25.03
	19.10
	34.90
	37.92
	0
	120

	Female (6)
	34.83
	26
	43
	7.83
	1
	13
	25.96
	21.04
	30.70
	36.67
	30
	60

	p-Value
	0.044
	–
	–
	0.058
	–
	–
	0.550
	–
	–
	0.905
	–
	–



Etiology, Comorbidities, and Exercise
Diabetes mellitus (63.3%) and road traffic accidents (33.3%) were the leading causes of amputation. Although 96.7% of participants engaged in exercise, only 43.3% achieved independent mobility, highlighting the need for targeted rehabilitation (Table 5).
Table 5. Participant Characteristics and Frequency Distribution
	Variable
	Category
	Frequency (%)

	Gender
	Female
	6 (20.0)

	
	Male
	24 (80.0)

	Comorbidities
	Diabetes Mellitus – Absent
	11 (36.7)

	
	Diabetes Mellitus – Present
	19 (63.3)

	
	Hypertension – Absent
	22 (73.3)

	
	Hypertension – Present
	8 (26.7)

	
	Malignancy/Transplant – Absent
	14 (46.7)

	
	Malignancy/Transplant – Present
	16 (53.3)

	Others
	Absent
	25 (83.3)

	
	Present
	5 (16.7)

	Etiology
	Diabetes Mellitus
	7 (23.3)

	
	Gangrene
	7 (23.3)

	
	Malignancy
	4 (13.3)

	
	RTA
	10 (33.3)

	
	Transplant
	2 (6.7)

	Exercise
	No
	1 (3.3)

	
	Yes
	29 (96.7)

	Houghton’s Ability Categories
	Limited Household
	2 (6.7)

	
	Limited Community
	15 (50.0)

	
	Independent Community
	13 (43.3)



Correlation Between BBS and Houghton Scale
A moderate positive correlation was observed between the 3-Task BBS and Houghton Scale scores (ρ = 0.432, p = 0.017), indicating a meaningful association between balance ability and functional mobility (Table 6).
Table 6. Correlation Between 3-Task BBS and Houghton Scale
	Scale
	Houghton’s Scale ρ
	p-value

	3-Task Berg Balance Scale
	0.432
	0.017



Discussion
This study examined the relationship between balance ability and functional mobility in transtibial amputee patients. The results demonstrated a significant association between balance performance, measured using the Berg Balance Scale (BBS), and functional mobility, assessed via the Houghton Scale. Participants with higher balance scores exhibited superior functional independence, supporting the importance of balance in overall mobility and community reintegration.¹
Age and comorbidities, particularly diabetes mellitus, were significant determinants of functional outcomes. Older participants and those with diabetes exhibited lower BBS and Houghton scores, reflecting reduced postural stability and impaired mobility. These findings are consistent with previous research, which has reported that aging and diabetes-related complications negatively affect proprioception, muscle strength, and coordination, thereby increasing fall risk and limiting functional independence.²–⁴
Gender disparities were observed, with fewer female participants accessing rehabilitation services. Although males predominated in this cohort, females exhibited slightly lower balance and mobility scores. This may reflect socio-cultural and economic barriers that restrict female participation in rehabilitation programs, a trend noted in previous studies.⁵,⁶
The moderate positive correlation between BBS and Houghton Scale scores highlights the interdependence of balance and functional mobility. This aligns with evidence indicating that targeted balance training improves gait performance, prosthetic use, and overall independence in daily and community activities.⁷–⁹
Regular exercise and physiotherapy interventions were associated with improved functional outcomes. Most participants (96.7%) engaged in physical activity, yet only 43.3% achieved independent community mobility, underscoring the need for structured, individualized rehabilitation programs that incorporate balance and functional training. Rehabilitation programs integrating muscle strengthening, coordination exercises, and proprioceptive training are essential for optimizing outcomes in this population.¹⁰,¹¹
The study findings emphasize the need for early intervention, particularly for older individuals and those with comorbidities. Incorporating technology, such as virtual reality or wearable feedback devices, may further enhance rehabilitation outcomes by providing personalized, real-time feedback during balance and mobility training.¹²,¹³
Strengths and Limitations
A key strength of this study is the use of validated outcome measures (BBS and Houghton Scale) to assess balance and functional mobility. The study provides baseline data on transtibial amputees in Pakistan, which can guide rehabilitation strategies. Limitations include a small sample size, convenience sampling, and the cross-sectional design, which limits causal inferences. Future studies with larger samples and longitudinal designs are recommended to confirm these findings and evaluate the long-term impact of targeted rehabilitation interventions.
Conclusion
Balance ability is strongly associated with functional mobility in transtibial amputees. The Berg Balance and Houghton Scales are reliable tools for assessing rehabilitation outcomes. Impaired balance negatively affects walking performance and community mobility, particularly among older patients and those with diabetes. Targeted balance training and structured rehabilitation programs can improve functional independence, reduce fall risk, and enhance quality of life. Diabetes mellitus and trauma were major causes of amputation, highlighting the need for early, individualized rehabilitation strategies.







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