Hi, I'm David Lawrence. And in this video,
we're diving into step training and we're going to get you walking.
Okay. So when we're talking about prosthetic step training,
I want to go over a few basic ground rules for us first.
And then we'll talk about the specifics of how I go through this process.
One thing that's really important is that if you haven't seen already our
amputee pregait, motor control exercises, or amputee motor standing,
motor control exercise video,
you need to see that you need to look at that because it's going to talk about
proprioception and a lot of awareness things that I'm going to assume, you know,
as we go through this process. So check out that video. If you haven't,
that will really help you with what we're going to talk about here.
Second thing I want you to understand is that no matter what technology we're
working with, we are going to basically treat,
teach the person to walk the same way.
I don't teach a microprocessor gait or a below-knee gait or an above-knee gait.
We keep human gait mechanics getting the technology the best we can towards that
technology. And the last thing is age. You might think, Oh gosh,
you're treating one person in a certain way. Nope.
I teach human gait mechanics the same way, eight years old to 80 years old,
it doesn't matter.
You're going to get the same basic technology training or technique on training
is probably a better word.
And I want you to understand that you do make variations based on age or a
person's activity level, but the principles of the mechanics are the same. Okay?
So with that being said, we're going to get started. And how do we get started?
We start in a position from our last video of finding neutral where a patient
is, but now we have to look into stepping.
And I get a question a lot from people is,
do I learn to step with my right foot first or my left foot first,
my prosthetic first or my non-prosthetic. First,
I tend to teach someone to teach step first with their non-prosthetic leg.
The reason is because we always want to learn and establish stance before swing.
In other words, we want load to the prosthetic.
So you get the technology load energy back. If I learned this,
pick up the prosthetic and just step it forward or carry it forward,
I tend to repeat that same pattern of just carrying the prosthetic.
What I want you to learn to do is how to load the prosthetic at the energy back
from it and let it carry a lot of its own weight. So with that process in mind,
I want to start with the idea of how do I learn to load the prosthetic
completely. So Tracy,
what I'm going to have you do is to step back about half a step.
That's plenty right there.
And she's in a position where she's got that prosthetic a little bit in front of
her, and we're going to go from a position and not a real wide stance.
If someone's just getting started,
you can keep it a pretty narrow stance like this to get them to feel for it.
Then you'll also notice where my hands are on her pelvis.
This is where the mechanics are going to occur,
where I can help her get the confidence to put her body weight in the right
position. I don't want to be standing back from her.
I want to be in a position where she can feel confident to really get on the
prosthetic.
Cause what we're going to do here from the very beginning is learn how do I load
the prosthetic?
It's gonna feel pretty comfortable where she is right now because all her
weight's on her sound limb,
but to get her to bring that weight forward onto the prosthetic gets into a
trust factor.
And what I need her to do is come all the way to what we call mid stance or
pylon vertical. That pylon should be vertical.
So Tracy when she first starts neutral pylon will feel like it's back here.
She won't really want to commit onto that prosthetic. So that's why you see,
we have mirrors all around here and we're going to use mirrors to help Tracy.
See, as she comes forward to get that pylon vertical, once it's vertical,
the next level of commitment is you'll notice that her other leg is straight.
If she relaxes that leg, that's really, what we call pre swing.
This is normal gait, mid stance pre swing on the other side.
But to relax this knee, she had to fully commit her weight to that prosthetic.
And that sounds simple,
but it's not simple if it's something you haven't done a lot of.
So I want you to shift your weight back. Step back just a little bit farther,
a little bit more than that. There you go.
Give yourself a little bit of room to work. Now, pylon's leaning back.
She's just made initial contact.
I want you to bring your weight forward Tracy come all the way into pylon
vertical, relax your other leg, right? And it should come into that position.
This is a neutral stable position.
If she doesn't get herself all the way to pylon vertical,
she won't be completely balanced on top of the prosthetic. So all we're doing,
and this can take time just to repeat this process over and over.
Someone could be standing at their kitchen sink. They could be using a walker,
lots of different mechanisms to simply go through this process of initial
contact into mid stance, true mid stance with your other leg, relaxed.
That means your hands are on for support,
but you're letting your other leg relax and get ready to take a step.
From that process we then want to finish stepping. So Tracy,
what I'm gonna have you do is come forward. You're going to load that leg.
Find pylon vertical. Your other leg is totally relaxed.
And then you're simply going to go ahead and step through.
But at this point in time,
you still keep a lot of the weight on the prosthetic side.
We want to see that that line across the metatarsal or where your toes meets
your foot. That there's a break there there's pressure there.
That pressure is the energy in that prosthetic or bending that prosthetic foot
to get energy back from it. If I just relax all of her weight off of it,
and it's basically a dead leg,
there's no energy going to come back from that foot.
I want to keep her in that position and notice where I'm at with my hands.
Again, I'm pressing down and keeping,
helping her feel the pressure on that prosthetic.
While my other hand on her other hip is helping bring her pelvis forward,
a little creating that rotation. Now I'm gonna have you step back, Tracy,
and we're going to do that all in one motion. So she's here nice and strong.
She has all her weight on the leg. Come forward. Let that knee bend,
take the step. Keep the weight on the prosthetic and finish right there.
That is what we call stance phase that is taking that prosthetic from heel
load. Come all the way back again. One more time and a little bit farther back.
There you go. Thank you all ...
all the weight on the heel load you're coming forward to mid stance.
Take the step,
all the weight into terminal stance all the way it's on the prosthetic.
And she's ready now to move forward with the next step.
So with that in mind, step back just a little bit, Tracy,
I would have somebody repeat that action over and over and over again,
lots of repetitions. Get the feel for it.
I'll put my hands in place to help her feel the pelvic action.
And then I'll talk to her about getting that same feeling of repeating that
motion yourself and just getting over and over and over of what that motion
feels like. So if we've got stance phase, what have we done?
We've learned how to load the prosthetic.
And now we've got to learn how to get the energy back from it because we don't
want to load it and just leave it on the ground. We want to load it.
And when I get the energy back, which takes us into swing phase,
if I'm not going to tote or carry or pick the leg up and move it forward,
I need the energy that I've just put into the foot to begin to move the foot
forward.
So swing phase then is taught very basically I'm going to put my foot on top of
her foot for a second. And there's a reason for this.
One of the negatives of a prosthetic limb is they will not plantarflex.
They won't actively plantarflex in terminal stance. If you stand on the heel ...
of a single access ankle,
that foot will go down or plantarflex or point to the ground. But in,
in this situation, any prosthetic that we have today,
once you get into toe load or terminal stance position,
the foot is going to at best hold neutral. It will not go into plantar flexion.
Now why is that so important is because when you and I move forward and we move
our pelvis forward,
our foot plantarflexes or points down a little bit before we leave the ground,
why does that occur?
It occurs so that our knee will bend passively as our hips move forward.
What I do to move forward and what she does on this side to move forward is
simply move her hips forward and that leg will bend and step forward. However,
with the prosthetic side, if we're not careful, when she brings her hip forward,
the leg will just slide across the floor, right? It won't even...
come and pick up just a little bit for me.
It'll just come forward and slide that foot without letting the knee bend.
Right? So what we want to do is keep her in contact with the ground.
So when she's here, I want to come back to that hip bone.
It's in the front and say to Tracy,
I just want you to bring that hip forward forward at me. Don't pick your leg up,
just bring your hip forward as you do,
I'm going to help her feel that what happens is that knee wants to bend and you
notice it bend, bends passively. I'm not telling Tracy,
I want you to bend your knee. That's a mistake.
If she's going to try to bend your knee, her hip off to go backwards,
to push your hip forward or to push your knee forward. Excuse me.
What we want from her is to say, leave that leg kind of behind you.
A lot of weight's on the toe,
bring your hip me as you bring your hip at me that knee will bend.
If it bends passively your her energy or her weight is still moving forward,
which is going to allow her to take the step here in a second. So again, Tracy,
I'm going to come back. I'm going to put a little pressure on your hip.
I want you to push into my hand. There you go,
come right at me and that need bends. You don't have to try to make a bend.
It bends itself again.
So a mistake we have for people as he kick the leg forward,
or your make the knee bend. You don't want to do that.
Push that hip at me as you do, boom, you can see that in the, all she has to do,
this is her power that trigger of that hip coming forward.
And she now has a powerful step moving forward. And we'll go back again.
So what we're going to do now, Tracy,
since we've released some of the energy of that foot into making the knee bend,
we want to take it all the way into a step. So this time,
what you're going to do as you're pushing into me,
and you can feel that knee bend as not after it bends as it's beginning to bend,
take a step. Don't kick don't throw don't do anything crazy. Just take a step,
really just take a normal step. All right. So here we go.
We bring that hip forward and you feel it start to bend step and
land and we've come all the way forward.
Now you'll find a lot of people will step and leave that leg stuck out in front
of them. Again, they're not under load,
the leg's not really committed to the next step.
You always want to take that step and help the patient with their hips finished
coming all the way up on top of the prosthetic or fully loading on it.
That puts them right into position for the next step to occur.
So we'll step all the way back and we're gonna repeat that process.
So here you go. Step forward with this guy.
We're going to start at that point in time. There you go.
I'm going to move my foot out of the way.
I'm going to have her push your hip into my, there you go. Feel it bend,
take a step and come through. Now.
You'll notice there a little bit of a drag and scuff.
A lot of that's going to occur because of the timing is going to be slow at this
point, I'm going a little bit off, so don't get worried.
If there's a little bit of a scuff of the floor right now,
I just want you to get you to the mechanics.
We'll fix that scuff on the floor by simply how she moves her pelvis through the
motion. So go ahead and step back again.
There you go just stay right there again, the key,
the trigger for your walking power Tracy comes from right here.
So you bring that point right into me. There you go. Step boom.
Now what did I do differently right there?
What you couldn't see on the video is...
and What Tracy felt is I gave her a lot of pressure.
And as she was pushing into me hard, I took the pressure away.
That means her hip came through much faster than she would have thought it was
going to. And as it did, boom, that leg just jumped forward.
She almost had to put no energy that the leg almost had a life of its own and
jumps forward. That's what we want it to do. We want it to move.
We want it to go. But what I have to do is learn that my...
my manual skills of applying pressure,
pulling her through the motion if she needs it. But if I can tell she can do it,
give her some pressure and then get out of her way and allow all of that
pressure to move forward.
And the step occurs and that step occurs and the leg is going to take off. Now,
what we're going to do is we're going to put those things together.
So I just want you to step back for me.
And we're going to take a couple of small steps a little bit more.
We're going to start kind of in neutral as if you are going to start walking.
And then if I'm working with somebody,
I'm going to start in this position where again, I'm here.
I gotta be out of her way, right?
So I've gotta be able to get out of her way at the same time.
But at the same point, I need her to get the mechanics of getting started.
So your first step is going to start with this side. Exactly.
So come back and I want you to think you're going to do a little shift into the
prosthetic, to feel the weight, and you're going to, again, don't ignore that.
You learned that from the last video,
you really have to understand your foot position in space.
But what I want you to do is a lot of weight on that prosthetic step forward
with your right foot. There you go. Push your hip into me. Take that step. Good.
Keep coming, press in to me. There you go. Press in to me.
Good. Turn it around.
Now I can do the same thing from behind her.
So I'm in a position here where I'm going to say the same thing, Tracy.
All I want you to think about is that your hips are moving.
You're thinking about load on the prosthetic and getting my hips moving.
So you're going to shift into the prosthetic a little bit.
Take that step forward, push that hip forward into my hand. Take that step.
Good push forward in my hand. Take that step. There you go. Push forward.
Take that step. Push forward. Take that step. Excellent.
Come back around to me and we'll come right up to here. There you go.
Perfect.
So the key with this when someone's getting started is that there's,
this can get somewhat confusing. Gosh,
all these different things I think about if you break it down and keep it
simple, you want to think about three things while we're getting started.
Two we've already talked about, and one,
we're going to start here in just a second. The first is load.
I've got to load the prosthetic.
If I don't think about putting a dent in the floor, every time I walk, right?
Some people will talk about putting like a think like there's a cockroach
underneath the knuckle of your big toe and I'm going to crunch it,
whatever it takes to feel pressure. And you feel like man,
I'm walking heavy on that prosthetic.
You won't be more than as much as you think you will.
But that load is going to make the device respond to you.
The second thing is your power. Doesn't come from lifting the leg.
The power comes from energy into the ground and pulling the trigger from right
here at your hip. If that hip rotation occurs, underload bang.
You can see the prosthetic and feel the prosthetic jump forward,
it wants to move. If I unload the prosthetic and lift and carry it,
I have lost all that energy, right? So my principles are number one.
If you're thinking I got too many things to think about.
So let's think about load the ground, load the ground, put a dent in the floor.
If I do that, that'll get you going. Number two, if you're saying, okay,
that's pretty good. Every time I come off of step forward, terminal stance,
I'm on my toe, I want to think all my power is right here.
I'm going to move my hip forward and that legs going to respond. All right.
If I go just from my hip and I'd think nothing else, nowhere else in the cycle,
but I moved that hip forward and that leg is going to respond for me. All right.
So step back. And the last component is if you've got that,
which is what we talk about now is bringing the arms into the equation.
Because when somebody walks, they obviously have good legs swinging.
If we're getting the pelvis moving,
but many times they've come off of walking with crutches or on a Walker.
And so they walk very stiff, very rigid. They're afraid of falling,
but they're also got very used to my arms. Don't swing when I walk.
So when it gets somebody to say, Oh gosh,
how do I get that sense of arm swing back.
This is more confusing than you think.
If you've ever tried to think about swinging your arms correctly and walk,
you realize it actually messes you up much of the time.
So we don't want to overthink this process, but I want to say Tracy,
just this general idea.
If you're going to get started and think since we're going to step forward with
this first, this foot first,
all I want you to think about is as you take that step,
I'm going to slide this hand forward. That's all I want you to think about.
Don't do anything more than that. Don't overthink it,
just do that because that counter rotation of the shoulders coming forward,
counters the pelvic rotation, and that's where power from when you walk.
So when this hip comes forward, that leg, that hand goes forward.
And then we just repeat that process.
So we're just going to take two steps where you're going to take a step and then
step with the prosthetic. So you're going to go ahead and step and step boom,
just that idea. Get that idea of doing that a few times.
That sense of getting the legs and arms to move separate from each other and
opposite.
The other way to do that is when someone gets away from the parallel bars,
is this idea. I like doing when you're here and saying,
when I take my very first step,
all I want to think about is I'm going to step with this foot.
As I take that step,
I'm going to reach for it like I'm going to shake someone's hand, right?
I want to reach for like, I'm gonna shake someone's hand that I like, right.
This isn't going to be like, Ooh, like a wimpy thing.
You're going to be step foward, reach forward.
I want you to feel that arm go forward. And then I want you to do is reach for,
to shake their hand and on my second step, there you go.
I'm going to step forward and reach out to shake their hands.
And then I'm going to relax. I don't want to walk like a robot.
I just want to think shake, shake, relax.
If I've got those arms moving a little bit,
they'll tend to keep on moving now as a therapist,
how I want to work on that is come up here, Tracy.
And we're going to step forward just a little bit and turn around right there.
If she's in this position and I've got her in position.
I want to be here at her shoulders. I remember we talked about pelvis.
That's really important for her to get that sense of pelvic control.
But once she starts to get that pelvic motion,
I'd want her to come back into not a stiff and rigid walk,
which means rotation of the shoulders is what gives me arm swing.
So I have to be a little bit coordinated.
So she's going to step with her right foot. First.
I want to step with her and I'm going to give her a little bit of shoulder
action. So step back. So we're going to just go ahead and step good and step.
So that's all I'm doing. Just relax, just relax.
And I'm really doing that for her. Go ahead and turn around and come back.
I can do the same here. Just walk right at me. Good. Good.
I'm just getting out of her way. Perfect.
But that motion to get her to overthink it.
Some people will get worried about that with the arm action and that motion will
create a loss of pelvic action.
So you have to come back to make sure she still has this feeling good and step
right back to the middle. So when she's here, that's good.
That step action is going to come forward and be very aggressive.
The last thing we want to talk about on this is the fact that pelvic rotation
and pelvic power, when you're walking or moving,
you have to remember that most of your power comes from your hips and comes from
rotation of your hips. And we know this from sports, right?
If you think of anybody hitting a baseball or hitting a golf ball,
you don't do that with your arms, right?
You do that by bringing your hips through the motion.
And you'll find that's where her power comes from.
So ultimately Tracy's best power is going to come from, as she's walking,
is this pelvis always driving forward. I'm going to always check that.
So if she's going to walk, go and just walk at me. And if I'm here,
just go ahead and walk at me and I create a pressure right there.
She should be able to just push me right out of the way, push me out of the way,
push me right out of the way. Good turn around. Same thing.
Going back as she's walking, go ahead and walk. If I create a pressure here,
she should push, see I can stop her.
So she should push me right out of the way there you got Tracy,
push me right out of the way. Good. Same thing. One more time coming back.
So I create some pressure. Keep coming at me and pressure, pressure.
There you go. Push me out of the way. Ooh, there you go. Push me out of the way.
Yeah, there you go.
So you can feel the power in her step as she starts to really drive that hip
forward. She just drives me right out of the way. Why is that important?
That's important. Not only for good mechanics and good energy conservation,
but also a lot of amputees don't like to walk in public where there's a lot of
people around. They feel like if they're going to get bumped,
they're going to get knocked over.
So the power in their walk comes in that pelvic rotation,
that pelvic rotation is what keeps you moving forward.
If you bump into something, it's not like, Oh, I'm knocked off balance.
I still have strength and control. Thanks for watching.
And we hope that you found this helpful.
This video is part of a series on prosthetic interventions ranging from managing
the residual limb after amputation to running with a prosthesis.
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