Hi, I'm David Lawrence and in this video,
I'm going to show you how to navigate stairs and ramps with a prosthetic device.
When we're working on stair training you want to start with the basics and going
up and down steps is a one and a step at a time process and something,
a lot of people have heard.
It says up with a good down with a bad or up with the sound limb,
down first with the prosthetic limb. So in this particular case,
all Keith is going to do is find that stance control on this side.
Step up with his sound foot. Now, before he brings his prosthetic up,
he just wants to think about not making this mistake. So let it slide forward,
Keith and come right up against a step and dragging it up the step.
If that step has a lip on it, all,
he's going to sink that prosthetic in like a hook and it is going to pitch him
forward. So he's wants to feel like once he steps up,
he tightens his butt muscles and clears that prosthetic and then brings it
forward. So step up with the sound foot, clear it, step it forward.
There you go. Clear it. There you go.
And always clear by going slightly backwards.
That way if you're walking beside someone,
you're not going to kick them by going out to the outside.
So it's a slight motion. Probably doesn't have to be as much as he is,
but he's demonstrating for us perfectly. Okay. Now we're coming down.
You just want to do one step at a time. The prosthetic limb comes first,
so he wants to step down with the prosthetic, tighten his butt muscles,
make sure the knee's engaged and simply step down to it. Step again,
and simply step down to it. One more step again. Simply step down to it.
Now let's say Keith is having a little more trouble.
He's a little more worried about this, or he feels like the knee is unsteady.
So if he turns about a 45 degree angle right here, step down again now Keith.
Here notice what's happening.
The pressure is pushing into the outside of the knee,
which is not the direction, the knee bends.
So it builds in natural stability for him. Then bring your other foot down.
So if he keeps himself sightly sideways on an unstable surface,
this gives him a lot more knee control. Turn back this way.
Let's say now Keith is doing well.
And he really wants to walk up steps at the same pace of everybody else,
but he really can't go more than one step at a time.
So what he's going to do is instead of going leg over leg,
which can be done on very few microprocessor, prosthetics,
not overly functional at this point in time,
but it's good moving in that direction. But in most prosthetics,
what Keith is going to do both hands on is simply skip one step.
So step up to the next step, bring the prosthetic to it. There you go.
Skip a step, bring the prosthetic to it.
If he walks at this pace with someone going step over step,
he'll end up at the top of the steps at the exact same pace.
Coming down the steps now what Keith is going to work on is using the
microprocessor for control. So both hands on the rails,
what I want you to do is start Keith with at the top,
take this prosthetic foot and you're going to hang it slightly off of the step.
That means that we're clearing some of the toe.
He's going to tighten his butt muscles to stabilize,
step off with the other and ride the hydraulic down. There you go.
So step out, ride the hydraulic down. There you go. Step on it,
heavy, a little bit heavier. Good.
Now there's a couple of different ways that people teach to do this.
One is kind of what Keith was showing you there.
When you step off land on a bent knee and try to control it.
I prefer the training of having someone come down on the knee, stabilized,
feel a second of control.
Bring the weight center over the top and then let the knee lower down. So Keith,
if you go back up, we're going to try that again. So do me a favor. Come down,
feel that stability. Then just push your hips forward.
Keep your hands on the whole time and feel that stability.
Bring your hips forward. Feel that stability, bring your hips forward.
Feel that stability. Bring your hips forward. That is what I like.
So when we start this process out, we're going again,
do one step at a time below knee or above knee doesn't matter.
So all Dan's going to do is balance on the pro...,
The other way around balance on the prosthetic,
Step up with the left foot and bring the prosthetic up to it. That's it.
And then do the, again, repeat that.
It's all he's doing find his balance on the prosthetic.
Step up with the sound foot. Balance, step up, balance,
step up balance, step up and balance.
Step up. So we're coming down the step. You just want to do one step at a time.
Prosthetic first, tighten that quad. Then come down to it. There you go.
Tighten up, come down to it. Feel that thigh tighten up. Come down to it again.
If you're on insecure, hold for a second coming down step,
you can turn slightly. Nope, this way.
Perfect step down with that prosthetic and push a little more weight into the
outset that knee can't bend at all now. So it's very stable feeling.
If you were coming down a step that you really didn't trust,
or maybe coming down some rocks, you want to get that point where I feel okay,
real stable and lock that knee. And it's not,
it can't come out from underneath me and then step down.
So it just gives you a little more stabilization to come down a really steep or
something more unsteady.
Now there's no reason why a below knee amputee can't go up and down, steps,
leg over leg.
The concern going up the steps is just to make sure you clear the toe.
So as you're coming up that step, if he doesn't get enough knee bend,
he's going to catch the foot on the toe.
So just make or catch the toe on the step.
He wants to make sure he clears that foot.
So all I want you to think about is a little bit of an exaggeration of your step
height to make sure you clear it. You don't want to do that. Exactly. So again,
exaggerate that knee bend and all the way up. There you go. Good,
exaggerate that knee bend. There you go. Now again,
we're working on lower steps right here for demonstration purposes,
five inch steps. These are seven and three eight (inch) steps.
That's what you're going to find in a normal house principles do not change.
I like to start on these steps to gain control, feel confident,
then come to normal step height. All right, when he comes down, steps,
the only difference coming down the steps on the prosthetic device. Step down.
If you don't mind Dan, what's your prosthetic hold for there.
If he leaves his whole foot on the step,
he's got to be very strong to overcome the lever of the toe pushing back on him.
So Dan I'd likely to move your foot out about three inches,
pick it up and step it out a little bit more than that.
What that's going to do is allow the knee to bend as you bring the weight over
the toe. So you're stable here.
Step over the toe and that knee will bend easier.
So always kind of clear the edge of the step and then ride right into it.
You always land your weight on the heel and then ride right over that toe.
And it gets out of the way. All right. So when he's coming down that step,
you always want this look of the prosthetic device,
has the toes hanging a little bit. The weights on the heel. Come over the top.
The knee will want to bend and the toe and the prosthetic foot get out of the
way. So in the situation next,
when we're talking about bilateral prosthetics,
great question is we were taught going up with a good down with the bad,
which one do we pick? I say to the patient, you choose,
usually patients have a more dominant side. A side they feel naturally more,
more stable with. So you usually say to them, which step do I go with?
Just pick one,
whatever one you naturally pick will probably be the one that feels right to you
to step first. And that's all you're going to do. Now.
You don't have to worry about going one step at a time because the process is
already progressing to... It's the same process on either side.
So I want you to do is pick whatever step you want. Step on.
Once you're there press into the ground, just like you're doing clear,
bend the knees a little bit more aggressively to make sure you clear the step
and press all the way up. So going up, remember just like on the ramp,
going up is all about power.
As long as you lean into that step and keep your weight on top.
It's a matter of just simply straightening your knee.
Don't try to lift yourself up the step.
All you do is lean in and straighten your knee and you will be lifted up the
step. So it's much harder to pull yourself up than to just press your knee into
extension. Good, coming down same thing. Remember, just hold for a second.
You can see what he's done is lined himself up to hang the toes off the edge.
That's exactly what he wants to do. He wants to step forward,
clear the toes a little bit on the next one,
give himself just a little bit more room.
So the toes roll off the front of the step.
Most patients are fearful about learning how to go up and down steps,
but the bigger concern is up and down ramps, especially a steep decline.
Going up a ramp is really just about power. Leaning into it,
keeping your body weight in front of the prosthetic and press in.
Then the prosthetic or the surface will push that prosthetic knee back into
extension. Feel very stabilizing. Coming down. The ramp though is about control.
It'll be very much a sense that the prosthetic wants to get away from you.
So learning how to control that is very important.
So when a patient gets started on the, on a ramp like this,
this is a standard ADA ramp.
All I'm going to say to Keith is I want to keep your steps a little shorter,
lean into the hill and just power straight up the step or up the ramp.
Excuse me, go ahead. So he just presses into it,
leans into it and you'll notice that as long as he leans into it,
that knee becomes very stabilized.
The prosthetic foot is pushing into the surface and gives him a lot of
stability. Coming down is going to be a little bit different.
That knee is going to want to get away from you. So go and step forward.
Just a little bit on the prosthetic. There you go. And just kind of come from...
There you go, see how that knee wants to get away from you, it wants to bend.
So at that point in time, you really want, as you step forward,
want to tighten up your butt muscles a little bit, stabilize that knee,
and then step your weight forward on top of it. Step, and ride over it step,
and ride over it. Most people are worried about trying to walk down the hill.
Walking will take care of itself.
The decline against gravity is going to really create a walk.
You don't have to try to walk. All you have to do is control the ex...,
The extension of the knee or the position of your knee. So again, Keith,
if you would just lean into it,
shorter strides and just power right up that step, very stabilizing,
very stabilizing to the knee unit. Coming down, step into it.
Control that knee. Control that knee. There you go. Nice.
You notice a couple of those steps. One went real fast, came over it quickly.
The next one,
he wasn't quite so sure held back and then became much more of a stiff leg
position, but notice none of them caused him to fall.
Even the stiff leg position because the foot clears the ground. Because again,
the ramp is tailing away from you. So try it again. One more time, lean into it,
power up that ramp. Excellent.
And then get that weight all over it all over it all over it. Stay on it.
Great. So if we come to a situation where we have a much steeper ramp,
let's talk an embankment or river embankment, you really have to come down.
It might even be unstable gravel. You don't want to walk down that straight.
The prosthetic knee is not going to react well to that steep of ramp or that
steep of a hill. So this one he could probably do,
but we're going to demonstrate what he should do if it was too steep and that is
turn. So his prosthetic limb is on the downside of the hill.
Sound limb is on the high side.
What Keith's going to do is step down the ramp leans,
dig into the instep of the prosthetic. Keep his weight leaning uphill,
step down, keep his weight on the instep of the prosthetic, keep it there. Good.
Keep the weight on the instep of the prosthetic, step down,
keep his weight on the instep of the prosthetic,
step down and step off the bottom. Come back up. It's exactly the same process,
the good foot or the sound limb on the high side,
he's going to keep his weight on the instep of the prosthetic.
Keep his weight leaned into the hill.
Cause a mistake he doesn't want to do is lean down the hill,
leaning into the hill, press up, lean into the hill, press up,
lean into the hill to the top. So again, if we're going up and down a ramp,
what we have to focus on is that sense of power going up, control coming down.
So in this particular case,
all Dan needs to do is focus on keeping the steps a little bit shorter,
keep his weight forward over top of the hill or over the top of the prosthetic,
lean into the hill. So go ahead and do that. Going up that hill step onto it,
press into the hill, press into the hill. Great.
The only mistake he can make going up is not get his weight forward.
You feel like the hill pushes him over backwards, coming down,
it becomes a little tirckier. So Dan, if you don't mind step foward,
but just go right there. Now you'll see that knee wants to bend, right?
Because his foot wants to become level with the ground.
So that can be very disconcerting.
You can feel like you're going to fall at that point in time.
But what should patients want to work on that sense of control?
Maybe even in parallel bars before they get to a ramp and work on kind of bend
my knee and tighten my quad and control that for a second.
So once Dan gets that he tightens that muscle,
then he simply wants to step through and take the next step,
tighten that muscle and step through, take the next step,
tighten that muscle and step through,
tighten that muscle and step off the ramp.
So when we're coming down a steep incline or an embankment.
Someplace that's going to be a lot more treacherous or difficult or just plain
steep prosthetics have a harder time that prosthetic foot is going to want to
keep pitching you forward. So the safest thing to do is to turn and to sidestep.
So in this case, I'd have our patient turn away. So her prosthetic towards,
towards me, excuse me so the prosthetic is on the low side.
Always keep the remaining limb or the sound limb on the high side,
when she sidesteps down this ramp.
I just want you to think about every time you step out with the prosthetic,
put your weight on the instep of the prosthetic,
keep your weight leaning into the hill. Okay?
So step out and leaning into the Hill and just stepped down to it.
That's it just like that?
Press in and keep your weight leading into the hill and just all the way down.
Excellent. The only mistake she could make is if she got herself,
what we call high sided too much on top of the prosthetic and comes over the
top. She really wants to keep that weight on the hill side.
If she makes any mistake or the foot slips out,
she just gonna put her hand down on the hill versus get toppled down the hill.
Okay. When you're coming up, it's the same thing.
This sound limb on the high side,
keep your weight on the instep of the prosthetic and lean into the hill.
Lean into the hill, lean into the hill, press off, press off,
press off.
Perfect.
So when we're dealing with ramps with bilateral prosthetic devices.
The principles are the same.
You still have to lean in and simply you don't have a sound side to give you a,
a factor of a way to push off or to control too much tempo.
So you have to control it from limb to limb.
So what has to happen here is just simply keep that weight forward.
Don't allow your weight to get behind your feet,
or you feel like you're going to come back down the ramp.
You want to keep your weight kind of over top of your toes and roll right
through your feet. So when he's going up, he's leaning into the hill,
feels that stability great. When he's coming down,
he's trying to control that speed. So press into the heels,
keep his weight a little more back, bend those knees a little bit,
but tighten up the quad muscle as he comes down.
That's how he controls the speed by using the prosthetic as a lever or a brake
pedal to slow himself,
versus just letting that weight come over the top too fast.
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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