Hi, I'm David Lawrence, and in this video,
I'm going to teach you early standing motor control exercises to help improve
your sense of balance and control over a prosthetic device.
When getting started with a prosthetic it's really important to get the sense
of what you need to know.
There's some basic terminology that's going to be really important.
Any therapist, doctor, healthcare worker,
is going to be working with you on these things and saying these terms.
So it's important for you that you understand them.
That first term of something called proprioception.
Proprioception is basically a term of understanding where you are in space.
You are wired to know that. For example, Keith,
right now holding onto this walker,
he would close his eyes and he knows he's holding onto the walker.
I know I'm sitting in a chair.
I know my feet are on the floor because I'm wired to know that. However,
when we're dealing with a prosthetic interface,
we've now changed that connection to the ground. Proprioception's still the key.
He has to understand where he is in space,
but he's got to figure out how to know where he is in space,
by the input coming into the residual limb, through the socket.
That'll tell him about where the prosthetic limb is in space.
So proprioception is that first term you really got to understand.
The second term that's really important to understand is called the center of
mass or center of gravity. That's that point right in the middle of you,
that with, if we shish kebab you,
he would balance even weight in all directions. For sake of arguments,
that's basically between the belly button and the spine.
So envision a point right in the middle of the body. That's your center of mass.
The next term is your base of support. So if we look down at the feet,
your base of support. If I took a marker across the front of Keith toes,
back the outside of one foot across the heels and up the other filled in that
whole black box, that whole black box would be his base of support,
right? So it's an area underneath the, the remaining foot,
the prosthetic foot and the area in between. Now by definition,
then balance is the ability to keep your center mass on top of your base of
support. If Keith moves that center of mass outside the base of support,
he's either going to fall or he has to create a new base of support or move his
foot. That's called walking. Walking is a series of controlled falls.
You let your center of mass move forward.
You move your foot forward to create a new base of support and you walk. So,
really important when a patient's getting started to understand that these are
things they've taken for granted their whole life,
but they need to get a better understanding of how do I recapture something that
I learned once when I was very, very young and I don't remember the process,
but the process is not going to be that different. So to regain proprioception,
we need to focus on three things. One is finding center.
Two is weight shift control.
Three is single limb support or stance control on the prosthetic side.
With that being said, we need have our patient have a place to practice.
So you could use a walker like Keith does here.
You could also use two crutches. You might use two high back chairs.
If we're in a clinic we'd love to use parallel bars.
That's the most stable place to work, and we love the parallel bars,
but at home you won't have that.
You could use the kitchen counter and the island.
You can be holding onto the kitchen sink,
just make sure you have a good solid chair or your wheelchair locked behind you,
in case you lose your balance and you have a good stable position,
then once we're going to get started and you have that sense of that position
and where you're at and feeling good about it.
You really want some sort of feedback in front of you. And that means a mirror.
If you could put any kind of cheap little mirror in front of you to see what
you're doing, why is going to become really important in just a second.
When a patient gets started on a prosthetic,
they've only had one leg for a few months. So if you've had an amputation,
you don't get a prosthetic immediately.
So a good well-meaning physical therapist has taught you how to shift your
weight onto that right leg, put all your weight there,
balanced there as you hop or move around. So your, that becomes your center.
So now that we say, well, if I'm going to walk,
my center of mass needs to be in the middle of my base of support.
Because this lined over one foot, I have an oblong machine.
A machine that's almost like a car trying to drive with a flat tire.
So if I'm going to find center,
I need to be able to move my center mass back to the middle,
but that's not going to feel like middle, right? Because you've taught yourself,
you've done a good job. Talught yourself, how to balance on one leg.
So we've got to get you in center, look in the mirror and say, gosh,
when I'm centered, I feel like I'm 60/40, 60% of my weight on the prosthetic.
Only 40% on the sound limb, right? That's where center will really be.
Cause if you feel like you're 50/50,
then your weight is too heavy on the prosthetic side.
So we have to relearn where center is from where we've taught ourselves,
how to hop on one leg. So finding center's simply that,
find center in the mirror, even though it feels weird,
like I'm too far to the prosthetic side and see if you can hold that position.
If you can take this hand off and see if you can still hold it,
if you can switch hands, hold it.
If you can't hold it and you start to keep your hand up there for a second
Keith, it starts to drift back. Then can I fix it?
Can I get myself back to center? If you can. Great.
If you can't put your hand back down,
eventually you can pick both hands up and hold center.
If you lose center, you've got to look in the mirror and say, no, no,
let me get back to here. But center is not going to feel like center.
So that's number one find center. It's a very simple practice. You can spend 20,
30 seconds and then put your hands back down rest it.
You can also try looking at a mirror and then look away from the mirror and for
30 seconds, come back and see if you were able to hold it.
See if you understand or get a feel where center really is proprioception.
Where truly is center. So that's number one.
Number two is weight shift control.
Now this is where things become more interesting as far as your dynamic ability
to control where you are in space.
So the first thing you're going to start with here is have the patient just
weight shift towards the right side. And they go, well, that's really simple.
That feels very much like home.
But then if I come back and have them weight shift to the left side,
that's going to feel much more like,
I'm not sure if I really want to go out there.
Remember the defense mechanisms in your brain are telling you don't do this.
Don't shift over here because if I didn't have a prosthetic on, I'd be falling.
So you've taught yourself not to come here.
So we're working on that process of getting comfortable with that movement.
So as he's going to go back and forth on that weight shift and just keep moving
slowly back and forth, he's not just moving. He's mainly the moving his hips,
not his shoulders. Don't move your shoulders so much.
Just kind of hips to the right.
And hips to the left. And right.
He's doing that.
He's going to be thinking about three things that are very important to him.
One foot floor interface. That means when he's here,
that foot is pretty level. Now notice when Keith gets over here,
he's on the outside edge of that foot.
Really important that if even Keith doesn't like the feeling,
I want him to know. You need to know where that is. You need to be thinking,
I want the outside edge of my foot. I don't want to be surprised by that.
I want to know when my foot feels level on the ground and as crazy as it sounds,
having a rubber foot and a carbon keel, they are carbon, um,
internal foot that you can really feel it on the ground. You can,
because remember your brain still has all the wiring inside there and the
imagery for where your foot is.
That's why you have phantom sensation and pain issues. That's absolutely normal.
But if I come over here,
his brain can pick up on the fact that he's on the outside edge of that foot and
where it feels like it was on his foot will be on the prosthetic foot.
So as he goes to the other direction,
have a hard time feeling that load he'll have to kind of push his weight down
into it, to try to feel the inside edge of the foot.
That's number one now.
To understand how he connects proprioceptively to that,
is he has to understand socket pressure.
So the next issue is the socket interface. So when he shifts to this side,
he feels the outside edge of the foot.
He also feels the pressure in the socket is quite different than it was when he
was in the center, whether he likes it or not,
he has to correlate that that pressure means I'm on the outside edge of my foot.
Great. And if I go the other way, I'm on the inside of my foot.
I have to try and feel that pressure and come back to center.
So that's the second issue. Does he feel the pressure in the socket?
Does he understand how it relates to the foot position on the ground?
Those two things take a lot of thought process.
And the number three is the motor control aspect.
This sensory motor integration we are use,
which means when you're over here and you feel the sensation of pressure in the
socket and that foot position, and you want to change your position.
Don't walk like you're walking on a stilt walk within the prosthesis,
which means you're going to push into the outside wall of the prosthetic and
push yourself back to center. Now,
if you haven't seen you should or looked at our videos on pre prosthetic
exercises, dynamic, residual limb exercises,
you should watch that video cause in that video you learn how to put a towel
underneath your residual limb,
push into that towel and press your body weight up.
Now you're going to basically use that exact same exercise in standing to press
yourself back into neutral position. You can do that side to side.
Then you want to work on that front to back, back on the heels, feel the toes,
come off the ground, feel the pressure in the socket change,
press into the back wall and press yourself forward.
Feel your weight come into the toes. A little bit of arch in your back.
The heels start to come off the ground. The pressure in the socket gets high.
I can push into the front wall as long as I'm under load,
that knee will stay locked. And I bring myself back to neutral. If I want,
I can combine those things,
which is either diagonal motions or what I call hula-hoops,
which is Keith just kind of moves around and gets used to moving his body in a
diagonal pattern all the way around in both directions. Same thing,
muscles tight, working from plane to plane pressure in the socket.
Change position of the foot changes.
None of that are you passive.
So at no time when you're getting started with a prospect,
do you want to be mentally passive? You want to be mentally active thinking,
what do I feel what's happening down there?
How am I getting myself reconnected with the ground?
And the third component is a stool step, a single limb step up.
We're going to spend time on the prosthetic and learn how to get your fgoot off
the ground.
Now we're going to look at the third component here.
Remember we've looked at finding center, we've looked at weight shift control.
Now we have to work on unilateral stance control. Why?
Because we need that prosthetic on the ground and for you to have balance so you
can get your other foot off. The ground gait is almost 50% of the time.
You've got your only leg, you know, and trust your sound,
them all in the air. So to do that,
you have to have great confidence to get your weight on the prosthetic.
So two things are really important along this component is can he find center
or the balance point of the prosthetic?
And he can control that with this strength inside the socket.
So the first thing Keith is going to do is shift towards this prosthetic side
till he starts to feel a little bit more weight on the outside of the foot,
then the middle of the foot and a little bit more on the front of the foot than
the back of the foot.
At that point in time,
he's going to tighten his butt muscles and his groin muscles.
The two muscles are going to squeeze into the back inside corner of the
prosthetic. That's going to pull the prosthetic socket up underneath him,
stabilize the device from there.
He steps up with his sound foot and puts it on the step.
I want him to relax at this point, but keep himself in this position,
then re-engage those two muscles and bring himself back down.
So each time he's shifting and trying to find the balance point,
believe it or not, as crazy as it might feel early on,
there is a balance point on that prosthetic where you can do this and feel fully
in control. But when you're starting with your weight shift on and with us,
whatever small stool you want, or step up, you want, You weight shift again,
you feel the pressure on the outside edge of the prosthetic,
a little bit to the front,
you tighten the butt muscles and groin muscles feel like it really tucks the
socket up underneath you. And then you step up good.
And then step down now with all these drills,
we follow the same progression. If you can do that with two hands easily,
you always take off the same side hand and try it without shifted,
tighten up, step up and step, tighten up and step down.
And if you can do that, you switch hands to the other side,
don't do it right now. And then you can,
and then you ultimately can go to no hands where you take both hands off and say
to yourself, okay, I'm going to shift in, tighten up and I can step up control,
tighten up those muscles. Step down. Control. Notice how he's moving faster.
It takes a little more balance control or more awareness of where am I in space
where I am I, where am I on top of the prosthetic limb.
All right, when we're dealing with bilateral prosthetic devices,
the process is the same.
As far as we need to gain proprioceptive awareness of position in space.
That means understanding without being fully connected to the ground,
how you're connected to the sockets and how the sockets are connected to the
feet, which gives you your connection to the ground.
Difference is with bilaterals there isn't one sound limb or
remaining limb connected neurologically to the ground.
So you're not as likely to be shifting to that side and only use the prosthetic
as an outrigger.
Because of that you send to be centered much easier from the beginning,
which in many ways makes it easier to learn, to walk as well.
Many bilateral patients can actually walk more rhythmically than a unilateral
patient quicker because there isn't one leg that functioning with neurologic
connection to the ground and the other one not connected.
However, the problem then with bilaterals often becomes balance.
Finding that point without the connection to the ground on one side as to where
do I find my balance?
So weight shift control becomes very important in a position like this patient
really is going to work on that sense of being able to shift their weight out
over one prosthetic and get a sense of what does it feel like when my weight is
getting way outside of one foot on the instep of the other.
Can I again feel that foot on the floor?
Can I feel the pressure change in my socket when I'm over there and the pressure
on the other soccer feelslike it almost goes away.
It's hard to feel the pressure on the other socket.
And I want to get myself back to neutral.
So I need to one first know that I'm out here and feel that pressure,
but I also then need to use those muscles on the outside edge to press into the
outside edge of the socket and press myself back to center.
And then I want to shift the other way, get a sense of knowing, Ooh,
when I feel like I'm getting out here and it's feeling starting to feel a little
uncomfortable, like I might fall,
I need to tighten those muscles on the outside,
push into the outside wall and bring myself back to a center position.
I can do that front to back. So if I come back and my knees stay straight,
my toes start to come off the ground.
So if those knees are straight and no toes start to come off the ground a little
bit, I feel like I'm going back.
I can tighten the butt muscles and pull myself back, back up to neutral.
If I come forward way onto my toes and feel my heels start coming off the ground
with my knees, nice and straight and locked out. And I want to go back.
I just push into those walls a little bit and bring myself back to neutral.
This for him is very important.
He'll want to spend a lot of time going from both hands on to one hand on
to just the other hand on to no hands on working on that weight shift control,
getting that sense of knowing where am I when I'm shifting left, right, front,
back, as well as what we call the hoop action,
where I'm moving around in a diagonal pattern and get a sense of what does it
feel like when I shift my weight diagonally? So bilateral amputation,
bilateral prosthetics, it's much more about balance control,
sway control than it is about finding center.
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.
We encourage you to view our other videos in this series and to share them as
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