Weight Shift Forward and Backward (Stride Position) (O Fig. 12.20)
When working on this activity it is important for the patient to shift the whole pelvis and trunk forward and backward. Do not allow the patient to come forward in a sideways position. Stand in front of the patient to emphasize forward weight shift, and behind to emphasize backward weight shift. As always, stand in the line of the patient's motion. The example below is for shifting forward; reverse the directions for shifting backward.
The patient is standing with weight on the left leg and the right leg forward. You stand in a diagonal stride position in front of the patient's right leg. Your right foot is forward in front of the patient's back foot. Your weight is on your forward foot.
— Stabilize: use approximation and resistance to stabilize the patient on the back leg (O Fig. 12.20 a)
— Resist: give diagonal resistance as the patient's weight shifts from the back to the front leg. Let the patient's movement push you back over your rear leg (O Fig. 12.20 b).
— Stabilize: give approximation through the left (front) leg combined with bilateral resistance to stabilize the patient on the front leg. Use your body weight to give the resistance.
— Resist: give diagonal resistance to eccentric or concentric work to return the patient's weight to his back leg:
- Eccentric: keep your hands positioned on the anterior superior iliac crests.
- Concentric: move your hands to the posterior superior iliac crests.
Repeated Stepping (Forward and Backward) (O Fig. 12.20 c, d)
This activity goes with weight shifting. You may have the patient shift weight three or four times before stepping or ask for a step following each weight shift. As the patient steps, you shift your body to place it in the line of the new stance leg. Use this activity to exercise any part of swing or stance that needs work. You may modify the activity to do repeated stepping sideways.
— Repeated stepping forward and back with the right leg.
- Stabilize on the back (right) leg.
- Resist the weight shift to the forward (left) leg.
- Stabilize on the forward leg.
- Stretch and resist: when the patient's weight is on the left leg, stretch the right side of the pelvis down and back. Resist the upward and forward motion of the pelvis to facilitate the forward step of the right leg. As the patient steps with the right leg, you step back with your left leg.
- Stabilize on the forward leg.
— Resist the weight shift back to the left leg:
- Eccentric: maintain the same grip as you push the patient slowly back over the left leg.
- Concentric: shift your grip to the posterior pelvic crest and resist the patient shifting his or her weight back over the left leg.
— Resist a backward step with the right leg:
- Eccentric: tell the patient to step back slowly while you maintain the same grip and try to push the pelvis and leg back rapidly.
- Concentric: shift your grip to the posterior pelvic crest, then stretch and resist an upward and backward pelvic motion to facilitate a backward step with the right leg.
Fig. 12.20. a,b Shifting the weight forward; c,d Stepping forward
Fig. 12.20. a,b Shifting the weight forward; c,d Stepping forward b a d c
After weight shifting and repeated stepping, it is time to put all the parts together and let the patient walk. When the objective of the walk is evaluation or function, give the patient just enough support to maintain safety. When the objective is to strengthen and reeducate, use approximation, stretch, and resistance as you did with weight shift and repeated stepping.
! Caution resisted walking interrupts the patient's momentum and coordination and decreases velocity.
Mirror the patient's steps. As the patient steps forward with the right leg you step back with your left. Use the same procedures and techniques as you used for repeated stepping (O Fig. 12.21 a, b).
Standing Behind the Patient (O Fig. 12.21 c-e)
Both you and the patient step with the same leg. When standing behind, your fingers are on the iliac crest. Your hands and forearms form a line that points down through the ischial tuberosities towards the patient's heels. Your forearms press against the patients gluteal muscles (O Fig. 12.21 c). Standing behind is advantageous when:
— The patient is much taller than you are: you can use your body weight to pull down and back on the pelvis for approximation, stretch, and resistance.
— You want to give the patient an unobstructed view forward.
— The patient is using a walker or other walking aid.
□ Fig. 12.21. Forward gait. a, b Therapist in front of the patient a b
□ Fig. 12.21. Forward gait. a, b Therapist in front of the patient
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