Stepping is defined as lifting one foot, setting it down away from the body, and then returning it back to its original starting position. Stepping movements vary in respect to direction (forward, to the sides, behind the body, or across midline), degree of weight transfer (light to heavy), speed (slow to fast), and presence of obstacles to step on or over. Stepping variations directly impact the degree of balance difficulty, e.g., the more variables, the more difficult the exercise. When introducing new stepping exercises, if the patient is unable to stay steady at least 20% of the time, consider following the “learning to let go” stepping progression noted below:
- Two-hands stable. Patient holds horizontal or vertical supports (parallel bars, ADL Balance Trainer, edge of table, etc.) with both hands while performing stepping exercise.
- Two-hands unstable. Patient stands with hands resting on unstable surfaces such as balls, sticks, foam, etc. Unstable surfaces provide sensory feedback, but are not helpful for weight bearing. Due to the lack of support, unstable surfaces help patient learn to rely more on their trunk and legs for balance.
- One-hand stable. Using only one hand for support on a stable surface, the patient performs the stepping exercise. The hand holding is on the opposite side of the leg that is stepping.
- One-hand unstable. Using only one hand for support on an unstable surface, the patient performs the stepping exercise. The hand on the unstable surface is on the opposite side of the leg that is stepping.
- No hands. Patient able to perform stepping exercise and maintain balance without hand support.
If patient struggles with steadiness (<20% steady during exercise time) during stepping progression, reconsider patient’s readiness for the exercise. Also consider the degree of difficulty involved in the stepping exercise (see Table 1), and consider modifying the exercise to make it easier. Well-designed exercises and appropriate progressions will help your patients build stronger and faster stepping strategies, helping them become steady for life!
Table 1: Stepping variable and degrees of difficulty.
|Degree of difficulty||Direction||Degree of Wt. Transfer||Speed||Obstacles|
|Easy||Forward & to the sides||Medium||Medium||None or small & narrow|
|Hard||Behind & across midline||Light or Heavy||Slow or fast||Tall & wide|