Ambulation devices final
- 1. AMBULATION DEVICES Kinesiotherapy Clinical Training Module 3
- 2. Ambulation Devices Definition • Equipment that assists or aides the mobility of a person who has an injury or illness that affects the ability to walk • Uses of these devices range from providing support for minor balance issues to eliminating full weight bearing Types • Parallel Bars • Walkers • Crutches • Canes • Rollators • Wheelchairs Ambulation devices 2
- 3. Parallel Bars Parallel Bars • Most stable assistive device • Provides security • Accommodates any weight bearing status Uses • Pre or initial ambulation training • Standing balance exercises • Weight shifting • Teaching appropriate gait pattern Adjustment • Bars are level with the greater trochanter • Elbows should be flexed between 25 – 30 degrees • Hands should be placed, on the bar, 6 inches in front of patient Ambulation devices 3
- 4. Walkers Types of Walkers • Standard • Wheeled walker • Platform walker When To Use • Patient has difficulty walking • Patient has balance problems • For support due to generalized weakness in both legs • When weight bearing is restricted or limited in one leg Ambulation devices 4
- 5. Walkers Advantages • Good stability • Sense of security • Easily adjusted/lightweight • Can accommodate any weight bearing status Disadvantages • Difficult to maneuver through doors and crowded spaces • Eliminates arm swing • Slow speed • Not safe to use on stairs Ambulation devices 5
- 6. Standard Walker Standard Walker • Also called four point or pick up • Has four legs with no wheels • Can be folding Advantages • Most stable of all the walkers • Useful for all weight bearing status Disadvantages • Requires more energy and arm strength to pick up and move forward than one with wheels • Does not allow for a normal gait pattern Ambulation devices 6
- 7. Wheeled Walkers Wheeled Walkers • Used when gait becomes more stable • Can be used with brakes/sliders • Can have two or four wheels • Can accommodate any weight bearing status Advantages • Allows functional ambulation for those unable to lift or move conventional walkers • Allows for a more normal gait pattern Disadvantage • Decreased stability Ambulation devices 7
- 8. Platform Walkers Platform Walkers • Used when patient cannot place weight through hands or wrist • Allows weight to be placed through the shoulders if shoulders are not injured Advantages • Allows functional ambulation for those with hand or wrist injury Disadvantage • Heavier and more difficult to lift forward Ambulation devices 8
- 9. Walkers Standard Wheeled Platform • Usually aluminum for ease of adjustment • Some have wheels on front • Rear legs often drag, so need plastic “skis” or tennis balls to make rolling easier (sometimes harder on carpet however) • Accessories • Baskets, seats, trays, cup holders Ambulation devices 9
- 10. Walkers Fitting Walkers • Similar to cane fitting for positioning and measurement • Position walker 10-12 inches anterior to patient • From a standing position fix the walker height to the level of the greater trochanter • This should allow 20-300 of elbow flexion with shoulders relaxed • Weight bearing should be on the heel of the hands with the elbows maintained in partial flexion • Avoid trunk flexion when using walker Ambulation devices 10
- 11. Walkers Non-Weight Bearing Gait • Movement sequence when weight bearing is restricted to one leg • Stand with the hands pressed to the walker handles, and shift weight to the strong limb • While bearing full weight on the strong leg, lift the walker and place it forward • Step with the strong leg to the center of the walker, keeping weight bearing on the heel of the hands and elbows extended • Keeping the non-weight bearing leg elevated, repeat the sequence • When placing the walker forward, place all 4 legs of the walker down evenly • Do not place the rear of the legs down first and rock the walker forward • When advancing forward, lift body evenly; do not hop forward Ambulation devices 11
- 12. Walkers Partial Weight Bearing Gait • Movement sequence when minimal to partial weight bearing is allowed. • Stand with most of the weight shifted to the stronger limb • Bearing weight on the hands, move the weak leg forward to a point that is in line with the rear legs of the walker • Step forward with the strong leg to a point that is just forward of the center of the walker • When placing the walker forward, place all 4 legs of the walker down evenly • Do not place the rear of the legs down first and rock the walker forward • Lift body weight forward; do not hop forward Ambulation devices 12
- 13. Crutches Types • Axillary • Forearm • Platform When To Use •Need more stability than a cane, but less than a walker •When there is a need to limit weight bearing in one or both legs • When patient has good upper body strength and standing balance • When patient has good coordination Ambulation devices 13
- 14. Axillary Crutches Axillary Crutches • Allows for transfer of 80% of the individual’s body weight from just below the axilla to the floor • Adjustable; children and extra long sizes available • Wood or aluminum with rubber suction tip • Rubber suction tip is1.5 -3 inch in diameter • Generally prescribed when duration of use is short Advantages • Provides lateral stability • Generally the easiest of crutches to master • Improves balance • Reduces or completely eliminates stress on weight bearing joints by transferring weight bearing, normally performed by the legs, ankles, and/or feet to the arms, hands, and shoulders Ambulation devices 14
- 15. Axillary Crutches Disadvantages • Poor posture – 1st time users tend to slouch • Potential for radial nerve damage if pressure is applied to the axilla area during ambulation • Needs enough upper body strength to support their bodyweight • Place a great deal of strain on the wrists and hands Ambulation devices 15
- 16. Forearm Crutches Forearm Crutches (Lofstrand, Canadian) • Allows for transfer of 40-50% of body weight through the forearm and down to the floor • Greater control over movement and allows for different gaits for different terrain • Forearm cuff adjustment is at proximal end of crutch, height adjustment is at distal end • Generally prescribed when duration of use is long term Advantages • Cuff helps keep some of the pressure off the wrist when ambulating • Tends to maintain correct posture • Generally more comfortable • May release grip without dropping crutch • More cosmetic • Allows functional stair climbing Ambulation devices 16
- 17. Forearm Crutches Disadvantages • Need good or better upper extremity and core strength • Requires more stability and balance • Decreased lateral support • Cuff may be difficult to release, especially when falling Ambulation devices 17
- 18. Platform/Specialty Crutches Uses • When it is contraindicated to bear weight through hands or wrists • Patient needs or wants more freedom of movement Advantages • Platform - patient's body weight is borne mostly by the forearm instead of by the hand Disadvantages • Requires more stability and balance • More expensive • Generally harder to learn how to use Ambulation devices 18
- 19. Crutches Fitting Axillary Crutches • Standing • From a standing position, place the tips of the crutches 6 to 8 inches in front of and to the side of the toes. Adjust the height of the crutch to 1.5 – 2 inches (approx. width of 2 fingers) below the axilla • With the hands hanging relaxed, the handgrips should be about the level of the wrist. When hands are placed on the grips the elbows should be flexed at least 30 degrees (more important indicator of correct height) • There should not be any weight bearing on the axillary pad of the crutch. Applying pressure to the axilla area during crutch ambulation can result in damage to the axillary, radial or ulnar nerve • Supine • Measure1-2 inches from anterior axillary fold to heel, then add 2 inches Ambulation devices 19
- 20. Crutches Fitting Forearm Crutches • Standing • Place the tips of the crutches 2-4 inches to the side of the toes and 6 inches in front of the toes • Stand erect with your arm and hands hanging relaxed at your side • The handgrips should be about the level of the wrist. When hands are placed on the handgrips the elbows should be flexed 20-300 (more important indicator of correct height) • Place arm inside the forearm cuff and hold on to the handgrip. Adjust the cuff so it rests 1-2 inches below the olecranon process • Widen or narrow the cuff to make it a snugger or looser fit to accommodate the thickness of the forearm Ambulation devices 20
- 21. Crutch Gaits Weight Bearing Status • The levels of weight bearing allowed on the affected lower limb can include: • Non-weight bearing • Partial-weight bearing • Touch weight bearing • Weight bearing as tolerated • Weight bearing limitations can be due to muscle weakness, injury or post surgical procedures • The weight bearing limitation determines the type of crutch gait used • Non-weight bearing crutch ambulation uses the most energy and requires almost twice the energy of normal ambulation Ambulation devices 21
- 22. Crutch Gaits Swing Through Gait - used when non-weight bearing is indicated • Movement Sequence • Stand with the affected leg elevated and both crutches placed out in front • Center the body weight on the heel of the hands with elbows extended • There should not be any weight bearing on the axilla • Tighten the abdominals and elevate the pelvis slightly • Swing the trunk forward and let the unaffected leg land in front of the crutches, then move crutches forward • Continue to repeat this sequence with no pause between steps • Each sequence of movements should be even in length Ambulation devices 22
- 23. Crutch Gaits Three Point Gait • Used when weight bearing on one leg is limited • Movement Sequence • Stand with body weight shifted more to the unaffected leg • Simultaneously move both crutches and the affected limb forward • Body weight should be centered on the heel of the hands with elbows extended • Step forward with the unaffected limb to a spot beyond the crutches. • Continue to repeat this sequence • Each sequence should be even in length with no pause between steps Ambulation devices 23
- 24. Crutch Gaits Four Point Gait • Used when both limbs can only support partial-weight • Movement Sequence • Move the right crutch forward, then left leg forward, left crutch forward, then right leg forward • Continue to repeat this sequence Two Point Alternate Gait • Used when both limbs can only support partial-weight bearing or weight bearing as tolerated • An accelerated phase of the 4 point gait • Movement Sequence • Move the right crutch and left leg forward simultaneously • Move the left crutch and right leg forward simultaneously • Each sequence of movements should be even in length with no pause between steps Ambulation devices 24
- 25. Crutch Gaits Ascending Steps or Curbs • Stabilize balance and step up with the unaffected leg. The affected leg and crutches remain behind • Bring the crutches and affected leg up simultaneously to the step • Repeat this sequence until the top of the staircase is reached • “Up with the good” Descending Steps or Curbs • Lead with the crutches and affected leg to step down from the step or curb. The unaffected leg remains behind • Bring the unaffected leg down from the step or curb • Repeat this sequence until the bottom of the staircase is reached • “Down with the bad” Ambulation devices 25
- 26. Canes Canes • The simplest and most basic type of supportive gait device • Assists in the distribution of weight • Assists balance and stability • Provides wide base of support (BOS) • Improves balance • Another point of ground contact to support part of the body weight • Reduces forces acting on the joints of the affected lower extremity When to Use • Need only minimal support • Are cleared for full weight bearing, but may need to unload weight on a lower limb joint to relieve pain or promote healing • Minimal endurance and balance issues Ambulation devices 26
- 27. Canes Types • Single Point • Offset/Curved Frame • Broad Based • Quad • Hemi Single Point Canes • Advantages • Easily adjustable and inexpensive • Lightweight • Fits easily on stairs • Disadvantages • Point of support is anterior to the hand versus directly beneath the hand – decreased stability • May lead to wrist, elbow, or shoulder injury over time Ambulation devices 27
- 28. Off Set Canes Off Set Canes • Advantages • Hand grip is positioned directly over the tip of the cane - enhances stability and reduces fatigue • Slightly more stable than single point since support is over the center of the cane • Easily adjustable • Lightweight • Fits easily on stairs • Disadvantages • More costly Ambulation devices 28
- 29. Quad Canes Quad Canes • Advantages • Broader base of support • Bases are different sizes for varied stability needs • Easily adjustable • Disadvantages • Heavier than a standard cane • Not ideal on stairs, especially wider based canes • Slower gait pattern • Point of support may not be centered Ambulation devices 29
- 30. Hemi Canes Hemi Cane – mostly used when dexterity is limited or non-existent in one hand or arm • Advantages • Very broad base of support • Folds flat • Easily adjustable • Good transition from walker to cane • Good lateral support • More stable than a quad cane • Disadvantages • Not ideal for stair climbing • Slower gait pattern • Expensive Ambulation devices 30
- 31. Canes • Single Quad Point • Off set Hemi Hemi Ambulation devices 31
- 32. Canes Cane Measurement • From a standing position, fix the cane height to the base of the wrist (styloid process) • Elbow should be flexed 20-300 (more important indicator of correct height). Lower degree for unloading, higher degree if used for balance only Proper Use of Cane • Place the cane in the hand that is opposite the affected lower extremity • Begin by moving the cane and the opposite lower limb (affected) simultaneously • Follow a reciprocal gait pattern. Holding the cane in the hand opposite the injury replicates the natural arm movement, and allows the hand an opportunity to absorb some weight while walking • Take full and even length steps with each leg. Do not take half steps • When using a quad cane, walk with the flat side of the base next to the body to avoid tripping over the two outwardly extended legs Ambulation devices 32
- 33. Canes Ascending Steps or Curbs • Stabilize balance, hold on to a railing if available and step up with the unaffected leg. The affected leg and cane remain behind • Bring the cane and affected leg up simultaneously to the step • Repeat this sequence until the top of the stairs/curb is reached • “Up with the good” Descending Steps or Curbs • Lead with the cane and affected leg as you step down from the step or curb. The unaffected leg remains behind • Bring the unaffected leg down from the step or curb • Repeat this sequence until the bottom of the stairs is reached • “Down with the bad” Ambulation devices 33
- 34. Specialty Walkers Types • Knee Walker • Rollator Knee Walker • One sided walker with elongated pad • Designed to rest knee of affected extremity on walker • Can function as an alternative to crutches • Mostly used for patients who are unable to maintain NWB due to upper extremity weakness or being overweight Ambulation devices 34
- 35. Knee Walker Advantages • Not as fatiguing as crutches since large leg muscles are being used more than upper body and arms • Minimal upper body strength is needed • Hands are free to use while standing still • Model available with handle bar that controls steering Disadvantages • Bulkier and heavier • More expensive Ambulation devices 35
- 36. Knee Walker Proper Fitting • Height is determined when standing. The unaffected leg should be straight and the injured leg should be resting comfortably in the center of the cushion • There should be equal pressure on the good foot and the knee of the injured leg • Hips should be level with back straight • Handlebars should be in a straight up position for use Ambulation devices 36
- 37. Rollators Rollator • Four wheeled walker with hand brakes and a seat • Allows patient the freedom to walk longer distances; ability to sit/rest if needed Advantages • Saves considerable energy • Arm and back muscles spared from repetitive lifting movements • Front wheels swivel for easy turning in a small space • Allows for a faster walking speed and a more normal gait pattern • Larger casters and heavier frames are geared to being more stable and safe outdoors Ambulation devices 37
- 38. Dolomite Walker Disadvantages • Requires more balance, coordination and cognitive function than a regular walker • Heavier and bulkier than standard walker • More expensive Proper Fitting • The handles should be at the same height as the user’s wrist • When seated both feet should touch the ground Ambulation devices 38
- 39. Ambulation Devices Spotting/Guarding • When using any device a therapist should be close, with a hand on the patient at all times • Use of a gait belt to provide a tool for gripping a patient when guarding should be used no matter how functional patient may seem to be • Stand behind and on the affected side • Varying amounts of assistance may be needed according to weakness/instability of the patient Ambulation devices 39
- 40. Wheelchairs • Types • Standard • Transport • Hemi Height • Tilt in Space • Power • Broda • Scooters • Sports
- 41. Standard Wheelchair • Standard • Full back height • Seat width - 16-20 inches • Seat depth - 16 inches • Seat Height ~ 20 inches • Accessories • Removable leg & arm rests • Bags/baskets, trays • Cushions, pads, neck/head rests
- 42. Transport Wheelchair • Transport • Seat width – 17 or 19 inches • Seat depth - 16 inches • Seat Height ~ 19 inches • Smaller, light weight, folds easier • Difficult to self propel • Smaller wheels • Accessories • Removable leg rests • Bags/baskets, trays • Seat cushions
- 43. Hemi-Height Wheelchair • Hemi-Height • Full back height • Seat width - 16-20 inches • Seat depth - 16 inches • Seat Height ~ 17 -19 inches • Both feet or one hand, one foot propulsion • Better for smaller persons • Has most features of standard model
- 44. Tilt in Space Wheelchair • Tilt in Space • Good for those spending long hours in chair and/or unable to pressure relief • Tilt reduces pressure on buttocks, allows for good blood return from lower limbs
- 45. Power Wheelchair • Power • Good for those with limited upper limb use • Battery life must be considered • Joy stick speed is adjustable • Can even have “sip & puff” for quadriplegic
- 46. Broda Chair • Broda • For use in long-term care facilities, hospitals • For patients with very limited mobility • Strapping helps conform to patient contours • Padding system is variable • Not for outside use
- 47. Scooters • Scooters • Multiple manufacturers • Variety of designs, weights • Speed is adjustable • Four wheel is more stable than three wheel • More for persons who need mobility for long range activities, rather than for constant daily support
- 48. Standing Wheelchair • Allows patient to function in upright position • Decreases bone loss from non-weight bearing • Some models can move while in upright position • Anti-tip features for safety
- 50. Ambulation Devices References • O’Sullivan, Susan B.; Schmitz, Thomas J. Physical Rehabilitation: Assessment and Treatment 6th Edition 2006 • Delisa, joel; Gans, Bruce; Walsh, Nicolas Physical Medicine and Rehabilitation: Principles and Practice Vol. 1 & 2 4th Edition 2005 Ambulation devices 50