LEC.09. Safety during gait.ppt safety during gait

safety during gait

1. AMBULATION AIDS, PATTERNS
AND INSTRUCTION
DR. ABDUL RASHAD
Assistant Professor
PhD*, MPhil(OPT), DPT, IASTM, SIR. CST,
CKPT,
  CMT
Nazeer Hussain University

2. OBJECTIVES
Understand and use key terms related to gait
and use of ambulation aids
Modify intervention based on weight bearing
status/restrictions
Apply a gait belt efficiently and correctly
Demonstrate safeguarding of a “patient” during
sit <-> stand, ambulation, stairs, and a simulated
fall
Measure and adjust all assistive devices for your
“patient” appropriately

3. Progressive Mobilization
•In what order should/do we progress
mobility?
•How does the environment impact this?
•When do we select a device?

4. Dynamic Systems Interaction

5. Key Terms
•Affected side/limb
•Ambulation
•Gait training
•Assistive device
•Reciprocal
•Weight Bearing Status
•Weight Bearing
Restrictions
•Swing-to/Step-to
•Swing-through/Step-
through

6. Safety First!
•Is your patient ready to walk? How do you
know?

7. Weight Bearing Status
FWB=Full Weight Bearing
PWB= Partial Weight Bearing
TTWB=Toe Touch Weight Bearing
TDWB = Touch Down Weight Bearing
NWB=Non-Weight Bearing
WBAT=Weight Bearing as Tolerated

8. Safety
•Set up environment
•Screen strength
•Assess orientation
•Check vitals
•Patient must wear appropriate, non-slip
footwear
•APPLY GAIT BELT BEFORE STANDING!

9. Safety
Be alert for signs of:
Pallor
Fatigue
Diaphoresis
Confusion
Dizziness/lightheadedness
Sudden weakness
If you are doubtful of your patient’s ability,
have assist nearby

10. Safety
•Do not become complacent or distracted
•Be ready for the patient to stumble or fall at any
time
•Never leave a patient unattended when standing
•Maintain proper body mechanics
•Protect IV’s, catheters & other equipment

11. Guarding
•Gait Belts:
–When to use?
–Stand behind and “in diagonal” with the vulnerable side
–One hand on belt, one lightly on vulnerable side shoulder
–Walk in “sync” w/ your patient
–Don’t pull
www.youtube.com

12. s387997107.initial-website.com www.tsitherapy.com

13. Guarding
•Stand on one side of the patient & slightly behind
•LE’s in stagger stance
•One hand underneath the gait belt and the other
lightly on shoulder

14. Falls
•This WILL happen to you.
•Two choices:
◦Prevent the fall
◦Control the fall

15. Falls
https://www.youtube.com/embed/ed5CY7mKqtg

16. LIGHTNING LAB!
DONNING/DOFFING GAIT BELT
GUARDING

17. Amount of Assist: FIM
•Independent
Pt ambulates alone
•Supervision
Pt requires observation
for safety, but NO Hands
on
•Standby Assist
Pt needs close
supervision, but NO
hands on
•Contact Guard
Pt needs light hands on
for safety
•Minimal Assist
Pt performs ≥75% of
effort
•Moderate Assist
Pt performs 50-75% of
effort
•Maximal Assist
Pt performs 25-50% of
effort
•Dependent/Total Assist
Pt exerts <25% of effort

18. Choosing an Assistive Device
•Patient goals
•What amount of support is required?
•Unilateral? Bilateral?
•What can the patient do?
•UE function
•How much stability is needed?
•What is the energy cost?
•Weight capacity of the device
•AMAP/ ANAP: AMAP/ ANAP: ““least restrictive deviceleast restrictive device””

19. Stability and Mobility
Johansson and Chinworth, p. 376

20. Assistive devices/Early mobilization
Device Use with patients with:
Tilt table Coma, extended periods of
bedrest, ROM loss, paralysis,
orthostatic hypotension
Standing frame Some emerging trunk control
Parallel bars Weakness, dizziness, poor
balance, but able to begin
ambulation training

21. Tilt Table
•Uses:
–Evaluate cause of fainting or syncope
–Increase tolerance for upright postures
–Promote beginning weight bearing for people with
limited trunk control
•Procedure for use to be covered in detail
during Clerkship

22. Tilt Table

23. Unilateral Assistive Devices

24. Bilateral Assistive Devices
Device When to use:
Walker (Standard/PUW) General weakness with 2 functional UE’s
Balance impairment
Rolling walker (FWW or four wheels)Promotes smoother, faster gait pattern
Less energy expenditure
Rollator walker Allows user to sit and rest
User needs better balance than rolling
walker
Axillary crutches Good balance + 2 functional UE’s, but
need to unload one LE
Allow increased speed, variable gait
patterns
Loftstrand crutches Less stable than axillary crutches
More lightweight and mobile

25. Fitting an Assistive Device

26. How to Measure Assistive Devices:
•General guidelines:
–Patient: stand upright, shoulders relaxed
–Hand hold  wrist crease
–20-30 degree elbow bend when holding device

27. Canes:
SPC, SBQC, LBQC, Hemi-walker
Device held on the
opposite side of the
involved extremity
Quad canes:
Pick up and set down all
4 legs at same time
Do not tip
Pattern: cane ->
involved -> uninvolved

28. Loftstrand Crutches
•Hand grip at distal
wrist crease
•Forearm cuff is 1-1.5
inches distal to
olecranon when
handpiece is grasped

29. Axillary Crutches
•FIRST, place crutches 6” anterior to small toe
•2-3 fingers between axilla and crutch pad
•NEXT, align hand grip at distal wrist crease

30. Walkers
•Pick up the walker
and set all 4 legs
down
•DO NOT TIP
•Walker-step-step
•Do not step past the
walker
•Do not keep the
walker too close nor
put it too far ahead

31. Rolling/Rollator Walkers
•Rolling --------->
–Standard walker plus
wheels
–2 in front: Front
Wheeled Walker
(FWW)
–Four Wheeled
Walker

32. Rolling/Rollator Walkers
Rollator ------->
Four wheels
Hand brakes
Seat
Both types allow for
faster, smoother gait
Require greater
balance and control
www.drivemedical.com

33. LAB:
ADJUSTING ASSISTIVE DEVICES

34. GAIT PATTERNS

35. 2 Point Gait Pattern
Assistive device moves at the same time as the
opposite leg
Can use with:
•1 or 2 canes
•1 or 2 crutches
•Hemiwalker
•Indicated for:  balance or weakness

36. 2 Point Gait Pattern

37. 3 Point Gait Pattern
•Assistive device and 1 weight bearing LE
remain in contact with the floor
•Device and involved extremity advanced
together, followed by the uninvolved
extremity
•Only used when one LE has restricted weight-
bearing

38. 3 Point Gait Pattern

39. 4 Point Gait Pattern
•2 assistive devices (canes, crutches)
required
•AD  opposite leg  other AD 
other leg
•Slower, but more stable
•“Deliberate 2-point gait”
•1, 2, 3, 4 pattern

40. 4 Point Gait Pattern

41. LAB PRACTICE:
ALL THREE GAIT PATTERNS

42. 2
ND
LAYER OF GAIT PATTERNS

43. Swing..step…through…to…huh?
Terms may be used interchangeably
BUT they are technically not the same thing
Let’s clarify….

44. APTA Acute Care Section Definitions
Swing-to
•Uses bilateral device(s),
typically crutches
•Both crutches advanced
together
•Then both legs advanced to
the line of the device(s)
•Non-reciprocal pattern
•Trunk momentum to help
advance LE’s
Swing-through
•Same as swing-to, EXCEPT:
•Both legs are advanced
anterior to the placement
of the device(s)
•Trunk momentum to help
advance LE’s

45. A Picture is Worth….
•https://www.youtube.com/watch?v=4uqXCRN7WfE
•https://www.youtube.com/watch?v=H1PoJXApgQA

46. Clinical Terminology
Step-to
•Allows increased double
stance time
•The LE in swing phase
advances up to the device
Step-through
•More “normal” pattern
•Possible when patient has
better balance and stability
on the opposite limb
•The LE in swing phase
advances beyond the device

47. Got it?
•Let’s find out…..
•Video then Vote

48. FUNCTIONAL ACTIVITIES WITH
ASSISTIVE DEVICES

49. How to get up from a chair with
crutches

50. How to get up from a chair with a
walker or unilateral device
Do not grab device & pull up
on it
Push up from chair and then
reach for the device
If using a wheelchair, LOCK THE
BRAKES!
Alternative for walkers: 1
hand on chair, 1 hand on
front cross bar of walker
Sit to stand using assistive devices: http://www.youtube.com/embed/gl5X9FG7zio

51. How to sit down into a chair
Lock brakes!!
Turn slowly with wide BOS
Back up to the chair
“Feel the chair with the backs of your legs”
Walker: let go and reach for the chair
Crutches: move both to involved side hand
Unilateral device: depends on patient
condition
Reach behind for the chair

52. CRUTCH WALKING:
HTTP://WWW.YOUTUBE.COM/EMBED/4ENW0PIREYA

53. Stairs
•Down:
–Assistive device, involved leg, uninvolved leg
•Up:
–Uninvolved leg, involved leg, assistive device
•“Up with the “good”, down with the “bad””
Guarding on stairs: http://www.youtube.com/embed/-jYKRa9Vx4M

54. Stairs Ambulation: Cane or 1
crutch
•Use handrail(s) initially
–Opposite side for 1 sided
device
•PT positioned behind and in
stride on the way up
•PT positioned in front on the
way down
•Step-to initially
•Progress to reciprocal

55. Stairs Ambulation: Crutches NWB
Going up:
•Stronger/uninvolved leg
up first
•Crutches and involved
leg follow
Going Down:
•Crutches and involved
leg lower first
•Stronger/uninvolved leg
hops down next

56. Guarding on the Stairs
•Maintain broad BoS with staggered feet
–Do not have both feet on the same step
•Stand between the patient and the direction
they are most likely to fall
•Do NOT pull the patient’s gait belt

57. Questions?

58. Objectives Revisited
Understand and use key terms related to gait
and use of ambulation aids
Modify intervention based on weight bearing
status/restrictions
Apply a gait belt efficiently and correctly
Demonstrate safeguarding of a “patient” during
sit <-> stand, ambulation, stairs, and a
simulated fall
Measure and adjust all assistive devices for your
“patient” appropriately

59. References
•Johansson C. & Chinworth SA. Mobility in Contexts: Principles
of Patient Care Skills. FA Davis, Philadelphia, 2012: Chapter
14.

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