Use of assistive devices

Use of assistive devices (cane, crutch and walker)

1. ASSISTING WITH USE OF WALKING AIDS (CANE, CRUTCH AND WALKER) -BY SHWETA SHARMA M.SC. NURSING I YEAR AIIMS,JODHPUR

2. WALKING AIDS/AMBULATORY ASSISTIVE DEVICES/MOBILITY AIDS To improve the walking pattern Balance or safety while mobilizing independently Means of transferring weight from the upper limb to the ground, in cases where reducing weight bearing through the lower limb is desired. Walking aids fall into multiple categories and include the following: Canes or walking sticks Crutches Walkers

3. CANE/WALKING STICK Used for improving postural stability. Generally prescribed for people with moderate levels of mobility impairment. Typically used when minimal stability is needed. Can be made of wood or a light metal such as aluminum . The wooden sticks usually have a crook handle and cannot easily have multi point tips. Aluminum walking sticks can either have a flat or "swan-neck" top and have the advantage of being adjustable in length and are able to have multiple points e.g. a tripod. Multi point walking sticks include tripods and quadripods , both of which can have either flat or swan-neck or handles.

4. TYPES OF CANE 1. The standard straight -legged cane 2. The tripod or crab cane, which has three feet 3. The quad cane, which has four feet and provides the most support.

5. CRUTCHES A crutch is a long stick with a crosspiece at the top, used as a support under the armpit by a lame person. Crutches are a type of walking aids that serve to increase the size of an individual’s base of support . It transfers weight from the legs to the upper body and is often used by people who cannot use their legs to support their weight. There are three types of crutches; Axilla crutches, Elbow crutches and Gutter crutches.

6. WALKER Has four points of contact with the ground and usually has three sides with the side closest to the patient being open. Provides a wider base of support than a walking stick . Walkers are mechanical devices for ambulatory clients who need more support than a cane provides. The standard type is made of polished Aluminium . It has four legs with rubber tips and plastic hand grips . Many walkers have adjustable legs.

7. TYPES OF WALKERS

8. MEASUREMENT OF CANE In measuring a cane height, the cane is placed approximately 6 inches from the lateral border of the toes. The patient should be wearing appropriate, comfortable shoes during measurement

9. There are various ways to determine the appropriate cane length: Elbow Angle The floor to the greater trochanter The distal wrist crease to the floor Use a formula: Length of cane = height of the individual (meters) x 0.45 + 0.87 m. (L = H x 0.45 + 0.87 m)

10. MEASUREMENT OF CRUTCH Underarm Crutch Measurements & Set-up: Place the person's regular walking shoes on and assist them to a standing position. Place the top axilla pad approximately 5cm (2–3 finger widths) under the armpit and extend the crutch to a point on the ground approximately 15cm out from the side of the foot. In this position the handgrip should then be adjusted to sit approximately at the height of the wrist crease. This should allow for around 15–30 degrees of bend at the elbow.

11. Forearm Crutch Measurements & Set-up: -Place the person's regular walking shoes on and assist them to a standing position. -Instruct them to flex their elbow so the crease of his wrist is level with his hip joint. -Measure the forearm from 3 inches below the elbow and then add the distance between the wrist and floor. -Measure around the largest part of the forearm for the cuff size.

12. MEASUREMENT OF WALKER To measure the walker length, follow the steps: -Start by standing up straight with your shoes on. -Allow your hands to hang naturally at your sides. -Measure from the crease in your wrist to the floor. -This length should be your handle height. -If possible, choose a walker that adjusts at least one inch higher and lower than actual measurement so length can be adjusted as necessary.

13. AMBULATION WITH CANE The cane must be on the opposite side of the affected leg and in tandem with it so as to simulate normal gait and to increase balance and aid in weight distribution (canes can easily support up to 25% of a patient’s body weight). A. From Sitting to Standing -Position the cane on the unaffected side of the patient. -Advise the patient to move to the edge of the seat, hold the cane handle and bear weight on the unaffected leg and cane to come up to the standing position. -Make sure the height of the cane is appropriate (level of greater trochanter), ensure elbow flexion is 20° to 30° and that the cane is 2” in front of the affected leg and 6” to the side of the affected leg.

14. B. Walking -Instruct the patient to position the cane on the unaffected side. Three Point Gait -Instruct the patient to balance the body weight on the strong or unaffected limb while moving the cane forward approximately 12-18 cms . Make sure the cane is close to the patient’s body. -The patient then moves the weak or affected foot forward. -The patient transfers the weight from the unaffected foot to the affected foot and cane, and then brings the unaffected foot forward to join the affected foot. -Repeat the steps 1 to 3 while supervising the patient closely and alertly.

15. Two Point Gait -Instruct the patient to balance body weight on the strong or unaffected foot. -Instruct the patient to move the cane and the weak or affected foot forward at the same time, keeping the cane close to the body to prevent leaning to the side. -Instruct the patient to transfer their body weight forward to the cane and move the unaffected leg forward. -Repeat steps 1 to 3 while supervising the patient closely and alertly.

16. C. Standing to Sitting -Instruct the patient to approach the chair (or bed), and turn in small circles toward the stronger side till the back is facing the chair or bed. -Assist the patient to back up to the chair until the chair can be felt against the back of the patient’s legs. -Instruct the patient to reach for one arm rest at a time. -The patient lowers to the chair in a controlled manner.

17. D. Stair climbing Canes can be used for stair climbing if proper instructions are followed (Up with the good leg, down with the affected one). Going up the stairs -As usual, the cane should be opposite the affected limb. -At the bottom of the stairs, instruct the patient to lift the strong or unaffected leg onto the first step. -Transfer body weight to the unaffected leg on the step while lifting the cane and the affected leg onto the same step. -Repeat steps 1 and 2.

18. Going down the stairs -As usual, the cane should be opposite the affected limb. -At the top of the stairs, instruct patient to transfer body weight to the strong or unaffected leg while lifting the cane and the affected leg simultaneously to land on the step below it. -Instruct patient to lift unaffected limb to land on the same step. -Repeat steps 1 and 2.

19. AMBULATION WITH CRUTCH 2 point: This gait pattern is less stable as only two points are in contact with floor and good balance is needed to walk with 2 points crutch gait. The nurse asks the client to: 1. Move the left crutch and the right foot forward together. 2. Move the right crutch and the left foot ahead together

20. 3 point: This gait pattern is used when one side lower extremity is unable to bear weight. It involves three points contact with floor (two crutch point and one unaffected lower extremity). To use this gait, the client must be able to bear the entire body weight on the unaffected leg. The two crutches and the unaffected leg bear weight alternately. The nurse asks the client to: 1.Move both crutches and the weaker leg forward. 2. Move the stronger leg forward.

21. 4 point: This gait pattern is used when there's lack of coordination, poor balance and muscle weakness in both lower extremities, as it provides slow and stable gait pattern with three points support. The nurse asks the client to: 1. Move the right crutch ahead a suitable distance, such as 10 to 15 cm. 2. Move the left foot forward. 3. Move the left crutch forward. 4. Move the right foot forward.

22. Swing-to gait: The swing gaits are used by clients with paralysis of the legs and hips. The nurse asks the client to: 1. Move both crutches ahead together. 2. Lift body weight by the arms and swing to the crutches.

23. Swing-Through Gait: The nurse asks the client to: 1. Move both crutches forward together. 2. Lift body weight by the arms and swing through and beyond the crutch.

24. AMBULATION WITH WALKER • Move the walker ahead about 15 cm while your body weight is borne by both legs. • Then move the right foot up to the walker while your body weight is borne by the left leg and both arms. • Next, move the left foot up to the right foot while your body weight is borne by the right leg and both arms.

25. Precautions in using cane: - - Check your cane frequently. -If it looks as though it is damaged, avoid using the cane until you can replace it. -Make sure that there are no wires or other hazards crisscrossing the floor. -You should also not have any small rugs around as these can snag your walking cane and pull you down. -Avoid wet patches or wait until the floor has dried until you begin walking.

26. Precautions in using crutches: - • Have someone nearby for assistance until accustomed to the crutches. • Frequently check that all pads are securely in place. • Check screws at least once per week. • Clean out crutch tips to ensure they are free of dirt and stones. • Remove small, loose rugs from walking paths. • Beware of ice, snow, wet or waxed floors. • Avoid crowds , leave class early. • Never carry anything in hands, use a backpack.

27. Precautions in using walkers: - -Take small steps . -Keep the walker close to your body. -Wear non-skid slippers, socks, or shoes. -Remove rugs from the floor. -Keep your head up while walking to maximize your balance. -Keep both hands-on walkers, if you need to carry items attach a basket to the walker.

28. RESEARCH ARTICLES 1.Determinants of use of a walking device in persons with parkinson’s disease A cross-sectional study was conducted to identify determinants for use of a walking device in persons with Parkinson's disease. 60 males with PD were studied. Their mean age was 69.4 ± 8.9 years. The average time since diagnosis was 7.9 ± 5.3 years. Age, gender, disease duration, disease severity and motor impairment were recorded. Participants were asked whether they usually used any walking device (e.g., cane or walker) and were categorized as either an “independent walker” or a “device walker.” Clinical balance measures including functional reach, turn duration, 5m Timed-Up-and-Go test (5m-TUG) and Activities-specific Balance Confidence (ABC) scale were investigated for their contribution to the prediction of walking with a device. Thirty-one participants (36.5%) reported they usually used a walking device. The study concluded that 5m-TUG test and ABC scale may be useful in clinical assessments of the need for a walking device in persons with PD.

29. 2.Analysis of Crutch Position in the Horizontal Plane to Estimate the Stability of the Axillary Pad in the Axilla during Single-crutch Walking A study was conducted to estimate the stability of the axillary pad in the axilla during single-crutch walking through kinematic analysis of the crutch position in the horizontal plane . The subjects were 19 healthy young males. The subjects were instructed to walk 5 m in a straight line while using a single crutch. This was repeated 10 times. Repeated-measures analysis of variance and Tukey’s honest significance test were used to compare crutch angles across three time points during crutch stance (crutch contact, mid stance and crutch off) for each subject. A statistically significant effect of time was found in 17 of the 19 subjects. Sixteen of these 17 subjects rotated the crutch externally. The study concluded that external rotation of the crutch throughout the stance phase is important to enable the axillary pad to be held tightly against the chest wall.

30. CONCLUSION Many people have disabilities that require an ambulatory assistive device in order to ambulate independently. Some people are prone to self-treat as canes are easily accessible and do not take a prescription before purchasing a walking aid. This increases the risks of falls, especially in elderly patients, and risk of musculoskeletal injuries or adaptations due to bad posture gotten from incorrect way of using or holding the assistive devices. So, we can ensure that people buy correct type of assistive device and learn the proper way to ambulate with these assistive devices.

31. REFERENCES •Annamma Jacob, Rekha R, Jadhav Sonali Tarachand. Clinical Nursing Procedure: The Art of Nursing Practice. 2015. New Delhi. Jaypee brother’s publication. 3nd Edition. Pg. no. 325-333. •PubMed. Analysis of Crutch Position in the Horizontal Plane to Estimate the Stability of the Axillary Pad in the Axilla during Single-crutch Walking. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4242948/ [cited 23 nov 2019] •PubMed. Determinants of use of a walking device in persons with parkinson’s disease. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4182107/#:~:targetText=Many%20factors%20are%20involved%20in,%2C%20vision%2C%20and%20living%20environment. [cited 23 nov 2019]

32. ASSIGNMENT Give the re-demonstration of use of cane, crutch and walker.