Walking aids

this PPT contains all the detailed information about walking aids including types, measurements, advantages & disadvantages, gait training with specific aid, etc.

1. WALKING AIDS Dr. Meghan Phutane (PT) Cardiorespiratory Physiotherapist

2. Walking Walking is the manner or way in which you move from place to place with your feet. It is a Movement at a regular and fairly slow pace by lifting and setting down each foot in turn, never having both feet off the ground at once. It is the highest level of motor control skill.

3. The major requirements for successful walking include: Support of body mass, by the lower extremities Production of locomotors rhythm Dynamic balance control of the moving body Propulsion of the body in the intended direction

4. Basic terms Ambulation: To walk from place to place or move about. It is a technique of post operative care in which a patient gets out of bed and engages in light activity (as sitting, standing, or walking) as soon as possible after an operation. Some time this term is also use in the place of walking . Gait:   Gait is a term to describe human locomotion, it is pattern of walking or a sequence of foot movements.

5. Gait cycle or walking cycle A cycle of walking is the period from the heel-strike of one foot to the next heel-strike of the same foot When a subject is walking on level ground, than the movements of the lower limbs may be divided into “swing” and “stance” phases. The swing phase occurs when the limb is off the ground, and the stance phase when it is in contact with the ground and is bearing weight.

6. Walking aid is a device designed to assist walking and improve the mobility of people who have difficulty in walking or people who cannot walk independently. WALKING AIDS

7. Purpose of walking aids Increase area of support or base of support Maintain center of gravity over supported area Redistribute weight-bearing area by decreasing force on injured or inflamed part or limb Can be compensate for weak muscles Decrease pain Improve balance Improves proprioception

8. Different Types of Walking Aids walker Cane/Stick crutches

9. Selection Stability of the patient Strength of upper and lower limbs Co-ordination of upper and lower limbs Required degree of relief from weight-bearing

10. Clinical descriptors of weight bearing status Full weight bearing (FWB) Non weight bearing (NWB) Partial weight bearing (PWB) Toe touch weight bearing (TTWB) weight bearing as tolerated (WBAT)

11. Parallel Bars Rigid Support through the length of bars Enables patients to concentrate on lower limbs A full length mirror placed at one end Adjustment: height of the bar should be at the level of greater trochanter

12. CANES

13. Canes Most common mobility aid Commonly made of wood or aluminium Transmits 20-25% of body weight Held in hand opposite the involved side Compensates for muscle weakness Relieves pain Elbow at 30° flexion

14. Advantages - Improves balance & postural stability Reduce biomechanical load on LE joints Widens BOS with less lateral shifting of COM Reduces forces on hip while walking Reduces knee pain in OA knee patients Restricted in NWB & PWB

15. TYPES OF CANE

16. Standard cane Single point or straight cane Made of wood or acrylic Has half circle or t-shaped handle Inexpensive & fits anywhere Not adjustable

17. Standard adjustable aluminum cane Same as standard, made of aluminum & handle with a molded plastic covering Adjustable height with a push button mechanism Approximate height is 27-38.5 inches (68-98cm) Light weight & fits easily anywhere Costly than standard

18. Adjustable aluminum offset cane Proximal component of shaft of cane is offset anteriorly – straight offset handle. Plastic or rubber molded grip Pressure can be given on center of the cane for greater stability Adjustable height, lightweight & fits anywhere. Costly

19. Tripods Made of aluminium alloy or steel Three rubber tipped legs at corner of an equilateral triangle Handgrip in same plane as a line joining two legs nearest and parallel to patient’s foot Elbow at 30° flexion More stable

20. Quadrupeds Has four rubber tipped legs More stable Adjustable hand grip height Provides broad base Each point is covered with a rubber tip Disadvantage – pressure exerted on handle may not be centered , causes instability; may not be used on stairs; slower gait pattern

21. Hemi cane Provides a very broad base Legs are angled to maintain floor contact to improve stability farther from body Handgrip is molded with plastic Fold flat & adjustable in height Easy for travel & storage May not allow pressure to be centered Can not be used on stairs Require slow forward progression Costly

22. Rolling cane Provides wide, wheeled base allowing uninterrupted forward progression Includes contoured handgrip, height adjustments & pressure sensitive break in the handle Wheeled base allows continuous weight on cane; no need to lift & lace it forward Provides faster forward progression Require sufficient UE & grip strength for breaking mechanism Not suitable for patients with propulsive gait pattern ( parkinson’s ) Costly

23. Laser cane Incorporates bright red lase line projected along the floor to assist freezing episodes while walking

24. Handgrip General consideration relevant to all canes is nature of handgrip. Variety of styles & sizes are available. Type of handgrip should be selected based on Patients comfort Grips ability to provide adequate surface area to allow effective weight transfer while walking Types of handgrips – Crook handle Straight offset handle T – shaped handle

25. Measuring canes Cane is placed approximately 6inches from the lateral border of the toes. 2 important landmarks for measurement are- greater trochanter & angle of elbow Top of cane should come at the level of greater trochanter & elbow flexed to 20-30 degrees (allows arm to shorten & lengthen during gait cycle; provides shock absorption mechanism) Height should be considered with regard to patients comfort & cane’s effectiveness in accomplishing purpose

26. Gait pattern with cane

27. WALKER (WALKING FRAME)

28. Walking Frames Used to improve balance & relieve weight bearing Greatest stability Provide wide BOS, improve anterior & lateral stability, allows UE to transfer body weight to floor. Typically made of aluminium with moulded vinyl handgrip & rubber tips Adjustable adult size- 32-37inches (81-92cms)

29. Features Glides Folding mechanism Handgrips Platform attachment Wheel attachment Braking mechanism Tripod rolling walker Storage attachment Seating surface

30. Standard Reciprocal Rollator Types:-

31. Standard walking frame Consist four almost vertical aluminium tubes joined on three sides by upper and lower horizontal tubes One side is left open Handgrips on upper horizontal tube Rubber tips at lower ends of vertical tubes

32. Reciprocal Walking Frame Identical with standard frame Each side of the frame can be moved forward Swivel joints between horizontal and vertical tubes

33. Advantages :- Allows unilateral forward progression Useful for patients incapable of lifting the walker to move it forward Relatively light weight & easily adjustable Disadvantages :- Less inherent stability Awkward in confined area Eliminate arm swing Can not be used on stairs

34. Rollator Two small wheels at front and two legs without wheels at back or one wheel at each leg N o need for lifting the whole device Care to be taken for elderly patients B est suited for children

35. Other Variants of Walking Frame Gutter frame Pulpit frame Gutter frame Pulpit frame

36. CRUTCHES

37. Used most frequently to improve balance & to relieve weight bearing (fully/partially) Typically used bilaterally – to increase BOS, improve lateral stability, allows UE to transfer body weight to the floor. 2 basic designs of crutches in clinical use are :- Axillary crutches Forearm crutches

38. Prerequisites for crutches Good strength of upper limb muscles is required. Range of motion of upper limb should be good. Muscle group which should be strong are – Shoulder flexor, extensors and depressor Shoulder adductors Elbow and wrist extensors Finger flexors

39. Axillary crutches /under arm crutches Referred as standard crutches. They are made of lightweight wood or metal with an Axillary bar, a hand piece and double uprights joined distally by single leg covered with rubber suction tip. Single leg allows height variations. Both the overall height of the crutch & height of the handgrip can be adjusted. Adjustable adult crutch size is 48-60 inch.

40. Advantages – Improve balance & lateral stability Provide functional ambulation with restricted weight bearing Easily adjustable Inexpensive Can be used for stair climbing easily Disadvantages – Awkward in small areas – may compromise safety when using in crowded place Limited upper body freedom Axillary crutches require good standing balance by the patient . Tendency to lean forward on axillary bar (pressure on radial groove - potential damage to vascular structures)

41. Precautions 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. Never carry anything in hands ,use a backpack.

42. Platform attachment Also referred as forearm rest or troughs. Also used with walkers. Function – to allow transfer of body weight from forearm to assistive device. Used when weight bearing is contraindicated through wrist or hand. Forearm piece is usually padded, has a dowel or handgrip, has hook or loop strap to maintain position of forearm.

43. Measurement of length Several methods are used but most common is in standing & supine position. Measurement in standing is most accurate & preferred approach. standing – Supported standing – from 2inches below the axilla to 2inches lateral & 6inches anterior to the foot. With shoulder relaxed adjust the hand piece to provide 20-30 degrees of elbow flexion. General estimate – subtract 16inch (40.64cms) from patient’s height. Supine – From the anterior axillary fold to a point 6-8 inches lateral from the border of the heel.

44. Measurement of axillary crutch

45. Forearm crutches Also known as lofstrand / elbow / canadian crutches. They are made of aluminum. Design includes a single upright, a forearm cuff & a handgrip. It adjusts both proximally (position of forearm cuff) & distally (height of crutch); using push button mechanism. Generally adult sizes are 29-35inches (74-89cms). Distal end of crutch is covered with rubber suction tip. Forearm cuffs are available with either medial or anterior opening.

46. Advantages – Forearm cuff allows use of hands Easily adjusted & allows functional stair climbing Most functional for patients with bilateral KAFO’s. Using forearm crutches requires no more energy, increased oxygen consumption or heart rate than axillary crutches. There is no risk of injury to the neurovascular structures in the axillary region when using this type of crutches . Disadvantages – Less lateral support Cuffs ay be difficult to remove They require good standing balance and upper-body strength. Geriatric patient sometimes feel insecure.

47. MEASUREMENT : Position of choice – supported standing From 1-1.5inches below the elbow to Distal end at a point 2inches lateral & 6inches anterior to the foot. Shoulders should be relaxed & elbow maintained at 20-30degrees flexion. Cuff placement at the proximal third of the forearm.

48. Preparation For Crutch Walking Arms: shoulder extensors, adductors and elbow extensors even all muscles of arms must be assessed and strengthened before the patient starts walking. The hand grip must also be tested to see that the patient has sufficient power to grasp hand piece. Legs: S trength and mobility of both legs should be assessed and strengthened if necessary. Main attention to the hip abductors and extensor, the knee extensors and the plantar flexors of the ankle should be given. Balance: sitting and standing balance must be tested. Demonstration: the physiotherapist should demonstrate appropriate crutch walking to the patient.

49. Crutch walking During first time, when the patient is to stand and walk, the physiotherapist should have an assistant for supporting the patient. Non-weight bearing: patient should always stand with a triangular base i.e. crutches either in front or behind the weight bearing leg Partial weight bearing: The crutches and the affected leg are taken forward and put down together. Weight is then taken through the crutches and the affected leg, while the unaffected leg is brought through.

50. Gait pattern with crutches Four point gait Three point gait Two point gait Two point swing through gait Two point swing to gait (the feet are advanced by a much shorter distance and placed behind the level of crutches)

51. Four-point gait In this gait pattern one crutch is advanced and then the opposite lower extremity is advanced. For example, the left crutch is moved forward, then the right lower extremity, followed by the right crutch and then the left lower extremity. Slow, Good stability - at least 3 point contact ground   Weight is on both lower extremities and used with bilateral involvement due to poor balance, in coordination( Ataxia) and muscle weakness

52. Three-point gait I n this type of gait three points of support contact the floor. Non-weight-bearing gait for lower limb fracture or amputation.

53. Non Weight Bearing

54. Two-point gait This gait pattern is similar to the four-point gait.  However, it is less stable because only two points of floor contact are maintained.  Thus, use of this gait requires better balance.  The two-point pattern more closely stimulates normal gait, in as much as the opposite lower and upper extremity move together.

55. Two additional, less commonly used crutch gaits are the swing-to and swing-through patterns.  These gaits are often used when there is bilateral lower extremity involvement, such as in spinal cord injuries. 

56. Swing-through gait Fastest gait, requires functional abdominal muscles In the swing-through gait, the crutches are moved forward together, but the lower extremities are swing beyond the crutches.

57. Swing-to gait Both crutches -> both lower limbs almost to crutch level The swing-to gait involves forward movement of both crutches simultaneously, and the lower extremities “swing to” the crutches.

58. 4 point gait –Balance and confidence / full weight bearing 3 point gait – Balance and partial weight bearing 2 point gait – non weight-bearing/ full weight bearing Point gait – stability, slow Swing gait – more energy, fast

59. STAIR CLIMBING

60. GUIDELINES If railing is available – use it (For axillary crutches, put both in one hand) Stronger LE always leads going up & weaker or involved limb leads coming down. (up with good; down with bad)

61. Ascending stairs :- Therapist – postero -lateral on affected side Maintain wide BOS Take step only when patient is not moving Hold guarding belt posteriorly by one hand & other anteriorly but not touching o the shoulder o affected side Leave crutches on the same level where standing. Support weight evenly on the crutch hand and railing. Raise the uninjured foot to the higher step, letting the injured foot trail behind. Straighten the uninjured leg and advance the crutches.

62. To Descend Therapist – anterolateral to affected side Maintain wide BOS Take step only when patient is not moving Hold guarding belt anteriorly by one hand & other anteriorly but not touching o the shoulder o affected side Place the crutches on the lower step, while extending the injured foot forward. Place the crutches on both sides of the body if no railing is present. Support weight evenly on the crutch hand and railing. Move the uninjured foot to the lower step. Narrow steps without a railing might require sitting on each step.

63. Stair Climbing Up With GOOD, Down With BAD

64. If balance is lost . . . Make contact of the hand guarding the shoulder. Therapist should move towards the patient. (don’t pull patient towards therapist) If needed, make the patient sit down on the staircase.

65. According to static and dynamic balance, starts from easy to hardest Underwater Use parallel bars Walker Crutches Canes Independent

66. Books References O’Sullivan, Susan B., Thomas J. Schmitz.   Physical Rehabilitation Assessment and Treatment. 4 th  ed . F. A. Davis Company.  1994.  p. 430-431 M.Dena Gardiner

67. ANY QUESTION ????

68. Don’t Give Up

69. Thanks