WALKING AIDS by Dr. Mumux

walking aids, aids, cane, crutch, walker, sticks, wheel chair, axillary crutch, elbow crutch, gutter crutch, gait, walking, walking patterns, gait determinants, physiotherapy, physio, healthcare

1. WALKING AIDS Dr. Mumux Mirani MPT Sports, Assistant professor, SSAIP. 1

2. 2

3. What is walking aids??? 3

4. Relate this image… 4

5. Walking Walking is the manner or way in which you move from one place to another . It is the forward propulsion of the body via coordinated and integrated action of neuromuscular system of the body. It is the highest level of motor control skill. Walking is a complex activity which requires the co operation and control of the whole body. 5

6. The major requirements for successful walking include : Support of body mass, by the lower extremities. Production of locomotors rhythm. Balance control of the moving body. Propulsion of the body in the intended direction. 6

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 7

8. Types of Walking aids There are a number of aids available to assist people who have difficulty in walking or who cannot walk independently without one. These external aids are crutches ,sticks and frames. Others include braces and splints 8

9. Crutches Crutches Introduction Types of crutches Measurement of length Preparation for crutch walking Crutch walking 9

10. 10

11. What is a crutch? These are devices which are used to reduce weight bearing on one or both legs and also give support where balance is impaired and strength is inadequate. 11

12. 12

13. Pre requisites 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 is given below - Shoulder flexor, extensors and depressor Shoulder adductors Elbow and wrist extensors Finger flexors 13

14. Types of crutches 1. Axillary crutches/ under arm crutches 2. Elbow crutches or Lofstrands crutches 3. Forearm support crutches (gutter crutches) 14

15. 1) Axillary Crutches - They are made of wood or metal with an Axillary pad, a hand piece and a rubber ferrule. Two upright shafts connected by axillary piece on top Hand piece in the middle 15

16. Extension piece below Extension piece and shafts has numerous holes at regular intervals so the total length of crutch and height of handle is easily adjustable. A large suction tip (rubber ferrule) is attached to extension piece to allow total contact with floor 16

17. 17

18. The Axillary pad should rest against the chest wall approx. 5 cm, beneath the apex of axilla and hand grip in slight flexion when weight is not being taken. 18

19. The elbow will go into extension and weight is transmitted down the arm to hand piece. On no account should weight be taken by axillary pad as this could lead to neuropraxia of the radial nerve or the brachial plexus. 19

20. Measurement of length There are variety of ways it may be in lying and also in standing position. In Lying it may be with shoes off and with shoes on With shoes off : measure from apex of axilla to the lower margin of medial melleolus. With shoes on : 5cm/2 inches vertically down from apex of axilla to a point 20 cm lateral to the heel of shoe. (Book Resource: M. Dena Gardiner) 20

21. In standing with shoe off and shoe on method is same. 2 inches below the axilla to the 2 inches anterior and 6 inch lateral to the foot in standing position. 21

22. The measurement from the axillary pad to the hand grip should be taken with the elbow slightly flexed (approx. 15 degree) from a point 5 cm below the apex of the axilla to the ulnar styloid . 22

23. Measurement of axillary crutches - 23

24. Crutches that are too tall or too short can affect balance and also cause back pain. Incorrectly fitted crutches or poor posture can cause a disorder called crutch palsy in which the nerves under the arm mostly radial nerve (brachial plexuses) are temporarily or permanently damaged, causing weakened hand, wrist and forearm muscles. 24

25. Advantages: Convenience for temporary injuries A large degree of support for the lower body Available at low cost. Axillary crutches allow the patient to perform a greater variety of gait patterns and ambulate at a faster pace. 25

26. DISADVANTAGES Limited upper body freedom Axillary crutches require good standing balance by the patient. Improper use of crutch can cause injury to axillary region, and Strain on the arms and upper body which can lead to crutch paralysis . 26

27. It is a condition in which the nerves under the arms (Radial nerve and brachial plexus) are pinched and also risk of losing balance. - Geriatric patient may fell insecure or may not have the necessary upper- body strength to use axillary crutches 27

28. 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. 28

29. 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. 29

30. 30

31. ELBOW /LOFSTRAND CRUTCHES They are made of metal, an aluminum tubular shaft with a handgrip and have a metal or plastic forearm band. Forearm piece bent backward and extended to 2 inches below the elbow. 31

32. Both handgrip and forearm piece are adjustable in length by means of a press clip or metal button and have a rubber ferrule. These crutches are suitable for patients with good balance and coordination with strong arms. Weight is transmitted exactly the same way as for axillary crutches. 32

33. Measurement - usually taken with the patient in the lying position with shoe on Elbow is slightly flexed (approximately 15˚) and the measurement is taken from the ulnar styloid to a point 20cm lateral to the heel of the shoe Once the patient is standing with support, the length must be checked 33

34. 34

35. 35

36. 36

37. ADVANTAGES Light weight Easily adjustable Using forearm crutches requires no more energy, increased oxygen consumption or heart rate than axillary crutches. 37

38. Being easily stored and transferred. There is no risk of injury to the neurovascular structures in the axillary region when using this type of crutches. 38

39. Disadvantages Forearm crutches are less stable . They require good standing balance and upper-body strength. Geriatric patient sometimes feel insecure with these crutches. They may not have the necessary upper-body strength to use forearm crutches. 39

40. Gutter crutches They are made of metal with a padded forearm support Platform, Velcro strap, an adjustable hand piece and a rubber ferrule. These are used for patients with Painful wrist and hand condition or elbow contractures, or weak hand grip 40

41. Elbow flexed 90 degrees, The hand rests on a grip which can be angled appropriately, depending on the user's disability. 41

42. 42 Mostly In rheumatoid disease, cerebral palsy, or other conditions for providing support. In these conditions patient cannot take weight through hands, wrists and elbows because of deformity. or pain.

43. 43

44. Measurement of length : IN LYING POSITION With shoes on : measure from the point of fixed elbow till 20 cm lateral to the heel. 44

45. ADVANTAGES : As similar like elbow crutch These are easily adjustable. More cosmetic than other crutches. DISADVANTAGES : Provide less lateral support due to absence of axillary pad. Cuffs may be difficult to remove. These can be expensive. 45

46. 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. 46

47. 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: T he physiotherapist should demonstrate appropriate crutch walking to the patient. 47

48. 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 48

49. To walk, the patient first moves the crutches a little further forward, takes weight down through the crutches and lifts the foot forward to a position just behind the line of crutches. Once this is mastered the patient may progress to lifting the foot forward to a position just in front of the line of the crutches. 49

50. 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

51. 51

52. 52

53. 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) 53

54. What is GAIT? Human locomotion, or gait, may be described as a translatory progression of the body as a whole, Produced by coordinated, rotatory movements of body segments. 54

55. The alternating movements of the lower extremities essentially support and carry along the head, arms, and trunk (HAT). HAT constitutes about 75% of total body weight, 55

56. Gait Phases of the Gait Cycle A gait cycle spans two successive events of the same limb, usually initial contact of the lower extremity with the supporting surface. During one gait cycle, each extremity passes through two major phases: a stance phase , when some part of the foot is in contact with the floor, which makes up about 60% of the gait cycle, and a swing phase , when the foot is not in contact with the floor, which makes up the remaining 40% 56

57. There are two periods of double support occurring between the time one limb makes initial contact and the other one leaves the floor at toe off. At a normal walking speed, each period of double support occupies about 11% of the gait cycle, Which makes a total of approximately 22% for a full cycle. The body is thus supported by only one limb for nearly 80% of the cycle 57

58. 58

59. 59

60. Gait terminology Temporal variables include Stance time , single-limb and double-support time , swing time , stride and step time , cadence, and speed. 60

61. The distance (spatial) variables include stride length, step length and Width and degree of toe-out 61

62. Stance time is the amount of time that elapses during the stance phase of one extremity in a gait cycle. Single-support time is the amount of time that elapses during the period when only one extremity is on the supporting surface in a gait cycle. Double-support time is the amount of time spent with both feet on the ground during one gait cycle. The percentage of time spent in double support may be increased in elderly persons and in those with balance disorders. The percentage of time spent in double support decreases as the speed of walking increases 62

63. Stride length is the linear distance between two successive events that are accomplished by the same lower extremity during gait. stride length is not always twice the length of a single step, because right and left steps may be unequal Stride length varies greatly among individuals, because it is affected by leg length, height, age, sex, and other variables 63

64. 64

65. Stride duration refers to the amount of time it takes to accomplish one stride. Stride duration and gait cycle duration are synonymous. One stride, for a normal adult, lasts approximately 1 second. 65

66. Step length is the linear distance between two successive points of contact of opposite extremities. It is usually measured from the heel strike of one extremity to the heel strike of the opposite extremity A comparison of right and left step lengths will provide an indication of gait symmetry. The more equal the step lengths, the more symmetrical is the gait 66

67. 67

68. Step duration refers to the amount of time spent during a single step. Measurement usually is expressed as seconds per step. When there is weakness or pain in an extremity, step duration may be decreased on the affected side and increased on the unaffected (stronger) or less painful 68

69. Cadence is the number of steps taken by a person per unit of time. Cadence may be measured as the number of steps per second or per minute, Cadence = number of steps/time A shorter step length will result in an increased cadence at any given velocity. when a person walks with a cadence between 80 and 120 steps per minute, cadence and stride length had a linear relationship 69

70. As a person walks with increased cadence, the duration of the double-support period decreases. When the cadence of walking approaches 180 steps per minute, the period of double support disappears, and running commences. A step frequency or cadence of about 110 steps per minute can be considered as “typical” for adult men; a typical cadence for women is about 116 steps per minute. stride cadence, is exactly half the step cadence 70

71. Walking velocity is the rate of linear forward motion of the body, which can be measured in meters or centimeters per second, meters per minute, or miles per hour. Women tend to walk with shorter and faster steps than do men at the same velocity. Increases in velocity up to 120 steps per minute are brought about by increases in both cadence and stride length, 71

72. But above 120 steps per minute, step length levels off, and speed increases are achieved with only cadence increases. Speed of gait may be referred to as slow, free, and fast. Free speed of gait refers to a person’s normal walking speed; slow and fast speeds of gait refer to speeds slower or faster than the person’s normal comfortable 72

73. Step width, or width of the walking base , may be found by measuring the linear distance between the midpoint of the heel of one foot and the same point on the other foot Step width has been found to increase when there is an increased demand for side-to-side stability, such as occurs in elderly persons and in small children. 73

74. 74

75. In toddlers and young children, the center of gravity is higher than in adults, and a wide base of support is necessary for stability. In the normal population, the mean width of the base of support is about 3.5 inches and varies within a range of 1 to 5 inches. 75

76. Degree of toe-out represents the angle of foot placement (FP) and may be found by measuring the angle formed by each foot’s line of progression and a line intersecting the center of the heel and the second toe. The angle for men normally is about 7 from the line of progression of each foot at free speed walking The degree of toe-out decreases as the speed of walking increases in normal men. 76

77. 77

78. Power generation is accomplished when muscles shorten (concentric contraction) . They do positive work and add to the total energy of the body. Power absorption is accomplished when muscles perform a lengthening (eccentric) contraction. They do negative work and reduce the energy of the body. If joint motion and moment are in opposite directions, negative work is being performed through energy absorption. 78

79. STICK/CANES They are wooden / metal sticks, which have to be cut to the correct length for the patient or there are adjustable metal sticks. Can are not normally recommended for non weight bearing and partial weight bearing cases. It is useful for increasing the base of support and to improve the balance . 79

80. Canes are preferred to provide opposite to affected side. During the normal gait the stance hip abductors counterbalance the swinging hip and prevent it from tilting. 80

81. Types of canes Standard canes Standard adjustable canes Standard adjustable offset canes Tripod cans Quadruped canes 81

82. 82

83. 83

84. Standard canes Made up of aluminium, wood and plastic It has half circle handpiece Height is not adjustable Inexpensive Standard adjustable canes Made up of aluminium and may be having the plastic cover Height is adjustable Easy to carry anywhere 84

85. Adjustable aluminium offset canes Upper half of the cane is offset anteriorly so that COG falls on the cane and it gives more stability it may be available in the standard adjustable canes 85

86. Quadruped and tripod canes It has the 4 or 3 leg with rubber tip and gives the broader base. As the result BOS of canes are huge. Give more stability than other canes More use full in neurological cases like hemiplegia and other elderly patient It is difficult to carry the cane in the staircase if the base is broader 86

87. Measurement 87 Usually taken with the patient in the standing position The elbow is slightly flexed and the measurement is taken from the ulnar styloid to floor approximately 15 cm from the heel

88. FRAMES Made of metal and adjustable. Light in weight Have ferrules attached to four struts. some have wheels attached but should be carefully used. There are reciprocal frames which are hinged So that one side can be moved forward than the other. 88

89. 89

90. Uses: Use full fro the NWB,PWB and FWB. In elderly patients with unsteady gait. In patients with cerebral palsy or spina bifida. The patient lifts the frame forward, then leans on it and takes two steps. The patient should take even steps, keeping the frame well forward. A bag can be attached to the front of the frame to carry small items. 90

91. Safety: The physiotherapist must check the safety of all walking aids not only when giving them to a patient, but regularly throughout a treatment programme. 91

92. Wheel chair This is one of the variety of mobility aids. The patient who has both lower limb non functioning or partial functioning has to be recommended for the wheel chair. It gives 100 percent stability to the patient Normally, wheelchair are recommended for paraplegic, quadriplegic, muscular dystrophy spinal cord injury and fracture conditions It provide physical as well as mental support to the patient. 92

93. Types Rigid foldable One arm driven wheelchair Powered wheelchair 93

94. 94

95. 95

96. THANK YOU…. 96