DR. ATEF EL GHAWEET

Neurological problems ( stroke, MS, Parkinsonism ) Orthopedic Injuries . Congestive Heart Failure . Back problems . Post traumatic cases . Arthritis .

Indications of walking aids:

Reasons for using walking aids

Poor balance, Inability to bear weight on a lower extremity due to fracture or other injury, Paralysis involving one or both lower extremities, or Amputation of a lower extremity . 5000000 side effects

Purpose of walking aids-Increase area of support, maintain center of gravity over support area and increase stability-Decrease weight-bearing

BENEFITS OF WALKING AIDSCompensate for weak LL decrease pain inc. healing. improves ADL ,increase joint motion ,increase balance-Improves respiratory function; appetite; bowel & urinary function-Increases social activity & mental stimulation

A piece of equipment used to provide support and stability for a person as he/she walk

Provide an extension of the UE to transmit BW to the ground

Walking aids such as canes, crutches and walkers can be used during short-term injury or post-operative recovery or for chronic and intermittent conditions.

General Principles

The patient to be carefully evaluated in order to select the appropriate assistive device to meet the patients needs. We must be aware of the patients total medical condition, weight-bearing status of the involved extremity when considering which type of assistive device to use with the patient. We will need to determine the range of motion of the extremities and the strength of the primary muscles required for ambulation.

The patient must press downward on the assistive gait device in order to move the body forward. The scapular, shoulder, and elbow musculature supports the bodys weight while the non-affected lower extremity is moved forward. The finger flexors fold the hand-piece of the assistive gait device.

The primary muscles required for ambulation with axillary crutches, using a three-point (non-weight bearing on one lower extremity) crutch gait pattern, are the scapula stabilizers, shoulder depressors, shoulder extensors, elbow extensors, and finger flexors for the upper extremity.

The primary lower-extremity muscles in the weight-bearing lower extremity are the hip extensors, hip abductors, knee extensors, knee flexors, and ankle dorsi-flexors. While the patient is standing on the unaffected lower extremity, the muscles of the hip and knee provide stability. The ankle dorsi-flexors position the foot so that it can clear the floor when the limb is swinging forward

The selection of an assistive walking aid is based on the patients disability, coordination, and stability. For example, you may have two patients with the same type of fracture. One of the patients may use crutches if he or she has adequate stability and coordination to safely use them. The other patient may require a walker due to poor stability and coordination. As the patients abilities improve, they may advance to an assistive device providing less stability and support for easier maneuverability. Types of assistive walking aid

Assistive walking aids are designed to improve the patients stability by increasing the base of support. The categories of assistive ambulation devices, in order from greatest to least amount of support, are: Parallel bars, Walkers,Axillary crutches, Forearm (Loftstrand) crutches, Two canes, and One cane. All categories of assistive gait devices are adjustable . Additionally, a special platform can be attached to walkers or axillary crutches for patients who are unable to bear weight through the hand, wrist, or forearm.Types of walking aids:

PARALLEL BARSWALKERSAXILLARY CRUTCHESFOREARM CRUTCHESBILATERAL CANESSINGLE CANE

NB :Types of Mobility devicesDevices used to help mobility:CANESWALKERSCRUTCHESWHEEL CHAIR PARALLEL BARS BELTS

When maximal patient stability and support is required in functional position : poor coordination, poor balance ,deb. Con.CVD, age ,fear, hip arthroplasty.

Parallel bars

Sitting to standing balanceStanding and walkingTuringWeight shifting

Parallel bars

Parallel bars are used when maximal patient support and stability are required. The gait pattern can be practiced in parallel bars and the fit of the assistive device can be checked. The parallel bars limit mobility. So once the patient becomes proficient with the appropriate gait pattern, the patient must be progressed to another assistive gait device to be mobile. Care must be taken so that the patient does not become dependent on the parallel bars.

The parallel bar height needs to be adjusted to provide 15 to 20 degrees of elbow flexion when the patient is standing erect and is grasping the bars about 6 inches anterior to the hips. The bars need to be approximately 2 inches wider than the patients hips when the patient is centered between the bars.

Disadvantages:Parallel Bars severely limit mobilityPt. must progress to another ambulation aid to be mobile

When maximal stability and support, along with MOBILITY is required.

Walkersan ambulation aid, with 4 contacts that are placed on floor and a frame to support patients weight during ambulationTrochanterlevel

WALKERS

Useful if partial, full, or non-weight bearing of one leg.s

WalkersWider and more stable base of support . For patients requiring maximum assistance :elderly, fearful, with poor balance, uncoordinated

WALKER

WALKERS are also used with clients who have total knee or hip joint replacement surgery, or another significant problem.

TYPES OF WALKERS Standard Folding Reciprocal WalkerWheeled or RollingPlatform Walker One-hand Walker (hemiplegic)

WalkersStandard walker

RECIPROCAL WALKER

Front wheeled walker

Using a walker with wheels

Four-wheel walker w/Seat

Platform attachment for walker

-Pre-requisites for the use of a walkerGood graspGood bilateral arm strength-PartsTubular aluminum, plastic hand grips & rubber tipped legs

Walker

-Patient should have at least one weight bearing leg and arm- walker with wheels easier for pts who have difficulty with lifting ,however can roll forward when weight is applied.-Height upper bar of walker should be at the level of GT with arms flexed 15-30 deg

Ambulation with Walker.Patients feet stationary when walker is moving.Patients feet should be shoulders width,apart, and one slightly ahead of the other.Healthcare worker stands slightly behind and to the affected side of patient

How To Use A WalkerStand with the walker and hold onto itPick up walker and move it forward 6-8 inchesTake a step forwardPt will support the body wt on the handgrips when moving the weaker leg (sort of dragging it along)Swing to Two point (Reciprocal walker)

Walkers

Walkers provide maximum stability and support and allow the patient to be mobile. Walkers are designed in many styles, but all have four legs. Some may have two or four wheels. Wheels allow the patient to gently push the device forward as opposed to picking the walker up to move it forward. Another variation in the design of the walker is the ability to fold the walker when it is not being used. This feature allows for easier transportation in a car and for storage.

Disadvantages of using walkers:

Walkers are cumbersome and difficult to store and transport.Walkers are very difficult to use on stairs.Walkers reduce the speed of ambulation. The patient is unable to use a normal gait pattern by using walker.slow gait (interfere smooth reciprocal gait)

-Provide support from the UL to floor-2 points of contact-Better stability than canes

Types of CrutchesAxillary crutches: rests under axilla, no pressure should be appliedForearm crutches :used by permanent crutch users to aid in walking like an C.P. ptPlatform crutches used for people who cant bear wt with their hands or wrists, (arthritis pts use these).

Triceps crutch

Axillary crutch

AXILLARY CRUTCHES-Transfers 80% of BW- Requires better trunk support

PARTSSHOULDER PIECE

DOUBLE UPRIGHT

HAND GRIP/ BAR

RUBBER SUCTION TIP

CRUTCH ACCESSORIES

CRUTCH TIP (RUBBER SUCTION TIP)AXILLARY PADS (RUBBER/ SPONGE)HAND GRIPS (SPONGE PAD)TRICEPS BAND (METAL/ STIFF LEATHER)WRIST STRAP (LEATHER/ PLASTIC)

Crutches

Measure by lying flat in bed with shoes used for walkingMeasure from anterior fold of axilla to the heel and add 1 inch = 2.5 cmStanding position: crutch pad should be three finger breaths from anterior fold of axilla

Crutches

-When standing tip of crutch rests 4-6 inches in front & 4-6 inches to side of foot.

-Do not rest on top of crutches pressure on axilla nerves can lead to paralysis called crutch paralysis (numbness, tingling, muscle weakness)

Measuring crutches in standing position

Appropriate position for handgrips

To properly fit a patient with axillary crutches, both the length of the crutches and the height of the hand piece must be properly adjusted. The length of the axillary crutch should be adjusted so the therapist can fit two or three fingers between the top of the axillary crutch and the patients axilla. When standing, the tips of the crutches should be approximately 6 inches from the toes of the patients shoes.

The handpiece of the axillary crutch should be adjusted so the patient has 15 to 30 degrees of elbow flexion.

Axillary crutches

Axillary crutches are used with patients who do not require as much stability or support as provided by a walker. Axillary crutches allow the patient to perform a greater variety of gait patterns and ambulate at a faster pace.

Axillary Crutches-Body weight carried on arms and hands and not axilla-2 Point Gait and 4 Point Gait used for partial weight bearing-3 Point Gait non-weight bearing--Swing to and Swing through for weight bearing

Disadvantages of axillary crutches:

Axillary crutches are less stable than walker.Improper use of axillary crutches can cause injury to the neurovascular structures in the axillary region. Axillary crutches require good standing balance by the patient.Geriatric patient may fell insecure or may not have the necessary upper- body strength to use axillary crutches.

be cautious regarding crutch palsy damage to the radial nerve in axilla area - numbness, tingling, muscle weakness and paralysis

NAC : Forearm crutch LC

Forearm Crutches Loftstrand Crutches

PARTS OF LOFTSTRAND CRUTCH

FOREARM CUFF

2. PADDED HAND BAR

3. TUBULAR ALUMINUM -SINGLE UPRIGHT

Lofstrand/forearm crutches-Adjustable shaft, forearm piece , 2 inches below elbow, forearm cuff anterior opening (hinge)-Elbow flexion 20 degreeCan release hand without loosing crutch-Requires great skill, good strength of UEs, trunk balance

To fit the patient with forearm crutches:

have the patient stand with arms hanging loosely by the side. Place the crutch parallel to the lateral aspect of the tibia and femur. Adjust the height of the hand-piece so that it is level with the ulnar styloid process. This will insure the elbow is flexed between 15 and 25 degrees. The top of the forearm cuff should be adjusted so that it is located 1 to 1.5 inches distal to the olecranon process of the elbow while the patient is grasping the hand-piece of the crutch with the wrist in neutral flexion-extension.

Forearm crutchesForearm crutches (Loftstrand or Canadian crutches) are used when the patient need crutches permanently, or for long periods of time. People who use Loftstand crutches must have the stability and coordination to use them. Using forearm crutches requires no more energy, increased oxygen consumption or heart rate than axillary crutches. This type of crutch has the advantage of 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.

Platform CrutchPlatform, velcro strapElbow flexed 90 degrees

PLATFORM CRUTCHFOR INDIVIDUALS WHO ARE/HAVE:-UNABLE TO BEAR WEIGHT THROUGH THEIR WRISTS & HANDS

-SEVERE DEFORMITIES OF THE WRIST OR FINGERS

-BELOW ELBOW AMPUTATION

-UNABLE TO EXTEND ONE OR BOTH ELBOWS PASSIVELY

Disadvantages of forearm crutches:

Forearm crutches are less stable than a walker.They require good standing balance and upper-body strength.Geriatric patient sometimes feel insecure with these crutches. BW40-50%

-Oldest of all walking aids-Opposite the affected LL-Provide more physiologic gait -Wider BOS-Reduce stress on opposite hipCanes

-Canes come in many styles, sizes, and models, from glass to steel.

-For greater stability, canes with four legs set on either a large or a small steel base are a good choice. These are called quad canes.

Canes

CanesStandard Cane

Standard Crook Cane

Modified Crook Cane

OFFSET CANE

Offset cane

Functoinal Grip Cane

PARTSHANDLE (J/ T/C- shaped, PISTOL GRIP, OFFSET)

SINGLE UPRIGHT

RUBBER SUCTION TIPhandle

Quad Cane with Offset Handle

Adjustable quad cane for Extra stability

Extra stability is ensured by four legged base.

Quad cane, handle is parallel to the hipQuadripod cane

CANE SEAT

Used to compensate for impaired balance or to improve stability

Approximately 25% of BW is transferredCanes

-Used for people who have weakness to one side of the body-Canes must be the right height for the pt to use effectivelyCanes

slight elbow flexiongreatertrochanterCanesShould be fitted properly:.cane handle level with femur (greater trochanter)Elbow flexed at 15 to 30 degree

CANES Aids in balance; Able to weight bear on both legs One leg weaker but not bilateral weaknessCheck rubber tip: Must be secure on the end to prevent slippingProper size: Cane should extend from greater trochanter down to floor:Hold 15 cm (4 - 6 in.) to side of strong leg withelbow flexion at 15 - 30 degrees

Advantages:More functional Can be used in narrow and confined placesEasy storage and transport

Canes

Disadvantages:Limited stability2 canes do not provide sufficient stability to perform a 3-point gait patternCanes

A standard cane provides limited stability because of its small base of supportA quad cane has a broad base, and will provide greater stability than the standard caneCanes

Selecting appropriate device

-Rubber tips & handgrips on ambulatory aids should be kept clean & replaced when worn. Worn or dirty tips & handgrips contribute to falls & unsafe mobility-Home use of canes/walkers: advise family to make home safer by removing scatter rugs, ensuring adequate lighting, no electric cords are within pathways. Railings & grab bars installed in bathrooms & outside entrances

NB: Device does not prevent falls, however does reduce risk of falls when used properly

"A method of locomotion involving the use of the two legs, alternately, to provide both support and propulsion. In order to exclude running, we must add 'at least one foot being in contact with the floor at all times'Definitions of normal gait:

1-Each leg must be able to support the body weight without collapsing.2-Balance must be maintained statically and dynamically during single leg stance.3-The swinging leg must be able to advance to a position where it can take over the supporting role.4-power must be provided to make the necessary limb movements and to advance the trunk.

In order that a person can walk, the locomotion system must be able to accomplish four things:

In normal walking each of these requirements achieved without any difficulty.However, in many pathological conditions these requirements can be achieved by means of abnormal gait or by the use of walking aids such as walker, crutches, cane .Failure to achieve all four requirements means that the subject is unable to walk.The pattern of gait is the outcome of a complex interaction between the many neuromuscular and structural elements of the locomotion system. Abnormal gait may result from a disorder in any part of this system. It may also result from the presence of pain.

Standing on one-leg leads to increase the load on the stance hip because of three components:

1-The whole of the weight of the trunk is now supported by the stance hip joint, instead of being shared between the two hips.2-The stance hip now takes the weight of the swing leg, instead of by the ground.3-The gluteus medius of the stance leg contract to keep the pelvis from dipping on the unsupported side, the reaction force of this contraction passes through the stance hip joint.

Gait Training

Gait training may begin by using parallel bars, walker, crutches, canes, and freedom without devices.

Basic gait patterns

The selection of the proper gait pattern is dependent upon the patients balance, strength, coordination, functional needs, and weight-bearing status.

WALKER GAIT PATTERNS

Crutch Walking Gait-Is the walking pattern used when ambulating with crutches -There are 6 different ways to walk with crutches 5-10 cc lat and15 cc top-

-Using crutches often appears easier than it actually is. proper instruction should be given to the ptatient including following points:

-Make sure the crutches fit properly, Your shoulders should lean forward slightly and your wrists and elbows should be bent. How to Use Crutches

There are six different way to use crutches to assist with ambulation, or walking (point, swing) . Each of these has advantages, disadvantages and appropriate indications.

How to Walk Safely with Crutches

four-point gaitthree-point gaittripod gaittwo-point gaitswing-to gaitswing-thru gait

Crutches Gaits

1. Four-point gait pattern

A four-point gait pattern is used when the patient requires maximum assistance with balance. It requires the use of bilateral assistive gait devices (canes or crutches). The pattern begins with the forward movement of one of the assistive gait devices, and then the contra-lateral lower extremity, the other assistive gait device, and finally the opposite lower extremity . This is a slow gait pattern, but a stable one.

Four-Point Crutch GaitIndication: Weakness in both legs ,ataxia or poor coordination. Pattern Sequence: Left crutch, right foot, right crutch, left foot. Then repeat. Advantages: Provides excellent stability as there are always three points in contact with the ground Disadvantages: Slow walking speed

Four-point gait

Four Point GaitProvides best balance & stability for person but must be able to weight bear on both legs

2. Three-point gait pattern The three-point pattern requires two crutches or a walker, but it cannot be performed with two canes. This pattern is used when the patient is only able to bear full weight on one lower extremity. When using axillary crutches and a three-point gait pattern, between 44.4 and 49 percent of the patients body weight is transmitted through the upper extremities. So the strength of the upper extremities and uninvolved lower extremity must be assessed prior to attempting ambulation. The energy cost (oxygen consumption) for this type of gait is about twice as high as normal walking.

Indication: Inability to bear weight on one leg. (fractures, pain, amputations) all weight bearing on strong leg

Pattern Sequence: First move both crutches and the weaker lower limb forward. Then bear all your weight down through the crutches, and move the stronger or unaffected lower limb forward. Repeat. Advantages: Eliminates all weight bearing on the affected leg. Disadvantages: Good balance is required.Three-Point Crutch Gait

Three-point gait-Non-weight-bearing gait for lower limb fracture or amputation-3-point PWB gait -> required 18-36% more energy per unit distance than normal-NWB required 41-61%more energy per unit distance than normal

Modified three-point gait pattern

The modified three-point gait pattern requires two crutches or a walker. This pattern is used when the patient can bear full weight with one lower extremity but is only allowed to touch the involved lower extremity to the floor. This is known as touchdown weight bearing (TDWB). The term partial weight bearing (PWB) refers to when the involved lower extremity is allowed only part of the patients weight to be transferred through it.

SUPPORT WEIGHT ON STRONG LEG AND MOVE CANE FORWARD ABOUT 6 - 10 INCHES THE WEAK LEG IS ROUGHT FORWARD EVEN WITH THE CANE SHIFT WEIGHT TO THE WEAK LEG AND THE CANE, MOVING THE STRONG LEG FORWARD AHEAD OF THE CANE REPEAT MOTIONS TO MOVE AHEAD Mdified Three-point gait

Indications: Initial pattern for patients with paraplegia learning to do swing to gait pattern. Pattern Sequence: Advance the left crutch, then the right crutch, then drag both legs to the crutches Advantage: Provides good stability. Disadvantage: Very energy consuming.3.Tripod Crutch Gait

4. Two-point gait pattern

The two-point gait pattern requires the use of bilateral assistive gait devices. This pattern is faster than the four-point gait. The two-point gait pattern closely approximates a normal gait pattern and should be encouraged. This pattern does require the patient to coordinate moving an assistive gait device and the contralateral lower extremity at the same time. This pattern is less stable than the four-point pattern.

Indication: Weakness in both legs or poor coordination Pattern Sequence: Left crutch and right foot together, then the right crutch and left foot together. Repeat.

Advantages: Faster than the four point gate. Disadvantages: Can be difficult to learn the pattern.Two-Point Crutch Gait

Two-point gait

-Faster than 4-point gait but less stability

-Decrease both lower limbs weight-bearing

Indications: Patients with weakness of both lower extremities. Pattern Sequence: Advance both crutches forward then, while bearing all weight down through both crutches, swing both legs forward at the same time to (not past) the crutches. Advantage: Easy to learn. Disadvantage: Requires good upper extremity strength.5.Swing-To Crutch Gait

Swing-to gait

Both crutches -> both lower limbs almost to crutch level

Indications: Inability to fully bear weight on both legs. (fractures, pain, amputations) Pattern Sequence: Advance both crutches forward then, while bearing all weight down through both crutches, swing both legs forward at the same time past the crutches. Advantage: Fastest gait pattern of all six. Disadvantage: Energy consuming and requires good upper extremity strength6.Swing-Through Crutch Gait

Swing-through gaitFastest gait, requires functional abdominal musclesRequired increase of 41-61% in net energy cost (= 3-point NWB)

Cane Gait patterns

The modified four-point and two-point gait patterns require only one assistive gait device. The assistive device is used with the opposite upper extremity to the involved lower extremity, if possible. This widens the base of support, increase stride lengths, cadence, and walking velocities than when using the cane on the same side as the involved lower extremity.

ONE CANE PATTERN

-Require only one ambulation aid and are used for patient who only has one functional UE or who uses only one ambulation aid.-Aid is held on the UE opposite the affected or protected LE.

1-Gait with a single aid: if only a single cane or crutch is used. The aids moved forwards together with the worse of the two legs during the stance phase of the better one.2-Three-point swing-through gait: it is used when it is impossible to support the body weight on one leg. Three-point gait involves support of the body weight by the two crutches while the leg or legs are moving forwards, and by the legs while the crutches are moved.GAIT PATTERN WITH WALKING AIDS

3-Three-point swing-to gait: this gait pattern is similar to three-point swing-through gait, except that feet are advanced by a much shorter distance, being placed on the ground behind the level of the crutches. 4-Four-point gait: It is only appropriate when both legs are able to support part of the body weight. Subject who have only minor stability problems my use two canes, each of which is moved forwards during the swing phase of the opposite leg, during which time the body has only two points of contact with the ground.

None weight bearing (NWB)Toe touch weight bearing (TTWB, TDWB) Partial weight bearing (percentage of the body weight) (PWB) we need to use weight scaleWeight bearing as tolerated (WBAT)Full weight bearing (FWB)

Weight bearing status

*****Walkers improve stability in patients with lower extremity weakness or poor balance also facilitate improved mobility by increasing patient vase of support and supporting the patients weight. Can be difficult to maneuver and can result in poor back posture and reduced arim swing. Standard walker most stable walker, but slower gait because patient has to fully lift walker off the ground with each step. Front-wheeled walkers less stable but maintains a more normal gait pattern and better for patients who can not lift standard walker.4 wheeled walker rollator useful for higher functional patients who do not need the walker to bear weight. Not appropriate for patients with balance issues or cognitive impairment because it can roll unexpectantly causing a fall. Usually have a seat and basket. Brakes should always be on, and leaned against solid object, like wall before sitting. Useful for patients with claudication, respiratory disease, or CHF all who main need to rest intermitently during ambulation.**Helpful for patients who need their upper extremities for weight bearing and propulsion. 1 crutch can provide 80% weight bearing support, 2 provides 100%. Require arm and should strength, and large amounts of energy usually inappropriate for frail older adultsAxillary crutch weight bearing ambulation, inexpensive, somewhat difficult to use. Incorrect fit can lead to nerve or axillary artery compressionForearm (lofstrand) crutch have a cuff around proximal forearmand distal hand grips. Provides B/L upper extremity support with occasional weight bearing. Platform crutch provide a horizontal platform for entire forearm which bears the weight instead of the hand. Good for patients with elbow contractures or weak, painful hands or wrists***--THOSE WHO HAVE SEVERE DEFORMITIES OF THE WRIST OR FINGERS MAKING IT DIFFICULT TO GRASP THE HANDPIECE OF A REGULAR CRUTCH*Canes help redistribute weight from weak or painful lower extremity., improve stability by increasing base of support, and provide tactile information about the ground to help improve balance. There is little evidence that favours 1 type of cane over anotherStandard cane made of wood or aluminum, lightweight, inexpensiveOffset cane distributes the patients weight over the shaft of the cane. Better for patients who occasionally need their upper extremity to bear weight (gait problems from pain due to osteoarthritis)3. quadripod cane provides larger base of support, allows for more upper extremity weight bearing. Can also freestand if patient needs to use their hands Handles standard cane has umbrella handle can increase risk of carpal tunnel syndrome due to pressure on palm of hand- Shot gun handle flat handle distributes pressure across entire hand from thenar to hypothenar muscles, putting less pressure on the palm, decreasing risk of carpal tunnel syndrome******