THE VARIOUS AMBULATION AIDS/ ASSISTIVE DEVICES COMMONLY PRESCRIBED TO PATIENTS WITH IMPAIRMENTS & LIMITATIONS IN WALKING.

BASIC FEATURES &

PURPOSE

CHARACTERISTICS ADVANTAGES, DISADVANTAGES & LIMITATIONS CORRECT MEASUREMENT

1. MEASUREMENT & FITTING 2.BASIC GAIT PATTERNS 3. WHEELCHAIR MOBILITY 4. SAFETY TECHNIQUES

Act of walking or being able to walk

A piece of equipment used to provide support or stability for a person as he/she walks
(Pierson, 1999)

Appliance to aid ambulation Provide an extension of the UE to help transmit BW & provide support for the patient

Functions of the Ambulation Aids

Increase area of support Increase patients stability Redistribute & unload a weightbearing limb Improve balance Provide sensory feedback

Selection of the proper ambulation devices & gait pattern is most important to provide optimal security, safety, & function with the least energy expenditure.

What is my role as a physiotherapist? Know WHEN to indicate Know the RIGHT ambulation aid to use Provide PRE-Ambulation Exercises
Stages: Strengthening Exe Coordination Exe Trunk Balance Exe Use of Ambulation Aids (END GOAL)

What are the factors that influence ambulation training program?

FACTORS THAT INFLUENCE AMBULATION TRAINING Joint ROM & Muscle Strength

of Upper Extremity Joint ROM & Muscle Strength of Lower Extremity Coordination Trunk Balance Impairment in Sensory Perception

What are the factors that help determine ambulatory needs?

FACTORS THAT HELP DETERMINE AMBULATORY NEEDS Nature of Disability Age of the Patient Mental Status Physical Endurance Energy Expenditure

Arrange the following ambulation aids according to the MOST stable & supportive to the LEAST stable & supportive. Single Cane Parallel Bars Walker Forearm Crutches Axillary Crutches Bilateral Canes

SINGLE CANE
BILATERAL CANES

FOREARM CRUTCHES
AXILLARY CRUTCHES

WALKERS

PARALLEL BARS

Arrange the following ambulation aids according to the MOST REQUIRING COORDINATION to LEAST REQUIRING COORDINATION.

WALKER CRUTCHES CANE PARALLEL BARS

 When maximal patient stability and support is required

Bars should be adjusted for proper fitting.

Disadvantages:
Bars severely limit mobility Pt. must progress to another ambulation aid to be mobile

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

Wider and more stable BOS

 Adv:
Lightweight Foldable Safer and provide good support

 Disadv:
Difficult to store/transport Difficult to use on stairs Slow & awkward gait pattern Difficult to use in narrow/ crowded places

 Pre-requisites for the use of a

walker

Good grasp Good bilateral arm strength

Parts
Tubular aluminum, plastic hand grips & rubber tipped legs

a) Standard

TYPES and VARIATIONS of WALKERS

Non-adjustable Adjustable

b) c) d) e) f)

Reciprocal Walker Wheeled or Rollator Folding Stair Climbing Walker One-hand Walker (hemiplegic)

ROLLATOR

Lightweight Aluminium Rollator Walker Standard

Lightweight Aluminium Triwalker Basic

PRONE CRAWLER

Walker Paraplegia (adult)

Stair Climbing Walker

RECIPROCAL WALKER

FORWARD HEMIWALKER

FOLDING WALKER WITH GLIDES/ ROLLATOR

Platform attachment for walker

Used to compensate for impaired balance or to improve stability

Approximately 25% of BW is transferred

Oldest of all assistive devices

Held opposite the affected LE

Provide more physiologic gait

Wider BOS

Reduce stress on opposite hip

 Adv:
More functional on stairs Can be used in narrow and confined places Easy storage and transport

 Disadvantages:
Limited stability 2 canes do not provide sufficient stability to perform a 3-point gait pattern

PARTS
HANDLE (J/ T/C- shaped, PISTOL GRIP, OFFSET) SINGLE UPRIGHT
handle

RUBBER SUCTION TIP

Standard Crook Cane

Modified Crook Cane

Cane w/ Ortho Grip

OFFSET CANE W/ WRIST STRAP

Quad Cane with Offset Handle

Quad cane with large inverted "V" base

Quad cane w/ "U" shape hand grip

CANE SEAT

 Provide support from axilla to floor 2 points of contact Better stability than canes

Two Basic Types:

Axillary Crutches Non-axillary Crutches

AXILLARY CRUTCHES
-Transfers 80% of

BW - Requires better trunk support - Allow selection of gait patterns & ambulation speed - Provide good support and stability

PARTS
SHOULDER PIECE DOUBLE UPRIGHT HAND GRIP/ BAR RUBBER SUCTION TIP

DISADVANTAGES
1. LESS STABLE THAN WALKER 2. CAN CAUSE INJURY TO AXILLARY VESSELS & NERVES IF USED PROPERLY 3. REQUIRE GOOD STANDING BALANCE 4. ELDERLY Pt. MAY FEEL INSECURE WITH THEM 5. FUNCTIONAL STRENGTH OF THE UE & TRUNK MUSCLES IS REQUIRED FOR MOST GAIT PATTERNS

NON-AXILLARY CRUTCHES
TRANSFERS 40-50% BW ELIMINATE THE DANGER OF INJURY TO AXILLARY VESSELS & NERVES MORE FUNCTIONAL ON STAIRS & IN NARROW, CONFINES AREAS RELATIVELY EASY TO STORE & TRANSPORT FOREARM CUFF RETAINS THE CRUTCH ON THE FOREARM WHEN Pt. REACHES FOR AN OBJECT

DISADVANTAGES
1. PROVIDE LESS STABILITY & SUPPORT THAN AXILLARY CRUTCHES, A WALKER, OR PARALLEL BARS 2. THEY REQUIRE GOOD STANDING BALANCE & GOOD UE STRENGTH FOR MANY GAIT PATTERNS 3. THE FOREARM CUFF MAKES IT DIFFICULT TO REMOVE THE CRUTCH 4. ELDERLY Pt. MAY FEEL INSECURE WITH THEM

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

Loftstrand Crutches

PARTS OF LOFTSTRAND CRUTCH 1. FOREARM CUFF 2. PADDED HAND BAR 3. TUBULAR ALUMINUM SINGLE UPRIGHT

Platform Crutch

PLATFORM CRUTCH
FOR 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
1. THE PATIENT LOSES THE USE OF HIS/HER TRICEPS TO ELEVATE & MAINTAIN HIS/ HER BODY DURING THE SWING PHASE 2. ANOTHER PERSON MAY NEED TO APPLY THEM 3. THEY ARE LESS EFFECTIVE ON STAIRS

MAJOR MUSCLE GROUPS USED FOR NON-WEIGHTBEARING AMBULATION

Upper Trunk
Scapular Depressors Scapular Stabilizers

Lower Trunk
Trunk Extensors Trunk Flexors

 Upper Extremity
Shoulder Depressors Shoulder Extensors and Flexors Elbow Extensors Finger Flexors

Weight Bearing Lower Extremities

Hip Abductors Hip Extensors Knee Extensors Ankle Dorsiflexors

1. SCAPULAR DEPRESSORS

IMPORTANT SPECIFIC CRUTCH WALKING MUSCLES

-stabilize the UE & prevent hiking of the shoulder on weight bearing

Latissimus dorsi Lower trapezius Pectoralis minor

2.SHOULDER ADDUCTORS - hold the crutch top to the chest wall with the arm Pectoralis major Latissimus dorsi 3. FLEXORS, EXTENSORS, ABDUCTORS OF THE ARM & SHOULDER - enable the placement of crutch forward, backeard, and sideward respectively Deltoids

4. ELBOW EXTENSORS

stabilize the elbow joint in weight bearing by preventing flexion or buckling; together with shoulder depressors these muscles are most important in raising the body from the floor to allow the LE to swing Triceps Anconeus 5. WRIST EXTENSORS hold wrist in proper position to bear weight on hand piece ECRL/ECRB ECU

6. FINGER AND THUMB FLEXORS

to adequately grasp the hand piece FDS

FDP FPL & FPB

BASIC CRUTCH GAIT PATTERNS 1.Four Point Pattern 2.Two Point Pattern 3.Modified Four Point or Two Point Pattern 4.Three Point Pattern

FOUR POINT PATTERN

Requires the use of bilateral ambulation aids. Uses an alternate and reciprocal forward movement of the ambulation aid and the patients opposite lower extremity.

 crutch- (L) foot- (L) crutch-

foot

Very slow but stable pattern, safest one to use in crowded areas Requires low energy expenditure Can be used when patient requires maximal stability or balance Approximates a normal gait pattern

TWO POINT PATTERN

Requires the use of bilateral ambulation aids Uses a simultaneous & reciprocal forward placement of the ambulation aid & the patients opposite extremity.

 crutch and (L) foot (L)

Relatively stable pattern and faster than 4 point pattern Relatively low energy expenditure & similar to normal gait pattern Requires more coordination to move one UE & its opposite LE forward simultaneously.

crutch and foot

MODIFIED 4- or 2POINT 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.

THREE POINT PATTERN

Requires bilateral ambulation aids or a walker Not for bilateral canes Referred to as step to or step through pattern rather than a swing to or swing through

 Used when the patient is able to bear weight on one LE but is NWB on the opposite LE. Walker or crutches and the NWB limb are advanced and then the patient steps up to the walker or through the crutches.

 Less stable pattern but more rapid ambulation Requires good strength of the UE, trunk and one LE. Higher energy expenditure

WHEELCHAIR
PURPOSE
To promote independent mobility/functioning Prevention of injury / deformity Healthy body image Minimize short/long term equipment cost

WHEELCHAIR
INDICATIONS FOR USE When ambulation is unadvisable When ambulation is impossible

SELECTION DETERMINANTS
1. AGE 2. SIZE (height & weight) 3. OPERATING CONDITIONS
TRANSFERS PROPULSION MODE OF LIVING

 AREAS OF OPERATION
DOORWAY: 36 WIDTH AVE TURNING SPACE: 60 X 60 HORIZONTAL WORKING TABLE REACH: 30.8 RAMPS: 1 ft. ELEVATION/ 12 ft. distance

 LEVEL OF DISABILITY (prognosis) SAFETY & COMFORT COST APPEARANCE

WHEELCHAIR FACTORS
* SEAT X 2 CHECKLIST
SUPPORT (SCALPS)- SAFETY, COMFORT OF ARMS, LEGS, PELVIS & SPINE SKIN EASY PROPULSION EASY TRANSFER ALTERATION OF TONE ACCOMMODATION (GROW FAST) OF GROWTH, OTHERS, WORSENING OF MEDICAL CONDITIONS, FUNCTIONAL ACTIVITIES, FUNCTIONAL ACTIVITIES, STRUCTURAL DEFORMITIES, TECH. TRANSPORTABILITY TERRAIN

PARTS OF A WHEELCHAIR
Handgrips / push handles

Back upholstery armrest

clothing guard

molded wheel

seat upholstery

wheel lock/lever
handrim cross brace Leg rest w/ calf pad caster footplate

TYPES OF WHEELCHAIR ADULT/ PEDIATRIC HEAVY/ MODERATE/ LIGHT WT./ ULTRALIGHT MANUAL/ POWERED FOLDING/ NON-FOLDING/ STAND-UP FRAME RECLINING/ NON-RECLINING TILTING/ NON-TILTING METAL/ COMPOSITE

MANUAL WHEELCHAIR

POWERED WHEELCHAIR

MANUAL vs. POWERED WHEELCHAIR

*Both types aims to increase independence level at work/school*

MANUAL vs. POWERED WHEELCHAIR

MANUAL POOR ENDURANCE/ DISTANCE WALKING Physical limitation is not compatible with ambulation

MANUAL vs. POWERED WHEELCHAIR

POWERED To spare the upper limb joints from premature deterioration To increase efficiency of mobility To improve self-esteem Physical limitations not compatible with manual wheelchair mobility

Semi- Reclining Wheelchair

Full Reclining Wheelchair

One Arm Drive Wheelchair

Slide-On Wheelchair Lap Tray

Pediatric Wheelchair

Wheelchair Folding (With Commode)

RECREATIONAL/ SPORTS WHEELCHAIR

WHEELCHAIR MEASUREMENT and CONFIRMATION OF FIT

MEASUREMENT
SEAT HEIGHT/ LEG LENGTH

AVERAGE ADULT SIZE

19.5 TO 20.5 INCHES

INSTRUCTIONS
USERS HEEL TO POPLITEAL FOLD + 2 IN (TO ALLOW CLEARANCE OF FOOTREST)

CONFIRMATION OF FIT
A. WITH YOUR HAND // TO THE FLOOR, YOU SHOULD BE ABLE TO INSERT 2 OR 3 FINGERS LENGTHWISE BET. THE Pt. POSTERIOR THIGH & THE SEAT UPHOLSTERY TO A DEPTH OF APPROX 2 INCHES B. THE BOTTOM OF THE FOOT PLATE MUST BE AT LEAST 2 IN ABOVE THE FLOOR

SEAT DEPTH

16 INCHES

POSTERIOR BUTTOCKS, ALONG LATERAL THIGH -2 INCHES (TO AVOID PRESSURE FROM THE FRONT EDGE OF THE SEAT AGAINST THE POPLITEAL SPACE)

WITH YOUR HAND // TO THE FLOOR, YOU SHOULD BE ABLE TO PLACE THE WIDTH OF 3 OR 4 FINGERS BETWEEN THE FRONT EDGE OF THE SEAT AND POPLITEAL FOLD

SEAT WIDTH

18 INCHES

WIDEST ASPECT OF THE BUTTOCKS, HIPS OR THIGH +2 INCHES (PROVIDE SPACE FOR BULKY CLOTHING, ORTHOSES, OR CLEARANCE OF THE TROCHANTERS FROM THE ARMREST SIDE PANEL

WITH YOUR HAND VERTICAL TO THE FLOOR YOU SHOULD BE ABLE TO SLIDE EACH HAND BETWEEN THE PATIENTS HIPS AND THE CLOTHING GUARD OF THE CHAIR WITH MINIMAL CONTACT

BACK HEIGHT

16 TO 16.5 INCHES

FROM THE SEAT OF THE CHAIR TO THE FLOOR OF THE AXILLA WITH SHOULDER FLEXED 90 -4 INCHES

WITH YOUR HAND VERTICAL TO THE FLOOR, YOU SHOULD BE ABLE TO PLACE THE WIDTH OF 4 FINGERS BETWEEN THE TOP OF THE BACK UPHOLSTERY AND THE FLOOR OF THE AXILLA
A. OBSERVE THE ANGLE MADE BY THE POSTERIOR ASPECT OF THE UPPER ARM AND THE BACK POST WHEN THE ELBOW REST ON THE ARMREST APPROX. 4 INCHES IN FRONT OF THE BACK POST B. OBSERVE THE POSITION OF THE TRUNK; IT SHOULD BE ERECT

ARMREST HEIGHT

9 INCHES ABOVE THE CHAIR SEAT

FROM THE SEAT OF THE CHAIR TO OLECRANON PROCESS WITH THE ELBOW FLEXED TO 90 +1INCH

Pray as if everything depends on God; Work as if everything depends on you.

Prepared & Updated by: ORTHO-PROSTHE CLINICAL TEAM
July 9, 2007