Ambulation Aids Normal Gait and Abnormal Gait

1. Ambulation AidsNormal Gait and Abnormal Gait

2. Assistive DevicesObjectives • Discuss the common types of ambulation aids that are used in the hospital and clinic • Discuss proper fit for the different types of crutches, canes and walkers • Review gait patterns that will be utilized with the different assistive devices

3. Ambulation AidsPatient Needs Assessment • Safety • Impaired balance • Decreased strength • Alteration in coordinated movements • Pain during weight bearing • Absence of a lower extremity • Altered stability

4. Outcomes • Improve functional mobility • Enhance body functions • Assist with fracture healing=too much weight too early, don’t want a fractured part to be movement in a dangerous way, though movement can help healing.

5. Prepare for Ambulation • Review Medical Chart • Assess Patient • ROM • Muscle Performance • Sensation • Balance/Coordination • Cognition

6. Pre-Ambulation Considerations • Assistive device • Amount of assistance • Height/weight • Can you get them up safely if they go down? • Safety – 1 or 2 person

7. Pre Ambulation Considerations • Equipment Issues • Gait belts • Patient’s tolerance/vitals • O2( 90% of less), BP, glucose, • Cognition/Ability to follow commands • Rolling walker because just need to push vs. lifting and placing walker.

8. Appropriate Equipment Van Hook FW et al. 2003

9. Ambulation Aids • Tilt Table=help stabilize BP for those that have been in bed for a long period of time. • Parallel Bars • Walker vsRollwalker • Platform walker=bear weight through elbows • Hemiwalker, hemicane= • Crutches • Standard cane, LBQC, SBQC

10. Tilt Table • Check BP and HR • Indications to use tilt table • SCI • L/E Amputations • Obese • Prolonged Bed Rest www.promedproducts.com

11. Parallel Bars • Maximal stability, support, safety • Confidence Booster • Adjustable • Pre-gait activities • Limited in length www.promedproducts.com

12. Standard Walker • Patient must be able to lift and advance walker • Greater attention demand • White, 1992 • Adjustable, nonadjustable • Folding • Reciprocal

13. Rolling Walkers • Rolling Walker Indications • Cognition/Unable to follow commands=cant figure out how to advance a normal walker. • Cardiopulmonary Issues • Patient carries standard • Height of walker • Higher for back surgeries

14. Additional Devices • Platforms=strap on to a walker then strap in exterminates. • Baskets • Seats

15. Measure/Fit Walker • Handgrip: • Level of greater trochanter • Level of ulnar styloid process • Level of wrist crease • Elbow Flexion • 20 – 25 dg • Walker Feet: • Middle of foot, all four walker feet on ground • Hips and knees straight

16. Disadvantages of Walkers • Difficult to store, transport • Stairs=almost impossible • Slower • Decreased stride length • Crowds • Hand Injuries possible

17. Axillary Crutches • More mobility, less stability • Greater speed, greater strength • Cognition • Coordination

18. Axillary Crutch Fit • Several Methods • Complicated Formula • 77% x height of patient in inches • Tape Measure • Standing: two – three finger widths between axillary pad and axilla • Crutch tips on ground, 2 inches lateral, 4-6 inches anterior to tip of shoe (2,3 inches lateral in armpit)

19. Avoid wrist flexion or extension while grasping hand grip=neutral writst • Elbow flexion: 20 – 25 degrees

20. Common Errors: Axillary Crutch Fitting • Shoulder elevation • Shoulder depression • No shoes (fit with shoes on) • Absence of tripod position during adjustments Always reassess fitting prior to ambulation

21. Disadvantages of Axillary Crutches • Decreased stability • Warn about rain in need to dry off. • Possible injury to brachial plexus and blood vessels, hands if “hanging” on crutches. • Require stronger UE, better coordination, balance

22. Forearm Crutches • Loftstrand, Canadien • Bilateral UE support, not as much weightbearing, and need to be stronger than with axillary • Hands can be free when standing • Used when going tobe on crutches for a long period of time.

23. Forearm Crutch Fit • Handgrip adjustment • Greater trochanter • Ulnar styloid process • Wrist crease • Elbow cuff: 1.5 inches below olecranon • Crutch tips on ground, 2 inches lateral, 4-6 inches anterior to toe • Elbow flexion: 20 – 25 dg

24. Disadvantages of Forearm Crutches • Less stability and support • Requires better standing balance • Support rather than replacement • Hand injuries= carpal tunnel, pressure on whole hand • Wear cycling gloves

25. Canes • Used in U/E opposite the affected L/E • Most mobile, least stable • Bases can trip a patient • Based canes can feel insecure

26. Cane Fit • Tip of cane is 2 inches lateral and 4-6 inches anterior to toe • Elbow flexion: 20 – 25 dg.

27. Disadvantages of Canes • Very limited support • Cannot perform some gait patterns • Hand injuries

28. Adaptations of canes

29. Gait Patterns with Assistive Devices: Four-Point Pattern • Bilateral Ambulation Aids • Alternating, reciprocal pattern • Low energy • Maximum stability and support • 3 points of contact at one time

30. Two-Point Gait Pattern • Bilateral aids • Simultaneous, reciprocal pattern • Stable pattern • Faster speed • Low energy • Similar to normal gait pattern

31. Modified Four-Point or Two-Point Pattern • One ambulation aid • One functional upper extremity • Aid opposite upper extremity • Widens base of support • Hemi pattern

32. Three-Point, Non-Weight-Bearing Pattern • Bilateral ambulation aids • Step to or step-through pattern (old swing to) • One NWB extremity • Higher energy expenditure • Good strength in UE

33. Three-One-Point/ Partial Weight-Bearing or Modified Three-Point Pattern • Bilateral ambulation aids • FWB one extremity, PWB on other • More stable than three-point • Requires less strength and energy than three-point

34. Documentation of Aid • Describe type of Ambulation Aid • Document Fitting of Aid • Document Adaptive Devices on Aid • Document Patients Instruction and Performance of Gait Pattern • Document amount of assistance necessary for Patient safety and support

35. References • Pierson FM, Fairchild SL. Principles and Techniques of Patient Care, 4th ed., 2008 Saunders, St. Louis. • Van Hook FW, Demonbreaun D, Weiss B. Ambulatory devices for chronic gait disorders in the elderly. Am Fam Phys, 2003:67(8):1717-24. • Wright DL, Kemp TL. The dual-task methodology and assessing the attentional demands of ambulation with walking devices. Phys Ther 1992;72(4):306-12.

36. GAIT: Normal and abnormal PTP 565 Fundamentals Of Tests and Measures

37. Gait Objectives: • Lecture • Discuss and explain definitions of gait cycle • Review basic terminology • Explain common gait deviations • Discuss Gait Evaluations

38. Gait Definitions: APTA Guide- The manner in which a person walks, characterized by rhythm, cadence, step, stride, and speed.

39. Gait • Walking: a process of falling forward and catching oneself • Gait: a manner of walking, stepping or running • Unique to the individual

40. Gait Traditional- refers to the points in time in the gait cycle. Stance: heel strike→ foot flat→ heel-off→ toe-off Swing: acceleration→ mid swing→ deceleration

41. Traditional

42. Gait Rancho Los Amigos– Stance Phase: initial contact → loading response → mid stance → terminal stance → pre swing. Swing Phase:initial swing → mid swing → terminal swing. Both are used in the clinical setting.

43. Abnormal Gait • Pathology or injury in specific joint • Compensations for injuries or pathologies in other joints on same side • Compensations for injury or pathologies on opposite side

44. Common Gait Deviations Influences on Gait Patterns • Pain • Posture • Flexibility and Amount of Available Range • Economy of Movement • Base of Support • Leg length • Gender • Pregnancy • Obesity • Age

45. Gait Deviations Due to Pain • Antalgic Gait Pattern • Decrease in stance phase on affected limb • Lack of weight shift laterally over stance limb • Decrease in swing phase of uninvolved limb • Decrease in cadence • Decrease in velocity in walking • Self protective • Result of injury to pelvis, hip, knee, ankle, or foot

46. Gait Deviations Due to Leg Length Discrepancies • True Leg length or Apparent Leg Length • Shorter limb- pelvis will drop laterally at initial contact • Frontal plane view: limping • Foot may supinate on short side to lengthen leg • Unaffected side: may compensate by increasing hip flexion or knee flexion during swing phase • Gait Deviations noted: vaulting =compensating the short leghip hiking, circumduction

47. http://www.victhom.com/en/neurostimulation/gait-disorders.phphttp://www.victhom.com/en/neurostimulation/gait-disorders.php Vaulting Circumduction www.limblength.com/pubs/articles/lld/lld.htm

48. Gait Deviations due to mm weakness • Gluteus Max. Weakness • Glut. Max needed in Midstance to keep upright. • Inability to counter flexion moment at hip at point of initial contact • Compensation is with posterior movement of trunk • COG stays behind the hip joint, thus no flexion occurs at the hip • Gait Deviations noted: Gluteus Maximus Gait, Lurch

49. Gait Deviations due to mm weakness • Gluteus mediusweakness (also in midstance) Trendelenburg Gait: pelvis drops on opposite side during stance on affected side COMPENSATED=trunk in line, but pelvis off. Gluteus Medius Lurch: lateral trunk flexion over the affected limb during single limb support to maintain center of gravity over the base of support UNCOMPENSATED=side bend over weak side

50. Gait Deviations due to mm weakness • Iliopsoas Weakness • Difficulty initiating swing-through • External rotation of femur, adductors will bring leg through in swing • Slight Circumduction=due to weakness of flexion.