AMBULATION AIDS & ASSISTIVE DEVICES 2007

THE VARIOUS AMBULATION AIDS/ ASSISTIVE DEVICES COMMONLY PRESCRIBED

TO PATIENTS WITH IMPAIRMENTS &

LIMITATIONS IN WALKING.

PURPOSE BASIC FEATURES &

CHARACTERISTICS ADVANTAGES, DISADVANTAGES &

LIMITATIONS CORRECT MEASUREMENT

1. MEASUREMENT & FITTING

2.BASIC GAIT PATTERNS3. WHEELCHAIR MOBILITY4. 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 patient’s 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

CoordinationTrunk BalanceImpairment in Sensory

Perception

What are the factors that

help determine ambulatory

needs?

FACTORS THAT HELP DETERMINE AMBULATORY

NEEDSNature of DisabilityAge of the Patient

Mental StatusPhysical EnduranceEnergy Expenditure

Arrange the following ambulation aids according to the MOST stable & supportive

to the LEAST stable & supportive.

Single CaneParallel Bars

WalkerForearm Crutches

Axillary Crutches Bilateral Canes

PARALLEL BARS

WALKERS

AXILLARY CRUTCHES

FOREARM CRUTCHES

BILATERAL CANES

SINGLE CANE

Arrange the following ambulation aids according to

the MOST REQUIRING COORDINATION to LEAST

REQUIRING COORDINATION.

WALKERCRUTCHES

CANEPARALLEL 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

TYPES and VARIATIONS of WALKERS

a) Standard • Non-adjustable • Adjustable

b) Reciprocal Walkerc) Wheeled or Rollatord) Foldinge) Stair Climbing Walkerf) 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 HEMI-

WALKER

FOLDING WALKER

WITH GLIDES/

ROLLATOR

Platform attachmen

t 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

• RUBBER SUCTION TIP

handle

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

DISADVANTAGES1. LESS STABLE THAN WALKER2. CAN CAUSE INJURY TO AXILLARY

VESSELS & NERVES IF USED PROPERLY3. REQUIRE GOOD STANDING BALANCE4. ELDERLY Pt. MAY FEEL INSECURE WITH

THEM5. 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

DISADVANTAGES1. 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 ACCESSORIESCRUTCH 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 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

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

IMPORTANT SPECIFIC CRUTCH WALKING MUSCLES

1. SCAPULAR DEPRESSORS

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

Latissimus dorsiLower trapeziusPectoralis 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/ECRBECU

6. FINGER AND THUMB FLEXORS

– to adequately grasp the hand piece

FDS

FDP

FPL & FPB

BASIC CRUTCH GAIT PATTERNS

1.Four Point Pattern2.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 patient’s 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 patient’s opposite extremity.

• ® crutch and (L) foot (L) crutch and ® foot

• 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.

MODIFIED 4- or 2- POINT 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. AGE2. 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 CHECKLISTSUPPORT (SCALPS)- SAFETY, COMFORT OF

ARMS, LEGS, PELVIS & SPINESKINEASY PROPULSIONEASY TRANSFERALTERATION OF TONEACCOMMODATION (GROW FAST) – OF GROWTH,

OTHERS, WORSENING OF MEDICAL CONDITIONS, FUNCTIONAL ACTIVITIES, FUNCTIONAL ACTIVITIES, STRUCTURAL DEFORMITIES, TECH.

TRANSPORTABILITYTERRAIN

PARTS OF A WHEELCHAIR

Handgrips/ push

handles

Back upholstery

armrest

seat upholstery

wheel lock/lever

footplate

cross brace

Leg rest w/ calf

pad

moldedwheel

handrim

caster

clothing guard

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

POWEREDWHEELCHAIR

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

andCONFIRMATION OF

FIT

MEASUREMENT AVERAGE ADULT SIZE

INSTRUCTIONS CONFIRMATION OF FIT

SEAT HEIGHT/ LEG LENGTH

19.5 TO 20.5 INCHES

USER’S HEEL TO POPLITEAL FOLD

+ 2 IN(TO ALLOW

CLEARANCE OF FOOTREST)

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 PATIENT’S 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

ARMREST HEIGHT 9 INCHES ABOVE THE CHAIR SEAT

FROM THE SEAT OF THE CHAIR TO

OLECRANON PROCESS WITH

THE ELBOW FLEXED TO 90˚

+1INCH

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 POSTB. OBSERVE THE POSITION OF THE

TRUNK; IT SHOULD BE ERECT

“Pray as if everything depends on God;

Work as if everything depends on you.

Prepared & Updated by: ORTHO-PROSTHE

CLINICAL TEAMJuly 9, 2007