Minerva Zaniebeth A. Gomez, PTRP Faculty Physical Therapy Department

Assistive Devices: Ambulatory Aids, Seating Devices and Mobility Orthosis
Minerva Zaniebeth A. Gomez, PTRP Faculty Physical Therapy Department College of Allied Medical Professions

Learning Objectives Describe the functions/ purposes of assistive devices Differentiate the various assistive devices Identify the parts of the different assistive devices Differentiate the indications of each assistive device

Learning Objectives Identify considerations in prescribing assistive devices Identify ways to relieve pressure for a wheelchair bound person Identify appropriate environmental modifications for persons using assistive devices

Assistive Devices: Ambulatory Aids
Devices designed, made or adapted to assist a person in performing particular tasks/ activities of daily living (ADLs) Medicinenet.com and Medline Plus Ambulatory aids: Allows safe ambulation for individuals with compromised ambulatory ability

Commonly used Ambulatory Aids
Walker Crutches Cane These are the three basic types of ambulatory aids. Several modifications has been made to the basic designs to meet the needs of patients.

Indications Balance problems
Decreased ability to bear weight on limb – post injury or surgery, result of a disease, etc… Lower limb pain Fatigue, weakness of lower extremity Joint instability

Ambulatory Aids Increase the base of support
Provide small propulsive forces Provide sensory feedback Eliminate weight bearing (full or partial) through the LE  Through the upper extremity Increase base of support - An increased base of support helps in maintaining the COG safely within the BOS needed to maintain stability during walking. Eliminate weight bearing – because the body weight is transmitted directly from the upper extremity to the support surface by downward pressure on assistive device.

Use of Ambulatory Aids Considered an extension of the upper limbs
Requires adequate upper limb strength, endurance and coordination Requires supervised training period after prescription of an aid

Parallel Bars Used for gait training Provides security and
safety while practicing Height of bars should allow 20°-30° elbow flexion Not only for use of assistive devices, but for typical gait re-training

Canes Widen BOS to improve balance
Unload weight on involved limb by 20%-25% Relieve pain on the involved limb Reduce forces acting at the hip

Canes: Types Standard cane Made of plastic or wood
Handle is half circle or “C” “J” or crook Distal rubber tip is at least 1 inch dm or larger

Canes: Types Advantages Disadvantages Inexpensive
Easy to use in limited spaces Disadvantages Not adjustable Point of support is anterior to the hand Limited spaces such as stairs

Canes: Types Standard adjustable cane Made of aluminum
Telescoping tubing design Because of the telescoping design

Canes: Modifications Advantages Disadvantages
Adjustable though push button Pin mechanism Lightweight, used in limited spaces Disadvantages More costly than standard cane Point of support is anterior to hand Because of the telescoping design

Canes: Modifications Functional grip cane More comfortable grip

Canes: Modifications Adjustable aluminum offset cane
Proximal portion is offset anteriorly Rubber molded grip Advantages Point of support is directly through the hand and center of cane Greater stability Lightweight, adjustable, fits small spaces Disadvantage Costly

Canes: Modifications Quad (quadriped) cane Made of aluminum
Telescoping design Handle varieties same as single tip cane Four contact points with ground Types: Small based: useful for stairs Wide based: better stability Telescoping design so adjustable also, same handle designs with the single tip cane

Canes: Modifications Quad (quadriped) cane Advantages
Broader BOS than single tip cane Increased stability Adjustable Disadvantages Not often practical to use on stairs Slower gait pattern Telescoping design so it is also adjustable

Canes: Modifications With standing assist
Lady picture: single tip cane Man: quad cane

Canes: Modifications Pediatric quad cane Lady picture: single tip cane
Man: quad cane

Crutches Increase BOS and lateral stability
Relieve weight bearing on limb (full or partial)  Allow transfer of weight on both UE to the floor Typically used bilaterally Two types: Axillary crutches – body wt transmission of 80% Forearm crutches –body wt transmission of 40-50% This transfer of weight through the UE  permits functional ambulation maintaining restricted weight bearing

Crutches: Axillary Known as regular or standard type
Dowl/ hand grip Known as regular or standard type Made of wood or aluminum Modification: ortho crutch SCBU Attachment: Platform/ forearm rest or trough SCBU: stabilizing crutch behind the user arm extends vertically behind the shoulder of the user permits user to stand more upright rather than leaning forward, faster walking reduce muscle fatigue because arms are kept straight Platform attachment: allow transfer of weight through the forearm in cases when weight bearing is contraindicated or not possible through the wrist and hand Velcro straps

Crutches: Axillary Advantages Disadvantages Improve balance
Functional ambulation with restricted weight bearing Adjustable Inexpensive Used in stairs Hard to used in small spaces Tendency to lean on axillary bar  compression of blood vessels and nerves (radial nerve crutch palsy)

Crutches: Forearm Known as Loftsrand Made of aluminum
Adjustable distally and proximally Canadian crutch – extends to the mid-arm level for triceps weakness Canadian crutch resembles axillary crutch but ends proximally in a cuff. This prevents buckling (flexion) of the elbow during gait.

Crutches: Forearm Advantages Disadvantages
Allows use of hands without dropping of crutches Easily adjusted Allow functional stair climbing esp. with bilateral KAFOs More cosmetic Less lateral stability Cuffs may be difficult to remove More costly than wooden type Less lateral stability because of absent axillary bars

Walker To improve balance To relieve weight bearing
(full or partial) through LE Greatest stability Frequently prescribed for patients with debilitating conditions when use of crutches is precluded Precluded: not allowed

Walker Provide wide BOS Improve anteroposterior and lateral stability
Allow UE to transfer body weight to the floor

Walker Modifications Folding Collapsible For easy storage
Easy mobility when using cars

Walker Modifications Rolling (wheeled) walkers
With casters (2 or 4) and pressure brakes Reduce walker stability If patient is unable to initiate walking or unable to lift conventional walker Facilitates walking as a continuous sequence Pressure brakes: can be through hand brakes Walkers with (two) front wheels: can help initiate walking

Walker Modifications Reciprocal walker Hinged Unilateral forward
progression of one side Used with reciprocating orthoses Reduce walker stability Same indications with rolling walker

Walker Modifications Stair climbing walker
Has two posterior extensions Additional hand grips at rear Legs Walkers are still extremely unsafe on stairs

Walker Modifications Posterior walker Support is form behind
Promotes trunk extension Recommended for children with difficulty maintaining upright position Neurologic conditions: neurologic conditions such as cerebral palsy, orthopoedic conditions

Walker Modifications Hemi walker (walk cane) Used with one hand only
just like the cane For stroke patients

Walker Modifications Walker with standing assist (Rising walker)

Walker: Attachments Platfrom: if weight bearing
through the wrist and hand is contraindicated or impossible Seats, baskets

Walker Disadvantages Advantages
Provides a sense of security Relatively light weight Adjustable Disadvantages Hard to maneuver in limited spaces, doorways Not safe on stairs No arm swing

Mobility orthosis & seating devices

Purposes of Wheelchair and Seating Systems
Maximize efficient independent mobility Prevent/ minimize deformity or injury Maximize independent functioning Cosmesis Efficient independent mobility: with as little energy consumption as possible and with minimal assistance from others Prevent deformity/ injury: pressure ulcers, contractures, joint deformities and other injuries Maximize independent functioning: maximize stable positioning, limit abnormal tone or dysfunctional movements

Wheelchair: A Mobility Orthosis
Consists of two systems Postural support system: Components needed to maintain postural alignment Mobility base

Postural Support System
Consists of the: Seat Additional support systems: torso supports, adductor/ abductor rolls, lap belts

Seat surface Sling seat Little support Puts hip in IR & ADD Post. Pelvic tilt  sacral sitting

Seat surface Insert/ contour seat Firm surface Neutral pelvic position  tendency to slide forward

Seat surface Seat cushion Distribute weight Prevent pressure ulcers Sitting push-ups every15-20 minutes

Seat surface: Types of seat cushion

Seat surface Seat plane angle Commonly ranges from 0-5 degrees Sports: 20 degrees Greater angle, more stable but  post. pelvic tilt Alter muscle tone at hips Seat plane angle: the angle the seat makes in reference with the horizontal For example, the patient has neuromuscular problems like in cases of cerebral palsy or MS, you would want a deeper seat by increasing the seat angle to put the hips into flexion to counter a strong extensor tone.

Abductor pommel Adductor cushions Groin strap  maintain alignment of LE in cases of neuromuscular problems

Back surface Low Common Midscapular level Less support, more mobile Sports High Shoulder level (acromion) Poor trunk stability, dominant extensor tone

Back surface Fabric type: less support Back insert: Improve trunk alignment Hard: Promotes trunk EXT; NOT a choice for bony individuals Should be at 90° with seat surface 90 degrees angle maintains the trunk in proper postural alignment.

Back surface Lateral trunk supports Improve trunk alignment For patients with scoliosis and poor stability Push handles: maneuvering Head rest: to support head

Reclining backs Patients prone to pressure ulcers & OH Easy for transferring patient back to bed Additional weight Difficult to transport Risk of shear stress  INC. occurrence of pressure ulcers OH: orthostatic hypotension Shear stress may occur when reclining the chair using simple hinge design; non-shear designs allows the back to slide during movement.

Tilt-in-space seats Alternative to reclining backs Seat and back can be tilted posteriorly as a unit NO shear stress Can be used in clearing pulmo secretions Advantageous for patients with spasticity Unstable for large individuals For patients prone to pressure ulcers and OH as well Hard to transfer from wheelchair to bed because the patient’s body cannot be placed in supine position unlike the reclining back.

Lap belt For safety Increase postural control Should be at 45° angle with sitting surface * posterior pelvic tilt 90°: excessive extensor tone Pelvis tilts posteriorly if the lap belt crosses the ASIS; happens if position is parallel to sitting surface.

Arm rests Provide assistance when standing Support UE Mechanism for ischial pressure relief (sitting push-up) Slight lateral stability

Armrests Desk length vs full length Facilitates use Proximity to desk/ table Adjustable height vs fixed Facilitates sit-stand transfer

Armrests Removable Facilitates transfers Wraparound Space saver Reduce chair width by 0.5 in. Detachable for transfers Wraparound: attached to the seat back rather than next to the seat

Lap board/ tray/ trough Secured to armrests Symmetrical UE positioning Support weight of arms Elevated: Inhibit tone around shoulders & neck Prevent involuntary UE movements in athetosis Support UE: especially in patients with weak UE musculature Athetosis: place UE under lap board during feeding activities

Foot support system Decrease load on buttocks and thigh Placement affect positioning of entire lower body, tone and posture of HAT Low foot supports: lower knees, hips in less than 90° flexion HAT: head, arms and trunk

Leg rest/ calf support Fixed Lighter Interfere with transfers Difficult to transport Swing away, detachable Facilitates transfer Portable Insert pic from braddom

Leg rest/ calf support Elevating Control of LE edema NOT ideal for knee flexor spasticity or tightness Presence of hamstring spasticity or tightness will pull the pelvis into posterior pelvic tilt, placing the hips in less than 90 degrees…leading to trunk extension.

Foot rest Foot plates Resting base for feet Feet in neutral position Knees in 90° flexion Can be flipped/removed to facilitate transfers

Foot rest Heel loops Increase foot control Maintain foot position Prevent posterior sliding of foot Use braddom for foot support system

Foot rest Straps Ankle or calf Increase stability of foot

Wheeled Mobility Base Frame
Tubular structure supporting the seat and the wheels Lightweight: easier to use Choice of material & design depends on expected activity & environment Fixed: increase in distance per stroke

Wheeled Mobility Base Frame Fixed INC stroke efficiency Folding
Easy to use on level surfaces Folding Facilitates mobility Ease of storage Easier to use on uneven surfaces Fixed: increase in distance per stroke, easier to use on even surfaces; one wheel often lifts off on uneven surfaces

Wheeled Mobility Base Wheels Casters (with/without locks)
8 inches (dm) Small: greater mobility, smooth, level surface Large: rough terrain, INC rolling resistance Locks: needed to stabilize wheelchair during transfers

Wheeled Mobility Base Wheels Drive wheels For propulsion
Has outer rim for hand grip and propulsion With/ without spokes Locks: needed to stabilize wheelchair during transfers

Wheeled Mobility Base Handrims Small vs large
Projections: poor hand grip Vertical Oblique, Horizontal INC w/c width limiting maneuverability Friction rims/ leather gloves Poor hand grip Small: greater distance per stroke Locks: needed to stabilize wheelchair during transfers

Wheeled Mobility Base Tires Hard: durable, low maintenance
Pneumatic: smoother ride,  shock absorption, more maintenance Semi-pneumatic: gel-filled Pneumatic: air-filled; susceptible to flats Semi-pneumatic: not susceptible to flats Hard: most durable but provide the roughest drive

Wheeled Mobility Base Brakes Prevent unwanted motion
utilize a lever system Extensions may be added for ease of locking/ unlocking  UE weakness Pneumatic: air-filled

Additional Attachments
Anti-tipping device Posterior extension attached to the lower horizontal supports Prevents backward tipping May get caught over obstacles (curbs, door sills)

Additional Attachments
Hill-holder device A mechanical reverse break Allows w/c to move forward Useful for patients who need to ascend long ramps or hills Especially if the patient needs frequent rests.

Components that Direct Comfort & Posture Maintenance
Seat surface Seat back Lap belt Armrests Foot supports These components should be interfaced together to ensure efficiency and effectiveness of the wheelchair.

Specialized Wheelchairs
Reclining back Tilt-in-space One-arm drive Drive mechanisms located on one wheel Difficult for patients with (L) hemiplegia, cognitive or perceptual impairments Two handrims are located in one wheel.

Hemiplegic (Hemi) chair Low to the ground Allows propulsion with non-involved UE & LE

Amputee chair Bilateral LE amputation Drive wheels are 2 inches posterior to back support INC antero-posterior stability Drive wheels are placed posteriorly because the COG of the patient is placed more posterior when seated.

Powered wheelchair For patients unable to independently propel w/c or with low endurance Joy sticks, head controls, puff-n-sip tubes (quadrilegia)

Sports wheelchair Variable Lightweight, solid frames Low seats, low backs, Tucked position seating, Leg straps, small push rims Slanted drive wheels:  Camber: if , more stable, easier to propel, better turning radius Slanted drive wheels: camber= outward angle of the main drive wheels at the bottom of the w/c

Standard Wheelchair Dimensions
Chair Style Seat Width (Inches) Seat Depth Seat Height Adult 18 16 20 Narrow Adult Slim Adult 14 Hemi chair - 17.5 Junior 18.5 Child 11.5 18.75 Tiny tot 12 19.5

Seating (Positioning) Devices
Goals: Control abnormal tone and reflexes Correct or accommodate deformities Enhance function and improve control Improve comfort and sitting tolerance Provide pressure relief and skin protection Facilitate management and care Correct/ accommodate deformity: Should not cause a new deformity Enhance function and improve control: example, support and proper head and neck alignment can help improve function such as swallowing; good head and trunk control can facilitate use of UE. Improve comfort and sitting tolerance: stable base with least restrictions for functional activities Pressure relief and skin protection: equalizes pressure distribution Management and care: especially in cases of severe neurologic impairments. Seating devices should allow them to be placed in the upright position to improve organ function. Aside from this, the seating system should also allow the caregivers to transport the patients easier and better care and hygiene.

Principles of Seating Should provide support, comfort and symmetrical midline posture Proper sitting alignment Seating systems: Planar/ linear Contoured Custom-moulded Proper sitting alignment: Head in midline Trunk erect Hips flexed to 90 degrees Knees at degrees Feet in neutral position pelvis is level

Principles of Seating Planar/ Linear Inexpensive
Can be readily modified, repaired or replaced Components: Seat Seat back Lateral/ head/ sternal supports Abductor supports Lap trays Foot rests cushions

Principles of Seating Contoured
For those needing mild to moderate support but free of severe deformity Varying foam density in seat cushion Curves to fit the body E.g. tumble forms Can use the different insert/contour seat

Principles of Seating Custom-molded Greater support Severe deformity
History of skin breakdown Not for pediatric patients Not for pediatric patients because it can’t accommodate growth.

Prescribing Seating Systems
Tone/ spasticity Rolled seats  proper pelvic positioning Abduction devices Back-seat angles Rolled seats: thinner over ischial tuberosities

Contracture Knee flexion: affect caster size and type of foot rest Hip extension: open hip angle and reclining back Rolled seats: thinner over ischial tuberosities

Sensory-perceptual problems Especially those with hemineglect Pathologic reflexes Either utilize or inhibit (breaking the pattern) Rolled seats: thinner over ischial tuberosities

Skin integrity Planar system: no history of skin breakdown Pressure pads/ foams: current ulcerations Other seating considerations Vision & hearing problems, need for orthosis, presence of deformities, behavior problems, SI problems, etc… You can read more on this on Page of Braddom

Environmental Considerations
Floors Entrances/ exits Ramps Doors and Switches Corridors Stairs Handrails Bathroom & toilet

Floors Use of nonskid materials is encouraged Avoid using scatter rags
Floor coverings should be glued/ tacked properly to prevent bunching or ripping under w/c

Standard w/c dimensions:
Length: 1.1m-1.3m (43-51 in) Width: 0.6m -0.75m (24-30 in)

Entrances/ Exits Should be level with arrival and departure points or with accessible elevators Ramps should be provided if the entrance level is not the same as the arrival grade Recommended grade 1:12 (ratio of slope to rise) Width should be1.2 m (48 in) 1:12 – for every 1inch in or vertical rise, 12 inches of ramp length is required.

Ramps Ramp length should not exceed 6 meters; if longer, provide landings 1.5 m long (60 in) Level area at top & bottom of ramp =1.8 m long (71 in)

Ramps If ramp rise is >0.2m & ends in a traffic area, there should be railings across the full width of lower end.

Ramps Handrails should be at both sides of the ramp
Handrails should extend 0.3 m (12 in) beyond the top and bottom of ramp Curbs at both sides should be 0.1m (4 in) high

Doors Consider dimensions of persons using ambulatory aids and w/c dimensions Crutches: width 0.79m-0.92 m (31-36 in) Walker: 0.71m-0.76m (28-30 in)

Doors Minimum width: 0.8 m (32 in)
Space before & after door opening: 1.5m X 1.5 m (60 in X 60 in) 360° turning space Outside door swing area: Walkers: 0.5 m (18 in) w/c: 0.7 m (26 in)

Door Knobs/ Switches Comfortable reach of persons confined to w/c:
Above floor: 0.7m- 1.2m (28-47 in) Min. forward reach: 15 in from floor Side reach: 24 in Room corners: 0.4 m (16 in) Knee & leg clearance: 0.7m (28 in)

Thresholds None as much as possible but if inevitable, should be kept to a minimum (25 mm in height) and should be beveled/ ramped

Door Knobs/ Switches Door knobs/ latches: 0.82 m – 1.06 m (32-42 in) above floor (0.9m is preferred) Vertical pull handles: centered at 1.06 m above floor Kick plate: 0.3m-0.4 m (12 in) high from floor

Door Knobs/ Switches Positioned at 1.2m -1.3m above floor
From latch side of door: 0.2m

Corridors Width: 1.2 m No obstructions Turnabout spaces:
1.5 m X 1.5 m (360° turn) 36 inches (90° turn)  T shape

Stairs Slip resistant (non skid) surfaces Nosings should be slanted
Avoid open stringers Slanted nosings are preferred because ambulatory aids usually get caught in the recess of protruding nosings  same reason for open stringers

Stairs High contrast color (red, orange, yellow) or gray value between runner/riser and rest of the stairs Tactile strip at bottom and top of stairs 0.3m wide High contrasting colors are helpful especially for the visually impaired Tactile strips should be provided to signal sudden changes in level surface especially for the visually impaired

Handrails Height: 0.7m-0.9m (32-38 in) above support surface
Ramps: extend by 0.3m (12 inch) at start and end Stairs: extend by 0.5 m (18 in) at start and end

Handrails f attached to: Diameter: 30mm-50mm (½-2in)
Wall: 50mm clearance from wall Ledges: 40 mm clearance Diameter: 30mm-50mm (½-2in)

Bathroom & Toilet Area: 1.7m X 1.8 m
Turning space: 2.25sqm with min. dimension of 1.5 m for w/c

Bathroom & Toilet Toilet seat height: 0.45 m (17-19 in)
Flush height: 1.2 m Grab bars: in

Bathroom & Toilet Urinal: Elongated lip/ trough type
Max height: 0.48 m Lavatory: Max height: 0.8 m Knee recess: 0.6m-0.7m vertical clearance Depth: 0.5 m

Bathroom & Toilet Bah tub Tub seat Grab bars Non skid tub surface/ mat

REFERENCES Batas Pambansa Bilang 344 (Accessibility Law) and its implementing rules and regulations (1995). Promoprint/ MJ Printhaus Corp. Braddom, RL et al (2001). Physical and medicine rehabilitation 2nd Ed. W.B. Saunders Company O’Sullivan SB & Scmitz TJ (1988). Physical rehabilitation: assessment & treatment. F.A. Davis Company O' Sullivan, S., & Siegelman, R. (2007). National Physical Therapy Examination. Review and Study Guide . USA: International Educational Resources Ltd.

ELECTRONIC SOURCES Assistive devices (2009). Retrieved July 26, 2009 from Medline Plus Canes, crutches and walkers (2007). Retrieved July 26, 2009 from Definition of assistive device (2009). Retrieved July 26, 2009 from Medicinenet.com

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“Teachers open the door. You enter by yourself.” Chinese saying

Minerva Zaniebeth A. Gomez, PTRP Faculty Physical Therapy Department

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