2Assistive Devices Objectives Discuss the common types of ambulation aids that are used in the hospital and clinicDiscuss proper fit for the different types of crutches, canes and walkersReview gait patterns that will be utilized with the different assistive devices
3Ambulation Aids Patient Needs Assessment SafetyImpaired balanceDecreased strengthAlteration in coordinated movementsPain during weight bearingAbsence of a lower extremityAltered stability
4Outcomes 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.
5Prepare for Ambulation Review Medical ChartAssess PatientROMMuscle PerformanceSensationBalance/CoordinationCognition
6Pre-Ambulation Considerations Assistive deviceAmount of assistanceHeight/weightCan you get them up safely if they go down?Safety – 1 or 2 person
7Pre Ambulation Considerations Equipment IssuesGait beltsPatient’s tolerance/vitalsO2( 90% of less), BP, glucose,Cognition/Ability to follow commandsRolling walker because just need to push vs. lifting and placing walker.
9Ambulation AidsTilt Table=help stabilize BP for those that have been in bed for a long period of time.Parallel BarsWalker vs RollwalkerPlatform walker=bear weight through elbowsHemiwalker, hemicane=CrutchesStandard cane, LBQC, SBQCAge, physical ability, balance, activity
10Tilt Table Check BP and HR Indications to use tilt table SCI L/E AmputationsObeseProlonged Bed Rest
12Standard Walker Patient must be able to lift and advance walker Greater attention demandWhite, 1992Adjustable, nonadjustableFoldingReciprocalOpposite the normal walking pattern. Take step advance, take a step advanced.
13Rolling Walkers Rolling Walker Indications Height of walker Cognition/Unable to follow commands=cant figure out how to advance a normal walker.Cardiopulmonary IssuesPatient carries standardHeight of walkerHigher for back surgeries
14Additional DevicesPlatforms=strap on to a walker then strap in exterminates.BasketsSeats
15Measure/Fit Walker Handgrip: Elbow Flexion Walker Feet: Level of greater trochanterLevel of ulnar styloid processLevel of wrist creaseElbow Flexion20 – 25 dgWalker Feet:Middle of foot, all four walker feet on groundHips and knees straight
16Disadvantages of Walkers Difficult to store, transportStairs=almost impossibleSlowerDecreased stride lengthCrowdsHand Injuries possible
17Axillary Crutches More mobility, less stability Greater speed, greater strengthCognitionCoordination
18Axillary Crutch Fit Several Methods Complicated Formula Tape Measure 77% x height of patient in inchesTape MeasureStanding: two – three finger widths between axillary pad and axillaCrutch tips on ground, 2 inches lateral, 4-6 inches anterior to tip of shoe (2,3 inches lateral in armpit)
19Avoid wrist flexion or extension while grasping hand grip=neutral writst Elbow flexion: 20 – 25 degrees
20Common Errors: Axillary Crutch Fitting Shoulder elevationShoulder depressionNo shoes (fit with shoes on)Absence of tripod position during adjustmentsAlways reassess fitting prior to ambulation
21Disadvantages of Axillary Crutches Decreased stabilityWarn 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
22Forearm Crutches Loftstrand, Canadien Bilateral UE support, not as much weightbearing, and need to be stronger than with axillaryHands can be free when standingUsed when going to be on crutches for a long period of time.
29Gait Patterns with Assistive Devices: Four-Point Pattern Bilateral Ambulation AidsAlternating, reciprocal patternLow energyMaximum stability and support3 points of contact at one time4-points for walking:
30Two-Point Gait Pattern Bilateral aidsSimultaneous, reciprocal patternStable patternFaster speedLow energySimilar to normal gait pattern2 points are moving at a time, always opposite sides=crutches. Alternating leg and crutch out
31Modified Four-Point or Two-Point Pattern One ambulation aidOne functional upper extremityAid opposite upper extremityWidens base of supportHemi patternantalgic, not willing to put 100% of weight on bad, so take shorter on hurt.The most “normal” gait.
32Three-Point, Non-Weight-Bearing Pattern Bilateral ambulation aidsStep to or step-through pattern (old swing to)One NWB extremityHigher energy expenditureGood strength in UEWith crutches, swinging through with good foot, with the injured foot still-up
33Three-One-Point/ Partial Weight-Bearing or Modified Three-Point Pattern Bilateral ambulation aidsFWB one extremity, PWB on otherMore stable than three-pointRequires less strength and energy than three-pointMost weight is still just in arms, can have less than 10% on injured foot that touches.
34Documentation of Aid Describe type of Ambulation Aid Document Fitting of AidDocument Adaptive Devices on AidDocument Patients Instruction and Performance of Gait PatternDocument amount of assistance necessary for Patient safety and support
35ReferencesPierson 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):Wright DL, Kemp TL. The dual-task methodology and assessing the attentional demands of ambulation with walking devices. Phys Ther 1992;72(4):
36GAIT: Normal and abnormal PTP 565FundamentalsOf Tests and Measures
37Gait Objectives: Lecture Discuss and explain definitions of gait cycle Review basic terminologyExplain common gait deviationsDiscuss Gait Evaluations
38GaitDefinitions: APTA Guide- The manner in which a person walks, characterized by rhythm, cadence, step, stride, and speed.
39Gait Walking: a process of falling forward and catching oneself Gait: a manner of walking, stepping or runningUnique to the individual
40GaitTraditional- refers to the points in time in the gait cycle. Stance: heel strike→ foot flat→ heel-off→ toe-off Swing: acceleration→ mid swing→ deceleration
42Gait Rancho Los Amigos – mid stance → terminal stance → pre swing. 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.
43Abnormal Gait Pathology or injury in specific joint Compensations for injuries or pathologies in other joints on same sideCompensations for injury or pathologies on opposite side
44Common Gait Deviations Influences on Gait PatternsPainPostureFlexibility and Amount of Available RangeEconomy of MovementBase of SupportLeg lengthGenderPregnancyObesityAge
45Gait Deviations Due to Pain Antalgic Gait PatternDecrease in stance phase on affected limbLack of weight shift laterally over stance limbDecrease in swing phase of uninvolved limbDecrease in cadenceDecrease in velocity in walkingSelf protectiveResult of injury to pelvis, hip, knee, ankle, or foot
46Gait Deviations Due to Leg Length Discrepancies True Leg length or Apparent Leg LengthShorter limb- pelvis will drop laterally at initial contactFrontal plane view: limpingFoot may supinate on short side to lengthen legUnaffected side: may compensate by increasing hip flexion or knee flexion during swing phaseGait Deviations noted: vaulting =compensating the short leg hip hiking, circumduction
48Gait Deviations due to mm weakness Gluteus Max. WeaknessGlut. Max needed in Midstance to keep upright.Inability to counter flexion moment at hip at point of initial contactCompensation is with posterior movement of trunkCOG stays behind the hip joint, thus no flexion occurs at the hipGait Deviations noted:Gluteus Maximus Gait, Lurch
49Gait Deviations due to mm weakness Gluteus medius weakness (also in midstance)Trendelenburg Gait: pelvis drops on opposite side during stance on affected sideCOMPENSATED=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 supportUNCOMPENSATED=side bend over weak side
50Gait Deviations due to mm weakness Iliopsoas WeaknessDifficulty initiating swing-throughExternal rotation of femur, adductors will bring leg through in swingSlight Circumduction=due to weakness of flexion.
51Gait Deviations due to mm weakness Quadriceps WeaknessInability to contract muscleCompensation is with forward bending of trunk, rapid plantarflexion, can get hyperextensionMay compensate by pushing knee posterior during stance
52Gait Deviations due to mm weakness Hamstring WeaknessKnee maintains extended positionEssentially elongates limbDecrease in shock absorption at kneeToe off more difficult , lose transition between stance and swing, greater hip and knee flexion required to clear limb
53Gait Deviations due to mm weakness Anterior Tibialis Weakness:Steppage gaitSwing phase on involved side with increase in hip and knee flexion occurringSlap sound may occur at initial contactMay see supination of foot to assist in compensation
54Gait Deviations due to mm weakness Plantarflexor weaknessTibia and knee aren’t well stabilizedNo real propulsion phase at toe offDecrease in stance phase with smaller step length on unaffected sideSimilar to Antalgic pattern
56Gait Deviations Ankle and Foot Portion of PhaseDeviationDescriptionPoss. CauseInitial ContactFoot FlatEntire foot contacts ground at HSExc. fixed DF;Flaccid/weak DFMid StanceExcessive positional PFTibia does not advance to neutral from 10° PFNo ecc. Contraction of PF;
57Gait Deviations Ankle and Foot Portion of PhaseDeviationDescriptionPoss. CauseMid StanceHeel lift at Mid stanceHeel does not contact ground in mid stanceSpasticity of PFExcessive positional DFTibia advances too rapidly over the foot, creating > normal amount of DFInability of PF to control tibial advance, knee flexion or hip flexion contracturesToe clawingToes flex and “grab” floorPF grasp reflex; + support reflex; spastic toe flexors
58Gait Deviations Ankle and Foot Portion of PhaseDeviationDescriptionPoss. CausePush-off (heel-off to toe-off)No roll-offInsufficient transfer of wt. from lat. heel to medial forefootFlaccid or inhibition of PF, inv, and toe flexors; rigid/co- contraction of PF/DF; Pain in forefootSwingToe dragInsufficient DF (and toe ext.) so that forefoot and toes do not clear floorFlaccid/weak DF and toe ext. Spasticity of PF. Inadequate knee or hip flexionVarusThe foot is excessively invertedSpasticity of inv.Flaccid/weak DF and ev. EX. pattern
59Gait Deviations Knee Deviation Description Poss. Cause Initial Contact Portion of PhaseDeviationDescriptionPoss. CauseInitial ContactHeel StrikeExcessive knee flexionKnee flexes or “buckles” rather than extends as foot contacts grd.Painful knee; Spasticity of kn √ or weak/flaccid quad.; short leg on contra sideFoot FlatGenu recurvatum> than normal knee ext.Flaccid/weak quads and soleus compensated for by pull of glut. Max.; Spasticity of quads;Mid stancesingle limb support, tibia is in back of ankle as body wt. moves over foot; ankle in PFSame as above
60Gait Deviations Knee Deviation Description Poss. Cause Push-off Portion of PhaseDeviationDescriptionPoss. CausePush-off(heel-off to toe-off)Excessive knee flexionKnee flexes to more than 40° during push-offCOG is forward of pelvis, rigid trunk, knee/hip √ contractures; √ withdrawal reflex;Limited knee flexionKnee flexes < 40°Spastic/over-active quads. and/or PF
61Gait Deviations Knee Deviation Description Poss. Cause Portion of PhaseDeviationDescriptionPoss. CauseAcceleration to mid swingExcessive knee flexionKnee flexes more than 65°Diminished pre- swing knee √; flexor withdrawal reflex; dysmetriaLimited knee flexionKnee does not flex to 65°Pain in knee; diminished ROM in knee; ext. spasticity;
62Gait Deviations Hip Deviation Description Poss. Cause Portion of PhaseDeviationDescriptionPoss. CauseHeel Strike to foot flatExcessive flexionFlexion > 30°Hip &/or knee √ contractures; knee √ d/t weak soleus and quads; hypertonicity of hip √Heel strike to foot flatLimited hip flexionHip flexion does not attain 30°Weak hip √;↓ROM; Glut. Max. weaknessFoot flat to mid stanceLimited hip ext.Hip does not attain neutral positionHip √ contracture;Spastic hip √
63Gait Deviations Hip Deviation Description Poss. Cause Portion of PhaseDeviationDescriptionPoss. CauseFoot flat to mid stanceInternal rotationInternally rotated position of LESpasticity of IR; weak ER; exc. forward rot. Of opp. pelvisExternal rotationExternally rotated position of LEExcessive backward rot. Of opp. PelvisAbductionAn abducted position of LEContracture of glut. med.; lat. trunk lean over ipsilateral side
64Gait Deviations Hip Deviation Description Poss. Cause Portion of PhaseDeviationDescriptionPoss. CauseFoot flat to mid stanceAdductionAdducted position of LESpasticity of hip √ and add. ; Pelvic drop to contra. sideSwingCircumductionLat. Circular mvmt. of LECompensation for weak hip √ or for inability to shorten LE
65Gait Deviations Hip Deviation Description Poss. Cause Swing Hip hiking Portion of PhaseDeviationDescriptionPoss. CauseSwingHip hikingShortening of swing LE by action Quad. LumborumCompensation for ↓ knee √ and /or ankle DF or for ext. spasticityExcessive hip flexionFlexion > 20-30°Attempt to shorten LE in presence of foot drop; Flexion pattern
66Gait Deviations Trunk Deviation Description Poss. Cause Portion of PhaseDeviationDescriptionPoss. CauseStanceLateral trunk leanTrunk lean over stance LE(glut. Med gait/ Trendelenburg)Weak/paralyzed glut. med. on stance LE; Pain in lean side LEBackward trunk leanHyperext. at hip (glut. max. gait)Weak/paralyzed glut. max. on stance legForward trunk leanForward lean of trunk→ hip √; forward √ of up. trunkWeak quads.; hip and knee √ contractures;Post. Rot. pelvis
67References Neumann D. Kinesiology of the Musculoskeletal System Magee D. Orthopedic Physical Assessment, 5th ed.