1. Ambulation Aids Normal Gait and Abnormal Gait

2. Assistive Devices Objectives
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 Aids Patient 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

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

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

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

12. Standard Walker Patient must be able to lift and advance walker
Greater attention demand
White, 1992
Adjustable, nonadjustable
Folding
Reciprocal
Opposite the normal walking pattern. Take step advance, take a step advanced.

13. Rolling Walkers Rolling Walker Indications Height of walker
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: Elbow Flexion Walker Feet:
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 Tape Measure
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 to be 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
4-points for walking:

30. Two-Point Gait Pattern
Bilateral aids
Simultaneous, reciprocal pattern
Stable pattern
Faster speed
Low energy
Similar to normal gait pattern
2 points are moving at a time, always opposite sides=crutches. Alternating leg and crutch out

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
antalgic, not willing to put 100% of weight on bad, so take shorter on hurt.
The most “normal” gait.

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
With crutches, swinging through with good foot, with the injured foot still-up

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
Most weight is still just in arms, can have less than 10% on injured foot that touches.

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):
Wright DL, Kemp TL. The dual-task methodology and assessing the attentional demands of ambulation with walking devices. Phys Ther 1992;72(4):

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 – 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.

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 leg hip hiking, circumduction

47. Vaulting Circumduction

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 medius weakness (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.

51. Gait Deviations due to mm weakness
Quadriceps Weakness
Inability to contract muscle
Compensation is with forward bending of trunk, rapid plantarflexion, can get hyperextension
May compensate by pushing knee posterior during stance

52. Gait Deviations due to mm weakness
Hamstring Weakness
Knee maintains extended position
Essentially elongates limb
Decrease in shock absorption at knee
Toe off more difficult , lose transition between stance and swing, greater hip and knee flexion required to clear limb

53. Gait Deviations due to mm weakness
Anterior Tibialis Weakness:
Steppage gait
Swing phase on involved side with increase in hip and knee flexion occurring
Slap sound may occur at initial contact
May see supination of foot to assist in compensation

54. Gait Deviations due to mm weakness
Plantarflexor weakness
Tibia and knee aren’t well stabilized
No real propulsion phase at toe off
Decrease in stance phase with smaller step length on unaffected side
Similar to Antalgic pattern

55. Gait Deviations Ankle and Foot
Portion of Phase
Deviation
Description
Poss. Cause
Initial contact
Foot Slap
At HS, forefoot slaps ground
Flaccid/ weak DF; reciprocal inhibition of DF
Toes First
Toes contact ground instead of heel, tip-toe posture poss. thru cycle
Leg length discrepancy; contracted heel cord; PF contraction; spastic PF; flaccid DF; heel pain

56. Gait Deviations Ankle and Foot
Portion of Phase
Deviation
Description
Poss. Cause
Initial Contact
Foot Flat
Entire foot contacts ground at HS
Exc. fixed DF;
Flaccid/weak DF
Mid Stance
Excessive positional PF
Tibia does not advance to neutral from 10° PF
No ecc. Contraction of PF;

57. Gait Deviations Ankle and Foot
Portion of Phase
Deviation
Description
Poss. Cause
Mid Stance
Heel lift at Mid stance
Heel does not contact ground in mid stance
Spasticity of PF
Excessive positional DF
Tibia advances too rapidly over the foot, creating > normal amount of DF
Inability of PF to control tibial advance, knee flexion or hip flexion contractures
Toe clawing
Toes flex and “grab” floor
PF grasp reflex; + support reflex; spastic toe flexors

58. Gait Deviations Ankle and Foot
Portion of Phase
Deviation
Description
Poss. Cause
Push-off (heel-off to toe-off)
No roll-off
Insufficient transfer of wt. from lat. heel to medial forefoot
Flaccid or inhibition of PF, inv, and toe flexors; rigid/co- contraction of PF/DF; Pain in forefoot
Swing
Toe drag
Insufficient DF (and toe ext.) so that forefoot and toes do not clear floor
Flaccid/weak DF and toe ext. Spasticity of PF. Inadequate knee or hip flexion
Varus
The foot is excessively inverted
Spasticity of inv.
Flaccid/weak DF and ev. EX. pattern

59. Gait Deviations Knee Deviation Description Poss. Cause Initial Contact
Portion of Phase
Deviation
Description
Poss. Cause
Initial Contact
Heel Strike
Excessive knee flexion
Knee flexes or “buckles” rather than extends as foot contacts grd.
Painful knee; Spasticity of kn √ or weak/flaccid quad.; short leg on contra side
Foot Flat
Genu recurvatum
> than normal knee ext.
Flaccid/weak quads and soleus compensated for by pull of glut. Max.; Spasticity of quads;
Mid stance
single limb support, tibia is in back of ankle as body wt. moves over foot; ankle in PF
Same as above

60. Gait Deviations Knee Deviation Description Poss. Cause Push-off
Portion of Phase
Deviation
Description
Poss. Cause
Push-off
(heel-off to toe-off)
Excessive knee flexion
Knee flexes to more than 40° during push-off
COG is forward of pelvis, rigid trunk, knee/hip √ contractures; √ withdrawal reflex;
Limited knee flexion
Knee flexes < 40°
Spastic/over-active quads. and/or PF

61. Gait Deviations Knee Deviation Description Poss. Cause
Portion of Phase
Deviation
Description
Poss. Cause
Acceleration to mid swing
Excessive knee flexion
Knee flexes more than 65°
Diminished pre- swing knee √; flexor withdrawal reflex; dysmetria
Limited knee flexion
Knee does not flex to 65°
Pain in knee; diminished ROM in knee; ext. spasticity;

62. Gait Deviations Hip Deviation Description Poss. Cause
Portion of Phase
Deviation
Description
Poss. Cause
Heel Strike to foot flat
Excessive flexion
Flexion > 30°
Hip &/or knee √ contractures; knee √ d/t weak soleus and quads; hypertonicity of hip √
Heel strike to foot flat
Limited hip flexion
Hip flexion does not attain 30°
Weak hip √;
↓ROM; Glut. Max. weakness
Foot flat to mid stance
Limited hip ext.
Hip does not attain neutral position
Hip √ contracture;
Spastic hip √

63. Gait Deviations Hip Deviation Description Poss. Cause
Portion of Phase
Deviation
Description
Poss. Cause
Foot flat to mid stance
Internal rotation
Internally rotated position of LE
Spasticity of IR; weak ER; exc. forward rot. Of opp. pelvis
External rotation
Externally rotated position of LE
Excessive backward rot. Of opp. Pelvis
Abduction
An abducted position of LE
Contracture of glut. med.; lat. trunk lean over ipsilateral side

64. Gait Deviations Hip Deviation Description Poss. Cause
Portion of Phase
Deviation
Description
Poss. Cause
Foot flat to mid stance
Adduction
Adducted position of LE
Spasticity of hip √ and add. ; Pelvic drop to contra. side
Swing
Circumduction
Lat. Circular mvmt. of LE
Compensation for weak hip √ or for inability to shorten LE

65. Gait Deviations Hip Deviation Description Poss. Cause Swing Hip hiking
Portion of Phase
Deviation
Description
Poss. Cause
Swing
Hip hiking
Shortening of swing LE by action Quad. Lumborum
Compensation for ↓ knee √ and /or ankle DF or for ext. spasticity
Excessive hip flexion
Flexion > 20-30°
Attempt to shorten LE in presence of foot drop; Flexion pattern

66. Gait Deviations Trunk Deviation Description Poss. Cause
Portion of Phase
Deviation
Description
Poss. Cause
Stance
Lateral trunk lean
Trunk lean over stance LE
(glut. Med gait/ Trendelenburg)
Weak/paralyzed glut. med. on stance LE; Pain in lean side LE
Backward trunk lean
Hyperext. at hip (glut. max. gait)
Weak/paralyzed glut. max. on stance leg
Forward trunk lean
Forward lean of trunk→ hip √; forward √ of up. trunk
Weak quads.; hip and knee √ contractures;
Post. Rot. pelvis

67. References Neumann D. Kinesiology of the Musculoskeletal System
Magee D. Orthopedic Physical Assessment, 5th ed.