1. Mazyad Alotaibi Gait Training - II

2. Goals of Gait Training Increase area of support, maintain center of gravity over support area Redistribute weight-bearing area Maximize functional independence and safety at a reasonable energy cost

3. Requirements ROM, muscle strength and endurance, coordination, trunk balance, sensory perception, mental status Amount of weight-bearing permitted on lower limb Gait aids

4. Preparation for Ambulation Review medical record  Assess and know the patient’s problems and abilities. Establish goals and expectations Determine selection, proper fit Safety belt Explain and demonstrate Body Mechanics

5. Preparing the Patient Patients need to improve:  Balance  Coordination  Flexibility (ROM)  Strength  Endurance

6. Major Muscle Groups Upper Extremity Shoulder depressor – latissimus dorsi, lower trapezius, pectoralis minor Shoulder adductor – pectoralis major Shoulder flexor, extensor and abductor – deltoid Elbow extensor – triceps Wrist extensor Finger flexor

7. Major Muscle Groups Lower Extremity  Hip Extensors  Hip Abductors  Knee Extensors  Ankle Dorsiflexors

8. Progression of Ambulation Initiate in Parallel Bars  Maximum security  Stability  Safety Explain to patient prior to beginning treatment Demonstrate Remain inside bars to assist  decreases risk of injury (patient, self ) For PWB status, special devices may be used

9. Equipment Purpose Increases stability by increasing BOS Decreases weight-bearing Permits mobility Decreases pain Types  Parallel Bars  Walkers  Crutches  Cane

10. Gait aids

11. Parallel Bars Maximum stability No mobility Adjustable Proper Fit  20-25 0 elbow flexion greater trochanter

12. Walker Wider and more stable base of support, but slow gait For patients requiring maximum assistance with balance, uncoordinated Add wheels to front legs for who lack coordination or power in upper limbs Front of walker 12 inches in front of patient Shoulder relaxed and elbow flexed 20 degree

13. Walker Types  Standard Adjustable, Non-adjustable  Reciprocal  Stair-climbing  Wheeled  Folding Proper Fit  Grip at level of trochanter, wrist crease, or styloid process  Feet of walker flat, even with heels  Hips/knees straight, shoes on

14. Axillary Crutches Types  Standard adjustable and nonadjustable  Offset  Triceps Proper Fit  3 fingerbreadths from axilla  Handpiece at level of greater trochanter, ulnar styloid process, wrist crease  20-25 0 elbow flexion

15. Uses Unilateral non/partial weight bearing e.g. fracture, amputee -> 3-point gait Bilateral partial weight bearing or in- coordination/ataxia -> 2 or 4-point gait Bilateral weakness of lower extremities e.g. paraplegia -> swing-to or through gait

16. Axillary Crutches Advantages  Increased selection of gait patterns, speed  Easily adjusted (wood or aluminum)  Easily stored, transported  Can use on stairs, crowded/narrow areas Disadvantages  Less stable than walker  Can cause injury to axillary nerve, vessels  Requires good standing balance  Elderly insecure  Functional strength of UE, trunk required

17. Crutch Gaits Point gait – stability, slow Swing gait – more energy, fast Four-point gait Good stability - at least 3 point contact ground Ataxia or incoordination Slowest, difficulty

18. Three-point gait/alternating Non-weight-bearing gait for lower limb fracture or amputation 3-point PWB gait -> required 18-36% more energy per unit distance than normal NWB required 41-61%more energy per unit distance than normal

19. Two-point gait Faster than 4-point gait but less stability Decrease both lower limbs weight-bearing

20. Swing-through gait Fastest gait, requires functional abdominal muscles Required increase of 41-61% in net energy cost (= 3-point NWB)

21. Swing-to gait Both crutches -> both lower limbs almost to crutch level

22. Forearm Crutches  Used when stability, support of axillary crutches not required,  Requires more stability or support than cane.  Eliminates danger of injury to axillary nerves and vessels  More functional on stairs  Easy to store and transport

23. Forearm Crutches Disadvantages  Decreased stability  Requires good standing balance and good UE, trunk strength  Difficult to remove  Elderly insecure Proper Fit  Cuff 1-1½ inches distal to olecranon

24. Canes Body weight transmission for unilateral cane opposite affected side is 20-25% Gluteus medius weakness, or pathological at knee or ankle Cane eliminate necessary gluteus medius force and reduces compressional force on hip Proper Fit Measure tip of cane to level of greater trochanter, elbow flexed 20-30 degree.

25. Cane Uses  Compensate for impaired balance  Increased stability Advantages  More functional on stairs, confined areas.  Easy storage, transport. Disadvantages  Provides limited stability decreased BOS