Assistive device handout PDF

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preparation for ambulation activities...

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Gait Training: Assistive Device Preparation for Ambulation Activities  Review the patient's medical record for information to assist in planning the ambulation activities. What information will be particularly important to you?  Assess, examine, and evaluate the patient to determine limitations and capabilities to assist in planning the pre-ambulation activities and gait pattern.  Determine the appropriate equipment and pattern based on the medical record, your assessment, and the goals of intervention.  Prepare the patient for ambulation (for example, explain the pattern, obtain consent, and improve physical abilities).  Remove items in the area that may interfere with ambulation to maintain a safe environment.  Verify the initial measurement of the equipment to ensure a proper fit and determine that the equipment is safe (for example, tighten loose nuts and bolts, be certain spring adjustment buttons are secure, and examine rubber tips for dirt or cracks in the rubber).  Always apply a safety belt to the patient.  Be certain the patient is mentally and physically capable of performing the selected gait pattern.  Explain and demonstrate the gait pattern for the patient; ask the patient to describe the pattern, how it is to be performed, and what is expected to be performed. Require an explanation of the procedure or activity to verify the person truly understands and comprehends your instructions.  Use the safety belt and the patient's shoulder as points of control when guarding the patient.  Maintain proper body mechanics for yourself and the patient.

Precautions for Ambulation Activities  Be sure the patient wears appropriate footwear; do not allow the patient to ambulate while wearing slippers or loosely fitting shoes or while not wearing shoes. These conditions can lead to patient insecurity and injury.  Monitor the patient's physiologic responses to ambulation frequently and evaluate vital signs, general appearance, and mental alertness during the activity. Compare your findings with normal values to determine the patient's reaction to the activity.  Avoid guarding or controlling the patient by grasping clothing or an upper extremity. These items are insufficient for protection.  Anticipate the unexpected and be alert for unusual patient actions or equipment problems; anticipate that the patient may slip or lose stability or balance at any time.  Guard the patient by standing behind and slightly to one side and maintain a grip on the safety belt until the patient is able to ambulate independently and safely.  Do not leave the patient unattended while standing; the patient may not be totally stable.  Protect patient appliances (such as cast, drainage tubes, intravenous tubes, and dressings) during ambulation.  Be certain the area used for ambulation is free of hazards, such as equipment or furniture, and the floor or surface is dry. Safe conditions must be maintained to reduce the risk of injury to the patient.

CANES Function:  To widen base of support  Improve balance 4 MAIN PARTS OF CANE 1. The handle can be almost any shape but is usually a knob, L shaped, crutch, opera T pistol grip or hook. 2. The shaf is the straight part of the cane (though it may be twisted or bent) and although usually made of wood or metal, can be made of bone, bamboo, or plastic 3. The collar attaches the handle to the shaf and is usually a band of metal 4. The ferrule or tip is the end of the can. It is usually made of copper and other metals or rubber. It protects the tip of the can from wear and tear. STANDARD CANE  Regular or conventional cane  Made of aluminum, wood or plastic  Has a half circle “crook” handle  Distal rubber tip is at least 1 in diameter or larger Advantages:  Inexpensive  Fits easily on stairs and limited space Disadvantages:  Not adjustable  Must be cut to fit  Pt. of support is anterior to the hand

STANDARD ADJUSTABLE ALUMINUM CANE  Made of aluminum tubing  Half circle handle with plastic molded covering  Telescoping design enables the height to be adjusted using push button mech.  27 to 38.5 in.  Distal rubber 1 in. Advantages:  Quickly adjustable  Light weight  Fits easily on stairs Disadvantages:  Point of support is anterior  Costly

ADJUSTABLE ALUMINUM OFFSET CANE  The proximal component of the body is offset anteriorly creating a straight handle  27 to 38.5 in adjustable range by a push button mech.  Rubber tip 1 in. diameter Advantages:  Design allow pressure to be borne over the center of the cane for greater stability  Quickly adjusted  Light weight  Fits easily on stairs Disadvantages:  Costly QUAD CANE  It provides broad base with four points of floor contact  Legs closest to pt. body are generally shorter and maybe angle to allow foot clearance  Handgrip made of plastic grips Advantages  Broad-based support  Available in different sizes  Easily adjustable Disadvantages  Depending on the design the pressure exerted by the patient’s hand may not be centered over the cane (instability)  Not practical to be use in stairs  Warrant use of slower gait pattern ROLLING CANE  provide wide-wheeled base allowing interrupted forward progression  contoured handholds  Easy height adjustments  Pressure sensitive brake built into handle Advantages:  Wheeled base allows weight to be continuously applied as the need to lif and placing the cane forward will be eliminated  Faster forward progression  The 2nd and 3rd handles placed between the uprights can assist in rising to standing Disadvantages:  Costly, require sufficient UE and grip strength

WALKERS  Used for maximal stability, support, and mobility Disadvantages:  It may be difficult to store or transport  It is difficult or impossible to use on stairs  It reduces the speed of ambulation  It may be difficult to perform a normal gait pattern  It can be difficult to use in narrow or crowded areas Types: Standard

Wheeled

Folding

Reciprocal Stair-climbing

WALK CANE (Hemi-Walker)  Very broad base w/ 4 points of floor contact  The legs farther from the pt.’s body are angled to maintain contact and stability Advantages:  Very broad based support  More stable  Fold flat for travel or storage Disadvantages:  the design and handles may not allow pressure to be centered over the cane  cannot be used on most stairs  Allow use of slow forward progression MEASURING CANE (Method 1)  Patient’s position: standing or supine  Hand grip should be placed at the level of greater trochanter  Place the cane parallel to the femur and tibia  Tape measure can be used to measure distance from the greater trochanter to the heel MEASURING CANE (Method 2)  Cane height -> 6 inches lateral border of toes  landmarks: o greater trochanter – top of the cane  PATIENT’S COMFORT o Angle at the elbow – flexed 20 to 30 deg.  Allows arm to shorten or lengthen during phases of gait  Provide shock-absorption mechanism  CANE should be held in the UE opposite the affected limb.  For ambulation on level surface, the cane and the involved extremity are advanced simultaneously  CANE should be closed to the body and should not be placed ahead of the toe of the involved extremity

CRUTCHES  Most frequent used to improved balance  Relieve of weight bearing partially or fully  Can be used bilaterally Function: 1. To ↑ BOS 2. Improve lateral stability 3. Allow UE transfer body weight to floor

AXILLARY CRUTCHES ADVANTAGE:  ↑ lateral stability  Provide fxn’l ambulation  Easily adjusted  Inexpensive  Can be used in stair climbing DISADVANTAGE:  Awkward in small places  Safety of the user is compromised when ambulatory in crowded areas  Pt. lean on axillary bar

FOREARM CRUTCHES  AKA Lofstrand or Canadian crutches ADVANTAGE:  FA cuff allows use of hand cuff s the crutches become  Easily adjusted, fitted  Allows standing activities  More cosmetic DISADVANTAGE:  Less lateral support  Cuffs may be difficult to remove

PLATFORM ATTACHMENT USED FOR:  Unable to bear weight through their wrists and hands  Severe deformities of the wrists or fingers  Below elbow amputation DISADVANTAGES:  The patient loses the use of the triceps to elevate and maintain the body during the swing phase  Another person may need to apply them  They are less effective on stairs

PARTS OF CRUTCHES

Arm Cuf

Axillary bar/ Axillary pad

Hand piece 2 Uprights

Hand Piece/ Hand grip cover Straight leg straight

Single leg straight

Crutch tips

Crutch tips

MEASURING AXILLARY CRUTCH (Method 1)  Standing Position  Most accurate procedure  Pt. standing in // bars measure 2” below axilla  Width of 2 finger is ofen used  The distal end crutch should be resting 2” lateral & 6” anterior to the foot

MEASURING AXILLARY CRUTCH (Method 2)  General estimate of crutch:  Pt’s height (inches) – 16”  Shoulder relaxed, handpiece should be adjusted to promote 20-30° elbow flexion MEASURING AXILLARY CRUTCH (Method 3)  Supine Position  From anterior axillary fold to a surface point 6-8” (5-7.5 cm) from lateral border of the heel MEASURING FOREARM CRUTCH (Method 1)  Standing is position of choice  Handpiece // to the greater trochanter in standing or supine position  Cuff placement should be on the proximal 1/3rd of FA ~ 1-1.5” below elbow Common Errors in Fitting of Axillary Crutches  The patient elevates or hunches the shoulders and the crutches will be measured improperly; they will be too long when the patient stands properly.  The patient depresses or drops the shoulders or flexes the trunk at the hips and the crutches will be improperly measured; they will be too short when the patient stands properly.  The patient flexes or extends the wrist and the handpiece will be improperly positioned.  The measurements are made without the patient wearing shoes or without the crutch tips or axillary pads in place; the crutches will be improperly measured and will be too long as a result.  The crutch evaluation is made without the patient in the tripod position; the crutches may be too short or too long depending how the patient stood initially.

Guarding Guidelines for Ambulation  Apply a safety belt on the patient before ambulation.  Stand behind and slightly to one side of the patient (that is, toward the weak or affected extremity); remain close.  Grasp the safety belt with one hand; use your other hand to guard at the patient's shoulder. DO NOT GRASP THE PATIENT'S ARM OR CLOTHING.  Position your feet anteroposterior; place your outside foot between the patient's foot and assistive aid and forward of your other foot; your inside foot trails your outside foot as the patient moves forward .  Move forward as the patient moves forward ; maintain your outside foot forward of your inside foot as you move forward .  If the patient loses balance forward, pull the person toward you using the safety belt and your hand on the shoulder or chest; assist the patient to regain balance and stability.  If the patient loses balance backward, position your body behind the patient with feet anteroposterior; allow the person to lean against the side of your body; assist the patient to regain balance and stability. Gait Patterns  Selected on the basis of pt’s balance, coordination, muscle function & weight bearing status Remember!  Axillary crutch: body weight should always be borne on hands not on axillary bar  To prevent pressure on vascular & nervous structure on axillary region  Maintain wide tripod BOS

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Keep crutches at least 4” (10 cm) to the front to the side of each foot Do not align crutches // to the foot Held axillary bars close to chest wall to provide lateral stability Maintain good postural alignment When turning do not pivot, walk on a small circle

GAIT PATTERNS

3 POINT GAIT  Non weight bearing status is required on LE  Body weight is borne on the crutches

POINT)  Weight is borne partially on B crutches & affected extremity  Use of normal heel toe progression of affected extremity  Do not put all weight or walk solely on toes or ball foot  Heel cord tightness

4 Point Gait  Weight is borne on (B) LE  Indicated for bilateral involvement due to poor balance, incoordination & muscle weakness  One crutch is advanced followed by opposite LE  If (R) crutch is moved forward, (L) LE should follow (L) crutch followed by (R) LE

2 POINT GAIT  Less stable  Only 2 point contact on the floor is maintained  Requires better balance  Simulates normal gait pattern  (L) crutch is moved forward together c the (R) LE; (R) crutch & (L) LE  Gait Patterns

MODIFIED 4 POINT GAIT  Only one assistive aid is used  Assistive device held at the opposite side of affected lower extremity

 One assistive aid is used  Assistive device held at the opposite side of affected lower extremity

MODIFIED 2 POINT GAIT SWING TO/THROUGH Used in bilateral involvement (SCI)  Swing To

o Forward movement of (B) crutches simultaneously, LE swing to crutches  Swing through o (B) crutches are moved forward together & LE are swing beyond the crutches ASCENDING & DESCENDING STAIRS CRUTCHES: Non weight bearing status/ Partial Weight Bearing status  Ascending: o PT: Guarding at the posterolateral of the patient. Position yourself behind and to one side of the patient.  If a handrail is used, position yourself to the side opposite it.  If a handrail is not used, position yourself to the side at which the greatest danger or potential for injury exists should the patient's balance be disturbed.  Note: Many caregivers prefer to be positioned to the patient's weakest side or the side of the least functional extremity. o Patient: Applying all weight at the handgrip of the crutches, hop the good leg on the 1 st step. Then, simultaneously lif the bad foot together with the crutches to the first step.  Descending: o PT: Guarding in front of the patient. Follow same general considerations as to ascending. o Patient: Position the (B) crutches on the step below together with the bad foot in a NWB/PWB status. Hop the good leg down the step together with the crutches. “GOOD leg goes to heaven, BAD leg goes to hell”...