Gait Training with Ambulation Aids
PTA 104L Orthopedic Dysfunctions Lab

Introduction

 

Many orthopedic conditions result in impaired gait. Deconditioning, weakness, pain, postural imbalances, and loss of joint mobility are some of the factors that impair safety, efficiency, and effectiveness of ambulation. PTAs apply knowledge of pathology, kinesiology and therapeutic exercise through progressive gait training techniques.

SW_Stairs.JPG

Ambulation aids are an invaluable tool to restoring functional ambulation. Selection of the most appropriate device is determined by medical status and patient goals. PTAs integrate body mechanics, motor learning principles, and safety awareness into mobility training interventions according to the plan of care.

Ambulation aids fitted correctly can allow patients/clients with chronic conditions can conserve energy and maximize participation with mobility. Individuals who are rehabilitating from illness or injury can increase strength, endurance, and confidence throughout the stages of healing and recovery.

This lesson reviews the basic components of the normal gait cycle, pre-ambulation considerations, and safe, effective techniques for gait training.

Objectives

Activities in this lesson will apply directly to practice activities in lab. A successful student will complete pre-lab assignments and activities before coming to lab. Your lab partner(s) will appreciate working with someone who is prepared to be safe.

 

 

Normal Gait Cycle Terminology

GaitCycle2.jpg

Stance phase: foot is in contact with the ground

subphases are

initial contact (heel strike/contact)

loading response

midstance (foot flat)

terminal stance (heel off)

preswing (toe off).

Swing phase: foot is in the air

subphases are

initial swing (acceleration)

midswing

terminal swing (deceleration).

Pierson, Frank M.. Principles & Techniques of Patient Care, 4th Edition. Saunders Book Company, 092007. 9.3.

 

 Hyperlink to Flash Card Activity 

 

 

Ambulation Aids

Function

Ambulation aides are designed to increase the base of support for standing and walking activities. Torque and other joint stresses can be minimized with an effective use of an ambulation aid. Selection of the most appropriate device is dependent on stability and mobility needs. Overall, ambulation aids can

The term "assistive device" can be substituted for ambulation aid, however, it is less specific and needs to be supported by language and instruction specific to its use in gait training. 

Factors Influencing Selection of Ambulation Aid

 

Pre-Ambulation Aids

TiltTable.JPG

Tilt tables may be indicated when the patient has experience extended bed rest, or if there are contraindications for joint motion(s). Gravity can be incrementally applied, resulting in increased demand to the cardiopulmonary system and postural muscles. Ankle plantar flexors and foot instrinsics are passively stretched and proprioception increases through WB in the feet.

 

Parallel bars can be fixed or folding are are most often found used in rehabilitation settings. Patients who have low endurance or need a significant amount of assistant to rise to sitting. The fixed nature of the bars can allow the patient to pull with the upper extremities when transitioning to standing.

Summary of Ambulation Aids

Ambulation aids are organized on the table based on progressively increasing patient mobility/safety levels. In the clinical setting, patients may be progressed through all of these devices. PTAs can select/modify the assistive device to meet the needs of the patient. Abrupt changes in mobility status (e.g., declines) must be communicated to the PT for reassessment and treatment planning

Summary of Ambulation Aids

Ambulation Aid

Types

Advantages

Disadvantages

Tilt-table

 --

Allows for progressive transition to upright position; can adapt for NWB situations

Dependent; tilt is functional up to ~70 degrees

Parallel Bars

 Folding

Floor Mounted

 

Allows for maximum stability, support and safety in a functional position

Some challenge with body mechanics by PT/PTA 

Stability may be challenged with larger/weaker patients

 Walkers

 

Front-Wheel

Standard or Pick-up

Four-Wheel

Hemi

 

Allows for maximal stability for ambulation/gait training;

Potential to increase mobility in community 

Adjustable

Some fold

Some environmental limitations


Gait pattern is altered

Walking speed is slower

Challenging to use with stairs

 

Axillary Crutches

Wood

Aluminum

Allows for increased variability in gait patterns

Provides support with increasing mobility

adjustable

Can be used on stairs 

Less stable 

Requires relatively good trunk and UE strength

Risk for nerve/vessel damage with improper fit/use

Forearm Crutches

Lofstrand

Canadian

Allows for increased mobility in patients who are unable to use a cane

adjustable

Functional on stairs and in narrow areas

Forearm cuff can make it difficult to remove crutch

Dynamic qualities may make some patients feel insecure (e.g., elderly) 

Quad Cane

Crab

Large Base (LBQC)

Small Base (SBQC)

Provide a broad base with four points of contact on floor

Height adjustable

Can feel unstable with transitioning weight through the device;

Results in a slower gait pattern

 Cane

Wood (standard)

Aluminum

Offset handle

Pistol grip

 

Allows for progressive increased mobility

Used for added stability during upright activities

Aluminum varieties are easily adjusted

Offset handle allows for weight distribution through shaft of cane

Less environmental constraints; easily stored

Inexpensive

Standard variety is not adjustable; must be cut to fit patient

Function is to widen BOS and improve balance

Relatively small BOS compared to other AD

Unable to use with 3-point gait pattern 

Measurement and Fit

General Guidelines

Elbow flexion.JPG

 

Specific guidelines for each ambulation aid are provided in Procedure 9-2 in Therapeutic Exercises (pg. 225)

 

Common Errors

Effects of Poor Fit

 

 

Gait Patterns and Ambulation Aids

Gait patterns are determined by the patient's status ( WB restrictions, musculoskeletal/neuromuscular impairments, safety) and the environmental constraints. As we discuss weight bearing status, we will integrate specific gait patterns to address the stability, mobility and safety needs of the patient.

What is a "point" in an adaptive gait pattern?

 

 

 

Weight Bearing Status

Weight bearing status can be physician ordered, established by the PT, and/or modified during treatment based on the patient response. A physician's order for weight bearing status is in place until changed/updated by the MD/PCP. Radiographic or other diagnostic imaging, mobility status, and patient response (pain, safety) are all considered in clinical decision making for weight bearing activities.

Pre-gait activities

 

A patient information sheet is included in this course to provide you with some patient-based descriptions of weight bearing status. Refer to your text for detailed definitions and use the table below to help summarize descriptions and gait pattern indications.

Summary Table of WB status

Weight bearing status

Description

 

Gait Pattern

Pattern description

NWB

No weight on the extremity

Three-Point

Use of walker or two crutches; Step to

Step through

Aid is advanced alternately with affected limb

PWB, also

TTWB

TDWB

Partial weight bearing

Three-One-Point

Use of walker or two crutches; Heel touch or flat foot with a fixed or proprioceptively-determined amount of WB in the affected limb

Aid is advanced simultaneously with affected limb

WBAT

Weight bearing As tolerated

Three-One-Point, Four point, or two point

(progress from most to least support from aid)

 

Use of walker or bilateral ambulation aids (crutches, canes); progression to more reciprocal pattern is dependent on patient safety, strength, confidence, and symptoms

FWB

Full weight bearing

Four point, or

two point

Use of walker or bilateral ambulation aid

Reciprocal pattern (slow to fast progression)

Unequal WB

Hemi pattern

Modified four-point

Modified two-point

Use of one ambulation aid (crutch, cane, hemi walker) or for patients with functional use of one upper extremity

LE and aid advance alternately (four-point) or simultaneously (two-point) ; aid is typically used on the contralateral side

 

Benefits of contralateral positioning

Bilateral Involvement Considerations

Use a patient-centered approach to critically assess which side of the body will most benefit from the cane. Specific considerations include:

 

 

 Toggle open/close quiz question

 Toggle open/close quiz question

 Toggle open/close quiz question

 Supplemental Patient Resources for Gait Training

Various patient handouts for sequencing gait with a variety of assistive devices and on a variety of terrains are available on the University of Pittsburgh Medical Center Patient Education Materials page

Lab Preparation

We will be practicing gait training in lab. Be prepared with appropriate footwear and clothing. There will be an in-class pre-lab quiz on your ability to describe the gait training patterns (two point, three-point, etc.) provided in your Pierson text.