Gait Training with Ambulation Aids
PTA 104L Orthopedic Dysfunctions Lab

Introduction

Gait training integrates the use of assistive devices and sequences to facilitate the most efficient and normal walking pattern possible. In lecture, the focus will be on understaning how gait sequence influences weight bearing through joint protection, safe cadence, and optimal posture.

Objectives

Activities in this lesson will apply directly to practice activities in lab. A successful student will complete study gati sequences and understand principles of gait patterns before coming to lab. Your lab partner(s) will appreciate working with someone who is prepared to be safe.

Lecture

Describe the mechanics, advantages and disadvantages of non-weight bearing (NWB), selected partial weight bearing (PWB), weight bearing as tolerated (WBAT), and full weight bearing (FWB) gait patterns.
Select safe step sequences for assisted gait on level ground and stairs based on a simulated conditions

Lab

Demonstrate time management by preparing equipment prior to skill check activity
Teach a simulated patient to perform a variety of gait pattern using appropriate equipment for the person's condition during a case simulation
Perform assisted gait for a given weightbearing status for a simulated case
Correct compensatory patterns during gait activities during simulation
Engage in risk management through demonstration of critical safety elements during gait training in a case simulation
Teach a patient to safely ascend/descend stairs/curb with a selected ambulation aid during a case simulation

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?

a point is when there is an episode of weight acceptance during a single gait cycle
two point - use of two crutches or canes; cane moves forward simultaneously with contralateral limb. Each step = one point
three point - use of walker or bilateral crutches; assistive device ― affected LE — unaffected LE. Assistive device and each LE are considered separate points
four point - reciprocal pattern with use of bilateral crutches. Each AD and LE are considered separate points in the gait cycle

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

sit to stand - facilitated weight shift in sagittal plane, trunk control, LE strengthening, endurance, and motor planning
weight shifting in standing - facilitated weight shift in frontal plane; able to progress from double UE to single UE to no UE support in static standing
dynamic loading and unloading of limb for proprioception in reciprocal activation

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 or Modified Three 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, wheeled 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

reduces forces of abductors at contralateral hip
ground reaction force from floor through cane counteracts contralateral pelvic tilt during swing
result is decreased joint compression forces at the hip

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:

comfort
balance/endurance effects
overall changes in gait deviations
safety (surfaces, stairs, outdoor ambulation needs)
grip strength
possibility for bilateral cane use

Show quiz question

Gait Training

In addition to close coordination with the supervising PT, the role of the PTA is to provide direct instruction in safe and effective modified gait techniques, observe and document progress, modify and progress gait as indicated, AND have the knowledge to explain the WHY behind the use of assistive devices and gait sequencing. Text book readings provide a strong foundation for the WHY.

The patient information sheets linked describe modified gait activities in patient-centered language. Be sure to integrate the clinical decision-making behind these interventions, so you may be effective in patient education, skill progression, communication, and documentation.

Using a Walker

Using Crutches

Walking with Crutches - Four Point

Walking with Crutches - Three Point

Walking with Crutches - Two Point

Stair Climbing with Crutches

Patterns and considerations for training are well-described in your text readings.