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.

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.

Recall and apply terminology associated with the gait cycle during laboratory practice and case simulations
Identify various types of ambulation aides.
Describe the advantages and disadvantages of various types of ambulation aids
Perform the two-point, four-point, three-point, three-one-point, and modified gait patterns
Describe the advantages and disadvantages of two-point, four-point, three-point, three-one-point, and modified gait patterns
Teach a patient to perform a selected gait pattern using appropriate equipment for the person's condition
Correct compensatory patterns during gait activities
Appreciate importance of safety parameters for gait training during a skill check activity

Normal Gait Cycle Terminology

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

decrease pain
decrease WB on involved limbs
allow for compensation when there are decreases in

coordination
endurance
balance
strength

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

patient status (medical history, WB, cognition)
prognosis for rehabilitation/mobility
home/work environment
community activities/demands
patient/client/family goals

Pre-Ambulation Aids

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

Parallel bars should be 2" wider than greater trochanters
ambulation aid grip/handle should line up with greater trochanter or ulnar styloid process (wrist crease) when the patient is in static standing
a range of 20 to 30 degrees of elbow flexion is optimal

Elbow flexion.JPG

measure from the greater trochanter to the patient's heel to determine grip/handle height if the patient needs to remain supine
forearm crutch cuff should be 1-1.5 inches distal to elbow crease
allow approximately 2 inches from the axilla to the axillary rest during standing/gait activities to minimize risk for neurovascular compression

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

Common Errors

measurements are not adjusted for postural imbalances in upright positions
measurements do not account for footwear
measurements are not confirmed in standing
optimal resting standing position is not maintained during measurements

crutches/cane - positioned too far or too close (ant/posterior/lateral) to lower extremities
walker - feet are too far anterior/posterior of rear legs

Effects of Poor Fit

decreased stability
increased energy expenditure
decreased function
decreased safety

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

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

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

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.