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TYPES AND GAIT PATTERNS
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There are three major categories of ambulatory assistive devices: canes, crutches, and walkers. Each has several modifications to the basic design, many of which were developed to meet the needs of a specific patient problem or diagnostic group. Assistive devices are prescribed for a variety of reasons, including problems of balance, pain, fatigue, weakness, joint instability, excessive skeletal loading, and cosmesis. Another primary function of assistive devices is to eliminate weight-bearing fully or partially from a lower extremity (LE). This unloading occurs by transmission of force from the upper extremities (UEs) to the floor by downward pressure on the assistive device. Prescribing an appropriate assistive device requires knowledge of the patient's weight-bearing status. Common clinical descriptors used to identify weight-bearing status are presented in Box 11A.1. Considerations specific to the bariatric population are presented in Box 11A.2.
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Box 11A.1 Clinical Descriptors of Weight-Bearing Status
Full weight-bearing (FWB): There are no restrictions on weight-bearing; 100% of body weight can be borne on the LE.
Non–weight-bearing (NWB): No weight is borne on the involved limb; foot/toes make no contact with floor/ground surface.
Partial weight-bearing (PWB): Only a portion of weight can be borne on the extremity; sometimes expressed as a percentage of body weight (e.g., 20% or 50%).
Toe-touch weight-bearing (TTWB) or touch-down weight-bearing (TDWB): Only the toes of the affected extremity contact the floor to improve balance (not to support body weight).
Weight-bearing as tolerated (WBAT): Weight-bearing is limited by patient tolerance of weight borne on extremity.
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Box 11A.2 Bariatric Ambulatory Assistive Devices
As with all patients, safety and function are paramount concerns in selection of assistive devices (canes, crutches, and walkers) for patients who are morbidly obese. Important considerations include the following:
Selecting devices with the appropriate weight capacity. Manufacturers of bariatric equipment typically include the maximum weight designation for each product. Standard devices have a weight capacity of 250 to 350 pounds; bariatric equipment carry weight capacities in the range of 400 to 1,000 pounds.
Identification of the needed dimensions (height and width) of the equipment; this requires knowledge of the anthropometric characteristics (measurements and proportions) of the patient's body.
Large patients often walk with a wide-based gait owing to lower extremity limb girth and the need to increase the base of support to carry body weight and maintain balance. If a disproportionate amount of weight falls anterior (e.g., abdominal region), upright postures will be further challenged by the need to counteract the anterior effects of gravity.a
Following are general characteristics and features of commercially available walkers, crutches, and canes designed for the bariatric population. The information presents a range of available options and is not representative of any individual assistive device. As new products are continually introduced to the market, consultation with a durable medical equipment (DME) supplier will help ensure prescription of the optimal device for an individual patient.
Note: For labeling or identifying bariatric equipment in patient care settings, the term expanded capability (EC) is recommended over less desirable terms such as oversized, extra- large, or heavy duty.b
Walkers
Bariatric walkers typically include deeper and wider frames.
May accommodate user heights from 5 feet 3 inches to 6 feet 10 inches.
Overall walker height adjustments range from 31 to 41.25 inches.
Available widths: 23.5 to 30 inches.
May include double anterior cross bracing to increase stability.
Weight capacity range: 500 to 700 pounds (without seat); 400 to 500 pounds (with seat).
Walker weight: 7 to 12 pounds (without seat); 19 to 26 pounds (with seat).
Seat dimensions: height, 22 inches; width, 17.5 to 18 inches; depth, 13 to 14 inches.
Some models are constructed using a reinforced steel frame; for rolling walkers, large casters are typically used.
Axillary Crutches
Bariatric axillary crutches are generally constructed of heavy-duty steel.
May accommodate user heights from 5 feet 2 inches to 7 feet 4 inches (youth sizes available).
Overall crutch height adjustments range from 44 to 60 inches.
Weight capacity range: 550 to 1000 pounds.
Crutch tips: 2-inch diameter.
Crutch weight: 4 pounds, 6 ounces to 5 pounds each.
Forearm Crutches
Bariatric forearm crutches are generally constructed of heavy-duty steel.
May accommodate user heights from 5 feet to 6 feet 7 inches (youth sizes available).
Crutch height adjustments (handle to floor) range from 28 to 42 inches and forearm piece adjustments (handle to center of cuff) range from 8 to 9.5 inches; as with standard forearm crutches, the leg and forearm sections adjust independently.
Weight capacity range: 500 to 700 pounds.
Crutch tips: 2-inch diameter.
Crutch weight: 2 pounds 6 ounces to 5 pounds 7 ounces.
Canes
Bariatric canes are generally constructed of stainless steel or heavy-duty steel tubing; most incorporate an offset handle and a reinforcing cuff tightened by a rotation sleeve.
May accommodate user heights from 4 feet 10 inches to 6 feet 4 inches.
Overall height adjustments range from approximately 25 to 46 inches.
Weight capacity range: 500 to 700 pounds.
Cane weight: 1.8 to 2 pounds.
Quadruped Canes
Bariatric quadruped canes are generally constructed of steel and often incorporate a double-plated base; most incorporate an offset handle and a reinforcing cuff tightened by a rotation sleeve.
May accommodate user heights from 4 feet 11 inches to 6 feet 5 inches.
Overall height adjustments range from approximately 29 to 39 inches.
Weight capacity range: 500 to 700 pounds.
Weight: 4 to 5 pounds.
Footprint size: small base, 6 × 8 inches; large base, 8 × 12 inches.
aTrimble, T: Outsize patients—a big nursing challenge. ENW, 2008. Retrieved July 13, 2012, from http://enw.org/Obese.htm.
bPatient Safety Center of Inquiry (Tampa, FL): Patient Care Ergonomics Resource Guide, Safe Patient Handling and Movement. Veterans Health Administration and Department of Defense, Washington, DC, 2005. Retrieved July 13, 2012, from www.visn8.va.gov/visn8/patientsafetycenter/resguide/ErgoGuidePtTwo.pdf.
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Most canes used in clinical practice are constructed of lightweight aluminum. Evidence supports the effectiveness of canes to improve balance1,2,3 and improve postural stability.1,4,5,6 Although canes reduce biomechanical load on LE joints,2,7 they are not intended for use with a restricted weight-bearing status (such as non–weight-bearing [NWB] or partial weight-bearing [PWB]). Patients are typically instructed to hold a cane in the hand opposite the affected extremity. This positioning of the cane most closely approximates a normal reciprocal gait pattern with the opposite arm and leg moving together. It also widens the BOS with less lateral shifting of the center of mass (COM) than when the cane is held on the ipsilateral side.
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Several investigations have confirmed that contralateral positioning of the cane reduces hip abductor activity on the side opposite the cane.4,8,9,10 During normal gait, the hip abductors of the stance extremity contract to counteract the gravitational moment at the pelvis on the contralateral side during swing. This prevents tilting of the pelvis on the contralateral side but results in compressive forces acting at the stance hip. Use of a cane in the UE opposite the affected hip will reduce these forces. The floor (ground) reaction force created by the downward pressure of body weight on the cane counterbalances the gravitational movement at the affected hip.3 Thus, the need for tension in the abductor muscles is reduced, with a subsequent decrease in joint compressive forces.
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Several components of floor reaction forces that create joint compression at the hip can be reduced by use of a cane. In an early study by Ely and Smidt,11 contralateral use of a cane was found to decrease the vertical and posterior components of the floor reaction force produced by the affected foot. They noted that the reductions in vertical floor reaction peaks were probably due to a shifting of body weight toward the cane, which was a contributing factor in reducing contact force at the affected hip. In a study of patients with total hip arthroplasty (THA), Neumann8 found that contralateral use of a cane reduced average hip abductor electromyography (EMG) activity to 31% below that generated when not using a cane. Cane use contralateral to a THA, with the addition of carrying an ipsilateral load, decreased hip abductor activity by 40% compared to walking without carrying a load or using a cane.10
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Research supports use of a cane as an effective method for reducing forces acting at the hip.4,8,9,10 This reduction is particularly important for activities such as stair climbing, when the forces generated at the hip are significantly increased. Contralateral cane use has also been found to reduce knee pain in patients with osteoarthritis (OA).7,12 Clearly, use of a cane has important implications for hip and knee involvement such as joint replacements or degenerative joint disease. Box 11A.3 Evidence Summary presents studies addressing the impact and function of canes.1,4,7,12,13,14
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Box 11A.3 Evidence Summary Canes
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Maguire et al4 found that contralateral cane use reduced gluteus medius activity by 21.86% and tensor fascia lata activity by 19.14% in patients with subacute stroke. This finding has important implications for patients with stroke, who often use canes, because strategies to improve postural control and balance reactions may be adversely affected by reduced hip abductor activity.
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In addition to altering the forces on the affected extremity, canes are selected on the basis of their ability to improve gait by providing increased dynamic stability and improving balance. This is achieved by the increased base of support (BOS) provided by the additional point(s) of floor contact. The level of stability provided by canes is on a continuum. Broad-based (four-point) canes provide the greatest stability and standard (single-point) canes provide the least. The following section presents several of the more common types of canes in clinical use and identifies their advantages and disadvantages.
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This assistive device also is referred to as a single-point or straight cane (Fig. 11A.1A). It is made of wood or acrylic and has a half-circle ("crook") or T-shaped handle.
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Advantages. This cane is inexpensive and fits easily on stairs or other surfaces where space is limited.
Disadvantages. The standard cane is not adjustable and must be cut to fit the patient. With a half-circle handle, the point of support (shaft of cane) is anterior to the hand, not directly beneath it. The T-shaped handle shifts the point of support only slightly closer to hand.
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Standard Adjustable Aluminum Cane
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This assistive device (Fig. 11A.1B) has the same basic design as the standard cane. It is made of aluminum and has a half-circle handle with a molded plastic covering. The telescoping design of this cane enables the height to be adjusted using a push-button mechanism. Variations in available height range differ slightly with manufacturers. However, they are generally adjustable within the range of approximately 27 to 38.5 in (68 to 98 cm). (Note: Most adjustable aluminum assistive devices [e.g., canes, crutches, walkers] use a push-button mechanism to alter height; many include a reinforcing cuff tightened by a thumbscrew or rotation sleeve.)
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Advantages. This cane is quickly adjustable, facilitating ease of determining appropriate height. It is lightweight and fits easily on stairs.
Disadvantages. The point of support is anterior to the hand, not directly beneath it. This cane is more costly than a standard wooden cane.
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Adjustable Aluminum Offset Cane
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The proximal component of the shaft of this cane is offset anteriorly, creating a straight offset handle. It is made of aluminum with a plastic or rubber molded grip-shaped handle (Fig. 11A.1C). Using a push-button mechanism, the telescoping design allows the height to be adjusted from approximately 27 to 38.5 in (68 to 98 cm).
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Advantages. The design of this cane allows pressure to be borne over the center of the cane for greater stability. This cane also is quickly adjusted, is lightweight, and fits easily on stairs.
Disadvantages. This cane is more costly than standard or adjustable aluminum canes.
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Note: For standard and offset canes, the diameter of both the distal rubber tips and shaft of the cane is generally at least 1 in (2.54 cm).
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Quadruped (Quad) Cane
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This assistive device is constructed of aluminum and is available in a variety of designs depending on the manufacturer. Both large-based quad canes (LBQCs) and small-based quad canes (SBQCs) are commercially available (Figs. 11A.2 and 11A.3). The characteristic feature of these canes is that they provide a broad base with four points of floor contact. Each point (leg) is covered with a rubber tip. The legs closest to the patient's body are generally shorter and may be angled to allow foot clearance. On many designs the proximal portion of the cane is offset anteriorly. The hand piece is usually one of a variety of contoured plastic grips. A telescoping design allows for height adjustments. Quad canes are generally adjustable from approximately 28 to 38 in (71 to 91 cm).
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Advantages. This cane provides a broad-based support. Bases are available in several different sizes. This cane is also easily adjustable.
Disadvantages. Depending on the specific design of the cane, the pressure exerted by the patient's hand may not be centered over the cane and may result in patient complaints of instability. As a result of the broad BOS, some quad canes may not be practical for use on stairs. Another disadvantage of broad-based canes is that they warrant use of a slower gait pattern. If a faster forward progression is used, the cane often "rocks" from rear legs to front legs, which decreases effectiveness of the cane. Patients should be instructed to place all four legs of the cane on the floor simultaneously to obtain maximum stability.
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The hemi cane also is constructed of aluminum (Fig. 11A.4). It provides a very broad base with four points of floor contact. Each point (leg) is covered with a rubber tip. The legs farther from the patient's body are angled to maintain floor contact and to improve stability. The handgrip is molded plastic around the uppermost segment of aluminum tubing. Hemi canes fold flat and are adjustable in height from approximately 29 to 37 in (73 to 94 cm).
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Advantages. Hemi canes provide very broad-based support and are more stable than a quad cane. These canes also fold flat for travel or storage.
Disadvantages. As with the quad canes, the specific design of a hemi cane or handgrip placement may not allow pressure to be centered over the cane. Hemi canes cannot be used on most stairs. They require use of a slow forward progression and are generally more costly than quad canes.
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Constructed of aluminum and aluminum tubing (Fig. 11A.5), this cane provides a wide, wheeled base allowing uninterrupted forward progression. It includes a contoured handgrip, height adjustment from 28 to 37 in (71 to 94 cm), and a pressure-sensitive brake built into the handle engaged using pressure from the base of the hand.
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Advantages. The wheeled base allows weight to be continuously applied as the need to lift and place the cane forward is eliminated. This also provides for a faster forward progression. The second and third handles placed between the uprights can assist in rising to standing (brake engaged).
Disadvantages. This cane is more costly than standard quadruped canes and requires sufficient UE and grip strength to engage the braking mechanism. This cane is not suitable for patients displaying a propulsive gait pattern (e.g., Parkinson's disease).
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This cane incorporates a bright red laser line projected across the floor designed to assist with overcoming freezing episodes while walking (Fig 11A.6). A walker with a laser is also available (Fig 11A.7). Donovan et al15 examined 26 patients with Parkinson's disease using either a laser cane or walker (selection based on type of device habitually used). The Freezing of Gait Questionnaire (FOG-Q)16,17 was used as an outcome measure (lower scores suggest improved function). Subjects were instructed not to look at the visual cue (laser beam) unless experiencing a freezing of gait (FOG) episode, at which time they were instructed to "step over" the light. Findings indicated a small but significant mean reduction in FOG-Q scores of 1.25 (±0.48; p = 0.0152). The mean reduction in fall frequency was 39.5% (±9.3%; p = 0.002). No significant changes in gait speed were noted. Although additional research is warranted, these initial findings suggest that assistive devices incorporating a laser beam may hold potential for addressing FOG episodes common in patients with Parkinson's disease.
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A general consideration relevant to all canes is the nature of the handgrip. A variety of styles and sizes are available. The type of handgrip should be judged and selected primarily on the basis of patient comfort and on the grip's ability to provide adequate surface area to allow effective transfer of weight from the UE to the floor. The more common types of handgrips are (1) the crook handle, (2) the straight offset handle, and (3) the T-shaped handle, which conforms to the patient's hand. It is useful to have several handgrip styles available for examination and trial with individual patients.
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In measuring cane height, the cane (or center of a broad-based cane) is placed approximately 6 in (15.24 cm) from the lateral border of the toes. Two landmarks typically are used during measurement: the greater trochanter and the angle at the elbow. The top of the cane should come to approximately the level of the greater trochanter, and the elbow should be flexed to about 20 to 30 degrees. Because of indivi dual variations in body proportion and limb lengths, the degree of flexion at the elbow is generally consi dered the more important indicator of correct cane height.
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The 20 to 30 degrees of elbow flexion serves two important functions. It allows the arm to shorten or to lengthen during different phases of gait, and it provides a shock-absorption mechanism. Finally, as with all assistive devices, the height of the cane should be considered with regard to patient comfort and the cane's effectiveness in accomplishing its intended purpose.
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Gait Pattern for Use of Canes
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As discussed, the cane should be held in the UE opposite the affected limb. For ambulation overground on level surfaces, the cane and the involved (or more involved) extremity are advanced simultaneously (Fig. 11A.8). The cane should remain relatively close to the body and should not be placed ahead of the toe of the involved extremity. These are important considerations, because placing the cane too far forward or to the side will cause lateral and/or forward bending, with a resultant decrease in dynamic stability.
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When bilateral involvement exists, a decision must be made as to which side of the body the cane will be held. This question is most effectively resolved by using a problem-solving strategy with input from both the patient and therapist. Questions to be considered include the following:
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On which side is the cane most comfortable?
Is one placement superior in terms of improving balance and/or ambulatory endurance?
If gait deviations exist, is one position more effective in improving the overall gait pattern?
Is safety influenced by cane placement (e.g., during transfers, stair climbing, or overground in community)?
Is there a difference in grip strength between hands?
Are two canes needed for stability?
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Consideration of these questions will generally provide sufficient information to determine the most effective cane placement and use when bilateral involvement exists.
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For some patients, optimal function is achieved using canes bilaterally (Fig 11A.9). In these situations, a two- or four-point gait pattern is used. For example, with a four-point pattern, the contralateral cane is moved forward and then the ipsilateral LE steps forward. Using a two-point pattern, the contralateral cane and ipsilateral LE are moved forward simultaneously. These gait patterns are described in the following section on crutches.
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Crutches are used most frequently to improve balance and to relieve weight-bearing either fully or partially on an LE. They are typically used bilaterally and function to increase the BOS, to improve lateral stability, and to allow the UEs to transfer body weight to the floor. This transfer of weight through the UEs permits functional ambulation while maintaining a restricted weight-bearing status. There are two basic designs of crutches in frequent clinical use: axillary and forearm crutches.
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Types of Crutches and Attachments
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These assistive devices also are also referred to as standard crutches (Fig. 11A.10, left). They are made of lightweight wood or aluminum. Their design includes an axillary bar, a hand piece, and double uprights joined distally by a single leg covered with a rubber suction tip (which should have a diameter of 1.5 to 3 in [1.5 to 3 cm]). The single leg allows for height variations. Height adjustments for wooden crutches are accomplished by altering the placement of screws and wing bolts in predrilled holes. The design of most aluminum crutches incorporates a push-button pin mechanism for height adjustments similar to those found on aluminum canes. Some aluminum crutches also have patient height markers adjacent to the notches to assist in adjustment. The height of the handgrips for wooden and some aluminum crutches is adjusted by placement of screws and wing bolts in predrilled holes. The handgrip height on some aluminum crutches is adjusted using a push-button mechanism with a reinforcing clip-lock (Fig. 11A.11). Both the overall height of the crutch and the height of the handgrip typically adjust in 1-in (2.54-cm) increments. Axillary crutches are generally adjustable in adult sizes from approximately 48 to 60 in (122 to 153 cm), with children's and extra-long sizes available.
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Advantages. Axillary crutches improve balance and lateral stability and provide for functional ambulation with restricted weight-bearing. They are easily adjusted, inexpensive when made of wood, and can be used for stair climbing.
Disadvantages. Because of the tripod stance required to use crutches and the resultant large BOS, crutches are awkward in small areas. For the same reason, the safety of the user may be compromised when ambulating in crowded areas. Another disadvantage is the tendency of some patients to lean on the axillary bar. This causes pressure at the radial groove (spiral groove) of the humerus, creating a situation of potential damage to the radial nerve, as well as to adjacent vascular structures in the axilla.
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These attachments (Fig. 11A.12) are also referred to as forearm rests or troughs. Although they are described here, they also are used with walkers. Their function is to allow transfer of body weight through the forearm to the assistive device. A platform attachment is used when weight-bearing is contraindicated through the wrist and hand (e.g., arthritis, Colles' fracture). The forearm piece is usually padded, has a dowel or handgrip, and has hook-and-loop straps to maintain the position of the forearm.
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These assistive devices are also known as Lofstrand and Canadian crutches (Fig. 11A.10, right). They are constructed of aluminum. Their design includes a single upright, a forearm cuff, and a handgrip. This crutch adjusts both proximally to alter position of the forearm cuff and distally to alter the height of the crutch. Adjustments are made using a push-button mechanism. The available heights of forearm crutches are indicated from handgrip to floor and are generally adjustable in adult sizes from 29 to 35 in (74 to 89 cm), with children's and extra-long sizes available. The distal end of the crutch is covered with a rubber suction tip. The forearm cuffs are available with either a medial or anterior opening. The cuffs are made of metal and can be obtained with a plastic coating.
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Advantages. The forearm cuff allows use of hands without the crutches becoming disengaged. They are easily adjusted and allow functional stair climbing activities. Many patients feel they are more cosmetic and they fit more easily into an automobile owing to the overall decreased height. They are also the most functional type of crutch for stair climbing activities for individuals wearing bilateral knee-ankle-foot orthoses (KAFOs).
Disadvantages. Forearm crutches provide less lateral support owing to the absence of an axillary bar. The cuffs may be difficult to remove.
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Several methods are available for measuring axillary crutches. The most common use a standing or a supine position. Measurement from standing is most accurate and is the preferred approach.
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Standing. From a supported standing position, crutches should be measured from a point approximately 2 in (5.08 cm) below the axilla. The width of two fingers is often used to approximate this distance. During measurement, the distal end of the crutch should be resting at a point 2 in (5.08 cm) lateral and 6 in (15.24 cm) anterior to the foot. A general estimate of crutch height can be obtained before standing by subtracting 16 in (40.64 cm) from the patient's height. With the shoulders relaxed, the hand piece should be adjusted to provide 20 to 30 degrees of elbow flexion.
Supine. From this position the measurement is taken from the anterior axillary fold to a surface point (mat or treatment table) 6 to 8 in (5.08 to 7.5 cm) from the lateral border of the heel.
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Standing is the position of choice for measuring forearm crutches. From a supported standing position, the distal end of the crutch should be positioned at a point 2 in (5.08 cm) lateral and 6 in (15.24 cm) anterior to the foot. With the shoulders relaxed the height should then be adjusted to provide 20 to 30 degrees of elbow flexion. The forearm cuff is adjusted separately. Cuff placement should be on the proximal third of the forearm, approximately 1 to 1.5 in (2.5 to 3.8 cm) below the elbow.
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Gait patterns are selected on the basis of the patient's balance, coordination, muscle function (strength, power, endurance), and weight-bearing status. The gait patterns differ significantly in their energy requirements, BOS, and the speed with which they can be executed.
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Before initiating instruction in gait patterns, several important points should be emphasized to the patient:
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During axillary crutch use, body weight should always be borne on the hands and not on the axillary bar. This will prevent pressure on both the vascular and nervous structures located in the axillary region.
Balance will be optimal by always maintaining a wide (tripod) BOS. Even when in a resting stance, the patient should be instructed to keep the crutches at least 4 in (10 cm) to the front and to the side of each foot. The foot should not be allowed to achieve parallel alignment with the crutches. This will jeopardize anterior–posterior stability by decreasing the BOS.
When using standard crutches, the axillary bars should be held close to the chest wall to provide improved lateral stability.
The patient should also be cautioned about the importance of holding the head up and maintaining good postural alignment during ambulation.
Stepping in a small circle rather than pivoting should be used when turning.
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In this type of gait three points of support contact the floor (two crutch points and a single LE). It is used when a non–weight-bearing status is required on one LE. Body weight is borne on the hands through the crutches instead of on the affected LE. The sequence of this gait pattern is illustrated in Figure 11A.13.
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Partial Weight-Bearing
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This gait is a modification of the three-point pattern. During forward progression of the involved extremity, weight is borne partially on both crutches and on the affected extremity (Fig. 11A.14). During instruction in the partial weight-bearing gait, emphasis should be placed on use of a normal heel–toe progression on the affected extremity. Patients may interpret "partial weight-bearing" as meaning that only the toes or ball of the foot should contact the floor. Use of this positioning over a period of days or weeks will lead to heel cord tightness. Limb load monitors are often a useful adjunct to partial weight-bearing gait training and are described in the section, Adjunct Training Devices. These devices provide auditory feedback to the patient regarding the amount of weight borne on an extremity.
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This pattern provides a slow, stable gait as three points of floor contact are maintained. Weight is borne on both LEs and typically is used with bilateral involvement due to poor balance, incoordination, or muscle weakness. In this gait pattern one crutch is advanced and then the opposite LE is advanced. For example, the left crutch is moved forward, then the right LE, followed by the right crutch and then the left LE (Fig. 11A.15).
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This gait pattern is similar to the four-point gait. However, it is less stable because only two points of floor contact are maintained. Thus, use of this gait requires better balance. The two-point pattern more closely simulates normal gait, inasmuch as the opposite LE and UE move together (Fig. 11A.16).
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Two additional, less commonly used crutch gaits are the swing-to and swing-through patterns. These gaits are often used when there is bilateral LE involvement, such as in spinal cord injury (SCI). The swing-to gait involves forward movement of both crutches simultaneously, weight is shifted onto the hands, and the LEs "swing to" the crutches. In the swing-through gait, the crutches are moved forward together, weight is shifted onto the hands, and the LEs are swung beyond the crutches.
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Walkers are used to improve balance and relieve weight-bearing either fully or partially on an LE. Of the three categories of ambulatory assistive devices, walkers afford the greatest stability. They provide a wide BOS, improve anterior and lateral stability, and allow the UEs to transfer body weight to the floor.
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Walkers are typically made of aluminum with molded vinyl handgrips and rubber tips. They are adjustable in adult sizes from approximately 32 to 37 in (81 to 92 cm), with children's, youth, and tall sizes available. Several design variations and modifications to the standard design are available and are described below.
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Types of Walkers and Features
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Glides are small, plastic attachments placed on the posterior legs of walkers typically in combination with wheels on the front legs (Fig. 11A.17A). They promote a smooth forward progression without having to lift and place the walker with each step. They are typically made of high-density plastic in an inverted-mushroom shape. Other common glide designs include a 1-in (2.54 cm) diameter "disk" with a central stem that slides into the tubular leg and is tightened into place with a screwdriver, and a fitted cap that is placed directly onto the walker leg (in the same manner the rubber tip is attached). Another style of glide incorporates a tennis ball within a fixed housing (Fig. 11A.18).
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Folding walkers are particularly useful for patients who travel. These walkers can be easily collapsed to fit in an automobile or other storage space (see Fig. 11A.17B).
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Enlarged and molded handgrips are available, and may be useful for some patients with arthritis. Some walkers offer a second set of handles to assist with sit-to-stand transitions (see Fig 11A.17A).
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This adaptation is used when weight-bearing is contraindicated through the wrist and hand (described in crutch section; see Figure 11A.12).
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This adaptation to walkers (often called rolling walkers) includes the addition of wheels (either to the two front wheels only or to all four wheels). The addition of wheels frequently allows functional ambulation for patients who are unable to lift and to move a conventional walker (e.g., frail elderly). Swivel wheels turn freely in a complete circle (Fig. 11A.19). Fixed wheels rotate around a central axis (Fig. 11A.20A). Wheels are generally available in 3-, 5-, and 6-in (7.62-, 12.7-, 15.24-cm) diameters. Eight-inch-diameter (20.32 cm) wheels are also available and can be used to add height for tall users.
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A braking system is an essential feature of walkers designed with wheels. Walkers with four wheels frequently include handbrakes that lock the rear wheels (see Fig. 11A.19). Spring-loaded locks can be placed on the rear walker wheels (Fig. 11A.20A). These locks engage when weight is placed on the posterior walker legs through the handgrips. Posterior pressure brakes are effective when wheels are placed only on the front walker legs.
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Tripod Rolling Walkers
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Three-wheel walkers incorporate a tripod design (Fig 11A.21); some manufacturers refer to these as rollators. A major advantage of this device is ease of maneuverability and turning. Height adjustments are made at the handles; the unit folds for storage and travel.
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The ability to transport items is an important consideration for many patients and is often essential for those needing frequent access to medications, a cordless or cellular phone, or remote control device. A variety of sizes and styles of attachable baskets and pouches are available (Fig. 11A.22). These storage attachments should be used judiciously and only for essential items. Overuse of the attachment creates an excessive anterior load that may pose a safety hazard and/or alter the patient's gait or ability to effectively use the walker.
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A variety of walker seat designs are available that fold out of the way when not in use. The structural design of many walkers also includes a contoured back support (see Figs 11A.19 and Fig 11A.20A). Seats are an important consideration for individuals with limited endurance (e.g., postpolio syndrome), as well as for community ambulators who require periodic rest intervals. Walker seats should be carefully examined for stability and safety with respect to individual patient needs. Patient practice in use of the walker seat should be provided.
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These walkers are designed to allow unilateral forward progression of one side of the walker (Fig. 11A.23). A disadvantage of this design is that some inherent stability of the walker is lost. However, they are useful for patients incapable of lifting the walker with both hands and moving it forward (in situations in which a rolling walker might be contraindicated).
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Advantages. Conventional walkers provide four points of floor contact with a wide BOS. They provide a high level of stability. They also provide a sense of security for patients fearful of ambulation. They are relatively lightweight and easily adjusted.
Disadvantages. Walkers tend to be cumbersome, are awkward in confined areas, and are difficult to maneuver through doorways and into cars. They eliminate normal arm swing and generally cannot be used safely on stairs.
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The height of a walker is measured in the same way as that of a cane. The handgrip or handle of the walker should come to approximately the greater trochanter and allow for 20 to 30 degrees of elbow flexion.
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Gait Patterns: Conventional Walkers
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Before initiating instruction in gait patterns using a conventional walker (four points of floor contact without wheel attachments), several points related to use of the walker should be emphasized with the patient:
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The walker should be picked up and placed down on all four legs simultaneously to achieve maximum stability. Rocking from the back to front legs should be avoided because it decreases the effectiveness and safety of using the assistive device.
The patient should be encouraged to hold the head up and to maintain good postural alignment; forward flexion of the trunk, neck, and head should be avoided.
The patient should be cautioned not to step too close to the front crossbar. This will decrease the overall BOS and may result in a fall.
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Three types of weight-bearing gait patterns can be accomplished with conventional walkers: full weight-bearing (FWB), partial weight-bearing (PWB), and non–weight-bearing (NWB) gait (rolling devices are generally not recommended for patients with altered weight-bearing status). The sequence for each pattern with a walker follows.
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The walker is picked up and moved forward about an arm's length.
The first LE is moved forward.
The second LE is moved forward past the first.
The cycle is repeated.
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Partial Weight-Bearing
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The walker is picked up and moved forward about an arm's length.
The involved PWB limb is moved forward, and body weight is transferred partially onto this limb and partially through the UEs to the walker.
The uninvolved LE is moved forward past the involved limb.
The cycle is repeated.
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The walker is picked up and moved forward about an arm's length.
Weight is then transferred through the UEs to the walker. The involved NWB limb is held anterior to the patient's body but does not make contact with the floor.
The uninvolved limb is moved forward.
The cycle is repeated.
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Note: Rolling walkers generally allow use of a reciprocal gait pattern because the walker can be rolled forward while walking. As the need to lift the walker forward following each step is eliminated, a smoother forward progression can be achieved.