Crutches and walkers in orthopedic patient

Introduction: Locomotion is the act of moving from one place to another, regardless of the method used-crawling, swimming or propelling a wheelchair. Ambulation is bipedal locomotion, or walking. An ambulation aid is a hand-held device used to help a person stand and walk. The most common varieties are Orthoses (splints and braces) and prostheses (artificial limbs) are not considered ambulation aids. Ambulation aids are most of ten prescribed to increase stability, to augment muscle action or to reduce the load on weight-bearing structures.

Introduction: STABILITY: For a person to be stable while standing or walking, the force line from the body's center of mass (just anterior to the second sacral vertebra) must fall within the base of support. The base of support is the area bounded by a line connecting the perimeter of all points touching the ground. Stability can be increased by enlarging the base of support. Stability can also be enhanced by lowering the center of gravity of the patientambulation aid combination. For the ataxic patient, this strategy involves hanging sandbags from the lower crossbars of the patient's walker. Patients who walk behind wheelchairs as an ambulation aid also use this principle.

CRUTCHES : Crutches are used by patients who must transfer more weight to their arms than is possible with canes. Axillary crutches have an axillary bar and a hand grip. Using two such crutches, patients can transfer as much as 100 percent of body weight to the arms during swinging gaits. Cushioning pads are often used for the axillary bars and handgrips. A retractable, shock-absorbing axillary bar ("pogo crutch") has been developed but is not widely available.

components of crutch: Crutch tip* - Crutch tips are made of rubber and are attached to the foot of the crutch. - The crutch tips should be at least 1.5 inches in diameter. - A retractable metal-spiked tip is available for use on ice, enhancing patient safety (prevents slippage). This special tip absorbs shock but may be uncomfortable for the patient. - Crutches without rubber tips or with inadequate rubber tips are dangerous. * Handgrips : - Made of sponge rubber - Could be built up or contoured to the needs of the patient - Function to reduce pressure on the hands - Enhance safety (prevent slippage)

components of crutch: * Axillary pads - Made of sponge rubber - Function to prevent unnecessary pressure under the axillary region * Triceps band - Made of metal or stiff leather and are attached to the upper part of the crutch. - Function to assist the patient in maintaining elbow extension during weight bearing - Very helpful for patients with weak triceps * Wrist strap - Made of either leather or plastic - Functions to assist patients in making their handgrip - Very helpful for patients with weak wrist extensors

Types of crutches: Crutches have 2 points of contact with the body, providing better stability than canes. Two types of crutches :- 1- Axillary. 2- Non Axillary.

Axillary crutches: An axillary crutch is a type of orthosis that provides support from the axilla to the floor. Wood and aluminum axillary crutches are available, both of which are adjustable. The extension crutch (ie, the length can be adjusted) is heavier than the regular crutch because of the one extra piece of wood. Standard axillary crutches have double uprights with a shoulder piece and handgrip or bar.

Axillary crutches: The primary advantage of an axillary crutch is that it allows transfer of 80% of the individual's body weight. Axillary crutches provide better trunk support than nonaxillary or forearm crutches, and patients can free their hands for activities by leaning on the shoulder piece. However, the patient should be advised of the possibility of sustaining compressive brachial neuropathies with the use of axillary crutches. The axillary crutch is not designed for the patient to rest for body support. Patients should avoid resting their body weight on the axillary area. Providing extra padding to the axillary area should be discouraged for this reason.

The measurement of axillary crutches: 1-Determine the crutch length by measuring the distance from the anterior axillary fold to a point 6 inches lateral to the fifth toe with the patient standing. 2- With the proper crutch length determined and the crutch then placed 3 inches lateral to the foot, proper hand piece location can be measured. The patient's elbow should be flexed 30°, the wrist should be in maximal extension, and the fingers should be held in a fist. 3- The patient should be able to raise the body 1-2 inches by performing complete elbow extension.

Nonaxillary crutches : Nonaxillary crutches allow transfer of 40-50% of the patient's body weight. Also called forearm or arm canes or forearm or arm orthoses, these devices require good trunk control. The patient needs confidence in his/her ambulation skills.

forearm crutches (Lofstrand crutches): 1- Most popular of nonaxillary crutches. 2- Most useful substitute for canes. 3- Most often used bilaterally. 4- Made of tubular aluminum. 5- Padded hand bar. 6- Forearm cuff. * The open end of the cuff is placed on the lateral aspect of the forearm to permit elbow flexion and grasping without dropping the orthosis. * The proximal portion of the orthosis is angled at 20° to provide a comfortable stable fit.

Measurement of forearm crutches: With the proper crutch length determined and the crutch then placed 3 inches lateral to the foot, proper hand piece location can be measured. The patient's elbow should be flexed 20°, the wrist should be in maximal extension, and the fingers should be held in a fist. Advantages associated with Lofstrand crutches include the following: 1- Ambulation is safer and easier. 2- This type of crutch is a good substitution for the cane because the forearm support stabilizes the wrist during weight bearing. 3- The patient's hands are free to perform various tasks while the body weight is supported through the forearm by the forearm cuff pivots. 4- The patient does not have to worry about dropping the crutches. 5- These crutches are shorter than axillary crutches. Disadvantage of Lofstrand crutches is that they provide less support for ambulation than axillary crutches.

Types of crutch gaits :  Two-point crutch gait : The proper sequence is the left crutch and right foot, then the right crutch and left foot. Repeat. Advantages Provides stability Faster than the 4-point gait Reduces weight bearing to both lower limbs Indication - Patients with weakness in lower limbs or poor coordination (ataxic) 1- Swing-through gait : The sequence involves both crutches, moving both lower limbs past the crutches. Advantage - Fastest gait (faster than normal walking gait) Disadvantage - Very energy-consuming gait that is difficult to learn Requires strong functional abdominal and upper limb muscles and good trunk balance 2- Swing-to gait : The proper sequence includes both crutches; the patient moves both lower limbs almost to the crutches. Advantage - Easy to learn Indication - Patients with paraplegia

Types of crutch gaits :  Drag-to (tripod) gait : An alternate sequence involves using the left crutch, the right crutch, and then dragging both lower limbs to the crutches. Simultaneous sequence involves both crutches. The patient should drag both lower limbs to the crutches. Indication - Used as the initial gait pattern during gait training for patients with paraplegia Patients could advance to swing gait once they improve their balance. Advantage - Provides good stability Disadvantage - Very energy-consuming and slow gait

Types of crutch gaits :  Three-point gait (non–weight-bearing gait) : The appropriate sequence is first both crutches and the weaker lower limb, then the stronger or unaffected lower limb. Repeat. Advantage - Eliminates all weight bearing on the affected lower limb Indications - Lower limb fractures, amputations, or pain Requires good balance and coordination  Four-point crutch gait The appropriate sequence is left crutch, right foot, right crutch, left foot. Then repeat. Advantages Stability Always have at least 3 points in contact with the ground Disadvantages Difficult to learn Relatively slow walking gait Indication - Patients with weakness in lower limbs or poor coordination (ataxic)

WALKERS : Walkers are particularly useful for patients who have poor balance. The disadvantages of walkers are that ambulation is slow and patient posture is often poor. Walkers also make it difficult to climb stairs. A walker has been specifically designed for stairs, but its extra weight and size have limited its use. The standard walker is made of aluminum, is rigid, has four feet and is adjustable in height. Foldable models are less durable but are easier to transport. When folded, these walkers can provide some assistance with stairs. An articulated reciprocal walker, which allows the patient to advance each side of the device independently of the other, has been developed but is not widely used. Platform walkers, like platform crutches, provide a horizontal surface for the forearms.

WALKERS

WALKERS : Some walkers have wheels on the front legs or all four legs to assist patients who have difficulty lifting the walker because of limited balance or endurance. 10 Wheels should not be used by patients who put much weight on the walker (unless the walker is specifically designed for such use), since the device may roll forward while being loaded. One type of walker has wheels that retract when weight is applied. Although this is a helpful innovation, the retractable wheels do not resist forward slippage as well as standard, rubber-tipped feet. Other walkers have fold-down seats to allow patients to rest. To achieve 15 to 30 degrees of elbow flexion, the handgrip of the aid should be at about the level of the greater trochanter or at the level of the wrist crease when the arm is hanging at the side. A cane that is too short forces the patient to lean toward the cane during the walking cycle. An aid with a handgrip that is too high may mechanically decrease the tricep's effectiveness. Improper length can therefore cause a poor gait pattern with a resulting increase in discomfort and energy expenditure. The upper end of an axillary crutch should rest on the ribs approximately 5 cm below the anterior axillary fold. Resting the axillary bar in the axilla can lead to axillary artery thrombosis or compression neuropathy of the radial nerve.