Ambulation Aids Normal Gait and Abnormal Gait

Assistive Devices Objectives Discuss the common types of ambulation aids that are used in the hospital and clinic Discuss proper fit for the different types of crutches, canes and walkers Review gait patterns that will be utilized with the different assistive devices

Ambulation Aids Patient Needs Assessment Safety Impaired balance Decreased strength Alteration in coordinated movements Pain during weight bearing Absence of a lower extremity Altered stability

Outcomes Improve functional mobility Enhance body functions Assist with fracture healing=too much weight too early, don’t want a fractured part to be movement in a dangerous way, though movement can help healing.

Prepare for Ambulation Review Medical Chart Assess Patient ROM Muscle Performance Sensation Balance/Coordination Cognition

Pre-Ambulation Considerations Assistive device Amount of assistance Height/weight Can you get them up safely if they go down? Safety – 1 or 2 person

Pre Ambulation Considerations Equipment Issues Gait belts Patient’s tolerance/vitals O2( 90% of less), BP, glucose, Cognition/Ability to follow commands Rolling walker because just need to push vs. lifting and placing walker.

Appropriate Equipment Van Hook FW et al. 2003

Ambulation Aids Tilt Table=help stabilize BP for those that have been in bed for a long period of time. Parallel Bars Walker vs Rollwalker Platform walker=bear weight through elbows Hemiwalker, hemicane= Crutches Standard cane, LBQC, SBQC Age, physical ability, balance, activity

Tilt Table Check BP and HR Indications to use tilt table SCI L/E Amputations Obese Prolonged Bed Rest www.promedproducts.com

Parallel Bars Maximal stability, support, safety Confidence Booster Adjustable Pre-gait activities Limited in length www.promedproducts.com

Standard Walker Patient must be able to lift and advance walker Greater attention demand White, 1992 Adjustable, nonadjustable Folding Reciprocal Opposite the normal walking pattern. Take step advance, take a step advanced.

Rolling Walkers Rolling Walker Indications Height of walker Cognition/Unable to follow commands=cant figure out how to advance a normal walker. Cardiopulmonary Issues Patient carries standard Height of walker Higher for back surgeries

Additional Devices Platforms=strap on to a walker then strap in exterminates. Baskets Seats

Measure/Fit Walker Handgrip: Elbow Flexion Walker Feet: Level of greater trochanter Level of ulnar styloid process Level of wrist crease Elbow Flexion 20 – 25 dg Walker Feet: Middle of foot, all four walker feet on ground Hips and knees straight

Disadvantages of Walkers Difficult to store, transport Stairs=almost impossible Slower Decreased stride length Crowds Hand Injuries possible

Axillary Crutches More mobility, less stability Greater speed, greater strength Cognition Coordination

Axillary Crutch Fit Several Methods Complicated Formula Tape Measure 77% x height of patient in inches Tape Measure Standing: two – three finger widths between axillary pad and axilla Crutch tips on ground, 2 inches lateral, 4-6 inches anterior to tip of shoe (2,3 inches lateral in armpit)

Avoid wrist flexion or extension while grasping hand grip=neutral writst Elbow flexion: 20 – 25 degrees

Common Errors: Axillary Crutch Fitting Shoulder elevation Shoulder depression No shoes (fit with shoes on) Absence of tripod position during adjustments Always reassess fitting prior to ambulation

Disadvantages of Axillary Crutches Decreased stability Warn about rain in need to dry off. Possible injury to brachial plexus and blood vessels, hands if “hanging” on crutches. Require stronger UE, better coordination, balance

Forearm Crutches Loftstrand, Canadien Bilateral UE support, not as much weightbearing, and need to be stronger than with axillary Hands can be free when standing Used when going to be on crutches for a long period of time.

Forearm Crutch Fit Handgrip adjustment Greater trochanter Ulnar styloid process Wrist crease Elbow cuff: 1.5 inches below olecranon Crutch tips on ground, 2 inches lateral, 4-6 inches anterior to toe Elbow flexion: 20 – 25 dg

Disadvantages of Forearm Crutches Less stability and support Requires better standing balance Support rather than replacement Hand injuries= carpal tunnel, pressure on whole hand Wear cycling gloves

Canes Used in U/E opposite the affected L/E Most mobile, least stable Bases can trip a patient Based canes can feel insecure

Cane Fit Tip of cane is 2 inches lateral and 4-6 inches anterior to toe Elbow flexion: 20 – 25 dg.

Disadvantages of Canes Very limited support Cannot perform some gait patterns Hand injuries

Adaptations of canes

Gait Patterns with Assistive Devices: Four-Point Pattern Bilateral Ambulation Aids Alternating, reciprocal pattern Low energy Maximum stability and support 3 points of contact at one time 4-points for walking:

Two-Point Gait Pattern Bilateral aids Simultaneous, reciprocal pattern Stable pattern Faster speed Low energy Similar to normal gait pattern 2 points are moving at a time, always opposite sides=crutches. Alternating leg and crutch out

Modified Four-Point or Two-Point Pattern One ambulation aid One functional upper extremity Aid opposite upper extremity Widens base of support Hemi pattern antalgic, not willing to put 100% of weight on bad, so take shorter on hurt. The most “normal” gait.

Three-Point, Non-Weight-Bearing Pattern Bilateral ambulation aids Step to or step-through pattern (old swing to) One NWB extremity Higher energy expenditure Good strength in UE With crutches, swinging through with good foot, with the injured foot still-up

Three-One-Point/ Partial Weight-Bearing or Modified Three-Point Pattern Bilateral ambulation aids FWB one extremity, PWB on other More stable than three-point Requires less strength and energy than three-point Most weight is still just in arms, can have less than 10% on injured foot that touches.

Documentation of Aid Describe type of Ambulation Aid Document Fitting of Aid Document Adaptive Devices on Aid Document Patients Instruction and Performance of Gait Pattern Document amount of assistance necessary for Patient safety and support

References Pierson FM, Fairchild SL. Principles and Techniques of Patient Care, 4th ed., 2008 Saunders, St. Louis. Van Hook FW, Demonbreaun D, Weiss B. Ambulatory devices for chronic gait disorders in the elderly. Am Fam Phys, 2003:67(8):1717-24. Wright DL, Kemp TL. The dual-task methodology and assessing the attentional demands of ambulation with walking devices. Phys Ther 1992;72(4):306-12.

GAIT: Normal and abnormal PTP 565 Fundamentals Of Tests and Measures

Gait Objectives: Lecture Discuss and explain definitions of gait cycle Review basic terminology Explain common gait deviations Discuss Gait Evaluations

Gait Definitions: APTA Guide- The manner in which a person walks, characterized by rhythm, cadence, step, stride, and speed.

Gait Walking: a process of falling forward and catching oneself Gait: a manner of walking, stepping or running Unique to the individual

Gait Traditional- refers to the points in time in the gait cycle. Stance: heel strike→ foot flat→ heel-off→ toe-off Swing: acceleration→ mid swing→ deceleration

Traditional

Gait Rancho Los Amigos – mid stance → terminal stance → pre swing. Stance Phase: initial contact → loading response → mid stance → terminal stance → pre swing. Swing Phase: initial swing → mid swing → terminal swing. Both are used in the clinical setting.

Abnormal Gait Pathology or injury in specific joint Compensations for injuries or pathologies in other joints on same side Compensations for injury or pathologies on opposite side

Common Gait Deviations Influences on Gait Patterns Pain Posture Flexibility and Amount of Available Range Economy of Movement Base of Support Leg length Gender Pregnancy Obesity Age

Gait Deviations Due to Pain Antalgic Gait Pattern Decrease in stance phase on affected limb Lack of weight shift laterally over stance limb Decrease in swing phase of uninvolved limb Decrease in cadence Decrease in velocity in walking Self protective Result of injury to pelvis, hip, knee, ankle, or foot

Gait Deviations Due to Leg Length Discrepancies True Leg length or Apparent Leg Length Shorter limb- pelvis will drop laterally at initial contact Frontal plane view: limping Foot may supinate on short side to lengthen leg Unaffected side: may compensate by increasing hip flexion or knee flexion during swing phase Gait Deviations noted: vaulting =compensating the short leg hip hiking, circumduction

Vaulting Circumduction www.limblength.com/pubs/articles/lld/lld.htm http://www.victhom.com/en/neurostimulation/gait-disorders.php

Gait Deviations due to mm weakness Gluteus Max. Weakness Glut. Max needed in Midstance to keep upright. Inability to counter flexion moment at hip at point of initial contact Compensation is with posterior movement of trunk COG stays behind the hip joint, thus no flexion occurs at the hip Gait Deviations noted: Gluteus Maximus Gait, Lurch

Gait Deviations due to mm weakness Gluteus medius weakness (also in midstance) Trendelenburg Gait: pelvis drops on opposite side during stance on affected side COMPENSATED=trunk in line, but pelvis off. Gluteus Medius Lurch: lateral trunk flexion over the affected limb during single limb support to maintain center of gravity over the base of support UNCOMPENSATED=side bend over weak side

Gait Deviations due to mm weakness Iliopsoas Weakness Difficulty initiating swing-through External rotation of femur, adductors will bring leg through in swing Slight Circumduction=due to weakness of flexion.

Gait Deviations due to mm weakness Quadriceps Weakness Inability to contract muscle Compensation is with forward bending of trunk, rapid plantarflexion, can get hyperextension May compensate by pushing knee posterior during stance

Gait Deviations due to mm weakness Hamstring Weakness Knee maintains extended position Essentially elongates limb Decrease in shock absorption at knee Toe off more difficult , lose transition between stance and swing, greater hip and knee flexion required to clear limb

Gait Deviations due to mm weakness Anterior Tibialis Weakness: Steppage gait Swing phase on involved side with increase in hip and knee flexion occurring Slap sound may occur at initial contact May see supination of foot to assist in compensation

Gait Deviations due to mm weakness Plantarflexor weakness Tibia and knee aren’t well stabilized No real propulsion phase at toe off Decrease in stance phase with smaller step length on unaffected side Similar to Antalgic pattern

Gait Deviations Ankle and Foot Portion of Phase Deviation Description Poss. Cause Initial contact Foot Slap At HS, forefoot slaps ground Flaccid/ weak DF; reciprocal inhibition of DF Toes First Toes contact ground instead of heel, tip-toe posture poss. thru cycle Leg length discrepancy; contracted heel cord; PF contraction; spastic PF; flaccid DF; heel pain

Gait Deviations Ankle and Foot Portion of Phase Deviation Description Poss. Cause Initial Contact Foot Flat Entire foot contacts ground at HS Exc. fixed DF; Flaccid/weak DF Mid Stance Excessive positional PF Tibia does not advance to neutral from 10° PF No ecc. Contraction of PF;

Gait Deviations Ankle and Foot Portion of Phase Deviation Description Poss. Cause Mid Stance Heel lift at Mid stance Heel does not contact ground in mid stance Spasticity of PF Excessive positional DF Tibia advances too rapidly over the foot, creating > normal amount of DF Inability of PF to control tibial advance, knee flexion or hip flexion contractures Toe clawing Toes flex and “grab” floor PF grasp reflex; + support reflex; spastic toe flexors

Gait Deviations Ankle and Foot Portion of Phase Deviation Description Poss. Cause Push-off (heel-off to toe-off) No roll-off Insufficient transfer of wt. from lat. heel to medial forefoot Flaccid or inhibition of PF, inv, and toe flexors; rigid/co- contraction of PF/DF; Pain in forefoot Swing Toe drag Insufficient DF (and toe ext.) so that forefoot and toes do not clear floor Flaccid/weak DF and toe ext. Spasticity of PF. Inadequate knee or hip flexion Varus The foot is excessively inverted Spasticity of inv. Flaccid/weak DF and ev. EX. pattern

Gait Deviations Knee Deviation Description Poss. Cause Initial Contact Portion of Phase Deviation Description Poss. Cause Initial Contact Heel Strike Excessive knee flexion Knee flexes or “buckles” rather than extends as foot contacts grd. Painful knee; Spasticity of kn √ or weak/flaccid quad.; short leg on contra side Foot Flat Genu recurvatum > than normal knee ext. Flaccid/weak quads and soleus compensated for by pull of glut. Max.; Spasticity of quads; Mid stance single limb support, tibia is in back of ankle as body wt. moves over foot; ankle in PF Same as above

Gait Deviations Knee Deviation Description Poss. Cause Push-off Portion of Phase Deviation Description Poss. Cause Push-off (heel-off to toe-off) Excessive knee flexion Knee flexes to more than 40° during push-off COG is forward of pelvis, rigid trunk, knee/hip √ contractures; √ withdrawal reflex; Limited knee flexion Knee flexes < 40° Spastic/over-active quads. and/or PF

Gait Deviations Knee Deviation Description Poss. Cause Portion of Phase Deviation Description Poss. Cause Acceleration to mid swing Excessive knee flexion Knee flexes more than 65° Diminished pre- swing knee √; flexor withdrawal reflex; dysmetria Limited knee flexion Knee does not flex to 65° Pain in knee; diminished ROM in knee; ext. spasticity;

Gait Deviations Hip Deviation Description Poss. Cause Portion of Phase Deviation Description Poss. Cause Heel Strike to foot flat Excessive flexion Flexion > 30° Hip &/or knee √ contractures; knee √ d/t weak soleus and quads; hypertonicity of hip √ Heel strike to foot flat Limited hip flexion Hip flexion does not attain 30° Weak hip √; ↓ROM; Glut. Max. weakness Foot flat to mid stance Limited hip ext. Hip does not attain neutral position Hip √ contracture; Spastic hip √

Gait Deviations Hip Deviation Description Poss. Cause Portion of Phase Deviation Description Poss. Cause Foot flat to mid stance Internal rotation Internally rotated position of LE Spasticity of IR; weak ER; exc. forward rot. Of opp. pelvis External rotation Externally rotated position of LE Excessive backward rot. Of opp. Pelvis Abduction An abducted position of LE Contracture of glut. med.; lat. trunk lean over ipsilateral side

Gait Deviations Hip Deviation Description Poss. Cause Portion of Phase Deviation Description Poss. Cause Foot flat to mid stance Adduction Adducted position of LE Spasticity of hip √ and add. ; Pelvic drop to contra. side Swing Circumduction Lat. Circular mvmt. of LE Compensation for weak hip √ or for inability to shorten LE

Gait Deviations Hip Deviation Description Poss. Cause Swing Hip hiking Portion of Phase Deviation Description Poss. Cause Swing Hip hiking Shortening of swing LE by action Quad. Lumborum Compensation for ↓ knee √ and /or ankle DF or for ext. spasticity Excessive hip flexion Flexion > 20-30° Attempt to shorten LE in presence of foot drop; Flexion pattern

Gait Deviations Trunk Deviation Description Poss. Cause Portion of Phase Deviation Description Poss. Cause Stance Lateral trunk lean Trunk lean over stance LE (glut. Med gait/ Trendelenburg) Weak/paralyzed glut. med. on stance LE; Pain in lean side LE Backward trunk lean Hyperext. at hip (glut. max. gait) Weak/paralyzed glut. max. on stance leg Forward trunk lean Forward lean of trunk→ hip √; forward √ of up. trunk Weak quads.; hip and knee √ contractures; Post. Rot. pelvis

References Neumann D. Kinesiology of the Musculoskeletal System Magee D. Orthopedic Physical Assessment, 5th ed.