What degree of elbow flexion is recommended with the use of parallel bars or axillary crutches?

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.

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

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

• 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

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

 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.

What degree of elbow flexion is recommended with the use of parallel bars?

How much elbow flexion should exist when an individual is grasping the handgrips of axillary crutches with the wrists in a neutral position?

When fitting a patient for crutches What is the degree of the angle of the elbows?

What degree of elbow flexion is optimal for patients who require use of a walker?