Ambulation Phase,Parallel bars,Walkers,Crutches,Canes,Gait Patterns..

 Ambulation Phase

Patient needs assisted ambulation before he attains independent ambulation. Assisted ambulation becomes necessary in the initial stages for the following reasons:

1. Due to the structural damage to the skeletal system, the patient has difficulty in bearing weight on the lower limbs.

2. The muscles of the trunk and limbs are weak.

3. Balance in the upright posture is poor.

For these reasons, assistive devices become necessary during the initial phase of ambulation.

The commonly used assistive devices are:

a. Parallel bars

b. Walkers

c. Crutches

d. Canes.

After having made the patient fit by a good preambulatory therapy mentioned earlier, a therapist mobilizes the patient with suitable assistive devices.

The following are some of the more frequently used assistive devices:

Parallel Bars 

This is the first choice ambulatory device. The reasons being:

a. It assists the patient in initial standing and walking.

b. It gives the patient a sense of security.

c. It helps the patient to get accustomed to upright posture

d. Other assistive aids can be fitted easily while the patient stands between the parallel bars.

Fig.: Ambulation within a parallel bar 

Regime within a parallel bar

• Adjust the height of the parallel bar such that the elbows of the patient are bent at 25-30° while standing within it.

• To propel forwards, patient first uses the hands than his legs by gripping the parallel bar firmly.

• Gradually the patient is trained to put the body weight on the lower limbs by just placing the hands on the bars and not gripping it.

Walkers

From parallel bars, the patient progresses to a ‘Walker’.

Though it serves the same function as the parallel bars, it is less stable.

The Frame

• It is made up of aluminium

• There are four adjustable legs

• Rubber tips are provided to the legs to prevent sliding

The functions

• Same as that of the parallel bar

• It can be used both at hospital and home

• It can also be transported.

Tips of usage

• Adjust the height of the walker such that the elbow is bent to 25-30° while the patient is standing holding it.

• During walking, lift it first with both the hands and place it towards 25-30 cm.

• Step into the walker first with the stronger leg and then with the weaker leg.

Limitations

• It is less stable when compared to the parallel bar.

• It is useful only on the level ground

• It cannot be used on staircases.

Advantages

• It is very useful in the initial stages of ambulation.

• It is easy to use.

• Can be used as a permanent walking aid for the elderly people.

• It is not very expensive.

Fig. Ambulation with walker

Crutches

Crutches are the most popular walking aid used to ambulate a patient with lower limb fractures.

Types There are two types of crutches

i. Axillary

ii. Forearm.

Axillary crutch

• This is made up of wood or aluminium.

• It is used in patients who require crutches for a short time.

• They are easier to use than forearm crutches.

Forearm crutch 

• These are also called lofstrand crutches.

• They are recommended in patients who need to use the crutches for a long time.

• They allow the patient greater freedom of movement.

• The demand on the patient’s clothing is less.

Fig. Ambulation with a forearm crutch

Axillary Crutch Walking 

The crutch structure

• It is made up of wood or aluminum.

• It is got two uprights.

• It has an adjustable bottom.

• The bottom is fixed to the uprights with the help of two screws.

• It has an adjustable hand grip.

• The bottom has rubber tips to prevent slippage.

Measurements and position

• Measurement for a suitable crutch is taken from the anterior fold of the axilla to the medial malleolus.

Note This prevents crutch palsy.

• Measurement can also be taken from a point 2" below the axilla to a point in the foot 6" in front and two inches lateral.

• In a standard positions, the tips of the crutches should be 15-20 cm in front and 15-20 cm to the sides of the foot. This forms a tripod base.

Important considerations in crutch walking

• Patient shifts 50 per cent of his body weight from the legs to his arms through a 30° flexed elbow.

• The following muscles needs to be strengthened:

a. The upper limbs Shoulder muscles, triceps, wrist extensors and finger flexors.

b. The lower limbs The gluteal, quadriceps, ankle plantar and dorsiflexors and the toe flexors.

• The patient should took straight ahead in the direction of his walk and not down.

• He should not bear the weight on the axillary crossbar for fear of crutch palsy.

• Posture in the crutch should be correct with the head erect, shoulder level, pelvis level, knee joint extended and straight, feet should be below the hip joints.

• A limb length discrepancy should be corrected first before the patient stands and walks on the crutch.

• The patient is first taught to balance himself on a single crutch. This is practiced by standing on one crutch with one or both legs and moving the crutch freely in all directions. This is repeated on the other side also.

• The patient should learn to take even and steps at equal length and stride.

• Gradually, the patient should learn to walk forwards, backwards, sidewards, turning and walking on slopes and stairs.

Gait Patterns

There are two types of gait patterns described in crutch walking:

a. Based on the type of step taken Here two types are described step-to or step-through.

b. Based on the number of contact points used to take a step Here three types are described 2 point, 3 point and 4 point gaits.

Now let us analyze each step in detail:

1. Step-to-gait In this the crutch and the fractured limb are advanced first and then the normal limb is advanced to the same position. E.g. Partial weight bearing or toe touch weight bearing after a tibial shaft fracture.

2. Swing through gait Here the intact leg is advanced first with the crutch and then the fractured leg is advanced towards it. E.g. oblique mid-shaft tibial fracture that is non weight bearing practices this gait.

Fig.two point gait (Fig.A), three point gait (Fig.B), Four point gait(Fig.C)

3. A two point gait (Fig. A)

• One point is formed by the fractured leg and crutches.

• Second unit by the uninvolved leg.

In this gait, the second unit is brought towards the first unit. e.g. A NWB fracture of femur.

4. A three point gait

• First point—formed by the crutches.

• Second point—involved leg.

• Third point—uninvolved leg.

In this, each crutch and the weight limb are advanced separately, with two of the three points touching the ground at any given point of time. E.g. In femoral neck fracture that are partially weight bearing. Here the crutches are advanced first, followed by the fractured and intact limb respectively (Fig. B).

5. Four point gait

Point No 1 This is the crutch on the involved side.

Point No 2 This is the uninvolved leg.

Point No 3 The involved leg.

Point No 4 Crutch on the uninvolved side.

Here the crutches and the limbs are advanced separately. With three of the four points touching the ground at any given time. E.g. a partially weight bearing fracture with an additional problem like muscle weakness, anxiety, etc. (Fig.C)

Crutch Walking in Special Situations

1. Walking on uneven surfaces like staircases

• Ascend the staircase with the unaffected leg first.

• Then bring the fractured limb up to meet the first leg, either simultaneously with the crutches or by keeping the crutches on the step below until both the feet are level.

• While descending the stairs, the reverse is done and fractured limb is brought down first.

2. Getting in and out of a chair The chair should be well supported to prevent it from slipping. Remove the crutches from under one arm thereby freeing it.

Now with the freed hand, the patient pushes down on the chair set or armrest to support the body weight.

Finally the patient gradually sits by flexing the elbow.

The reverse technique is used while getting up from the chair.

3. Climbing staircases with support (bannister) Hold one or two crutches on the uninvolved side. Hold the bannister with the hands on the side of fracture. Climb the staircase first with the uninvolved leg then pull the body up to bring the affected leg on the same point as the unaffected leg.

The opposite is followed to descend down the staircase with bannister.

Quick facts

Weight-bearing status in a lower limb fractures

• Non-weight-bearing (NWB)

• Toe-touch weight-bearing (TTWB)

• Partial weight-bearing (PWB)

• Weight-bearing as tolerated (WBAT)

• Full weight-bearing (FWB)

What is Shadow Walking?

This is a non-weight-bearing gait—Here

• The crutch on the opposite side of NWB is put forward first.

• The non-weight bearing limb is advanced next.

• The second crutch is put forward next.

• This is followed by the advancement of the normal limb.

Ambulation with the Help of a Cane

Purpose of a cane To relieve one extremity of some weight bearing load. This also provides continuous stability to the patient.

Types of cane

1. Standard cane

2. Axillary crutch can be used like a cane

3. Three or four legged cane can be used by the elderly.

This provides greater stability.

4. Hemi walker: Patient uses this walker like a cane by holding it on the opposite side.

Parts of a cane

• Hand grip

• An upright

• Bottom with a rubber tip.

• It is made up of either aluminium or wood.

Methods of walking with a cane

• The patient stands holding the wall or chair for support.

• The heel of the shoes should be about 1-1½”.

• The height of the cane should be such that, the elbow is flexed to 25-30°.

• The patient is instructed to hold the cane on the unaffected side.

• Patient is advised to take short steps.

Quick facts

Why should the patient, hold the cane on the unaffected side:

1. In normal walking the leg and opposite arm move together.

2. It increases stability by providing a wider base.

3. The shifting of the centre of gravity is eliminated.