Ambulation Aids, Patterns

and Instruction

PT 6280: Clinical Assessment

University of Minnesota
Division of Physical Therapy
Teresa Bisson, PT, DPT, NCS, ATP
Amanda LaLonde, PT, DPT, GCS
 Objectives
 Understand and use key terms related to gait
and use of ambulation aids
 Modify intervention based on weight bearing
status/restrictions
 Apply a gait belt efficiently and correctly
 Demonstrate safe guarding of a “patient” during
sit <-> stand, ambulation, stairs, and a simulated
fall
 Measure and adjust all assistive devices for your
“patient” appropriately
 Progressive Mobilization
• In what order should/do we progress
mobility?

• How does the environment impact this?

• When do we select a device?
Dynamic Systems Interaction
 Key Terms
• Affected side/limb • Weight Bearing Status
• Ambulation • Weight Bearing
• Gait training Restrictions
• Assistive device • Swing-to/Step-to
• Reciprocal • Swing-through/Step-
through
 Safety First!
• Is your patient ready to walk? How do you
know?
 Weight Bearing Status
 FWB=Full Weight Bearing

 PWB= Partial Weight Bearing

 TTWB=Toe Touch Weight Bearing

 TDWB = Touch Down Weight Bearing

 NWB=Non-Weight Bearing

 WBAT=Weight Bearing as Tolerated

 Safety
• Set up environment

• Screen strength

• Assess orientation

• Check vitals

• Patient must wear appropriate, non-slip

footwear

• APPLY GAIT BELT BEFORE STANDING!

 Safety
 Be alert for signs of:
 Pallor
 Fatigue
 Diaphoresis
 Confusion
 Dizziness/lightheadedness
 Sudden weakness

 If you are doubtful of your patient’s ability,

have assist nearby
 Safety
• Do not become complacent or distracted

• Be ready for the patient to stumble or fall at

any time

• Never leave a patient unattended when

standing

• Maintain proper body mechanics

• Protect IV’s, catheters & other equipment

 Guarding
• Gait Belts:
– When to use?
– Stand behind and “in diagonal” with the vulnerable side
– One hand on belt, one lightly on vulnerable side shoulder
– Walk in “sync” w/ your patient
– Don’t pull

www.youtube.com
s387997107.initial-website.com www.tsitherapy.com
 Guarding
• Stand on one side of the patient & slightly behind
• LE’s in stagger stance
• One hand underneath the gait belt and the other
lightly on shoulder
 Falls

• This WILL happen to you.

• Two choices:
◦ Prevent the fall
◦ Control the fall
Falls

https://www.youtube.com/embed/ed5CY7mKqtg
LIGHTNING LAB!
DONNING/DOFFING GAIT BELT
GUARDING
 Amount of Assist: FIM

• Independent • Minimal Assist

 Pt ambulates alone  Pt performs ≥75% of
effort
• Supervision
 Pt requires observation • Moderate Assist
for safety, but NO Hands  Pt performs 50-75% of
on effort
• Standby Assist • Maximal Assist
 Pt needs close
supervision, but NO  Pt performs 25-50% of
hands on effort
• Contact Guard • Dependent/Total
 Pt needs light hands on Assist
for safety
 Pt exerts <25% of effort
 Choosing an Assistive Device
• Patient goals
• What amount of support is required?
• Unilateral? Bilateral?
• What can the patient do?
• UE function
• How much stability is needed?
• What is the energy cost?
• Weight capacity of the device
• AMAP/ ANAP: “least restrictive device”
Stability and Mobility

Johansson and Chinworth, p. 376

Assistive devices/Early mobilization

Device Use with patients with:

Tilt table Coma, extended periods of
bedrest, ROM loss, paralysis,
orthostatic hypotension
Standing frame Some emerging trunk control

Parallel bars Weakness, dizziness, poor

balance, but able to begin
ambulation training
 Tilt Table

• Uses:
– Evaluate cause of fainting or syncope
– Increase tolerance for upright postures
– Promote beginning weight bearing for people with
limited trunk control

• Procedure for use to be covered in detail

during Clerkship
Tilt Table
Unilateral Assistive Devices

Cane
Small base
quad cane

Large base quad cane

Hemiwalker
 Bilateral Assistive Devices
Device When to use:
Walker (Standard/PUW) General weakness with 2 functional UE’s
Balance impairment
Rolling walker (FWW or four wheels) Promotes smoother, faster gait pattern
Less energy expenditure
Rollator walker Allows user to sit and rest
User needs better balance than rolling
walker
Axillary crutches Good balance + 2 functional UE’s, but
need to unload one LE
Allow increased speed, variable gait
patterns
Loftstrand crutches Less stable than axillary crutches
More lightweight and mobile
Fitting an Assistive Device
 How to Measure Assistive Devices:
• General guidelines:
– Patient: stand upright, shoulders relaxed
– Hand hold  wrist crease
– 20-30 degree elbow bend when holding device
 Canes:
SPC, SBQC, LBQC, Hemi-walker
 Device held on the
opposite side of the
involved extremity
 Quad canes:
 Pick up and set down all
4 legs at same time
 Do not tip
 Pattern: cane ->
involved -> uninvolved
Loftstrand Crutches
• Hand grip at distal
wrist crease

• Forearm cuff is 1-1.5

inches distal to
olecranon when
handpiece is grasped
 Axillary Crutches
• FIRST, place crutches 6” anterior to small toe
• 2-3 fingers between axilla and crutch pad
• NEXT, align hand grip at distal wrist crease
 Walkers
• Pick up the walker
and set all 4 legs
down
• DO NOT TIP
• Walker-step-step
• Do not step past the
walker
• Do not keep the
walker too close nor
put it too far ahead
 Rolling/Rollator Walkers
• Rolling --------->
– Standard walker plus
wheels
– 2 in front: Front
Wheeled Walker
(FWW)
– Four Wheeled
Walker
 Rolling/Rollator Walkers
 Rollator ------->
 Four wheels
 Hand brakes
 Seat

 Both types allow for

faster, smoother gait

 Require greater
balance and control
www.drivemedical.com
LAB:
ADJUSTING ASSISTIVE DEVICES
Gait Patterns
 2 Point Gait Pattern
 Assistive device moves at the same time as
the opposite leg

 Can use with:

• 1 or 2 canes
• 1 or 2 crutches
• Hemiwalker

• Indicated for:  balance or weakness

2 Point Gait Pattern
 3 Point Gait Pattern
• Assistive device and 1 weight bearing LE
remain in contact with the floor
• Device and involved extremity advanced
together, followed by the uninvolved
extremity
• Only used when one LE has restricted weight-
bearing
3 Point Gait Pattern
 4 Point Gait Pattern
• 2 assistive devices (canes, crutches)
required
• AD  opposite leg  other AD 
other leg
• Slower, but more stable
• “Deliberate 2-point gait”
• 1, 2, 3, 4 pattern
4 Point Gait Pattern
LAB PRACTICE:
ALL THREE GAIT PATTERNS
2nd layer of Gait Patterns
 Swing..step…through…to…huh?
 Terms may be used interchangeably
 BUT they are technically not the same thing

 Let’s clarify….
APTA Acute Care Section Definitions
Swing-to
• Uses bilateral device(s),
typically crutches
• Both crutches advanced
together
• Then both legs advanced to
the line of the device(s)
• Non-reciprocal pattern
• Trunk momentum to help
advance LE’s
Swing-through
• Same as swing-to, EXCEPT:
• Both legs are advanced
anterior to the placement of
the device(s)
• Trunk momentum to help
advance LE’s
 A Picture is Worth….
• https://www.youtube.com/watch?v=4uqXCRN7WfE
• https://www.youtube.com/watch?v=H1PoJXApgQA
 Clinical Terminology
Step-to Step-through
• Allows increased double • More “normal” pattern
stance time • Possible when patient has
• The LE in swing phase better balance and stability
advances up to the device on the opposite limb
• The LE in swing phase
advances beyond the device
 Got it?
• Let’s find out…..

• Video then Vote

FUNCTIONAL ACTIVITIES WITH
ASSISTIVE DEVICES
How to get up from a chair with
crutches
 How to get up from a chair with a
walker or unilateral device
 Do not grab device & pull up
on it

 Push up from chair and then

reach for the device
 If using a wheelchair, LOCK THE
BRAKES!

 Alternative for walkers: 1

hand on chair, 1 hand on
front cross bar of walker

Sit to stand using assistive devices: http://www.youtube.com/embed/gl5X9FG7zio

 How to sit down into a chair

 Lock brakes!!
 Turn slowly with wide BOS
 Back up to the chair
 “Feel the chair with the backs of your legs”
 Walker: let go and reach for the chair
 Crutches: move both to involved side hand
 Unilateral device: depends on patient
condition
 Reach behind for the chair
CRUTCH WALKING:
HTTP://WWW.YOUTUBE.COM/EMBED/4ENW0PIREYA
 Stairs
• Down:
– Assistive device, involved leg, univolved leg

• Up:
– Uninvolved leg, involved leg, assistive device

• “Up with the “good”, down with the “bad””

Guarding on stairs: http://www.youtube.com/embed/-jYKRa9Vx4M
Stairs Ambulation: Cane or 1 crutch
• Use handrail(s) initially
– Opposite side for 1 sided
device

• PT positioned behind and in

stride on the way up

• PT positioned in front on the

way down

• Step-to initially

• Progress to reciprocal
 Stairs Ambulation: Crutches NWB
Going up:
•Stronger/uninvolved leg
up first
•Crutches and involved
leg follow

Going Down:
•Crutches and involved
leg lower first
•Stronger/uninvolved leg
hops down next
 Guarding on the Stairs
• Maintain broad BoS with staggered feet
– Do not have both feet on the same step

• Stand between the patient and the direction

they are most likely to fall

• Do NOT pull the patient’s gait belt

Questions?
 Objectives Revisited
 Understand and use key terms related to gait
and use of ambulation aids
 Modify intervention based on weight bearing
status/restrictions
 Apply a gait belt efficiently and correctly
 Demonstrate safe guarding of a “patient” during
sit <-> stand, ambulation, stairs, and a simulated
fall
 Measure and adjust all assistive devices for your
“patient” appropriately
 References
• Johansson C. & Chinworth SA. Mobility in Contexts: Principles
of Patient Care Skills. FA Davis, Philadelphia, 2012: Chapter 14.