AMBULATION

& ASSISTIVE
DEVICES

GUCIO
TODAY I WILL LEARN AND ABLE TO PERFORM:
• The various ambulation aids/ assistive devices
commonly prescribed to patients with impairments
& limitations in walking.
For each ASSISTIVE DEVICE, i will learn about their:
• Purpose
• Basic features & characteristics
• Advantages, disadvantages & limitations
• Correct measurement
1. Measurement & Fitting
2.Basic Gait Patterns
3. Wheelchair Mobility
4. Safety Techniques
AMBULATION – Act of walking or being
able to walk

AMBULATION AIDS
• A piece of equipment used to provide support or
stability for a person as he/she walks (Pierson, 1999)
• Appliance to aid ambulation
• Provide an extension of the UE to help transmit BW &
provide support for the patient
Functions of the Ambulation Aids

•Increase area of support

•Increase patient’s stability
•Redistribute & unload a weight
bearing limb
•Improve balance
•Provide sensory feedback
SELECTION of the proper
Ambulation Devices & Gait
Pattern is most important to
provide:
- optimal security
- safety
- function with the least energy
expenditure.
What is my role as a physiotherapist?
•Know WHEN to indicate
•Know the RIGHT ambulation aid to use
•Provide PRE-Ambulation Exercises
•Stages:
•Strengthening Exe Coordination Exe
Trunk Balance Exe Use of Ambulation
Aids (END GOAL)
 FACTORS THAT INFLUENCE
AMBULATION TRAINING
•Joint ROM & Muscle Strength of UE
•Joint ROM & Muscle Strength of LE
•Coordination
•Trunk Balance
•Impairment in Sensory Perception
FACTORS THAT HELP DETERMINE
AMBULATORY NEEDS

•Nature of Disability
•Age of the Patient
•Mental Status
•Physical Endurance
•Energy Expenditure
SINGLE CANE
BILATERAL CANES
FOREARM CRUTCHES
AXILLARY CRUTCHES
WALKERS
PARALLEL BARS
MOST REQUIRING LEAST
COORDINATION  REQUIRING
COORDINATION
PARALLEL BARS
• When maximal patient stability and support is
required
• Bars should be adjusted for proper fitting.
•Disadvantages:
– Bars severely limit mobility
– Pt. must progress to another ambulation
aid to be mobile
WALKERS
•When maximal stability and support,
along with MOBILITY is required.
•Wider and more stable BOS.
•Advantages:
•Lightweight
•Foldable
•Safer and provide good support
 WALKERS
•Disadvantages:
• Difficult to store/transport
• Difficult to use on stairs
• Slow & awkward gait pattern
• Difficult to use in narrow/ crowded places
•Pre-requisites for the use of a walker
• Good grasp
• Good bilateral arm strength
•Parts
• Tubular aluminum, plastic hand grips & rubber tipped legs
TYPES and VARIATIONS of
WALKERS
a) Standard
• Non-adjustable
• Adjustable
b) Reciprocal Walker
c) Wheeled or Rollator
d) Folding
e) Stair Climbing Walker
f) One-hand Walker (hemiplegic)
ROLLATOR
Lightweight Aluminium
Rollator Walker Standard
Lightweight Aluminium
Triwalker Basic
PRONE CRAWLER
Walker
Paraplegia
(adult)
Stair
Climbing
Walker
RECIPROCAL WALKER
FORWARD
HEMI-WALKER
FOLDING WALKER
WITH GLIDES/
ROLLATOR
Platform
attachment
for walker
CANES
•Used to compensate for impaired balance or to
improve stability
•Approximately 25% of BW is transferred
•Oldest of all assistive devices
•Held opposite the affected LE
•Provide more physiologic gait
•Wider BOS
•Reduce stress on opposite hip
CANES
•Advantages:
•More functional on stairs
•Can be used in narrow and confined
places
•Easy storage and transport
•Disadvantages:
•Limited stability
•2 canes do not provide sufficient stability
to perform a 3-point gait pattern
PARTS of CANE

•HANDLE (“J”/ “T”/”C”-

shaped, PISTOL GRIP,
OFFSET)

•SINGLE UPRIGHT

•RUBBER SUCTION TIP

Standard Crook Cane
Modified Crook Cane
Cane w/ Ortho Grip
OFFSET CANE W/ WRIST STRAP
Quad Cane with Offset
Handle
Quad cane with
large inverted
"V" base
Quad cane
w/ "U" shape
hand grip
CANE SEAT
CRUTCHES
•Provide support from axilla to floor
•2 points of contact
•Better stability than canes
•2 TYPES:
•Axillary
•Non-axillary
1. AXILLARY CRUTCHES
Transfers 80% of BW
Requires better trunk
support
Allow selection of gait
patterns & ambulation speed
Provide good support and
stability
PARTS

SHOULDER PIECE

DOUBLE UPRIGHT
HAND GRIP/ BAR

RUBBER SUCTION TIP

 DISADVANTAGES
1. Less stable than walker
2. Can cause injury to axillary vessels &
nerves if used properly
3. Require good standing balance
4. Elderly pt. May feel insecure with
them
5. Functional strength of the ue & trunk
muscles is required for most gait
patterns
2. NON-AXILLARY CRUTCHES
•Transfers 40-50% bw
•Eliminate the danger of injury to axillary
vessels & nerves
•More functional on stairs & in narrow,
confines areas
•Relatively easy to store & transport
•Forearm cuff retains the crutch on the
forearm when pt. Reaches for an object
DISADVANTAGES
1. Provide Less Stability & Support Than
Axillary Crutches, A Walker, Or Parallel
Bars
2. They Require Good Standing Balance &
Good UE Strength For Manuy Gait
Patterns
3. The Forearm Cuff Makes It Difficult To
Remove The Crutch
4. Elderly Pt. May Feel Insecure With
Them
CRUTCH ACCESSORIES
Crutch tip (rubber suction tip)
Axillary pads (rubber/ sponge)
Hand grips (sponge pad)
Triceps band (metal/ stiff leather)
Wrist strap – (leather/ plastic)
Loftstrand Crutches
PARTS OF LOFTSTRAND
CRUTCH

FOREARM CUFF

PADDED HAND BAR

TUBULAR ALUMINUM
-SINGLE UPRIGHT
 PLATFORM CRUTCH
For individuals who are/have:
•Unable to bear weight through
their wrists & hands
•Severe deformities of the wrist
or fingers making it difficult to
grasp the hand piece of a
regular crutch
•Below elbow amputation
•Unable to extend one or both
elbows passively
DISADVANTAGES
1. The patient loses the use of his/her
triceps to elevate & maintain his/ her
body during the swing phase
2. Another person may need to apply
them
3. They are less effective on stairs
MAJOR MUSCLE GROUPS USED FOR
NON-WEIGHTBEARING AMBULATION

•Upper Trunk
•Scapular Depressors
•Scapular Stabilizers
•Lower Trunk
•Trunk Extensors
•Trunk Flexors
•Upper Extremity
•Shoulder Depressors
•Shoulder Extensors and Flexors
•Elbow Extensors
•Finger Flexors

•Weight Bearing Lower Extremities

•Hip Abductors
•Hip Extensors
•Knee Extensors
•Ankle Dorsiflexors
 IMPORTANT SPECIFIC CRUTCH
WALKING MUSCLES

1. SCAPULAR DEPRESSORS
• stabilize the UE & prevent hiking of
the shoulder on weight bearing
Latissimus Dorsi
Lower trapezius
Pectoralis Minor
2. SHOULDER ADDUCTORS
• hold the crutch top to the chest wall
with the arm
Pectoralis major
Latissimus Dorsi
3. FLEXORS, EXTENSORS, ABDUCTORS OF
THE ARM & SHOULDER
• enable the placement of crutch
forward, backward, and sideward
respectively
Deltoids
4. ELBOW EXTENSORS
• stabilize the elbow joint in weight bearing
by preventing flexion or buckling; together
with shoulder depressors these muscles are
most important in raising the body from
the floor to allow the LE to swing
Triceps
Anconeus
5. WRIST EXTENSORS
• hold wrist in proper position to bear weight
on hand piece
ECRL/ECRB
ECU
6. FINGER AND THUMB FLEXORS
• to adequately grasp the hand piece
FDS
FDP
FPL & FPB
FOUR POINT PATTERN
• Requires the use of bilateral ambulation aids.
• Uses an alternate and reciprocal forward movement
of the ambulation aid and the patient’s opposite
lower extremity.

• (R) crutch- (L) foot- (L) crutch- (R) foot

• Very slow but stable pattern, safest one to use in
crowded areas
• Requires low energy expenditure
• Can be used when patient requires maximal stability
or balance
• Approximates a normal gait pattern
TWO POINT PATTERN
•Requires the use of bilateral ambulation aids
•Uses a simultaneous & reciprocal forward
placement of the ambulation aid & the patient’s
opposite extremity.
•® crutch and (L) foot  (L) crutch and ® foot
•Relatively stable pattern and faster than 4 point
pattern
•Relatively low energy expenditure & similar to
normal gait pattern
•Requires more coordination to move one UE &
its opposite LE forward simultaneously.
MODIFIED 4- or 2- POINT
PATTERN
•Require only one ambulation aid and
are used for patient who only has one
functional UE or who uses only one
ambulation aid.
•Aid is held on the UE opposite the
affected or protected LE.
THREE POINT PATTERN
•Requires bilateral ambulation aids or a
walker
•Not for bilateral canes
•Referred to as “step to” or “step
through” pattern rather than a “swing
to” or “swing through”
• Used when the patient is able to bear weight on one
LE but is NWB on the opposite LE.
• Walker or crutches and the NWB limb are advanced
and then the patient steps up to the walker or through
the crutches.
• Less stable pattern but more rapid ambulation
• Requires good strength of the UE, trunk and one LE.
• Higher energy expenditure
GUCIO
 WHEELCHAIR
PURPOSE
•To promote independent mobility/functioning
•Prevention of injury / deformity
•Healthy body image
•Minimize short/long term equipment cost

INDICATIONS FOR USE

•When ambulation is unadvisable
•When ambulation is impossible
SELECTION DETERMINANTS

1. Age
2. Size (height & weight)
3. Operating conditions
• Transfers
• Propulsion
• Mode of living
4. Areas of operation
Doorway 36” width
Average Turning Space 60”x60”
Horizontal working table reach 30.8”
Ramps 1ft elevation / 12ft
distance
5. Level of disability (prognosis)
6. Safety & comfort
7. Cost
8. Appearance
 WHEELCHAIR FACTORS
* Seat X 2 Checklist • Accommodation (Grow
•Support (SCALPS)- Fast) – Of Growth, Others,
Worsening Of Medical
• Safety, Comfort Of Arms,
Conditions, Functional
Legs, Pelvis & Spine
Activities, Functional
•Skin Activities, Structural
•Easy Propulsion Deformities, Tech.
•Easy Transfer • Transportability
• Terrain
•Alteration Of Tone
PARTS OF A WHEELCHAIR
Back
upholstery

Handgrips armrest
/ push
handles
clothing guard

molded seat
wheel upholstery
wheel lock/lever

handrim cross brace

Leg rest w/
calf pad

caster footplate
TYPES OF WHEELCHAIR
•Adult/ Pediatric
•Heavy/ Moderate/ Light wt./ Ultralight
•Manual/ Powered
•Folding/ Non-folding/ Stand-up frame
•Reclining/ Non-reclining
•Tilting/ Non-tilting
•Metal/ Composite
 MANUAL POWERED
*Both types aims to increase
independence level at work/school*
 MANUAL vs. POWERED
WHEELCHAIR
MANUAL POWERED
•POOR ENDURANCE/ •To spare the upper limb
DISTANCE WALKING joints from premature
•Physical limitation is deterioration
not compatible with •To increase efficiency of
ambulation mobility
•To improve self-esteem
•Physical limitations not
compatible with manual
wheelchair mobility
Semi- Reclining Wheelchair
Full Reclining Wheelchair
One Arm Drive Wheelchair
Slide-On Wheelchair Lap Tray
Pediatric Wheelchair
Wheelchair Folding (With Commode)
RECREATIONAL/
SPORTS WHEELCHAIR
WHEELCHAIR MEASUREMENT
and CONFIRMATION OF FIT
MEASUREMENT AVERAGE ADULT SIZE INSTRUCTIONS CONFIRMATION OF FIT

SEAT HEIGHT/ LEG 19.5 to 20.5 inches USER’S HEEL TO A. With your hand //
LENGTH POPLITEAL FOLD to the floor, you should
+ 2 IN be able to insert 2 or 3
(TO ALLOW fingers lengthwise bet.
CLEARANCE OF The pt. Posterior thigh
FOOTREST) & the seat upholstery
to a depth of approx. 2
inches

B. The bottom of the

foot plate must be at
least 2 in above the
floor
MEASUREMENT AVERAGE INSTRUCTIONS CONFIRMATION OF FIT
ADULT SIZE

SEAT DEPTH 16 inches Posterior buttocks, along lateral With your hand // to
thigh the floor, you should
-2 inches be able to place the
(to avoid pressure from the front width of 3 or 4 fingers
edge of the seat against the between the front
popliteal space) edge of the seat and
popliteal fold

SEAT WIDTH 18 inches Widest aspect of the buttocks,
hips or thigh
+2 inches
(Provide space for bulky
clothing, orthoses, or clearance
of the trochanters from the
armrest side panel
With your hand
vertical to the floor
you should be able to
slide each hand
between the patient’s
hips and the clothing
guard of the chair
with minimal contact
 MEASUREMENT AVERAGE ADULT INSTRUCTIONS CONFIRMATION OF FIT
SIZE
BACK HEIGHT 16 to 16.5 inches From the seat of the With your hand vertical to
chair to the floor of the floor, you should be
the axilla with able to place the width of
shoulder flexed 90˚ - 4 fingers between the top
4 inches of the back upholstery and
the floor of the axilla

ARMREST HEIGHT 9 inches above the From the seat of the A. Observe the angle
chair seat chair to olecranon made by the posterior
process with the aspect of the upper arm
elbow flexed to 90˚ and the back post when
+1inch the elbow rest on the
armrest approx. 4 inches
in front of the back post
B. Observe the position of
the trunk; it should be
erect
Manual Wheelchair Setup

•Seat and back angle adjustments

•Rear wheel camber
•Axle position
•Horizontal
•Vertical
Wheelchair Propulsion
Techniques