Transcript Ambulation Aids Normal Gait and Abnormal Gait

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
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
Rolling Walkers
• Rolling Walker Indications
– 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:
– 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
• 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
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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
Two-Point Gait Pattern
• Bilateral aids
• Simultaneous,
reciprocal pattern
• Stable pattern
• Faster speed
• Low energy
• Similar to normal gait
pattern
Modified Four-Point or
Two-Point Pattern
• One ambulation aid
• One functional upper
extremity
• Aid opposite upper
extremity
• Widens base of support
• Hemi pattern
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
Three-One-Point/ Partial Weight-Bearing or
Modified Three-Point Pattern
• Bilateral ambulation
aids
• FWB one extremity,
PWB on other
• More stable than threepoint
• Requires less strength
and energy than threepoint
Documentation of Aid
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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
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Discuss and explain definitions of gait cycle
Review basic terminology
Explain common gait deviations
Discuss Gait Evaluations
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Gait
Definitions:
APTA Guide- The manner in which a person walks,
characterized by rhythm, cadence, step, stride, and speed.
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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
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Traditional
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Gait
Rancho Los Amigos –
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.
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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
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Pain
Posture
Flexibility and Amount of Available Range
Economy of Movement
Base of Support
Leg length
Gender
Pregnancy
Obesity
Age
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Gait Deviations Due to Pain
• Antalgic Gait Pattern
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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
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Gait Deviations Due to Leg Length
Discrepancies
• True Leg length or Apparent Leg Length
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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
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Vaulting
www.limblength.com/pubs/articles
/lld/lld.htm
Circumduction
http://www.victhom.com/en/neuro
stimulation/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
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Gait Deviations due to mm weakness
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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
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Gait Deviations due to mm weakness
• Iliopsoas Weakness
Difficulty initiating swing-through
 External rotation of femur, adductors will bring leg
through in swing
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Slight Circumduction=due to weakness of flexion.
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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
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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
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Gait Deviations due to mm weakness
• Anterior Tibialis
Weakness:
Steppage gait
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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
www.wrongdiagnosis.com
Gait Deviations due to mm weakness
• Plantarflexor weakness
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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
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Gait Deviations
Ankle and Foot
Portion of Phase
Initial contact
Deviation
Description
Poss. Cause
Foot Slap
At HS,
Flaccid/
forefoot
weak DF;
slaps ground 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
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Gait Deviations
Ankle and Foot
Portion of Phase
Initial Contact
Mid Stance
Deviation
Foot Flat
Excessive
positional PF
Description
Poss. Cause
Entire foot
contacts
ground at HS
Exc. fixed DF;
Flaccid/weak
Tibia does not
advance to
neutral from
10° PF
No ecc.
Contraction of
DF
PF;
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Gait Deviations
Ankle and Foot
Portion of
Phase
Mid Stance
Deviation
Description
Poss. Cause
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
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Gait Deviations
Ankle and Foot
Portion of Phase
Deviation
Description
Poss. Cause
Push-off (heel- No roll-off
off to toe-off)
Insufficient
transfer of wt.
from lat. heel
to medial
forefoot
Flaccid or
inhibition of PF,
inv, and toe
flexors; rigid/cocontraction 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
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Gait Deviations
Knee
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
Genu
recurvatum
single limb
support, tibia is in
back of ankle as
body wt. moves
over foot; ankle in
PF
Same as above
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Gait Deviations
Knee
Portion of
Phase
Push-off
(heel-off to
toe-off)
Deviation
Description
Poss. Cause
Excessive
knee flexion
Knee flexes to
more than 40°
during pushoff
COG is
forward of
pelvis, rigid
trunk, knee/hip
√ contractures;
√ withdrawal
reflex;
Limited knee
flexion
Knee flexes <
40°
Spastic/overactive quads.
and/or PF
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Gait Deviations
Knee
Portion of Phase
Deviation
Acceleration to Excessive
mid swing
knee flexion
Limited knee
flexion
Description
Poss. Cause
Knee flexes
more than 65°
Diminished preswing knee √;
flexor withdrawal
reflex; dysmetria
Knee does not Pain in knee;
flex to 65°
diminished
ROM in knee;
ext. spasticity;
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Gait Deviations
Hip
Portion of
Phase
Deviation
Description
Poss. Cause
Hip &/or knee √
contractures;
knee √ d/t weak
soleus and
quads;
hypertonicity of
hip √
Heel Strike to
foot flat
Excessive
flexion
Flexion > 30°
Heel strike to
foot flat
Limited hip
flexion
Hip flexion
Weak hip √;
does not attain ↓ROM; Glut.
30°
Max. weakness
Foot flat to
mid stance
Limited hip
ext.
Hip does not
attain neutral
position
Hip √
contracture;
Spastic hip √
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Gait Deviations
Hip
Portion of
Phase
Foot flat to
mid stance
Deviation
Description
Poss. Cause
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
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Gait Deviations
Hip
Portion of
Phase
Deviation
Description
Poss. Cause
Adducted
position of LE
Spasticity of
hip √ and add.
; Pelvic drop
to contra. side
Foot flat to
mid stance
Adduction
Swing
Circumduction Lat. Circular
mvmt. of LE
Compensation
for weak hip √
or for inability
to shorten LE
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Gait Deviations
Hip
Portion of
Phase
Swing
Deviation
Description
Poss. Cause
Shortening of
swing LE by
action Quad.
Lumborum
Compensatio
n for ↓ knee √
and /or ankle
DF or for ext.
spasticity
Excessive hip Flexion > 20flexion
30°
Attempt to
shorten LE in
presence of
foot drop;
Flexion
pattern
Hip hiking
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Gait Deviations
Trunk
Portion of
Phase
Stance
Deviation
Description
Poss. Cause
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
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References
• Neumann D. Kinesiology of the
Musculoskeletal System
• Magee D. Orthopedic Physical Assessment, 5th
ed.