COE Ambulations Devices

1. AMBULATION DEVICES
Kinesiotherapy Clinical Training
Module 3

2. Ambulation Devices
Definition
• Equipment that assists or aides the mobility of a person who has an injury
or illness that affects the ability to walk
• Uses of these devices range from providing support for minor balance
issues to eliminating full weight bearing
Types
• Parallel Bars
• Walkers
• Crutches
• Canes
• Rollators
• Wheelchairs
Ambulation devices 2

3. Parallel Bars
Parallel Bars
• Most stable assistive device
• Provides security
• Accommodates any weight bearing status
Uses
• Pre or initial ambulation training
• Standing balance exercises
• Weight shifting
• Teaching appropriate gait pattern
Adjustment
• Bars are level with the greater trochanter
• Elbows should be flexed between 25 – 30 degrees
• Hands should be placed, on the bar, 6 inches in front of patient
Ambulation devices 3

4. Walkers
Types of Walkers
• Standard
• Wheeled walker
• Platform walker
When To Use
• Patient has difficulty walking
• Patient has balance problems
• For support due to generalized weakness in both legs
• When weight bearing is restricted or limited in one leg
Ambulation devices 4

5. Walkers
Advantages
• Good stability
• Sense of security
• Easily adjusted/lightweight
• Can accommodate any weight bearing status
Disadvantages
• Difficult to maneuver through doors and crowded spaces
• Eliminates arm swing
• Slow speed
• Not safe to use on stairs
Ambulation devices 5

6. Standard Walker
Standard Walker
• Also called four point or pick up
• Has four legs with no wheels
• Can be folding
Advantages
• Most stable of all the walkers
• Useful for all weight bearing status
Disadvantages
• Requires more energy and arm strength to pick up and move forward than
one with wheels
• Does not allow for a normal gait pattern
Ambulation devices 6

7. Wheeled Walkers
Wheeled Walkers
• Used when gait becomes more stable
• Can be used with brakes/sliders
• Can have two or four wheels
• Can accommodate any weight bearing status
Advantages
• Allows functional ambulation for those unable to lift or move conventional
walkers
• Allows for a more normal gait pattern
Disadvantage
• Decreased stability
Ambulation devices 7

8. Platform Walkers
Platform Walkers
• Used when patient cannot place weight through hands or wrist
• Allows weight to be placed through the shoulders if shoulders are not
injured
Advantages
• Allows functional ambulation for those with hand or wrist injury
Disadvantage
• Heavier and more difficult to lift forward
Ambulation devices 8

9. Walkers
Standard Wheeled Platform
• Usually aluminum for ease of adjustment
• Some have wheels on front
• Rear legs often drag, so need plastic “skis” or tennis balls to make rolling
easier (sometimes harder on carpet however)
• Accessories
• Baskets, seats, trays, cup holders
Ambulation devices 9

10. Walkers
Fitting Walkers
• Similar to cane fitting for positioning
and measurement
• Position walker 10-12 inches anterior to patient
• From a standing position fix the walker height
to the level of the greater trochanter
• This should allow 20-300 of elbow flexion with shoulders relaxed
• Weight bearing should be on the heel of the hands with the elbows
maintained in partial flexion
• Avoid trunk flexion when using walker
Ambulation devices 10

11. Walkers
Non-Weight Bearing Gait
• Movement sequence when weight bearing is restricted to one leg
• Stand with the hands pressed to the walker handles, and shift weight to
the strong limb
• While bearing full weight on the strong leg, lift the walker and place it
forward
• Step with the strong leg to the center of the walker, keeping weight
bearing on the heel of the hands and elbows extended
• Keeping the non-weight bearing leg elevated, repeat the sequence
• When placing the walker forward, place all 4 legs of the walker down
evenly
• Do not place the rear of the legs down first and rock the walker
forward
• When advancing forward, lift body evenly; do not hop forward
Ambulation devices 11

12. Walkers
Partial Weight Bearing Gait
• Movement sequence when minimal to partial weight bearing is allowed.
• Stand with most of the weight shifted to the stronger limb
• Bearing weight on the hands, move the weak leg forward to a point
that is in line with the rear legs of the walker
• Step forward with the strong leg to a point that is just forward of the
center of the walker
• When placing the walker forward, place all 4 legs of the walker down
evenly
• Do not place the rear of the legs down first and rock the walker
forward
• Lift body weight forward; do not hop forward
Ambulation devices 12

13. Crutches
Types
• Axillary
• Forearm
• Platform
When To Use
•Need more stability than a cane, but less than a walker
•When there is a need to limit weight bearing in one or both legs
• When patient has good upper body strength and standing balance
• When patient has good coordination
Ambulation devices 13

14. Axillary Crutches
Axillary Crutches
• Allows for transfer of 80% of the individual’s body weight from just below
the axilla to the floor
• Adjustable; children and extra long sizes available
• Wood or aluminum with rubber suction tip
• Rubber suction tip is1.5 -3 inch in diameter
• Generally prescribed when duration of use is short
Advantages
• Provides lateral stability
• Generally the easiest of crutches to master
• Improves balance
• Reduces or completely eliminates stress on weight bearing joints by
transferring weight bearing, normally performed by the legs, ankles, and/or
feet to the arms, hands, and shoulders
Ambulation devices 14

15. Axillary Crutches
Disadvantages
• Poor posture – 1st time users tend to slouch
• Potential for radial nerve damage if pressure is applied to the axilla area
during ambulation
• Needs enough upper body strength to support their bodyweight
• Place a great deal of strain on the wrists and hands
Ambulation devices 15

16. Forearm Crutches
Forearm Crutches (Lofstrand, Canadian)
• Allows for transfer of 40-50% of body weight through the forearm and
down to the floor
• Greater control over movement and allows for different gaits for different
terrain
• Forearm cuff adjustment is at proximal end of crutch, height adjustment is
at distal end
• Generally prescribed when duration of use is long term
Advantages
• Cuff helps keep some of the pressure off the wrist when ambulating
• Tends to maintain correct posture
• Generally more comfortable
• May release grip without dropping crutch
• More cosmetic
• Allows functional stair climbing
Ambulation devices 16

17. Forearm Crutches
Disadvantages
• Need good or better upper extremity and core strength
• Requires more stability and balance
• Decreased lateral support
• Cuff may be difficult to release, especially when falling
Ambulation devices 17

18. Platform/Specialty Crutches
Uses
• When it is contraindicated to bear weight through hands or wrists
• Patient needs or wants more freedom of movement
Advantages
• Platform - patient's body weight is borne mostly by the forearm instead of
by the hand
Disadvantages
• Requires more stability and
balance
• More expensive
• Generally harder to learn
how to use
Ambulation devices 18

19. Crutches
Fitting Axillary Crutches
• Standing
• From a standing position, place the tips of the crutches 6 to 8 inches in
front of and to the side of the toes. Adjust the height of the crutch to
1.5 – 2 inches (approx. width of 2 fingers) below the axilla
• With the hands hanging relaxed, the handgrips should be about the
level of the wrist. When hands are placed on the grips the elbows
should be flexed at least 30 degrees (more important indicator of
correct height)
• There should not be any weight bearing on the axillary pad of the
crutch. Applying pressure to the axilla area during crutch ambulation
can result in damage to the axillary, radial or ulnar nerve
• Supine
• Measure1-2 inches from anterior axillary fold to heel, then add 2
inches
Ambulation devices 19

20. Crutches
Fitting Forearm Crutches
• Standing
• Place the tips of the crutches 2-4 inches to the side of the toes and 6
inches in front of the toes
• Stand erect with your arm and hands hanging relaxed at your side
• The handgrips should be about the level of the wrist. When hands are
placed on the handgrips the elbows should be flexed 20-300 (more
important indicator of correct height)
• Place arm inside the forearm cuff and hold on to the handgrip. Adjust
the cuff so it rests 1-2 inches below the olecranon process
• Widen or narrow the cuff to make it a snugger or looser fit to
accommodate the thickness of the forearm
Ambulation devices 20

21. Crutch Gaits
Weight Bearing Status
• The levels of weight bearing allowed on the affected lower limb can
include:
• Non-weight bearing
• Partial-weight bearing
• Touch weight bearing
• Weight bearing as tolerated
• Weight bearing limitations can be due to muscle weakness, injury or post
surgical procedures
• The weight bearing limitation determines the type of crutch gait used
• Non-weight bearing crutch ambulation uses the most energy and requires
almost twice the energy of normal ambulation
Ambulation devices 21

22. Crutch Gaits
Swing Through Gait - used when non-weight bearing is indicated
• Movement Sequence
• Stand with the affected leg elevated and both crutches placed out in
front
• Center the body weight on the heel of the hands with elbows extended
• There should not be any weight bearing on the axilla
• Tighten the abdominals and elevate the pelvis slightly
• Swing the trunk forward and let the unaffected leg land in front of the
crutches, then move crutches forward
• Continue to repeat this sequence with no pause between steps
• Each sequence of movements should be even in length
Ambulation devices 22

23. Crutch Gaits
Three Point Gait
• Used when weight bearing on one leg is limited
• Movement Sequence
• Stand with body weight shifted more to the unaffected leg
• Simultaneously move both crutches and the affected limb forward
• Body weight should be centered on the heel of the hands with elbows
extended
• Step forward with the unaffected limb to a spot beyond the crutches.
• Continue to repeat this sequence
• Each sequence should be even in length with no pause between steps
Ambulation devices 23

24. Crutch Gaits
Four Point Gait
• Used when both limbs can only support partial-weight
• Movement Sequence
• Move the right crutch forward, then left leg forward, left crutch
forward, then right leg forward
• Continue to repeat this sequence
Two Point Alternate Gait
• Used when both limbs can only support partial-weight bearing or weight
bearing as tolerated
• An accelerated phase of the 4 point gait
• Movement Sequence
• Move the right crutch and left leg forward simultaneously
• Move the left crutch and right leg forward simultaneously
• Each sequence of movements should be even in length with no pause
between steps
Ambulation devices 24

25. Crutch Gaits
Ascending Steps or Curbs
• Stabilize balance and step up with the unaffected leg. The affected leg and
crutches remain behind
• Bring the crutches and affected leg up simultaneously to the step
• Repeat this sequence until the top of the staircase is reached
• “Up with the good”
Descending Steps or Curbs
• Lead with the crutches and affected leg to step down from the step or curb.
The unaffected leg remains behind
• Bring the unaffected leg down from the step or curb
• Repeat this sequence until the bottom of the staircase is reached
• “Down with the bad”
Ambulation devices 25

26. Canes
Canes
• The simplest and most basic type of supportive gait device
• Assists in the distribution of weight
• Assists balance and stability
• Provides wide base of support (BOS)
• Improves balance
• Another point of ground contact to support part of the body weight
• Reduces forces acting on the joints of the affected lower extremity
When to Use
• Need only minimal support
• Are cleared for full weight bearing, but may need to unload weight on a
lower limb joint to relieve pain or promote healing
• Minimal endurance and balance issues
Ambulation devices 26

27. Canes
Types
• Single Point
• Offset/Curved Frame
• Broad Based
• Quad
• Hemi
Single Point Canes
• Advantages
• Easily adjustable and inexpensive
• Lightweight
• Fits easily on stairs
• Disadvantages
• Point of support is anterior to the hand versus directly beneath the
hand – decreased stability
• May lead to wrist, elbow, or shoulder injury over time
Ambulation devices 27

28. Off Set Canes
Off Set Canes
• Advantages
• Hand grip is positioned directly over the tip of the cane - enhances
stability and reduces fatigue
• Slightly more stable than single point since support is over the center
of the cane
• Easily adjustable
• Lightweight
• Fits easily on stairs
• Disadvantages
• More costly
Ambulation devices 28

29. Quad Canes
Quad Canes
• Advantages
• Broader base of support
• Bases are different sizes for varied stability needs
• Easily adjustable
• Disadvantages
• Heavier than a standard cane
• Not ideal on stairs, especially wider based canes
• Slower gait pattern
• Point of support may not be centered
Ambulation devices 29

30. Hemi Canes
Hemi Cane – mostly used when dexterity is limited or non-existent in one
hand or arm
• Advantages
• Very broad base of support
• Folds flat
• Easily adjustable
• Good transition from walker to cane
• Good lateral support
• More stable than a quad cane
• Disadvantages
• Not ideal for stair climbing
• Slower gait pattern
• Expensive
Ambulation devices 30

31. Canes
• Single Quad
Point
• Off set Hemi
Hemi
Ambulation devices 31

32. Canes
Cane Measurement
• From a standing position, fix the cane height to the base of the wrist (styloid
process)
• Elbow should be flexed 20-300 (more important indicator of correct height).
Lower degree for unloading, higher degree if used for balance only
Proper Use of Cane
• Place the cane in the hand that is opposite the affected lower extremity
• Begin by moving the cane and the opposite lower limb (affected)
simultaneously
• Follow a reciprocal gait pattern. Holding the cane in the hand opposite the
injury replicates the natural arm movement, and allows the hand an
opportunity to absorb some weight while walking
• Take full and even length steps with each leg. Do not take half steps
• When using a quad cane, walk with the flat side of the base next to the body to
avoid tripping over the two outwardly extended legs
Ambulation devices 32

33. Canes
Ascending Steps or Curbs
• Stabilize balance, hold on to a railing if available and step up with the
unaffected leg. The affected leg and cane remain behind
• Bring the cane and affected leg up simultaneously to the step
• Repeat this sequence until the top of the stairs/curb is reached
• “Up with the good”
Descending Steps or Curbs
• Lead with the cane and affected leg as you step down from the step or
curb. The unaffected leg remains behind
• Bring the unaffected leg down from the step or curb
• Repeat this sequence until the bottom of the stairs is reached
• “Down with the bad”
Ambulation devices 33

34. Specialty Walkers
Types
• Knee Walker
• Rollator
Knee Walker
• One sided walker with elongated pad
• Designed to rest knee of affected extremity on walker
• Can function as an alternative to crutches
• Mostly used for patients who are unable to maintain NWB due to upper
extremity weakness or being overweight
Ambulation devices 34

35. Knee Walker
Advantages
• Not as fatiguing as crutches since large leg muscles are being used more
than upper body and arms
• Minimal upper body strength is needed
• Hands are free to use while standing still
• Model available with handle bar that controls steering
Disadvantages
• Bulkier and heavier
• More expensive
Ambulation devices 35

36. Knee Walker
Proper Fitting
• Height is determined when standing. The unaffected leg should be straight
and the injured leg should be resting comfortably in the center of the
cushion
• There should be equal pressure on the good foot and the knee of the
injured leg
• Hips should be level with back straight
• Handlebars should be in a straight up position for use
Ambulation devices 36

37. Rollators
Rollator
• Four wheeled walker with hand brakes and a seat
• Allows patient the freedom to walk longer distances; ability to sit/rest if
needed
Advantages
• Saves considerable energy
• Arm and back muscles spared from repetitive lifting movements
• Front wheels swivel for easy turning in a small space
• Allows for a faster walking speed and a more normal gait pattern
• Larger casters and heavier frames are geared to being more stable and safe
outdoors
Ambulation devices 37

38. Dolomite Walker
Disadvantages
• Requires more balance, coordination and cognitive function than a regular
walker
• Heavier and bulkier than standard walker
• More expensive
Proper Fitting
• The handles should be at the same height as the
user’s wrist
• When seated both feet should touch the ground
Ambulation devices 38

39. Ambulation Devices
Spotting/Guarding
• When using any device a therapist should be close, with a hand on the
patient at all times
• Use of a gait belt to provide a tool for gripping a patient when guarding
should be used no matter how functional patient may seem to be
• Stand behind and on the affected side
• Varying amounts of assistance may be needed according to
weakness/instability of the patient
Ambulation devices 39

40. Wheelchairs
• Types
• Standard
• Transport
• Hemi Height
• Tilt in Space
• Power
• Broda
• Scooters
• Sports

41. Standard Wheelchair
• Standard
• Full back height
• Seat width - 16-20 inches
• Seat depth - 16 inches
• Seat Height ~ 20 inches
• Accessories
• Removable leg & arm rests
• Bags/baskets, trays
• Cushions, pads, neck/head rests

42. Transport Wheelchair
• Transport
• Seat width – 17 or 19 inches
• Seat depth - 16 inches
• Seat Height ~ 19 inches
• Smaller, light weight, folds easier
• Difficult to self propel
• Smaller wheels
• Accessories
• Removable leg rests
• Bags/baskets, trays
• Seat cushions

43. Hemi-Height Wheelchair
• Hemi-Height
• Full back height
• Seat width - 16-20 inches
• Seat depth - 16 inches
• Seat Height ~ 17 -19 inches
• Both feet or one hand, one foot
propulsion
• Better for smaller persons
• Has most features of standard
model

44. Tilt in Space Wheelchair
• Tilt in Space
• Good for those spending long
hours in chair and/or unable to
pressure relief
• Tilt reduces pressure on
buttocks, allows for good
blood return from lower limbs

45. Power Wheelchair
• Power
• Good for those with limited
upper limb use
• Battery life must be
considered
• Joy stick speed is adjustable
• Can even have “sip & puff”
for quadriplegic

46. Broda Chair
• Broda
• For use in long-term care
facilities, hospitals
• For patients with very
limited mobility
• Strapping helps conform to
patient contours
• Padding system is variable
• Not for outside use

47. Scooters
• Scooters
• Multiple manufacturers
• Variety of designs, weights
• Speed is adjustable
• Four wheel is more stable
than three wheel
• More for persons who need
mobility for long range
activities, rather than for
constant daily support

48. Standing Wheelchair
• Allows patient to function in
upright position
• Decreases bone loss
from non-weight
bearing
• Some models can
move while in upright
position
• Anti-tip features for safety

49. Sports Wheelchair

50. Ambulation Devices
References
• O’Sullivan, Susan B.; Schmitz, Thomas J. Physical Rehabilitation:
Assessment and Treatment 6th Edition 2006
• Delisa, joel; Gans, Bruce; Walsh, Nicolas Physical Medicine and
Rehabilitation: Principles and Practice Vol. 1 & 2 4th Edition 2005
Ambulation devices 50