AD Flashcards
What does full weight bearing (FWB) mean?
All weight put on limb
What does weight bearing as tolerated (WBAT) mean?
“allowed” to put full weight, but person may not be able to due to pain or weakness
What does partial weight bearing (PWB) mean?
Some of your weight is put on limb
May be in form of a percentage (ex: 50%)
What does touch down or tow touch weight bearing (TDWB/TTWB) mean?
- Little to no weight is put through leg
- Foot or toes are on ground more for balance than to bear weight
What does non weight bearing (NWB) mean?
- No weight is put through limb
- Limb is not touching the ground
What does therapist keep in mind when guarding during gait training?
- Determine if one or two to guard
- Stand behind and slightly to one side of patient (Position opposite to assistive device if unilateral)
- Note assist level
- Keep your base of support wide yet keep your feet out of the way
- Move in step with the patient
What precautions does therapist take when working on gait with patient?
- Appropriate footwear, safe walking surface, clear pathway, place to sit if necessary
- Response to activity (vitals, S&S, fatigue, SOB)
- Do NOT use clothing to guard or support (could rip)
What should therapist do if patient experiences loss of balance during gait training?
- Stop fall early
- React quickly and determinedly
- If cannot recover balance, slowly lower patient to floor
What is an independent level of assistance?
completes task without assistance or device
What is modified independence level of assistance?
Completes task without assistance but uses some sort of assistive device
What is supervision level of assistance?
No physical assistance is needed, but requires cueing (due to safety, cognition, etc.)
What is contact guard (CTG or CG) level of assistance?
No physical assist is needed, but hands are on the individual “just in case” or for manual cues
What is minimal assist (min A)?
Individual performs more than 75% effort
What is moderate assist (mod A)?
Individual performs 25%-74% effort
What is maximal assist (max A)?
Individual performs <25% effort
What is total assist or dependent?
Individual performs 0% (unconscious, spinal cord injury, etc.)
What are indications for using ADs?
Correct gait deviation Pain Limited weight bearing Balance issues Promote or assist with healing Sensory or coordination impairment Structural deformity Muscle weakness or paralysis Fear?
ADs provide what changes?
1) a larger “cone of stability” where the CoG can shift without loss of balance
2) a redistribution of support within that wider BoS
If NWB, TTWB or PWB, what type of device is required?
2 handed device
WBAT or FWB, what types of devices are possible?
All, including 1 or 2 handed devices
Selection of AD is dependent on what 8 things?
- Weight bearing status
- Strength (upper and lower)
- ROM (both U/L)
- Medical status (endurance, IV, O2)
- Balance
- Cognitive Status
- Overall mobility
- Home environment
When preparing for gait training, what should you do first?
- Review patient’s medical record to determine safety of ambulation and weight bearing status
- Evaluate patient’s strength, ROM, sensation/proprioception, balance, transfers, etc.
- Determine appropriate equipment, level of assistance & gait pattern based on your assessment
- Prepare the environment
- Use gait belt when necessary
- Guard or assist patient using appropriate points of control
- Maintain proper body mechanics for yourself & patient
- Adjust ambulation aid to ensure proper fit
What are two pre-ambulation devices?
- Parallel Bars
2. Tilt table
What are the pros of parallel bars? Cons? Indications?
pros: most supportive and easiest to learn, excellent for training
cons: can’t take it with you; limit mobility
indications: training, pre-gait activities
What are the pros of walkers? Cons? Indications?
pros: high degree of stability, easy to learn and to use, easiest to reduce weight bearing, many designs
cons: may be cumbersome, difficult to use on stairs, reduces speed of ambulation,difficult to store and transport
indications: decreased weight bearing and/or impaired balance or stability
Research has shown that some people who walk with a reverse device have improved what?
Posture and hip extension
When balance is a concern, why might a posterior walker help?
the person’s center of mass is within the base of support of the walker.
What is a gait trainer?
- mobility aid designed to properly stabilize, support, and assist a physically disabled individual by offering unweighted support and postural alignment to allow secure and safe gait practice
- Can be anterior, posterior, or both
What are the pros of axillary crutches? Cons? Indications?
pros: allow greater selection of gait patterns, increased ambulation speed, easier to use in crowded areas, fair stability, may be used on stairs
cons: fair stability, axillary compression, requires good balance and trunk and UE strength
indications: reduced weight bearing, good UE and trunk strength, good coordination
What are the pros of forearm crutches? Cons? Indications?
pros: highly adaptable, no pressure on axillary vessels or nerves, easy to store and transport,
cons: less stable than a. crutches, requires
functional balance and UE and trunk strength; there are better options if ↓ WB is required
indications: pt’s with functional balance and strength that require increased access to the environment.
What are the pros of a cane? Cons? Indications?
pros: maximum access to the environment, lots of options for increased or decreased stability, easy to use on stairs, easy to transport
cons: there are better options to limit weight bearing, provides relatively little support, small BOS
indications: pt’s that have mild weight bearing or stability deficits
List of AD ordered from those providing the most stability & support to those providing the least stability & support:
Parallel bars Standard Walker Rolling walker Axillary crutches Forearm crutches (Lofstrand) Two canes One cane
What type of standing posture do you want a patient to have when using ADs?
Upright standing posture with relaxed shoulders and elbows fully extended
What degree of elbow flexion should the patient have when using walker/cane?
Elbow flexion should be 20-30° when gripping grips - Grip at the level of the ulnar styloid process
How should parallel bars fit the patient?
- 20-25° of elbow flexion when the patient grips the bars 6 inches anterior to the hips
- Bars 2 inches wider than the patient’s greater trochanters
Describe how to fit axillary crutches to a patient:
- Patient stands with good posture
- Adjust the hand grip so that it is level with the patient’s ulnar styloid process when arm hanging down with elbow in extension, and tip of crutches at 45° ant. and lat. (4-6 inches from the small toe)
- Elbows should flex 20-30° when the patient grips the hand grips
- Therapist should be able to fit 2-3 fingers in the axilla between the axillary pad and the patient’s axilla
Describe how to fit forearm (loftstrand) crutches:
- Adjust the hand grip so that it is level with the patient’s ulnar styloid process when arm hanging down with elbow in extension, and tip of crutches at 45° ant. and lat. (4-6 inches from the small toe)
- Elbows should flex 20-30 ° when the patient grips the hand grips
- Cuff should be positioned as high on the forearm as possible as long as it does not interfere with elbow motion
- Cuff should not bind, but should stay on the arm when the patient releases the hand grip
What are some common errors when fitting AD to patient?
- Measurements are not adjusted for postural imbalances in upright positions
- Measurements do not account for footwear
- Measurements are not confirmed in standing
- Optimal resting standing position is not maintained during measurements
- Crutches/cane - positioned too far or too close (ant/posterior/lateral) to lower extremities
- Walker - feet are too far anterior/posterior of rear legs
Gait patterns are determined by the patient’s impairments, including:
Strength Balance Multi-limb coordination Weight-bearing status Endurance Unilateral versus bilateral involvement
Gait patterns are determined by the patient’s functional limitations, including:
Inability to ambulate on flat surfaces/stairs/ramps
Environmental constraints
What AD/s for 4-point gait? What is the sequencing?
- Two crutches or two canes
- Sequencing:
1. Right crutch/canes
2. Left foot
3. Left crutch/canes
4. Right foot
What are indications for using 4-point gait? Requires what WB status?
Indications: Bilateral weakness, pain, or problems with balance
REQUIREMENT: No weight bearing restrictions
What are 5 advantages of 4-point gait?
- Uses a reciprocal gait pattern
- Stability
- Safety
- Low Energy Expense
- Somewhat similar to normal gait pattern
What are 2 disadvantages of 4-point gait?
- Complex Task - requires multi-limb coordination
2. Slow
When using 1 cane or crutch, what side is the AD used on?
Opposite side of involved side (natural arm swing of opposite leg)
What AD/S for 4-point modified gait? What is the sequencing?
- one crutch of cane
- Sequencing:
1. Crutch/cane
2. Contralateral foot
3. Ipsilateral foot
What are indications for using 4-point modified gait? Requires what WB status?
INDICATIONS: Bilateral weakness, pain, or problems with balance
REQUIREMENT: No weight bearing restrictions
What are 4 advantages of 4-point modified gait?
- Uses a reciprocal gait pattern
- Stability
- Safety
- Low Energy Expense
What are 2 disadvantages of 4-point modified gait?
- Complex Task - requires multi-limb coordination
2. Slow
What AD/S for 3-point gait? What is the sequencing?
- 2 crutches, or walker (NOT BILATERAL CANES)
- Sequencing:
1. Both crutches/walker forward
2. Keep involved leg off the ground
3. Stronger extremity moved forward while placing body weight on arms
T/F walker provides more stability than crutches
True
What are indications for using 3-point gait? Requires what WB status?
INDICATIONS: One non-weight bearing LE, Requires good upper extremity trunk, and one unaffected lower extremity strength
REQUIREMENT: One FWB limb, good trunk and UE strength
What are 2 advantages of 3-point gait?
- Can use with non-weight bearing LE
2. Can be relatively fast, especially with crutches
What are 5 disadvantages of 3-point gait?
- Moderately Complex
- High Energy Expense
- Less Stable
- Not similar to normal gait pattern
- Requires functional UE strength
What AD/S for 3-point modified gait? What is the sequencing?
- 2 crutches, walker, or 2 canes
- Sequencing:
1. Both crutches/canes/walker forward
2. Involved leg moved forward while maintaining PWBing or TTWBing the ground
3. Stronger extremity moved forward while placing most of body weight on arms
What are indications for using 3-point modified gait? Requires what WB status?
INDICATIONS: One PWBing or TTWBing LE, one FWB LE; Requires good upper extremity trunk, and unaffected lower extremity strength OR patient without weight bearing restrictions
REQUIREMENTS: one FWB limb OR no weight bearing restrictions, good trunk and UE strength
What are 2 advantages of 3-point modified gait?
- Can use with partial or toe touch weight bearing LE
2. Allows involved lower extremity to function actively and bear weight
What are 4 disadvantages of 3-point modified gait?
- Moderately Complex
- High Energy Expense
- Less Stable
- Requires functional UE strength
What AD/S for 2-point gait? What is the sequencing?
- 2 canes or 2 crutches
- sequencing:
1. Right crutch and left foot
2. Left crutch and right foot
What are indications for using 2-point gait? Requires what WB status?
INDICATIONS: Bilateral weakness, pain, or problems with balance, no weight
bearing precautions
REQUIREMENTS: no weight bearing precautions on either extremity
What are 4 advantages of 2-point gait?
- Safety
- Low Energy Expense
- More similar to normal gait pattern
- Faster than 4-point
What are 2 disadvantages of 2-point gait?
- Less Stability than 4-pt
2. Complex Task - requires multi-limb coordination
What AD/S for 2-point modified gait? What is the sequencing?
- 1 cane/crutch
- Sequencing:
1. Assistive device with involved leg
2. Uninvolved leg
What are indications for using 2-point modified gait? Requires what WB status?
INDICATIONS: Unilateral weakness, pain, or problems with balance; no weight
bearing restrictions
REQUIREMENTS: No weight bearing restrictions
What are 2 advantages of 2-point modified gait?
- More similar to normal gait pattern
2. Faster than 4-point
What is 1 disadvantages of 2-point modified gait?
Less Stability than 4-pt and 2-pt gait, though stability improves with walker
What is the sequencing of swing to gait?
- Bear weight on good leg
- Advance both crutches forward simultaneously
- Lean forward while swinging body to a position even with crutches
What is the sequencing of swing through gait?
- Bear weight on good leg
- Advance both crutches forward simultaneously
- Lift legs off ground and swing forward landing in advance of the crutches
What is the sequencing of step to gait?
Advance assistive device(s)
Step forward to a position even with crutches
What is the sequencing of step through gait?
Advance assistive device(s)
Step forward to a position in advance of the crutches
Generally how do you ascend/descend stairs?
Up with good down with bad
What is the sequencing of ascending stairs?
- Step up with uninvolved leg
- Push through hands and uninvolved leg as bring involved leg up to step
- Bring assistive device up to the step
What is the sequencing of descending stairs?
- Put assistive device down on step below
- Bring involved leg down to step below
- Follow with uninvolved leg
When guarding patient going up stairs, where does therapist stand?
stand behind individual
When guarding patient going down stairs, where does therapist stand?
stand in front of individual
T/F When guarding patient on stairs, my feet should be on the same stair at all times.
False, your feet should not be on the same stair
When ascending a curb with a walker and no WB restrictions, what is the sequence?
- Place the walker on the curb
- Place weight through the upper extremities to unweight the involved LE and move uninvolved side onto the curb
- Bring involved LE up onto curb
When descending a curb with a walker and no WB restrictions, what is the sequence?
- Lower walker off the curb
- Place weight onto walker, being careful to direct the pressure straight down
- Lower involved LE off the curb first, using upper extremities and uninvolved LE
- Bring uninvolved LE off the curb
When patient is transitioning from sit to stand, what should their hand placement be?
- Push down onto the AD to assist with standing as long as the AD is secure and the pressure is downward.
- Ideally patient should always have at least one hand on the chair during transitions (preferably on involved side).
When patient is transitioning from sit to stand, where should I ideally be standing?
Ideally you should be on involved side prepared to help.
How would a patient make a turn using an AD?
use several small steps and turn toward uninvolved side
Sling seat, a standard on WC, tends to reinforce what type of poor pelvic position/posture?
- Hips tend to slide forward, thighs tend to adduct and internally rotate
- Reinforces poor pelvic position (Posterior pelvic tilt and slouched posture)
A wc insert or contour seat is used for what purpose?
create a stable surface to improves neutral pelvic position and reduce tendency to slide forward
A WC seat cushion is used for what purpose?
- Distributes weight bearing pressures
- assists in preventing decubitus ulcers in patients with decreased sensation
Back support of a WC generally goes up to what region on the back?
Midscapular
Why might lower back height WC be used?
may increase functional mobility i.e. sports chairs
Why my high back WC be used?
for individuals with poor trunk control or extensor spasm
Why would WC utilize elevating leg rests?
LE edema control
Postural support
Why would heel loops be used on foot rests?
help maintain foot position, prevent posterior sliding of foot
Why would one choose lighter WC frame over heavy duty WC?
greater ease of use
What is the purpose of inner/outer rims on WC?
Inner: mounting tires
Outer: propelling
- Projections can be attached to facilitate propulsion
What is the purpose of hill holder devices on WC?
mechanical brake that allows forward progression but automatically brakes if rolling backwards
What is a one-arm drive WC? When would it be used?
- 2 hand rims attached to the same wheel (larger rim controls far drive wheel and smaller rim controls near drive wheel)
- If patient has only one functional UE
What is a hemiplegic chair?
- Low to the ground
- Allows for propulsion with noninvolved UE and LE
What is the purpose of an AMP chair?
Drive wheels set behind vertical back support moving BoS further to the rear and decreasing chance of LE amputee from tipping posteriorly
Recliner WC indicated for what patient populations?
- Indicated for patients who can not maintain upright position
- Helps redistribute weight
What should I consider when selecting WC for a patient?
- Prognosis (Temporary or Permanent
- Functional Abilities (User and/or helper)
- Environmental constraints
- Safety
- Expense
- Low tech vs. High tech
Standard seat width measurement:
16-18
Standard seat depth measurement:
16
Standard seat to floor height:
20
Standard back height:
16
Standard armrest height:
9
What is the purpose of WC seat depth?
provides support for pelvis and thighs
If seat depth of WC is too shallow, what can happen?
thighs are not properly supported, affecting weight distribution and comfort, pelvic position
If seat depth of WC is too deep, what can happen?
- sacral sitting
- Individual slouches, sliding buttocks forward and posteriorly tilting pelvis
- Posterior aspect of sacrum on the seat, can lead to improper postural alignment
- Increases pressure on sacrum
- Not optimal for efficient propulsion
If seat width of WC is too wide, what can happen?
- Pelvic obliquity and/or arms out too wide for efficient propulsion
- difficult to reach drive wheels
- may lean to one side to rest on armrests
If back height is too high, what can happen?
restricts movement, skin irritation over inferior angles of scapulae
If back height is too low, what can happen?
- decreased trunk stability, postural deviations
T/F Lower back height decreases W/C weight and improves mobility within the W/C if pt does not need the support.
True
If the armrest is the improper height, what can happen?
- Pt unable to rest his/her forearms comfortably
- Promotes improper alignment
- Unequal pressure on forearms and ischia
- Abnormal spinal curvature
What is the ideal Seat-to-footplate length ?
set so that the thigh rests parallel to the cushion surface with the foot comfortably placed on the footrest
If the Seat-to-footplate length is too great what can happen?
individual may sacral sit in order to rest feet on footplates
If the Seat-to-footplate length is too short what can happen?
- pressure distribution along thigh is uneven
- Excessive WB on ischium and coccyx
What are the areas at risk for pressure while sitting in WC?
- Inferior angle of scapulae
- Ischial tuberosity (Sacrum/coccyx)
- Greater trochanter
- Popliteal fossa
