Week 11- Assistive Devices; Types and Safety, Gait Patterns, Wheelchair Components and Measurements Flashcards
ASSISTIVE DEVICES: TYPES AND SAFETY
ASSISTIVE DEVICES: TYPES AND SAFETY
What are the 5 weight bearing status descriptors?
FWB (full weight bearing)
-All weight put on limb
WBAT (weight bearing as tolerated)
-“Allowed” to put full weight, may not due to pain
PWB (partial weight bearing)
-Some weight put on limb, in form of %
TDWB/TTWB (touch down/ toe touch weight bearing)
-little or no weight, foot or toes more so for balance
NWB (non weight bearing)
-No weight put through limb
Who determines weight bearing status?
Ultimately the medical doctor overseeing their care.
What things are important for guarding during gait training?
- Determine if 1 or 2 to guard.
- Stand behind and slightly to one side of pt.
- Note assist level.
- Keep BOS wide yet feet out of the way.
- Move in step with the pt.
If there is a unilateral dysfunction with an assistive device, do we want to stand on the same side or opposite of the assistive device?
Opposite
What 3 things should we be aware of when using assistive devices?
- Patient concentration
- Fatigue
- Methods of instruction
With Guarding:
- Always use a gait belt properly when necessary.
- Do not interfere with individual’s __________.
- Stay _____.
- Constantly __-_______.
- __________
- Be observant.
- Do not leave a patient _________ in standing.
- Manage all other appliances connected to patient.
- movement
- alert
- re-evaluate
- anticipate
- unattended
Precautions to gait training:
- Appropriate _________
- Safe walking _________
- Clear _________
- Place to ____ if needed
- Appropriate footwear
- Safe walking surface
- Clear pathway
- Place to sit if needed
What responses to activity should we be on the lookout for when walking?
- vitals
- S/Sx
- fatigue, SOB
Should we use clothing to guard?
NO!
If a patient has a loss of balance, what should we do?
- Stop the fall early
- React quickly and determinedly
If the patient can not recover balance, what should the PT do?
Lower patient slowly to the floor, protect head and neck.
What are the 4 levels of assistance (before a patient requires help) and their description?
Independent
-Completes task without assistance or device.
Modified Independence
-Completes task without assistance but uses some sort of device.
Supervision
-No physical assistance needed, requires cueing (due to safety, cognition, etc.)
Contact Guard (CTG or CG)
-No physical assistance needed, but hands are on the individual “just in case” or for manual cues.
What are the 4 levels that require a PT to help and their description?
Minimal Assist (min A) -Individual performs more than 75% effort Moderate Assist (mod A) -Individual performs 25%-74% effort Maximal Assist (max A) -Individual performs <25% effort Total Assist or Dependent -Individual performs 0% (unconscious, spinal cord injury, etc.)
- Minimal assist (min A) = pt performs more than __% effort.
- Moderate assist (mod A) = pt performs __% - __% effort.
- Maximal assist (max A) = pt performs
- 75%
- 25%-74%
- 25%
- 0%
What are some indications for using assistive devices?
- 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?
What are the biomechanical effects of assistive devices (ADs)?
- Increases BOS
- Redistributes weight
- Provides larger “cone of stability” where the CoG can shift without loss of balance.
- Provides a redistribution of support within the wider BOS.
What are some common types of ADs?
- Parallel bars
- Walkers
- Crutches (axillary or forearm)
- Canes
- Knee walker; iwalk
What are the 3 main things that contribute to the selection of an assistive device?
- Weight bearing status
- Strength
- ROM (both UE and LE)
- If NWB, TTWB, or PWB, a __________ device is required.
- Only WBAT or FWB can use a ___________ device.
- two-handed device
- one-handed device
Why are we concerned about ROM and strength for ambulating with assistive devices?
- Do they have the ROM to even use the device.
- Strength to take weight off LE as needed.
What other factors go into the selection of an assistive device?
- Medical status (endurance, IV?, oxygen)
- Balance
- Cognitive status
- Overall mobility
- Home environment
Preperation for Gait Training:
- Review patient’s __________ 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 and gait pattern based on your assessment
- Prepare the ___________.
- Use gait belt when ___________.
- Guard or assist patient using appropriate points of control.
- Maintain proper ____________ for yourself and patient.
- Adjust ambulation aid to ensure proper fit.
- Be flexible and open to trying other devices.
- medical record
- environment
- necessary
- body mechanics
What are a few pre-ambulation devices?
- Parallel bars
- Tilt table
When is a tilt table used?
Used on someone to get them used to being upright. (orthostatic hypotension)
What are some one-handed devices?
- Loftstrand and platform crutches
- Hemi-walker
- Quad cane
- Straight cane
What are some two-handed devices?
- Standard walker
- Rollator walker
- Tripod rollator walker
- Folding rolling walker
What are some specialized equipment?
- Platform attachments
- Cane handles
- Cane tps
- Knee walker; iwalk
Parallel Bars:
- Pros?
- 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
Walkers:
- Pros?
- Cons?
- Indications?
Pros
-high degree of staility, easy to learn/use, easiest to reduce weight bearing, many designs
Cons
-may be cumbersome, difficult to use on stairs, reduces ambulation speed, difficult to store/transport
Indications
-decreased weight bearing and/or impaired balance or stability
What is the use of a posterior posture walker?
Person pulls from behind to improve posture and hip extension.
What is the use of a gait walker?
Designed to stabilize and support disabled individual to unweight them and catch them if they fall.
Axillary Crutches
- Pros?
- 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, requires trunk and UE strength
Indications
-reduced weight bearing, good UE and trunk strength, good coordination
Forearm Crutches
- Pros?
- Cons?
- Indications?
Pros
-highly adaptable, no pressure on axillary vessels/nerves, easy to store/transport
Cons
-less stable than a. crutches, requires functional balance, requires UE and trunk strength, there are better options if decreased WB is required
Indications
-pt’s with functional balance and strength that require increased access to the environment
Cane
- Pros?
- 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 these ADs from most stability/support to least.
- Rolling walker
- Axillary crutches
- Two canes
- Forearm crutches (Lofstrand)
- One cane
- Parallel bars
- Standing walker
- Parallel bars
- Standard Walker
- Rolling walker
- Axillary crutches
- Forearm crutches (Lofstrand)
- Two canes
- One cane
Fitting Assistive Devices General Guidelines:
- __________ check (pads, screws, tips, grip, etc.).
- Upright standing posture with ________ shoulders and elbows fully _________.
- Elbow flexion should be __-__ degrees when gripping grips.
- Confirm fit.
- equipment
- relaxed shoulders and elbows fully extended
- 20-30 degrees
Grip should be at the level of the ______ _______ ________.
ulnar styloid process
Parallel bars should have __-__ degrees of elbow flexion when the patient grips the bars 6 inches anterior to the hips. The bars should also be __ inches wider than the patient’s greater trochanters.
- 20-25 degrees
- 2 inches
Canes hand grip should be at the level of the _______________ when the tip of the cane is positioned at __ degrees ant. and lat. and the elbow is fully extended. Elbow should flex __-__ degrees when the patient grips the hand grip.
- ulnar styloid process
- 45 degrees
- 20-30 degrees
Axillary crutches grip should be at the ____________ when arm hanging down with elbow in extension, and tip of crutches at __ degrees ant. and lat.
-Elbows should flex __-__ degrees when the patient grips the hand grips. Therapist should be able to fit _______ in the axilla between the axillary pad and the patient’s axilla.
- ulnar styloid process
- 45 degrees
- 20-30 degrees
- 2-3 fingers
Forearm crutches are the same as axillary crutches except for the cuff, which should be positioned as ____ on the forearm as possible as long as it doesn’t interfere with elbow motion. The cuff should not bind, but should stay on the arm when the patient releases the hand grip.
high
Walkers grip should be at the level of the __________________. Elbows should flex __-__ degrees when the patient grips the hand grips.
- ulnar styloid process
- 20-30 degrees
Assistive Devices Common Errors:
- Measurements are not adjusted for _________ imbalances in upright positions.
- Measurements do not account for __________.
- Measurements are not confirmed in __________.
- Optimal resting standing position is not maintained during measurements.
- postural
- footwear
- standing
ASSISTIVE DEVICES: GAIT PATTERNS
ASSISTIVE DEVICES: GAIT PATTERNS
Gait patterns are determined by the patient’s __________ as well as their ___________ limitatons.
- imipairments
- functional limitations
What are some examples of impairments?
- strength
- balance
- multi-limb coordination
- weight-bearing status
- endurance
- unilateral vs. bilateral involvement
What are some examples of functional limitations?
- inability to ambulate on flat surfaces/stairs/ramps
- environmental constraints
What are 8 gait patterns that are commonly used with ADs?
- Four-Point Gait
- Modified Four-Point Gait
- Three-Point Gait
- Modified Three-Point Gait
- Two-Point Gait
- Modified Two-Point Gait
- Step-To/Step-Through Gait
- Swing-To/Swing-Through Gait
- Four-Point Gait involves using ___ crutches or canes.
- What are the 4 steps of sequencing in this gait?
-two
- ) Right crutch/cane
- ) Left foot
- ) Left crutch/cane
- ) Right foot
Four-Point Gait:
- Indications?
- Requirement?
- Equipment?
- Advantages?
- Disadvantages?
Indications
-bilateral weakness,pain, or problems with balance
Requirement
-no weight bearing restrictions
Equipment
-two crutches/canes
Advantages
- uses a reciprocal gait pattern
- stability
- safety
- low energy expense
- somewhat similar to normal gait pattern
Disadvantages
- complex task- requires multi-limb coordination
- slow
- Modified Four-Point Gait involves using ___ crutches or canes.
- What are the 3 steps of sequencing in this gait?
-one
- ) Crutch/cane
- ) Contralateral foot
- ) Ipsilateral foot
Which hand does the assistive device go on when using a cane or single crutch?
The hand opposite the involved side.
Modified Four-Point Gait:
- Indications?
- Requirement?
- Equipment?
- Advantages?
- Disadvantages?
Indications
-bilateral weakness, pain, or problems with balance
Requirement
-no weight bearing restrictions
Equipment
-one cane/crutch
Advantages
- uses a reciprocal gait pattern
- stability
- safety
- low energy expenses
Disadvantages
- complex task- requires multi-limb coordination
- slow
- Three-Point Gait involves using ___ crutches or a walker, NOT with bilateral ______.
- What are the 3 steps of sequencing in this gait?
-two, canes
- ) Both crutches/walker forward
- ) Keep involved leg off the ground
- ) Stronger extremity moved forward while placing body weight on arms
Three-Point Gait:
- Indications?
- Requirement?
- Equipment?
- Advantages?
- Disadvantages?
Indications
-one non-weght bearing LE, requires good UE trunk strength and one unaffected LE
Requirement
-one FWB limb, good trunk/UE strength
Equipment
-two crutches, or walker (NOT bilateral canes)
Advantages
- can use with non-weight bearing LE
- can be relatively fast, especially with crutches
Disadvantages
- moderately complex
- high energy expense
- less stable
- not similar to normal gait pattern
- requires functional UE strength
- Modified Three-Point Gait involves using ___ crutches or a walker, NOT with bilateral ______.
- What are the 3 steps of sequencing in this gait?
-two, canes
- ) Both crutches/walker forward
- ) Involved leg moved forward while maintaining PWB or TTWB the ground
- ) Stronger extremity moved forward while placing most of body weight on arms
Modified Three-Point Gait:
- Indications?
- Requirement?
- Equipment?
- Advantages?
- Disadvantages?
Indications
-one PWB or TTWB LE, one FWB LE; requires good trunk/UE strength
Requirement
-one FWB limb, good trunk/UE strength
Equipment
-two crutches, or walker (NOT bilateral canes)
Advantages
- can use with partial or toe touch weight bearing LE
- allows involved LE to function actively and bear weight
Disadvantages
- moderately complex
- high energy expenditure
- less stable
- requires functional UE strength
- Two-Point Gait involves ____ canes/crutches.
- What are the 2 steps of sequencing in this gait?
-two
- ) Right crutch and left foot
- ) Left crutch and right foot
Two-Point Gait:
- Indications?
- Requirement?
- Equipment?
- Advantages?
- Disadvantages?
Indications
-bilateral weakness, pain, or problems with balance, no weight bearing precautions
Requirement
-no weight bearing precautions on either extremity
Equipment
-two crutches/canes
Advantages
- safety
- low energy expenditure
- more similar to normal gait pattern
- faster than 4-point
Disadvantages
- less stability that 4-point
- complex task-requires multi-limb coordination
- Modified Two-Point Gait involves ____ canes/crutches or walker.
- What are the 2 steps of sequencing in this gait?
-one
- ) Assistive device with involved leg
- ) Uninvolved leg
Modified Two-Point Gait:
- Indications?
- Requirement?
- Equipment?
- Advantages?
- Disadvantages?
Indications
-unilateral weakness, pain, or problems with balance; no weight bearing restrictions
Requirement
-no weight bearing restrictions
Equipment
-one crutch/cane (AD goes on opposite side of involved limb)
Advantages
- more similar to normal gait pattern
- faster than 4-point
Disadvantages
-less stability than 4-point and 2 point gait, though stability improves with walker
What is the sequencing of a 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 a 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 a Step-To Gait?
- ) Advance assistive device
2. ) Step forward to a position even with crutches
What is the sequencing of a Step-Through Gait?
- ) Advance assistive device
2. ) Step forward to a position in advance of the crutches
Stairs involve going up with the ____, and down with the ____.
- good (uninvolved)
- bad (involved)
Ascending stairs sequencing?
- ) Step up with uninvolved leg
- ) Push through hands and uninvolved leg as bringing involved leg up to step
- ) Bring assistive device up to the step
Descending stairs sequencing?
- ) Put assistive device down on step below
- ) Bring involved leg down to step below
- ) Follow with uninvolved leg
How do we guard when patients are going up and down stairs?
- Going up: stand behind
- Going down: stand in front
-Make sure you are stable on stairs, feet should not be on the same stair
Ascending a curb sequencing?
- ) Place the walker on the curb
- ) Place weight through UE to unweight the involved LE and move uninvolved side onto curb
- ) Bring involved LE up onto curb
Descending a curb sequencing?
- ) 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 UE and uninvolved LE
- ) Bring uninvolved LE off the curb
- ____________ are considered an integral part of gait training, and functional walking; training your patient in transtions with an AD is critical.
- Pt should NOT pull on the ____ to stand.
- Transitions
- AD
Pt can push down onto the AD to assist with standing as long as the AD is secure and the pressure is ___________. Ideally pt should always have at least one hand on the chair during transitions (preferably on involved side). Ideally you should be on the _______ side prepared to help.
- downward
- involved
ASSISTIVE DEVICES: WHEELCHAIR COMPONENTS
ASSISTIVE DEVICES: WHEELCHAIR COMPONENTS
What are the components of a wheelchair?
- Seat and cushion
- Back
- Arm rests
- Leg rests
- Foot rests
- Wheels (rims, tires, casters)
- Wheel locks
What are the 3 types of seating in a wheelchair?
- Sling seat
- Insert or contour seat
- Seat cushion
Sling Seat:
- ________ on wheelchairs.
- Hips tend to slide forward, thighs tend to ______ and _________.
- Reinforces poor _______ positon.
- standard
- adduct and IR
- pelvic
What kind of pelvic tilt does a sling seat promote?
posterior pelvic tilt
Insert or Contour Seat:
- Creates _______ surface; made of wood or plastic padded with foam
- Improves ________ position (neutral pelvis)
- Reduces tendency for patient to slide _______
- stable
- pelvic
- forward
Seat Cushion:
-Distributes weight bearing pressures; assists in preventing decubitus ______ in patients with decreased sensation. (foam cushion, fluid/gel, air cushion)
-ulcers
Back Support:
- Generally goes up to the __________ region on standard wheelchairs.
- Lower back height may increase __________ mobility i.e. sports chairs.
- High back height may be necessary for individuals with poor _____ control or ________ spasm.
- Lateral trunk support can be beneficial for what?
- midscapular
- functional
- trunk control or extension spasm
- helps keep pt centered
- Armrests can be ____/________ or ______/______ length.
- UE support surfaces can be secured to armrests for what reason?
- fixed/removable
- full/desk length
-Provide additional postural assistance for patients with decreased UE use.
Leg rests can be _______, swing away/___________, or _______.
-fixed, swing away/detachable, elevating
- What is the use of swing away/detachable leg rests?
- What is the use of elevating leg rests?
- increases ease of transfers
- LE edema control, postural support
____ _____ can be put on foot rests to help maintain foot position and prevent posterior sliding of the foot. _______ can also be added to stabilize feet on foot plates.
- heel loops
- straps (ankle, calf)
The frame can be _____ or _______ and are available in what?
-fixed or folding
- Heavy duty
- Standard
- Lightweight
- Active duty lightweight
- Ultra-lightweight
Why might you pick one frame over another?
Lighter frames = greater ease of use
Heavier = not as much function
Caster wheels are small front wheels, and can be a solid rubber or pneumatic tire.
- Pneumatic tires are often wider- travel easier on ________ surfaces.
- “Rollerblade” wheels- ultra light or ______ wheelchairs.
- uneven
- sports
Drive wheels and tires can be solid rubber or pneumatic tires.
-Inner rims are for _________ tires while the outer rims are for _________.
- mounting
- propelling
Additional Attachments:
- Extensions for brakes
- Seat belts
- ____ _________: lateral at hips or knees or medial at knees to facilitate LE alignment
- Seat back positioners: lateral trunk support
- ___-_____ device: posterior extension attached to horizontal supports to prevent tipping backwards
- ____ _______ device: mechanical brake that allows forward progression but automatically brakes if rolling backwards
- seat positioners
- anti-tipping
- hill holder
What are the variations of wheelchairs?
- Reclining back
- Tilt in space
- One-arm drive wheelchair
- Hemiplegic chair
- AMP chair
When are One-Arm Drive Wheelchairs used and how are they different?
- Used if the pt has one functional UE
- 2 hand tims attached to the same wheel, larger rim controls far drive wheel, smaller rim controls near drive wheel. Pushing both rims simultaneously moves wheelchair forawrd/backward.
A Hemiplegic chair is low to the ground, why?
Allows for propulsion with noninvolved UE and LE.
AMP Chair:
- A LE amputation moves the pt’s COM ___________ when seated.
- Wheelchair has increased chance to tip posteriorly.
- Drive wheels set behind the vertical back support.
- Moves BOS further to the rear.
posteriorly
When are Recliner chairs used?
- pt can’t maintain upright position
- help distribute weight
A Bariatric Chair involved the axis moving _________ so the person is less likely to tip forward.
anterior
Basic Concepts for Wheelchair Fitting:
- )Stabilize ___________ to promote improved distal mobility and function
- ) Achieve and maintain _________ alignment
- ) Facilitate optimal __________ alignment in all body segments, accommodating for impairments in range of motion
- ) Limit abnormal movement and improve ________
- ) Provide the __________ support necessary to achieve anticipated goals and expected outcomes
- proximally
- pelvic
- postural
- function
- minimum
What are some considerations for wheelchair selection?
- Prognosis (temp or permanent)
- Functional ability (user and/or helper)
- Environmental constraints
- Safety
- Expense
- Low tech vs high tech
What are the 4 principles of positioning?
- Patient comfort
- Stability and alignment
- Pressure sore prevention
- Respect precautions/contraindications
What measurements are often taken during measuring for a wheelchair?
-seat to floor height
-seat depth
-seat width
-back fack heigh
-armrest height
seat-to-footplate length
Seat Width
- Measure?
- +/-
- Too Little?
- Too Much?
- Measure = widest point while seated
- +/- = +.5-1” to both sides
- Too Little = Pressure on sides of greater trochanters
- Too Much = Hard to reach wheels
Seat Depth
- Measure?
- +/-
- Too Little?
- Too Much?
- Measure = Back of support surface to popliteal crease
- +/- = 2-3”
- Too Little = Feel like sliding off = pressure on ischial tub
- Too Much = Popliteal crease pressure = slide forward and slouch
Seat to Floor Height
- Measure?
- +/-
- Too Little?
- Too Much?
- Measure = Floor to top of seat cushion
- +/- = +1-2” to clear foot plates
- Too Little = Knees higher than hips; pressure on ischial tuberosity
- Too Much = Footrest too long: sacral sit and slouch, Seat too high: cant sit close to table
Back Height
- Measure?
- +/-
- Too Little?
- Too Much?
- Measure =
- +/- =
- Too Little =
- Too Much =
Armrest Height
- Measure?
- +/-
- Too Little?
- Too Much?
- Measure =
- +/- =
- Too Little =
- Too Much =
