walking aids presented by FELIX ANTONY

1. WALKING
AIDS

7. CRUTCHES
• 3 basic types of crutches
• Used to reduce weight bearing on one or both
legs
• To give additional support where balance is
impaired and strength inadequate

8. Axillary
• Made of wood
• Axillary pad
• A hand piece
• Rubber ferrule
• The position of hand piece and the total
length are usually adjustable

10. • Axillary pad should rest against the chest wall
approximately 5cm apex of axilla
• Hand grip should be adjusted to allow the
elbow to be slightly flexed
• Weight is transmitted down the arm to the
hand piece
• If weight is transmitted through axillary pad
laed to a neuropraxia of the radial nerve or
brachial plexus

11. Measurement of length
• Usually carried out with the patient in lying.
• With shoe off: apex of axilla to lower margin of
medial malleolus
• With shoe on: 5 cm vertically down from the apex
of axilla to a point 20 cm lateral to the heel of the
shoe
• Axillary pad to the hand grip :5 cm below the apex
of axilla to the ulnar styloid with elbow slightly
flexed ( approximately 15 deg)

12. • do not allow axillary pad to press into the
axilla

13. ELBOW CRUTCHES
• Made of metal
• have a metal or plastic forearm band
• Length adjustable press clip or metal button
• Rubber ferrule
• Suitable for patients with good balance and
strong arms

15. Measurement of length
• Patient in lying position with shoes on.
• Elbow is slightly flexed ( approximately 15 deg)
• Measurement is taken from ulnar styloid to a
point 20 cm lateral to the heel of shoe

16. Gutter crutches
• Adjustable arthritic crutches/ forearm support
crutches
• Made of metal with a padded forearm support
and strap
• Adjustable hand piece
• Rubber ferrule
• Used for patients with Rheumatic disease who
require some form of support but cannot take
weight through hands, wrists and elbows because
of deformity and or pain

18. • Length is adjustable
• Length of forearm support adjustable
• Angle of the hand piece also adjustable
• to allow for deformities

19. Measurement of length
• If the patient is able to stand : elbow to the
floor
• Patient lying with shoes on : Point of flexed
elbow to 20 cm lateral to the heel

20. Preparation for crutch walking
• Arms
Assess power of extensors and adductors of
shoulder
Extensors of elbow
If necessary strengthen before starts walking
Assess hand grip

21. • Legs
1. non-weight bearing
Assess mobility and strength of unaffected leg
Particularly hip abductors and extensors , knee
extensors and the plantar flexors of the ankle
2. partial weight bearing
Mobility and strength of both legs
Strengthen if necessary

22. • Balance
Test and train sitting and standing balance

32. MEASURMENT OF CANE
• Patient in standing position
• Elbow is slightly flexed
• Ulnar styloid to the floor approximately 15 cm
from the heel

51. s

54. GAIT PATTERNS USED WITH
CRUTCHES:
• Different types of gait pattern can be adopted by patient
based on their weight-bearing stated balance and
coordination, and muscle power.
• Before teaching the required gait pattern to the patient, it
is important to instruct basic principles to be followed while
using crutch.
• 1. The length of the crutch should be ideal for the patient.
• 2. Crutches should be held at an optimal distance from the
feet neither too close nor too far to maintain adequate BOS
while both walking and standing. A tripod stance is ideal,
i.e., 4 inches anterior and 4 inches lateral to each foot.

55. • 3. A good erect posture should always be
maintained with the back straight and holding the
head up.
• 4. Weight should always be borne on the hand
piece. While using axillary crutch the patient is
instructed strictly not to bear weight on axillary
pad as it might compress the radial nerve in the
radial groove leading to a condition called axillary
crutch palsy.
• 5. The axillary pad should be held close to the
chest wall.
• 6. Turning should be done by taking small steps
rather than pivoting

56. • Types of gait pattern:
Various types of gait pattern can be used in
crutches, which are as follows:
1. Non-weight-bearing
2. Partial weight-bearing
3. Four-point gait
4. Two-point gait
5. Swing to/swing through gait

57. Sequence of non-weight-bearing gait
• 1. The patient stands with bearing full on sound limb.
The affected limb is flexed at hip and knee and held
exactly under the body. The crutches are held firmly
against the chest wall, the hand piece is gripped firmly.
The crutches are placed 4 inches anterior to the feet.
• 2. Both the crutches are lifted and moved 6-12 inches
forward.
• 3. Whole the body weight is transferred to the crutches
by pushing down the hand piece and the sound limb is
advanced forward beyond the crutches.
• 4. Weight is then transferred to the sound limb and both
the crutches are advanced beyond the foot.
• 5. The cycle is repeated.

58. • In some cases, it is recommended to hold the
affected limb anterior to the body by keeping
the knees extended and is advanced
alternately with the weight-bearing limb. This
type of gait resembles to normal gait though
the limb is non-weight-bearing. It is called
shadow walking

60. Partial weight-bearing gait
• The affected limb is allowed to bear some amount of weight but
not fully.
• The amount of weight depends upon the patient's condition. To
start with; it is toe-touch weight-bearing (TTWB).
• Only the toe of the involved limb contacts the floor and bears small
amount of weight.
• It progresses to weight-bearing to tolerance (WBTT) where the
patient transfers as much weight as he can tolerate.
• If it is required to transfer certain percentage of body weight, the
patient is trained by placing the affected limb on a weighing
machine and transferring the required amount of weight through it.
• This gives the patient an idea of how much weight should be
transferred’

61. Sequence of partial weight-bearing gait:
• 1. The patients stands with tripod stance with
the crutches held inches anterior to the feet.
Both the crutches are lifted and advanced
arm's length. Then the affected limb is
advanced till the level of crutches.
• 2 Weight is now transferred partially to the
crutches and partially to the affected limb
• 3. The unaffected limb is now advanced
beyond the crutches.
• 4. The cycle is repeated.

63. Full weight-bearing gait
• This type of gait pattern is used when both the
lower limb are equally weight-bearing.
• It is used in problems of balance, coordination
and muscle weakness
• It may be four-point or two-point gait pattern:
• ➤ Four-point gait: One crutch is advanced then
the opposite lower limb is advanced followed by
another crutch and opposite lower limb. This
cycle is repeated
• ➤ Two-point gait: One crutch and opposite lower
limb advanced simultaneously followed by the
other crutch and opposite lower limb

64. FOUR POINT GAIT PATTERN

66. TWO POINT GAIT PATTERN

68. Swing to and swing through gait:
• It is used when both the limb are weight
bearing.
• It allows faster progression
• From starting position both the crutches are
advanced forward then weight is transferred
through them and both the limbs are
advanced either to the crutches (swing to) or
beyond the crutches (swing through) gait.

69. Gait Pattern with Walker
• There are three types of gait pattern:
• 1. Full weight-bearing
• 2. Partial weight-bearing
• 3. Non-weight-bearing

70. • Full weight-bearing gait
• The patient stands in the center of the walker-
bearing weight equally on both the limbs.
• A good erect posture is maintained.
• The walker is picked up and moved forward at
an arm's length. One lower extremity is
advanced followed by other.
• The feet should be placed in the center of the
walker for more stability.

71. • Partial weight-bearing:
• The patient stands in the center of the walker.
• A good erect posture is maintained.
• The walker is picked up and moved forward at
an arm's length.
• The partial weight-bearing limb is advanced.
• Weight is transferred to the walker and
partially to the involved limb and the sound
limb advanced till the first.
• Cycle is repeated.

72. • Non-weight-bearing:
• The patient stands in the center of the walker
bearing weight on one limb.
• A good erect posture is maintained.
• The walker is picked up and moved forward at
an arm's length.
• Weight is transferred to the walker and the
sound limb is advanced to the center of the
walker.
• Cycle is repeated.

73. Stair Climbing
• Several general guidelines are there
• First, if a railing is available it should always be
used.
• For stair climbing with axillary crutches using a
railing, both crutches are placed together under
one arm.
• Second, the patient should be cautioned that the
stronger LE always leads going up the stairs, and
the weaker or involved limb always leads coming
down (“up with the good and down with the
bad”).

74. Stair climbing techniques

78. guarding technique
during stair climbing
• Ascending Stairs (Fig. 11A.25)
1. he therapist is positioned posterior and lateral
on the affected side behind the patient.
2. A wide BOS should be maintained with each
foot on a different stair.
3. A step should be taken only when the patient is
not moving.
4. One hand is placed posteriorly on the guarding
belt and one is anterior to, but not touching, the
shoulder on the weaker side.

80. • Descending Stairs (Fig. 11A.26)
1. he therapist is positioned anterior and lateral on
the affected side in front of the patient.
2. A wide BOS should be maintained with each
foot on a different stair.
3. A step should be taken only when the patient is
not moving.
4. One hand is placed anteriorly on the guarding
belt and one is anterior to, but not touching, the
shoulder on the weaker side.

82. • 1. Instruction in assuming the standing and
seated positions with use of the assistive
device.

86. 2.Instruction in use of assistive device (with
selected gait pattern) for forward progression
and turning.
• Demonstration

87. • Following the demonstration, manual
contacts, verbal cueing, and explanations can
be used again to guide performance of the
activity.
• Following these preliminary instructions gait
training using the assistive device can be begin
overground on level surfaces.
• The following guarding technique should be
used:

88. 1. The therapist stands posterior and lateral to
the patient’s weaker side.
2. A wide BOS should be maintained with the
therapist’s leading LE following the assistive
device.
• the therapist’s opposite LE should be
externally rotated and follow the patient’s
weaker LE.
3. One of the therapist’s hands is placed
posteriorly on the guarding belt and the other
anterior to, but not touching, the patient’s
shoulder on the weaker side.

90. • Should the patient’s balance be lost during
training, the hand guarding at the shoulder
should make contact.
• Frequently, the support provided by the
therapist’s hands at the shoulder and on the
guarding belt would be enough to allow the
patient to regain balance.
• If the balance loss is severe, the therapist should
move in toward the patient so that the therapist’s
body and guarding hands can be used to provide
stabilization.

91. PRECRUTCH TRAINING
• Precrutch training involves a group of exercise
to strengthen the muscles of both upper limb
and lower limb that are responsible for
propelling the body forward while using an
assistive device for ambulation.
• It also involves balance training along with
strengthening which is essential for
ambulation using assistive device.

92. Strength Training
• There are a set of muscles that plays a major role
while using crutch. They are referred as crutch
muscles. Prior to crutch training the crutch
muscles must be assessed and strengthened.
Crutch Muscles of Upper Limb:
• Shoulder-flexors, extensors, and adductors
• Pectoralis major, latissimus dorsi, teres major,
coracobrachialis, and posterior deltoid
• Depressors and medial rotators of shoulder
• Elbow extensors-triceps and anconeus
• Wrist-wrist extensors

93. • Gripping muscles of the hand-flexor carpi
radialis, flexor carpi ulnaris, flexor digitorum
superficialis and profundus, and flexor pollicis
longus
• Push-up exercise in sitting position with the
help of push-up bars is the best exercise to
strengthen all crutch muscles.
• Standing push-up in parallel bar is also used to
strengthen these muscles.

94. Crutch Muscles of Lower Limb
• • The mobility and strength of the unaffected
limb should be assessed mainly of hip
abductors extensors, knee extensors, and ankle
plantar flexors.
• Hip hiking of the non-weight-bearing limb
should be performed in the parallel bar.
• As the weight-bearing status changes
strengthening of both the lower limbs should
be considered

95. Balance Training:
• It involves assessing the balance in sitting and
standing. Then training program is designed as
per the requirement of the patient. Usually
chronic bedridden patients (neurological
condition) requires an extensive balance
training program whereas traumatic and
postsurgical patient requires a short balance
training program.

96. Steps of Balance Training
1. Teaching sitting balance on the plinth
2. Transferring the patient to wheelchair
3. Making the patient stand in parallel bars
4. Teaching standing balance in parallel bar
5. Teaching dynamic balance and walking in
parallel bar
6. Training the patient with the recommended
walking aid and gait pattern

97. Sitting Balance:
Five basic sitting balance exercises which help in
strengthening the back muscle and improve sitting balance
are as follows:
1. Trunk tilt: The patient is instructed to tilt his trunk in
various directions, i.e., forward, backward, sideways, or
diagonally and hold this position for 3 seconds and
then return to stating position. The therapist can also
help the patient in tilting the trunk and then ask him to
hold this position.
2. Reaching: The therapist gives a target to the patient by
placing her own hand in different places in air within
the reach of the patient and the patient is asked to
touch it by his hand. It is again performed with the
other hand.

98. 3. Seated march: Patient sits on a chair with the
feet flat on the floor and alternately lift the knees
as high as he can without leaning backward.
4. Pelvic tilt: It is done by asking the patient to
hollow the lower back and then flatten it while
sitting on a chair.
5. Seated push-up: The patient sits on a chair
with arm rest and places his hands on the arm
rest and lifts his body up by gently pushing down
on the arm rest and straightening the elbow then
lowers the body slowly be bending the elbows

99. Transferring the Patient to Wheelchair
• After the patient develops proper sitting balance, he is
transferred to the wheelchair for gait training in the
parallel bar.
• For transferring the patient to the wheelchair flowing
steps are followed:
• The patient sits close to the edge of the plinth with feet
firm on the floor.
• If required, the therapist supports the feet by his toes
to prevent from slipping.
• The wheelchair is placed at right angle to the plinth on
the stronger side of the patient with brakes engaged.
• A gait belt is fastened at the waist level of the patient.
• The therapist grasps it whenever required.

100. • Therapist stands in front of the patient clasping
both his hands at the chest level under the axilla of
the patient.
• The therapist knees may support the knees of the
patient to prevent buckling.
• With a count of three the patient pushes down the
plinth with both the hand and raises himself to
standing position and the therapist assist him as
required.
• The patient is allowed to stand for some time till he
is accustomed to this erect position.
• He is then helped to pivots and sit on the
wheelchair by the therapist.

101. Transferring the Patient to the Parallel Bar:
• The patient is brought to the parallel bar in wheelchair.
• Patient moves forward in wheelchair and the therapist
is positioned directly in front of the patient.
• Guarding belt should be held firmly around the waist of
the patient.
• The nonaffected lower limb is placed on the floor.
• The patient is instructed to come to standing position
by leaning forward and pushing down the arm rest of
the wheelchair rather the pulling up by holding the
parallel bar.
• As the patient reaches the erect posture his hands
should be released from the arm rest and hold the rails
of the parallel bar.

102. Standing Balance in the Parallel Bar:
• Once the patient assumes standing position, he
is allowed to get accustomed to this upright
position.
• The therapist should be alert to the complain
of giddiness, light headedness, or nausea,
which develops due to sudden drop in blood
pressure in erect standing position (postural
hypotension).
• These symptoms disappears by itself once the
patient develops tolerance to this position.

103. Weight Shifting Activities
• The patient stands in the center of the parallel bar
with a feet apart and grasping the rails of the
parallel bar firmly.
• He is instructed to shift the weight from side to
side, front, and back, without altering BOS and
hand placement on the parallel bar.
• Then the patient moves his hands forward on the
rails and shifts the body weight anteriorly.
• The same is repeated by placing the hands
backward. He then balances with support from
only one hand, the hands are altered.

104. • Hip hiking, flexion-extension of hip, and abduction-
adduction of hip - are performed in the parallel bar
• Sanding push-up-patients hands placed just anterior
to the thigh on the parallel bar then he lifts his body up
by extending the elbows and depressing the shoulders.
• Stepping forward and backward - the patient places
on feet forward and then shifts the weight from front
leg to back.
• Once the patient effectively performs all these activities
he is now taught to ambulate using the recommended
gait pattern. Usually the sequence is non-weight-
bearing-part weight-bearing-swing-to-swing through,
and then full weight-bearing using four-point and two-
point gait pattern.

105. THANK YOU