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Rehabilitation is a dynamic, health-oriented process that assists an ill person or a person with disability (restriction in performance or function in everyday activities) to achieve the greatest possible level of physical, mental, spiritual, social, and economic functioning.
ASSISTIVE DEVICES Assistive devices for mobility/ambulation can be referred to as ambulatory aids. Any item, piece of equipment, or product systemwhether acquired commercially, off the shelf, modified, or customized that is used to improve the functional capabilities of individuals with disabilities.
Note! The type of ambulatory aid needed depends on how much balance and weight-bearing assistance is needed.
Uses of assistive devices include the following: Redistribute and unload a weight-bearing lower limb Improve balance Reduce lower limb pain Provide sensory feedbackAdequate upper limb strength, coordination, and hand function are required for the proper use of ambulatory aids.
Evaluation and Selection Criteria Batavia and Hammer identified 4 key evaluation and selection criteria for long-term users of assistive devices : Effectiveness Affordability Operability Dependability
Canes Canes widen the base of support and decrease stress on the opposite lower extremity. Canes can unload the lower limb weight by bearing up to 25% of a patient's body weight. Determining the proper cane length is important. A cane that is fitted incorrectly produces an inefficient gait pattern. To determine the proper cane length, measure from the tip of the cane to the level of the greater trochanter while the patient is in an upright position. The elbow should be flexed approximately 20.
1. Adjustable aluminum cane. 2. Unadjustable aluminum cane. 3. T-top cane. 4. Quad cane. 5. Walk cane (hemiwalker).
Biomechanics The cane usually is used on the side opposite the affected lower limb. The cane helps decrease the force generated across the affected hip joint by decreasing the work of the gluteus medius-minimus complex. The force is exerted by the upper extremity through the cane to help minimize pelvic drop on the side opposite the weight-bearing lower limb.
FunctionAmbulation The cane usually is held on the patient's unaffected side so that it provides support to the opposite lower limb. The cane is advanced simultaneously with the opposite, affected lower limb. The patient always should have the unaffected lower limb assume the first full weight-bearing step on level surfaces.
Stair climbing The mnemonic "up with the good and down with the bad" can help patients to recall the appropriate step pattern for stair climbing. Advance the unaffected lower limb first when going upstairs, and advance the affected lower limb first when coming downstairs. The patient always should have the unaffected lower limb assume the first full weight-bearing step on level surfaces.
CRUTCHES\ Crutch TypesCrutches have 2 points of contact with the body, providing better stability than do canes. Two types of crutches (ie, axillary, nonaxillary) currently are in use.
The measurement prescription for axillary crutches is determined in the following manner: With the patient standing, determine the crutch length by measuring the distance from the anterior axillary fold to a point 6 inches lateral to the fifth toe. With the proper crutch length determined and the crutch then placed 3 inches lateral to the foot, proper handpiece location can be measured. The patient's elbow should be flexed 30, the wrist should be in maximal extension, and the fingers should be held in a fist. The patient should be able to raise his/her body 1-2 inches by performing complete elbow extension.
Measurement A standing patient is positioned against the wall with the feet slightly apart and away from the wall. Then a distance of 5 cm (2 inches) is marked on the floor, out to the side from the tip of the toe; 15 cm (6 inches) is measured straight ahead from the first mark, and this point is marked on the floor. Next, 5 cm (2 inches) is measured below the axilla to the second mark for the approximate crutch length. If the patient has to be measured while lying down, he or she is measured from the anterior fold of the axilla to the sole of the foot, and then 5 cm (2 inches) is added. If the patients height is used, 40 cm (16 inches) is subtracted to obtain the approximate crutch length. The hand piece should be adjusted to allow 20 to 30 degrees of flexion at the elbow. The wrist should be extended and the hand dorsiflexed
Nonaxillary Crutches Nonaxillary crutches allow the transfer of 40-50% of the patient's body weight. Also called forearm or arm canes (or forearm or arm orthoses), these devices require good trunk control. The patient needs confidence in his/her ambulation skills.16 Measurement prescription - With the proper crutch length determined and the crutch then placed 3 inches lateral to the foot, the proper handpiece location can be measured. The patient's elbow should be flexed 20, the wrist should be in maximal extension, and the fingers should be held in a fist.
Gait Training and Preambulation ExercisesAt a minimum, gait training should include the following: Aerobic conditioning exercises Coordination and balancing exercises ROM of both upper and lower limbs Muscle strengthening of both upper and lower limbs Performing upper limb strengthening exercises is one of the most important components of the preambulatory exercise program.
To sit down: 1. Grasp the crutches at the hand pieces for control. 2. Bend forward slightly while assuming a sitting position. 3. Place the affected leg forward to prevent weight-bearing and flexion. To stand up: 1. Move forward to the edge of the chair with the strong leg slightly under the seat. 2. Place both crutches in the hand on the side of the affected extremity. 3. Push down on the hand piece while raising the body to a standing position.
GAITSFour-Point Gait1. Left crutch 2. Right foot 3. Right crutch 4. Left foot Stability (at least 3 points are always in contact with the ground) Difficult to learn Relatively slow walking gait Weakness in the lower limbs or poor coordination (ataxic)
Three-Point (Non Weight-Bearing) Gait1. Both crutches and the weaker lower limb 2. The stronger or unaffected limb
Eliminates weight-bearing on the affected lower limb Requires good balance and coordination Lower limb fracture, amputation, or pain
Two-Point Gait1. Left crutch and right foot 2. Right crutch and left foot Stability Faster than the 4-point gait Reduces weight-bearing on both lower limbs
Weakness in the lower limbs or poor coordination (ataxic)
Swing-to Gait1. Both crutches 2. Move both limbs almost TO THE CRUTCHES. Easy to learn Lower energy consumption
Swing-through Gait1. Both crutches 2. Move both lower limbs PAST THE crutches Fastest gait (faster than normal walking gait) Patient must expend a large amount of energy Difficult to learn Strong, functional abdominal and upper limb muscles and good trunk balance are required. Paraplegia, with strong upper body muscles
Drag-to (Tripod) Gait1. Left crutch 2. Right crutch 3. Drag both lower limbs to the crutchesor (simultaneous sequence) 1. Both crutches 2. Drag both lower limbs to the crutches Stability Patient must expend a large amount of energy Slow Initial gait pattern used during gait training for patients with paraplegia; once they improve their balance, patients can advance to the swing gait
1. Adjustable axillary crutch 2. Permanent axillary crutch. 3. Forearm crutch with closed leather circle cuff. 4. Ortho crutch.
1. Platform crutch. 2. Forearm aluminum crutch with adjustable forearm piece.
Walkers Advantage - Maximum support for the patient Disadvantages Slow and awkward gait Creates bad posture and walking habits Limited to indoor use in most cases Cannot be safely used to climb stairs (especially the standard walker) Indications Best suited for patients who are confused or who have an unsafe gait because of poor balance (eg, patients with hemiplegia, patients with ataxia) Early gait training
Measuring prescription Place the front of the walker 12 inches in front of the patient. The walker should partially surround the patient. Measure the proper height of the walker by having the patient stand upright with his/her elbows flexed 20. Components Tubular aluminum or other tubular metal Plastic handgrips Rubber-tipped legs
1. Standard walker. 2. Forearm support walker. 3. Stair-climbing walker.
references Delmar's.Fundamental.&.Advanced.Nursing.Skills. Brunner and Suddarth's Textbook of Medical-Surgical Nursing_ eMedicine Specialties > Clinical Procedures > Medical Devices>Assistive Devices to Improve Independence.emedicine.medscape.com