ASSISTIVE DEVICES

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 system—whether 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 feedback

Adequate 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.

Function

Ambulation• 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 Types

Crutches 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 patient’s 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

Exercises

At 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.

GAITS

Four-Point Gait1. Left crutch2. Right foot3. Right crutch4. Left foot

Stability (at least 3 points are always in contact with the ground)Difficult to learnRelatively slow walking gait

Weakness in the lower limbs or poor coordination (ataxic)

Three-Point (Non – Weight-Bearing) Gait1. Both crutches and the weaker lower limb2. 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 foot2. Right crutch and left footStabilityFaster than the 4-point gaitReduces weight-bearing on both lower limbs

Weakness in the lower limbs or poor coordination (ataxic)

Swing-to Gait1. Both crutches2. Move both limbs almost TO THE CRUTCHES.Easy to learnLower energy consumption

Paraplegia

Swing-through Gait1. Both crutches2. Move both lower limbs PAST THE crutchesFastest gait (faster than normal walking gait)Patient must expend a large amount of energyDifficult to learnStrong, functional abdominal and upper limb muscles and good trunk balance are required.

Paraplegia, with strong upper body muscles

Drag-to (Tripod) Gait1. Left crutch2. Right crutch3. Drag both lower limbs to the crutchesor (simultaneous sequence)1. Both crutches2. Drag both lower limbs to the crutchesStabilityPatient must expend a large amount of energySlowInitial 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