Locomotion and Assistive Devices

    Assistive devices can be used for clients for many reasons such as increasing balance, strength, stability, and safety as well as decreasing pain after surgery, fracture, and/ or amputation. Devices such as walkers, crutches, and canes are necessary to adapt to these reasons and must be fitted accordingly to each person's body physique. It is important to properly fit the client with an assistive device to provide better stability and prevent injuries, especially falls. This can ensure client safety as well. It is also vital to make sure the client is standing straight and looking ahead with their arms relaxed to their sides when fitting them for their devices because if the devices are measured inaccurately, this can lead to poor posture and cause strain or even nerve damage depending on how poorly the equipment is being used.

Walkers:
Rolling Walker and Platform Walker

Fitting:
    When it comes to fitting a walker, you want the client to stand straight within the walker and look straight ahead with their shoulders and arms relaxed by their sides. This helps show the correct natural body positioning and helps assess the correct way to fit the device. The walker handgrips should be in line with the wrist crease, ulnar styloid, or greater trochanter when the hands are relaxed at the sides. The elbows should be slightly flexed to about 20-30 degrees. For clients that cannot bear weight through their wrist or hand, they are fitted for a platform walker. When being fitted for a platform walker, the elbow should be flexed at about 90 degrees and be positioned on the platform surface to allow weight-bearing through the forearm. It is important to remember the client's body mechanics for this as well and make sure they are standing straight with their shoulders and arms relaxed. The handgrips for the platform walker need to be positioned in a way where nerve compression is avoided but can still provide a comfortable grip. The client should have their proximal ulna positioned 1 to 2 inches off the platform surface and have the handle positioned slightly medially while the forearm is in a resting position. 

Sit to Stand:
    It is important to keep the walker in front of the client within arm's reach. If the client is non-weight bearing, keep the injured leg, or involved leg, off the ground. If the client is weight-bearing, keep both feet on the ground with toes below the knees. The client should be at the edge of the seat and have hands on either the armrest of the seat or the actual seat surface to allow them to get up. Never let the client bring their hands on the actual walker until they are fully standing and balanced. When getting up from the edge of the seat, the client should lean forward and push up to stand using arms and unaffected, or uninvolved, legs. Once the client is stable, they are allowed to place both hands on the walker.

Stand to Sit:
    Have the client approach their seat to where the seat is placed behind them. They should approach the seat, turn, and back up until the back of their legs touches the seat. If they are non-weight bearing, the involved leg should be extended and lifted off the ground. Allow the client to reach back with their hands to feel for armrests or the seat surface. Instruct them to slowly sit down and avoid plopping into the seat.
    Platform walkers will follow the same techniques for sitting to stand and vice versa, but there are some precautions to be considered. The client should not push up from the seat with the involved arm. Once they are standing and stable, they can place the forearm(s) on the platform(s). Always remember to remove the forearm(s) from the platform(s) before sitting down.

Ambulation:
    When the client starts walking, it is important to instruct proper ambulation techniques. The client should not push the walker more than arm's length. They should place their involved leg forward and if it is non-weight bearing, keep it elevated off the ground. When taking a step, the weight should be transferred onto the hands and then the uninvolved leg can swing through. If the client has to turn, they should take controlled steps.

Safety Precautions:
    When it comes to safety, it is important to make sure the walker is not too far or too close when walking as that can lead to instability and falls. It is also important to note that even though rolling walkers are for clients with upper extremity weakness who cannot lift the walker, it is still considered unstable. As for a platform walker, it is important to educate clients to be aware of putting weight on the involved hand and prevent further injury.

Crutches:
Axillary Crutches and Lofstrand Crutches

Fitting:
    The crutch length should be about the same length as the distance from the client's forearm to the fingertips of the opposite hand. Estimate the crutches' length based on the client's height and make sure they are standing properly. The arm pads of the axillary crutches should be about 1 to 1.5 inches (2 to 3 finger widths) under the axilla. The handgrips should be in line with the wrist crease, ulnar styloid, or greater trochanter. For Lofstrand crutches, the armband should be positioned 2/3 of the forearm following the same rules for the handgrips.

Sit to Stand:
    Always remember that if a client is non-weight bearing, they must keep their involved leg elevated from the ground. If weight bearing is allowed, both feet must be on the ground with toes under the knees. The client must scoot to the edge of the seat and have both crutches placed on the involved side while holding onto the hand grips. The other hand can be placed on an armrest or seat surface. The client must lean forward and push up to stand using arms and the uninvolved leg. Once the client is standing and stable, they can move one of the crutches under the uninvolved arm.

Stand to Sit
    The process to sit back down is very similar to how you would sit back down with a walker. You want the client to turn around and back up to the seat until the back of the legs touches the seat. Both crutches should be placed on the involved side and held from the handgrip. Instruct the client to sit down slowly.
    The techniques for sitting to stand and vice versa are the same for the Lofstrand crutches, however, the forearm should be placed into the cuff after standing and removed before sitting.

Ambulation:
    The crutches should be placed with the tips in a tripod position and the weight should be transferred onto the handgrips, not the axilla, and then swing through. For Lofstrand crutches, the pattern is the same as axillary crutches, however, the handgrip should face forward during ambulation. 

Safety Precautions:
    It is important to not have the crutches too close together or too far apart as that can lead to slips and falls. It is important to have crutches at an equal distance with equal weight distribution within the grips and not the axilla in order to prevent nerve damage in the area.  For the Lofstrand crutches, it is important to not have the cuff up too high on the forearm.

Canes:
Standard Cane and Quad Cane

Fitting:
    To fit a standard and quad cane, the client should stand straight and look ahead while having shoulders and arms relaxed. The handle should be in line with the wrist crease, ulnar styloid, or greater trochanter. The elbow should be flexed to about 20-30 degrees when holding the cane.

Sit to Stand:
    The client must scoot to the edge of the seat and have their feet flat on the ground with their toes under their knees. The cane should be in the hand opposite of the involved leg and the handle should be held loosely. To lift up, the client should place their hands on the armrest or seat surface. Once situated, the client can lean forward and push up to stand using arms and legs. 

Stand to Sit:
    Just like the walker and the crutches, the client should back up to the seat until the back of their legs touches the seat. Hold the cane handle loosely and reach back to feel the armrests/ seat surface. Sit down slowly and avoid plopping into the seat. 
    Since the quad cane can balance alone, there is no need to hold it during standing up or sitting down.

Ambulation:
    When walking, it is important to advance the cane and the involved leg at the same time and then step through with the uninvolved leg. The uninvolved leg should step a bit further than the involved leg. 

Safety Precautions:
    Do not ever use the cane on the same side as the involved side. It should always be placed on the opposite side. It is also important to never lean onto the cane as this can lead to injury if balance is lost since it is an assistive device that is the least stable. Always remember to have the position of the cane handle facing forward as well as having the wider long feet of the quad cane facing away from the body.

References:
Giles, A.K. & Kraft, S. (2019). MOBI- Mobility Aids. Available from https://apps.apple.com/us/app/mobi-mobility-aids/id1205309397