PT Fundamentals Week 9 - Notes

Gait Training

• Refers to a skilled therapeutic intervention.
• Involves verbal instruction, tactile cueing, physical contact, and possible use of assistive devices.
• Aims to improve some aspect of gait.

Ambulation

• Refers to walking with or without an assistive device and with or without physical assistance.
• Not considered skilled therapy.
• Maintenance activity, often not performed by licensed professionals.

Goals of Gait Training

• Provide appropriate assistance to maximize patient independence in mobility.
• Minimize risk of injury.
• Encourage movement patterns as close to normal as possible, while functional for the patient's condition.
• Asymmetry in gait doesn't always require training.

Safety Considerations

• Verify any weight-bearing restrictions or precautions.
• Consult medical doctor's orders.
• Use a gait belt for safety, ensuring proper placement and fit.
• Use appropriate footwear.
• Prepare the environment: clear path, prepared lines and tubes, oxygen on wheels, second person with wheelchair.

Gait Belt Use

• Provides additional safety and central control.
• Place around patient’s hip girdle level, snug and secure.
• Allows for fingertips to slide between belt and patient.
• Grip underhand with opposite hip positioned for good upper-body control.

Gait Belt: Incorrect Use

• Overhand or pronated grip reduces effectiveness.
• Holding on to patient’s upper arm, belt loops, or pants is unsafe.
• Grasping waist of pants along with gait belt can be embarrassing.

Patient Instruction

• Explain the process clearly and concisely, consider demonstration.
• Engage the patient cognitively.
• Encourage repetition of instructions.
• Progress motor learning from simple to complex environments, with internal references progressing to external ones.

Guarding

• Stand posterior and to the side of the patient, increasing base of support.
• Position to the weaker side, minimizing distance to the patient's center of mass.
• Stabilize your spine and use proper foot placement.
• One forearm on gait belt, other arm ready to control or direct the patient's trunk.
• Never leave a patient unguarded while standing.

Forward Gait

• Training typically starts on level surfaces with minimal obstacles.
• Surface type complications can include: rough surfaces, slippery surfaces, poor or reflective lighting.
• Proper cueing includes: erect posture, normal spinal curves, relaxed shoulders, head up with eyes forward.

Turning

• More challenging than straight gait, requiring more stability and decreased gait speed.
• Cueing is specific to the patient's needs:
• Increased stability: turn using multiple small steps towards the stronger side.
• Decreased stability: pivot turns.
• Non-weight-bearing restrictions: series of small "hops" while pivoting.

Gait Training with Assistive Devices

• Provides appropriate assistance for patient mobility.
• Ensures safety during training.
• Uses varied devices with differing levels of stability and mobility.
• Requires understanding of weight-bearing restrictions.

Types of Assistive Devices

• Parallel Bars:
  • Provide maximum stability.
  • Support gait for short distances.
• Walkers:
  • Increase base of support and improve balance.
  • Types: Rollator, front-wheeled, standard, single-arm, ergonomic, knee walkers, reverse walkers, pediatric.
• Canes:
  • Widens base of support and improves balance.
  • Used on the opposite side of the involved limb.
  • Types: single point, offset handle, round handle, quad cane.
• Crutches:
  • Increase base of support and lateral stability.
  • Types: axillary, ortho, forearm.

Fitting Assistive Devices

• Each device requires proper height adjustments for a safe and effective fit.
• General fitting principles:
• Handle at wrist crease
• Elbows flexed 20-25 degrees
• Devices positioned 2-4” lateral and 4-6” forward.
• Axillary crutches: 2-3 fingers between top of crutch and axilla.
• Forearm crutches: forearm cuff 1-1.5” below olecranon process.

Importance of Device Fitting

• Enhances safety.
• Improves mobility.
• Promotes correct alignment and posture.
• Increases comfort.
• Optimizes gait pattern.

Choosing Assistive Devices

• Individual factors:
  • Patient's goals, current capabilities, experiences, limitations, environment, perceptions.
• Therapist factors:
  • Redirecting load, increasing stability, reducing energy expenditure.

Weight-Bearing Restrictions

• Different levels:
  • Non-weight-bearing: 0% weight.
  • To-touch: foot touches floor for balance, no weight.
  • Partial weight-bearing: 30-50% of body weight.
  • Weight-bearing as tolerated: 50-100% based on tolerance.
  • Full weight-bearing: 100% of body weight.

Monitoring Weight Bearing

• Most reliable method: biofeedback sensors.
• Clinically: placing hand under foot, bathroom scale.
• Patient and therapist perceptions are variable and unreliable.

Stability vs. Mobility

• Greater stability reduces mobility, decreasing speed and functional tasks.
• Increased mobility decreases stability.
• Stability increased by widening base of support.
• More stable devices require less coordination.

Energy Expenditure

• Consider device's influence on energy expenditure.
• Gait deviations and compensatory patterns increase energy costs.
• Device use increases energy expenditure.

Gait Patterns

• Specific sequences of advancement for lower extremities and device.
• Two-point: Assistive device and one LE advance simultaneously, followed by the other.
• Three-point: Bilateral assistive devices and WB-restricted LE advance simultaneously, followed by unrestricted LE.
• Four-point: Sequential advancement of alternating devices and LE.
• Step-to: LE in swing phase advanced only as far as the assistive device.
• Step-through: LE in swing phase advanced beyond the assistive device.
• Swing-to: Both crutches advance simultaneously, followed by simultaneous advancement of bilateral LE up to the assistive device line.
• Swing-through: Both crutches advance simultaneously, followed by simultaneous advancement of bilateral LE beyond the assistive devices.
• Reciprocal: UE and contralateral LE advance simultaneously, resulting in normal trunk rotation.

Gait Patterns

• Gait patterns used depend on the patient’s weight-bearing restrictions and assistive device.
• Instruction should be clear, concise, and use verbal communication and demonstration.

Learning Objectives

• Explain therapist positioning and patient cueing during transfer training with assistive devices.
• Demonstrate correct therapist positioning and patient cueing using assistive devices.
• Describe steps involved in ascending and descending stairs and curbs with assistive devices.

Parallel Bar Transfer

• Sit to Stand
  • Ensure wheelchair is locked.
  • Patient scoots forward to the edge of the chair with feet placed underneath.
  • Patient leans forward and pushes up from the armrests of the chair.
  • Avoid pulling up by bars.
• Stand to Sit
  • Patient turns in the bars.
  • Back up to feel the chair against legs.
  • Reaches back with one hand followed by the other to the armrests of the chair and slowly descends.

Walker Transfer

• Sit to Stand
  • Ensure wheelchair or bed is locked.
  • Stand on the involved side of the patient.
  • One hand on the gait belt and the other hand on the shoulder assist as needed.
  • Standard method
    • Patient scoots forward to the edge of the chair.
    • Keeps the involved leg extended.
    • Leans forward and pushes up through both armrests.
    • Once upright, one hand is placed on the handle of the walker followed by the other hand.
  • Alternative method
    • Patient leans forward and places one hand on the center crossbar of the walker, forearm vertical, with the other hand on the armrest.
• Stand to Sit
  • Back of the legs to touch the chair.
  • Uninvolved leg underneath and involved leg extended.
  • Reach back for the armrests or surface.
  • Slowly sit down.

Crutch Transfer

• Sit to Stand
  • Ensure wheelchair or bed is locked.
  • Stand on the involved side of the patient.
  • One hand on the gait belt to assist if needed.
  • Both crutches placed together on the uninvolved side and hold onto both handgrips in one hand.
  • Keep the involved leg extended.
  • Push through the armrest and handgrip to stand.
  • One crutch transferred to the opposite hand.
• Stand to Sit
  • Back of the legs to touch the chair.
  • Strong leg underneath and involved leg extended.
  • Transfer both crutches into the uninvolved side.
  • Reach back for the armrest or surface.
  • Slowly sit down.

Cane Transfer

• Sit to Stand
  • Ensure wheelchair or bed is locked.
  • With armrest
    • Grasp the canes and armrests together and pushes to stand.
  • No armrest
    • Push down on the cane handle to stand.

Ascending Stairs

• Therapist Position

  • Stand behind the patient and slightly to the affected side or side with the least support.
  • Maintain a wide staggered stance on the stairs.
  • Reposition only when the patient is stationary and safe.
  • Hand on gait belt.

• Patient Cueing

  • NWB
    • Knee flexed on the involved leg > held off the ground.
    • Uninvolved leg advances up the step.
    • Both crutches advance up.
  • PWB/Affected Leg
    • Uninvolved leg advances up the step.
    • Involved, weaker, or less stable leg advances.
    • Both crutches advance up.
  • “Up with the good, down with the bad.”

Descending Stairs

• Therapist Position

  • Stand in front of the patient and slightly to the affected side or side with the least support.
  • Maintain a wide staggered stance on the stairs.
  • Reposition only when the patient is stationary and safe.
  • Hand on gait belt.

• Patient Cueing

  • NWB
    • Involved leg hovers forward.
    • Both crutches advanced down to the step.
    • Non-involved leg advances down to the step.
    • Non-involved leg advances down.
  • PWB/Affected LE
    • Both crutches advanced down to the step.
    • Involved, weaker, or less stable leg advances down.
    • Non-involved leg advances down.
  • “Up with the good, down with the bad.”

Ascending and Descending Stairs with Crutches

• With handrail options
  • Both crutches under one arm.
  • “T” Pattern
    • Crutch parallel to the handrail.

Ascending Stairs with Walker

• With handrail
  • Option 1
    • Sideways placement of the open walker with secure contact of all four legs on the steps.
    • Pushing down through the higher handgrip.
  • Option 2
    • Sideways placement of the folded walker.
    • Steps up with the non-involved leg first.
    • Repeats the process.
• Without Handrails
  • Patient backs up the walker to the bottom of the steps.
  • Patient lifts the back legs of the walker up onto the first step as far back as possible.
  • Patient steps up on the non-involved leg first.
  • Advances the involved leg up next.
  • Repeats the process.

Descending Stairs with Walker

• With handrail
  • Option 1
    • Sideways placement of the open walker with secure contact of all four legs on the steps.
    • Pushing down through the higher handgrip.
  • Option 2
    • Sideways placement of the folded walker.
    • Steps down with involved leg first.
    • Advances the non-involved leg down.
    • Repeats the process.
• Without Handrails
  • Patient moves the walker to the edge of the top step.
  • Grasps the walker posterior to the handgrip.
  • Moves the front legs of the walker to the first step down.
  • Steps down with the involved leg first.
  • Advances the non-involved leg down.
  • Repeats the process.

This quiz covers essential concepts related to gait training and ambulation. It explores the goals, methods, and safety considerations involved in improving gait and mobility in patients. Test your knowledge on the differences between skilled therapeutic interventions and maintenance activities.