Assistive devices for ambulation: Clinical skills notes



Basic Client Care Skills

Basic Client Care Skills

Assistive Devices for Ambulation

Assistive devices for ambulation, or just ambulation devices, are tools used to aid in walking.  The most common types include walkers, canes, and crutches. You need to know when each of these are appropriate and assess if the client is using them correctly. Remember that a client’s ambulation device is ordered to fit them specifically, kind of like glasses, so they should not be shared with other clients.
Figure 1: Common ambulation devices: a walker (left), a cane (second from left), and a pair of axillary crutches (second from right) and forearm crutches (right).

Let’s start by looking at walkers. These are movable, lightweight devices that consist of a metal frame, two hand grips, and four legs. Walkers provide great stability due to their wide base, so they are great for people who can bear weight on their feet but have trouble walking due to weakness of the legs or balance issues. 

Figure 2: Proper fit and use of a walker. A. Correct height of hand grips. B. Client should lift or roll the walker to move it 6–10 inches in front of client (C.) D. Using the walker as support, client should move one leg forward, then the other. E. Re-establish balance.
When assessing the proper fit of a client’s walker, make sure that the hand grips are at the client’s waist level (Fig. 2a). Check the legs because they should have non-slip tips, like a rubber cover.

To use a walker:
  1. The client should stand straight while holding the hand grips (Fig. 2b). 
  2. When moving forward, they lift it up and move it another 6–10 inches in front of them and set it down (Fig. 2c). 
    • Because many clients have difficulty lifting a walker, many models now have wheels on the front legs. However, these are prone to rolling forward, so brakes are usually built in. So, when the client is going to stand for a while, make sure the brakes are locked.
  3. Using the walker as support, they should move one leg forward and then the other (Fig. 2d). 
  4. Once balance is reestablished, repeat the process (Fig. 2e).

Next up, we have canes. These are also movable, lightweight devices made of a strong material like wood or metal. Canes consist of a handle, a shaft, and legs. There are single leg, triple leg or quad leg canes, and the ones with multiple legs provide more stability but are also more cumbersome. Canes are used by clients who could bear weight but have weakness in one of their legs, like a stroke patient or those with paralysis in one leg. Crutches and walkers are better for people with two weak legs. A properly fitted cane should have the handle at the client’s hip level (Fig. 3a). The tips should also be non-slip. 

Figure 3: Proper fit and use of a cane. A. Correct fitting and placement of cane. B. Client should lift and move cane forward 6–10 inches. C. Client should step forward with the weaker leg first. D. After balance is re-established, client should move the stronger leg forward
When using a cane:
  1. Hold it on the strong side, or the side without weakness. The cane tip should rest flat on the ground at the start.
  2. Lift and move the cane tip forward 6–10 inches before placing it flatly on the ground again. 
  3. Step forward with the weaker leg first, using the cane for support. 
  4. After balance is established, move the stronger leg forward. 

The most vulnerable point is when only the weak leg and the cane are on the ground.    

Crutches are the last kind of common ambulation device (Fig. 4). They are either single or paired and are used by people who cannot bear weight on one or both legs. There are two common types of crutches: underarm, or axillary, and forearm crutches. Axillary crutches stretch from the armpits, or axilla, to the ground. They provide better balance but require more upper body strength to use. They are often used temporarily, like when someone is recovering from leg injuries. Forearm crutches are shorter, reaching from the elbow level to the ground. They have a hand grip and a cuff for the arm. The cuff lets the crutch stay attached to the arm when the person needs to use their hands for other tasks. This is one of the reasons that this type is preferred for people with permanent leg weakness. 

For proper fit, axillary crutches should leave 2–3 finger widths between the top of the crutch and the armpit. This prevents compressing the nerves found in the axilla. The person should be able to reach the handle with their elbows slightly flexed. Forearm crutches are often adjustable. With the arms relaxed and slightly flexed, the hand grip should be at the level of the hand, and the cuff should be at the level of the elbow.  Check the bolts on the crutches to make sure they’re tight, that the non-slip tip is intact, and that there are no cracks or other deficits.
Figure 4: Types of crutches. A. Axillary crutches and B. Forearm crutches.
The proper usage of crutches should be taught to the client by a nurse or a physical therapist; here are some general considerations:
  • Crutches should be squeezed between the arms and chest. 
  • They should be about shoulder-width apart when they reach the ground. 
  • There are four different types of gait. 
    • In a four point gait, the right crutch moves forward, followed by the left leg. Then the left crutch moves forward, followed by the right leg. 
    • In a three point gait, both crutches move forwards, followed by the strong leg and then the weak leg. 
    • In the two point gait, the left foot and right crutch moves forward together, followed by the right foot and left crutch. 
    • Finally, for the swing-to gait, both crutches move forwards, then using them as support, both legs are lifted and swing to the crutches position.
Figure 5: Four point gait. A. Stationary. B. Right crutch moves forward, followed by C. the left leg. D. Left crutch moves forward, followed by E. the right leg.
Figure 6: Three point gait. A. Stationary. B. Both crutches move forward. C. Strong leg moves forward. D. Weak leg moves forward.
Figure 7: Two point gait. A. Stationary. B. Left foot and right crutch move forward together. C. Right foot and left crutch move forward together.
Figure 8: Swing-to gait. A. Stationary. B. Both crutches move forward together. C. Both legs lifted and swing forward to D. new position.

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