walking aids and orthotics

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Walking Aids And Orthotics

Presenters:Afifa MunafJaweriah MahmoodFatima Bhutto

Presented to:Sir Saad

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Walking• walking together with its

variants is a skilled coordinated action which involves many joints and muscles.

• The whole sensory input is involved in walking and when any part of sensory system is disordered gait may also be affected.

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Muscles involved in walking

• flexors and extensors of the toes

• planterflexors and dorsiflexors of the ankle

• flexors and extensors of the knee and hip

• Head rotators

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Walking Aids• These are the appliances which

may be a means of transferring weight from upper limb to the ground or which may be used to assist balance.

Continued..

Factors involved in choosing walking aids:• age of patient

• their disability

• general physical condition

• their home environment

• duration for which walking aids are likely to be

used.

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Walking Aids equipments

The broad subdivision of walking aids would be between:

• frames

• crutches

• sticks

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Walking frames• Have very wide base

• Very stable

• Commonly used in elderly• Also used in children

having neurological or musculo-skeletal dysfunction

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Types of walking frames

• Rigid frames

• folding frames

• reciprocal frames

• forearm supporting frames

• wheeled frames

• rollators

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Rigid frames

• It needs to be adjusted to the correct height

• patient stand upright with the elbows flexed at approximately 15 degrees

• The frames should be of light material i.e. aluminum.

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Folding frames• These frames are useful if

the patient is regularly transported by the car.

Folding frames may either be:

• three-legged

• v-shaped

• traditional four-legged collapsible design

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Reciprocal frames

• Useful for those patients who find it difficult lifting a traditional frame.

• It is hinged at the front.

• Their main indication is in certain neurological conditions where Ataxia is a dominant feature.

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Forearm supporting frames

• These may also be called pulpit or gutter frames.

• They allow walking training of patients who has difficulty in weight-bearing through the upper limb

• Used for the patient with Rheumatoid arthritis.

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Wheeled frames

• Most standard adjustable height walking frames

• The front extension legs are replaced with small wheeled legs.

• They encourage a more normal gait pattern

• They lack stability

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Rollators• Have two fixed wheels at the front and two

ferrules at the rear.

• It is stable but not very maneuverable.

• Can be awkward in tight spaces and corners

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Walking patterns with a frame

• patient lifts the frame forward transfers their weight onto it

• takes two steps up to the frame

• keep the frame well forwards

• place all four legs of frame at a time on ground before taking a step

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Crutches

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• A crutch is a mobility aid that transfers weight from the legs to the upper body.

• The muscles of the arms, shoulders, back, and chest work together to manipulate the crutches

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Categories of crutches1.Axillary or

underarm crutches:

• These are usually prescribed when non-weight bearing gait is required

• The axillary top is rested against the chest wall while the bulk of the patient’s weight is borne through the hands.

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2.Elbow crutches or forearm crutches

• These are the most functional type of crutches and are

• suitable for both non and partial weight bearing gaits.

• it consists of a metal cuff and a handle fixed at 97 degrees

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3.Forearm/gutter crutches

• Useful for the patients who are unable to use normal handgrips

• Velcro straps fix the forearm into the tough and weight is applied via the forearm

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Walking sticks

• Provide support for the patients with good grip and sound joints of the upper limb

• Suitable for partial weight bearing

• To be used in the contra lateral hand in most cases

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Tetrapods/tripods

• These are four or three-legged sticks which give greater stability than a traditional stick

• They are prescribed for the patient with poor balance and confidence

• Commonly used by hemiplegic patients

• Quite heavy as compared with the sticks and cant be used on stairs

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Tetrapod Tripod

Effects of walking Aids

• Increases confidence• Relief of weight-bearing from affected leg• Psychological support• Relief of pain• Provides support

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Walking Aid Height

• Measure the height of walking aid, from the ulnar styloid to the ground, with the patient standing erect , shoulders relaxed & elbows flexed to 15°.

• crutches must be settled at either 77% of reported height or height minus 16 inches.

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Advantages of Contralateral Gait

• Reduce the force through affected leg

• Prevents tilting of the pelvis.

• Facilitates a reciprocal gait pattern.

• Provide stability as it has a greater BOS.

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Advantages of Ipsilateral Gait

• If used in the dominant hand, feels more natural. • May limit hip and knee flexion.

• Subjectively feels to offer more support as it is adjacent to the affected leg.

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Metabolic Cost of Walking Using Walking Aids

• A swing through gait with crutches requires a very high rate of physical effort compared with normal walking.

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Continued..

• With time, crutch users become adapted so that their energy expenditure & heart rate dec. as they become habitual walking aid users, suggesting the presence of both upper limb conditioning & training response.

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Forces through the Upper limbs when using Walking Aids

• If a person is utilizing a walking aid in a non-weight bearing or partial weight bearing manners, then most of the body weight will be transmitted through the upper arms via the walking aid to ground.

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Continued..

• Such a gait style creates joint moment forces on the shoulder of a similar magnitude to those on the hip joint during non-aided gait.

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Pre-walking Exercise Programmes

• As crutch walking is a learned skill, the patient must demonstrate adequate muscle strength, balance & co-ordination.

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Continued..

• The strength of the upper extremities can be increased by weight-resistive exercises graduated springs, the use of theraband & PNF techniques, etc.

• Balance exercises can occur in bed or by mat work.

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Gait Patterns with Walking

Aids

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Swing-to Gait

• In this gait both crutches are brought forward together. • The trunk & lower extremities lean forwards, weight is transferred to the upper limbs & walking aids & both lower limbs are lifted & swung forwards to the level of crutches

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Continued…

Swing-through Gait

• Both crutches are taken forward, then both lower limb are lifted & swung past the crutches, so that the crutches are left behind the point where the feet land on the floor.

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Continued..

• This gait is most commonly used by those with no lower limb control such as Spinal cord injury patients.

• Unsuitable for those with painful lower limbs.

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Ipsilateral Two-point Gait with One Stick

• Stick in the ipsilateral hand is move forward, together with the affected leg.

• Followed by the non-affected leg.

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Contralateral Two-point Gait with One Stick

• Contralateral hand and stick are moved, together with the affected leg.

• The weight is shared b/w the stick and affected side as the non-affected leg is brought through.

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Three-point Gait

• It requires two walking aids, either crutches or sticks followed by the affected leg then unaffected leg.

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Continued..

• If a minimal weight-bearing gait is required, e.g toe touching only, then a delayed three point gait must be utilized where the walking aid makes contact with the ground before the affected leg touches the floor.

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Continued..

• Partial weight bearing is often prescribed in orthopaedic conditions, with a gradual progression on weight bearing over time. E.g uncemented hip arthroplasty.

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Four-point Gait

• In this gait two walking aids are used, one for each leg. • The right walking aid is put forward, followed by the left leg, then the left walking aid and the right leg.

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Continued..

• A Four-point gait is ideal for balance & as a step to relearning a normal reciprocal gait pattern.

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Reciprocal Two-point Gait

• It uses two sticks, right leg and left stick being placed on the ground together, followed by left leg and right stick. • It provides a style of walking that allows fast walking speeds to be achieved. 50

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Orthotics

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• Orthotics (Greek: ortho, "to straighten" or "align") is a specialty within the medical field concerned with the design, manufacture and application of orthoses.

• An orthoses is a device applied directly and externally to the patient’s body with the object of supporting, correcting or compensating or an anatomical deformity or weakness

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Uses of orthoses

• Control, guide, limit and/or immobilize an extremity, joint or body segment

• To restrict movement in a given direction

• To assist movement generally• To reduce weight bearing forces for

a particular purpose.

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Foot orthoses

• Foot orthoses are specially designed shoe inserts that help support the feet and improve foot posture

• the foot is the point at which contact is made with the ground and reaction forces are generated

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1.Foot instability due to muscle weakness or imbalance

A. weak supinators:• On weight bearing, if supinators are

weak it will result in a pronated foot

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Corrective measures• Usage of medial flares• Wedge building into an insole• Heel cup or a flexible insole

Medial flare

Heel cups

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B.Weak pronators• A foot with a weak or

absent pronators will adopt a supinated position at foot contact.

Correction:• Valgus moment required by

a lateral flare or a wedge

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C.Weak extensors/flexors

• Claw toes: it consists of subluxation at the metatarsophalangeal joint, and flexion at the proximal (and distal interphalangeal joints)

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Continued….

• Hammer toes: plantar flexion deformity of the proximal interphalangeal joint, the abnormal plantar flexion of the distal phalanx may occur.

• Corrective measures includes Moulding using polyurethane or silicone materials

Continued….• Metatarsalgia:it is a condition

marked by pain under the metatarsal heads

• You may experience metatarsalgia if you're physically active and you participate in activities that involve running and jumping

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Corrective measures• An insole with either a

metatarsal dome or bar • A metatarsal bar fixed to the

bottom of the shoe• conservative treatments, such

as ice and rest Metatarsal bar under the shoe

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2.Foot instability or deformity due to structural misalignments

• Structural misalignments are often congenital and generally result in a foot with mobile joints but function about abnormal positions.

• Heel cup can be used to re align the foot in children

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3.foot instability or deformity due to loss of structural integrity

• Pain may result from joint instability or excessive motion

• The patient will try to avoid this pain by changing the portion of their foot that they present to the ground

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Heel pain causing diseases

Abnormal walking styles

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Pain relief measures

• Usage of shock absorbing insoles• Flexible medial arch support• Rose-parker insole

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Ankle-foot orthoses (AFO)

• An ankle-foot orthoses (AFO) is a most common orthoses or brace that encumbers the ankle and foot.

• They are also used to immobilize the ankle and lower leg in the presence of arthritis or fracture, and to correct foot drop.

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Types of AFOs

1.metal and leather: these have a leather covered cuff band with metal bars inserting into the heel of the shoe

2.plastic moulded: thermoplastic splints moulded to fit the limbs and inserted inside the shoe

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Knee-ankle-foot orthose(KAFOs)

• A knee-ankle-foot orthoses (KAFO) is an orthoses that encumbers the knee, ankle and foot.

• A KAFO can have a great effect on motion at these lower limb areas

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Metal and leather Thermoplastic moulded

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Cast braces

• These are used to maintain normal limb function while fracture healing occurs

• Most cast braces run parallel to the broken bone to provide a protective structure and guide during the healing process.

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Knee orthoses(braces)

• A knee orthoses (KO) or knee brace extends above and below the knee joint and is generally worn to support or align the knee

• Biomechanically difficult as they have to act with a short lever arm

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Trunk and limb braces

• The HKAFO is a knee-ankle-foot-orthoses with an extension of hip joint and pelvic components. These are used on patients requiring more stability of the hip and lower torso

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Types of HKAFOs

1.Hip guidance orthoses(HGO):

• Also called the pace walker has free hip joints between stops at the limit of flexion and extension

• The patient walks by using the arms and walking aids to move the trunk forward the weight is taken on forward leg to take step

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2.Reciprocating gait orthoses

• It has hip joints linked by a cable so that extension occurs on one side causes flexion on the other side

• The patient pushes down both the crutches and pulls pelvis forward leaning on one side

• Non-weight bearing leg moves forward with the help of the cable

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Reciprocating gait orthoses

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Advantages

HGO• Has low energy

consumption • Allows user to

achieve walking speed of 50% of normal individual

• Easy to wear and take off

RGO• Cosmetically

acceptable• Lighter• Gives ability to

the patient to stand unsupported

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