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Ambulation aids (including walkers, crutches, and canes) are assistive devices that are used to help a person walk by providing extra support and stability.(1) This ATwiki article is designed as an introduction to ambulation aids, walkers specifically, but by no means represents an exhaustive description of current devices or clinical recommendations.
It has been estimated that more than 1.5 million people in the U.S. use walkers. However, researchers have estimated that 30% to 50% of patients abandon their ambulation aid soon after it is delivered to them.(6) This statistic reveals the criticality of an appropriate device selection, proper fit, and patient education and training.
Functions of Ambulation Aids
There are number of reasons for which a person may use an ambulation aid.(1,2,3) These may include the following:
- If he or she needs help compensating for:
- Impaired balance
- Weakened strength
- Difficulty coordinating movement
- Pain when bearing weight on the lower extremity (e.g. feet, knee, hip)
- Lower extremity amputation or congenital absence
- Altered stability
- To improve functional mobility
- To enhance body functions
- To assist with fracture healing
- To assist with propulsion
- To transmit sensory cues to the hands
- For the psychological benefits of standing
- To enable a wheelchair user to move through areas that are inaccessible to a wheelchair
- To reduce the risk of falling
- To protect a healing amputation site.
It is important to select the proper type of ambulation aid in order to provide the best security, safety, and function while minimizing energy expenditure.
Indications for Walkers
Walkers are typically indicated for patients who require maximum stability and support from an ambulation aid.(1) These patients include those with generalized weakness, extremely limited ability to bear weight on the lower extremity, very poor balance, and a variety of debilitating conditions. Like other ambulation aids, walkers can help users to feel more safe and confident, which may lead to increased activity and independence. Standing posture and walking provides physiological benefits such as enhanced venous return, improved renal function, and helps prevent osteoporosis and cardiorespiratory deconditioning. The maintenance of mobility may also allow users to maintain their occupational skills.(6)
Biomechanically, the benefits of walkers include an increased base of support within which the user’s center of mass can move without losing stability. The accompanying figure illustrates this enlarged based of support during walking with a standard non-rolling walker. Another biomechanical advantage is that the walker allows the upper extremities to develop reaction forces and moments at the handles in order to improve stability.(6)
Disadvantages of Walkers
In addition to the indications and advantages outlined above, healthcare professionals should also be aware of a number of disadvantages that might accompany the use of a walker. These may include the following: (1,4,5)
- Slower walking speed
- Abnormal gait pattern
- Difficult storage and transportation (e.g. in automobile)
- Difficulty using on stairs and steps
- Awkwardness in narrow passages or crowds
- May induce poor posture
- Often have limited usability outdoors.
For individuals with lower-limb amputations, standing and walking in the post-operative period is encouraged for those who have the ability to do so. To this end, some patients may require or prefer walkers because of the increased stability. However, clinicians often suggest that patients use crutches whenever possible. This is because walker users, with the associated hop-to gait pattern, may have difficulty adopting a smooth step-through gait when they eventually receive their prosthesis. The hop-to or step-to gait pattern used with a walker will prevent fluid progression of the user’s center of mass and may further increase energy expenditure. A wheeled walker that is advanced between steps may help reduce this disadvantage.(3)
Types of Walkers
There are a multitude of designs, features, and accessories that are currently available for walkers. The majority of designs employ four legs, and some designs include wheels at the tips of two or more of these legs. Other features include adjustability for proper fit and the ability to fold up for easier storage/transport. The following section outlines and describes a number of the available designs and options.(1,2,4,5,7-11)
Standard walkers employ a rigid design with 4 legs that are usually adjustable for patients of different heights. They are typically made of aluminum and are relatively lightweight and durable. For ambulation, these walkers require that the user lift the device and move it forward. Therefore, this design requires a certain degree of upper extremity strength and coordination.
Wheeled, or rolling, walkers include wheels that are attached to the front two or all four legs. These may be useful for patients who have difficulty lifting the walker for advancement, as is required for standard designs. These patients include those with especially poor balance, strength, or endurance. Research has suggested that users may be able to walk faster and with less attention demand when using a wheeled walker than with a standard design. They also may be able to negotiate side-walk cracks easier. However, wheeled walkers may be more difficult to use on carpets and are often bulkier and more difficult to transport.(2)
A possible danger with wheeled designs is that they may roll undesirably. A modification to the wheeled design includes retractable wheels that only touch the ground when the walker is offloaded (e.g. when advancing the walker forward). This design resists unwanted rolling when the user applies his weight to the walker, but not as well as standard rubber tips.
Another type of wheeled walker is the 3-wheel design. This style provides increased maneuverability but may not be as stable as 4-leg designs.
While the majority of these wheeled walkers are designed to be used with the frame in front of the patient, some are designed such that the walker frame is placed posterior. Some researchers have suggested that children with disabilities are able to walk faster and with more upright posture while using a posterior walker than with anterior ones.(2)
The reciprocating walker design has swivel joints that allow each side of the walker to be advanced forward alternatively and independently of the other. This allows a more reciprocal gait pattern than other designs, and thus may provide faster and less awkward walking.
Walkers have also been developed that attempt to improve stair-climbing ability. These designs require good balance and strong upper extremities. The extra size and weight might limit their usability.
One-handed (“hemi walker”)
One-handed designs have been developed to be used by patients who have limited or no use of one arm or hand.
Horizontal support surfaces can be added to walkers for patients who have weakness, pain, elbow contracture, or other deformity that makes grasping handles difficult. The disadvantages of this feature include added bulk and weight.
Features and Accessories
- Folding: many walker designs are foldable to allow easier transport. The folding feature may decrease the walker’s durability. Some users find that these walkers can be used in the folded position to help with stairs.
- Fold-down seats: allow the user to take rests.
- Tips: a number of different tip designs are available that make the walker easier to advance. For help with snowy or icy conditions, winterized tips can be added to improve traction.
- Trays, pouches, and baskets
Fitting a Walker
A patient can be measured for a walker while standing or recumbent. If a recumbent measurement is used, the fit should be reassessed once standing. For a starting point, the hand grip of the walker should sit at the wrist crease, ulnar styloid process, or greater trochanter of the patient as he/she stands erect with hands down at the side. A tape measure can also be used to measure for this starting point. Proper fit is critical; a poor fit could impede the user’s ability to perform the desired gait pattern and add to his/her instability in walking. To confirm that a proper fit has been attained, the walker should be positioned so that the rear feet are set at about the midpoint of the shoes (viewed in the sagittal plane). When the hands grasp the walker, the elbows should flex about 15 to 25 degrees. Finally, the fit should be assessed as the user ambulates to ensure that the walker functions properly with the desired gait pattern.(1,2)
Gait Pattern with a Walker
There are number of different gait patterns (sequences of foot and device movements) that a person can adopt while using an ambulation aid. In the typical gait for walking with a walker, the user first advances the walker, then the patient steps forward with one foot, followed by the other.(1,2)
References and Links
- Pierson FM, Fairchild SL, editors. Principles & Techniques of Patient Care, 3rd ed. Philadelphia, Pennsylvania: Saunders; 2002:213-272.
- Goldberg B, LeBlanc M, Edelstein J. Canes, crutches, and walkers. In: Goldberg B, Hsu JD, eds. Atlas of Orthoses and Assistive Devices. St. Louis, Missouri: Mosby; 1997:557-573.
- Lusardi MM, Nielson CC, editors. Orthotics and Prosthetics in Rehabilitation, 2nd ed. St. Louis, Missouri: Saunders; 2007.
- Kedlaya D, Kuang T. Assistive devices to improve independence. eMedicine from WebMD. 2007 http://www.emedicine.com/pmr/topic210.htm.
- Joyce BM, Kirby RL. Canes, crutches, and walkers. American Family Physician 1991;43(2):535-538.
- Bateni H, Maki BE. Assistive devices for balance and mobility: benefits, demands, and adverse consequences. Arch Phys Med Rehabil 2005;86:134-145.
|Author:||John D. Alexander|
|Affiliation:||Georgia Tech MSPO 2008|