Summer 2008

Practical Perspectives on Ambulation Aids
By Michael Moran, PT, DPT, ScD
Aging Well
Vol. 1 No. 3 P. 26

Selecting safe, effective ambulation aids for older adults involves a variety of factors. Guidelines vary with users’ needs and environments.

Older adults may require ambulation aids for a variety of reasons, such as pain or decreased balance, strength, and endurance. Such problems typically result from some sort of degenerative process such as arthritis (e.g., reduced strength from pain and/or inactivity). Other factors include injuries (often from a fall) and surgery. An ambulatory aid can increase independence for many older adults with these problems.

Practical Considerations
Typical ambulation aids include canes, crutches, and walkers. Selecting an ambulation aid requires the consideration of several factors, including changes in gait, weight-bearing status, fall risk, the environments that a person must negotiate, lifestyle, sensory input (such as vision and hearing), cosmesis (making someone or something look acceptable), and cognition. A general rule of thumb is to select the least restrictive device (e.g., a cane rather than a walker) that promotes independence to the greatest extent possible. Keep in mind that an aid is of no value if the individual won’t use it.

The optimal location for determining the ideal ambulation aids for older adults is in their living environments. In this context, environment means all or almost all of the places older adults typically inhabit in a normal day or week. For instance, it is unwise to select a device that aids mobility on level surfaces but hampers the use of steps. An example is a wide-base quad cane that aids a patient’s mobility in the home but has a base too large for proper use on the steps leading to or from the home. Another example is the type of walker designed for use on both level surfaces and steps but whose unwieldiness makes it impossible to navigate the steps of the bus used to go shopping.

Deciding what ambulation aids best suit older adults’ needs requires an accurate assessment of individuals and their typical environments. Community-based assessments often more accurately identify patient-specific issues and problems. While elders may try different ambulation aids in an institutional setting, such as a hospital or a rehabilitation facility, and may even be extensively trained in their uses, carryover to a home or community setting may be impractical or even unsafe.

Typical Problems and Potential Solutions
Surfaces (inside and outside): The most common surfaces an older adult needs to negotiate are level, inclined, and elevated (steps). Sometimes, an ambulation aid isn’t a solution; portable ramps or a wheelchair may offer better options. For instance, if individuals need to traverse a long, level distance, they may not have the necessary endurance. Using a wheelchair could be less stressful and help them avoid exhaustion.

Ice can be another obstacle in negotiating level surfaces. While ambulation aids can be outfitted with ice grips, it’s still inadvisable for older adults to walk on icy surfaces. The risk of falling is simply too great.

Walking isn’t the only concern related to the mobility of older adults. They need to possess the ability to change surface heights and levels safely. Stair glides and seat lift chairs can help previously dependent individuals become independent.

Securely mounted handrails can sometimes substitute for ambulation aids for elders who can negotiate steps. It’s important that the railings be secure and installed at a height suitable for the individual requiring assistance. In most situations, having the handrail at the level of the person’s greater trochanter (near the hip) is appropriate. If a landing is adjacent to the set of steps, the railings on the landing should be level rather than on angles as they are on the steps and likewise should be situated at the height of the greater trochanter.

Walking speeds: How quickly does the individual need to walk? Many times, a person’s preference determines walking speed. However, some situations, such as crossing a street with the traffic light, require traveling a given distance in a specific period of time. If ambulation aids such as walkers slow down elders so that they are unable to cross streets at a timely pace, it may be essential to consider one of several changes. The situation may require a different aid, retraining with a faster walking speed, or selecting an alternative means of crossing the street, such as taking the arm of another person.

Functional needs while using aids: Do individuals conduct all daily activities on one level or must they also use steps? Elders may benefit from having two of the same ambulation aids—one at the top and one at the bottom of the steps. Handrails then become the aid on the steps, but older adults don’t need to carry an extra device while using the steps.

Some older adults need to carry items with them as they walk. If they can use both hands, a single-hand aid such as a cane or crutch frees the other hand for carrying tasks. Different strategies are required if an elder uses both hands on ambulation aids (e.g., a walker or two canes or crutches). In using a walker, an older adult can attach a basket to the upper rail. However, experience shows that a weighted basket may cause the walker to tip forward while in use, possibly resulting in a fall. Tying a plastic bag to the front rail provides a preferable solution, lowering the center of gravity of the items being carried and making the walker more stable. The plastic bag should not hang too low or it can hamper the movement of the elder’s legs when walking forward.

If an older adult requires two crutches, a fanny pack fastened around the waist works well to carry small items. It’s essential for individuals to secure packs appropriately because if they fall to the ground, elders may be unable to retrieve them safely.

Fitting Ambulation Aids
Variations in footwear provide the most challenging problem in fitting ambulatory aids. Individuals select and wear different shoes or sometimes no footwear at all. Slippers, shoes, boots, and other footwear can effectively change a person’s height. Aids fitted when older adults wear sneakers may be too tall for the same individuals who walk to the bathroom at night wearing nothing on their feet. While it’s uncommon, some people use a night cane, or one fitted for use without footwear.

Another factor to consider when fitting an ambulation aid is a change in posture. A device suited to a person walking in a flexed trunk posture may become too short if the individual can assume a more upright posture. For example, if older adults use an aid to help relieve low back pain and subsequent medical intervention, such as injections in the back, relieves the pain, it’s likely they would assume a more upright posture and the aid would need to be refitted. In some cases, the pain relief eliminates the need for an aid.
Unfortunately, some patients demonstrate an increased flexion posture (e.g., from increasing kyphosis associated with spinal osteoporosis and/or compression fractures). In such cases, height adjustment of the aid to accommodate for a shorter individual is usually necessary.

Selecting an ambulation aid sometimes requires the consideration of products not originally intended for older adults. For instance, if a person is quite short, pediatric equipment may provide a solution. Another example is a bariatric patient whose body dimensions require specialized aids. Fortunately, searching the Internet for devices is relatively simple. Selection, however, requires professional judgment for making appropriate choices among various ambulation aid options and attachments.

Keeping It Practical and Effective
Needs for ambulation aids can change over time. An older adult recovering from hip replacement surgery may need a walker at first but eventually progress to walking with a cane and, ultimately, with no aid at all. In selecting ambulation aids of any kind, there are many such factors to consider.

Walkers are multilegged items that can include wheels of varying heights and widths. Since inappropriate wheels can increase the energy required to move the walker on carpeted or irregular surfaces, wheel selection is critical. Usually, wheels are installed on the front legs of a walker. Modification of a walker’s back legs allows some older adults to ambulate better with a wheeled walker. Tennis balls on a walker’s back legs permit them to slide more easily on some surfaces such as tile. However, the drag of the tennis balls on carpets may be more than an older adult can handle. For use on carpet and most surfaces, plastic skis on the back legs can reduce friction.

While some walkers are designed for use on steps, experience proves that the added weight and difficulty of use outweigh the benefits. As previously noted, even if a walker can be used on steps in a home, it probably won’t be useful on other types of steps, such as on a bus. Also, if handling the weight of a device such as a standard “pickup” walker leads to fatigue, it may increase the risk of a fall. In such cases, adding wheels may allow a patient to walk functionally but avoid excessive fatigue.

With some wheeled walkers, brakes may be an appropriate feature. Brakes can be operated by exerting downward pressure on a part of the walker or by squeezing a lever-type hand attachment. It’s important for the individual to be capable of functionally using the brakes. An increased tendency to fall may occur if elders use a brake that requires squeezing a device, causing his or her hand to lose contact with the support grip.

The most commonly used crutches are axillary crutches, or the kind that fit under a person’s upper arm. One problem specific to axillary crutches is that older adults tend to lean on the part that comes up under the shoulder, especially if the crutches are too long. Placing weight on the top of the crutch in this way can lead to discomfort, but a proper crutch height can effectively eliminate the problem. By design, the top of the axillary crutch will come near the individual’s underarm. If clothing is in the way, the top of the crutch may not lie squarely under the axilla and can move forward abruptly during use, possibly leading to a fall. In this case, patient education and adherence to proper technique provide the ideal solution.

Another common problem with axillary crutches is that even though the length of the crutch may be correct, the handgrip can be located improperly. While variations depend on specific patient needs, the handgrip is usually placed so that the angle of the elbow is approximately 45 degrees.

Lofstrand crutches, also called Canadian or cuff crutches, are shorter than axillary crutches and have a cuff that fits around an older person’s arm near the wrist. Lofstrand crutches are designed to stay with elders as they use their hands for daily tasks, such as putting a key in a door. If the cuff is too loose, however, the crutch can fall away, leaving an individual without the aid.

Canes vary considerably in both appearance and use. Canes are meant to help individuals with balance, not individuals who have weight-bearing limitations. Canes are typically single-arm items, though an older adult may occasionally need one for each hand. Commonly called straight canes, these aids are in fact rarely straight. The top part of the cane usually has a rounded appearance. The rounded portion may serve as the hand grip, or a molded grip may be used.

Canes may have a single support leg or several, such as a quad cane with four support legs. Designs vary, but quad canes are usually grouped as those having either a narrow or wide base. While more stable than a single-leg cane, quad canes have the possible disadvantage of being too large to fit entirely on a step. One solution is to turn the quad cane sideways, but that changes the function of the handgrip.

Lessons Learned
Over three decades of working with community-based older adults, the most frequent problem I’ve encountered arises when an older adult uses an ambulation aid that was fitted for another person. While their efforts are well intentioned, local community groups that lend ambulation aids usually don’t have specialists to fit the devices to the older adults who intend to use them.

Frequently, the situation may result in an older adult attempting to use an aid that is too short or too tall. Older adults sometimes also take time- or money-saving shortcuts when attempting to use an aid fitted for another individual, such as a deceased spouse or family member. Many physical therapists perform pro bono work in their communities, offering their assistance to older adults who need to use ambulatory aids.

As you may expect, in the course of daily use, ambulation aids may bump into walls, especially corners. Mounting plastic strips called outside corners helps prevent damage.

Many older adults use ambulation aids. Properly chosen and fitted aids can reduce dependence and enhance independence. It’s essential for caregivers to remember that an older adult’s needs for ambulatory aids may vary over time. And the type of ambulation aid required may change as an older adult’s condition changes. Professional input can make the difference between safe and unsafe situations.

— Michael Moran, PT, DPT, ScD, is a tenured professor of physical therapy at Misericordia University in Dallas, PA, who has published extensively. With more than 30 years’ experience in working with older adults, he focuses specialized efforts on helping elders remain in their own homes.

Safety First
Whether living at home or in care facilities, older adults are vulnerable to accidents and other difficulties, many of which could be avoided. Among the most common problems are falls the improper use of an ambulation aid or using the wrong ambulation aid.

Selecting the right aid requires a mix of experience, insight, and data from research literature. For instance, physicians and nurses often express concern that a particular older adult is “a disaster waiting to happen” because of an aid selected especially for that individual. One recent case involved a patient who was an amputee. Other professionals expressed concern that the wheeled walker I had selected would “get away from him” and lead to a fall. I had carefully assessed the individual and found that a wheeled walker was less tiring for him. One particular reason I chose a wheeled walker was his tendency to lean forward over the four-footed walker to reach for items. This resulted in a loss of balance. With the wheeled walker, the elder simply turned the walker slightly to the side, making reaching safe. Literature shows that for carefully selected older adults, a wheeled walker is as safe as a four-footed model (Tsai, Kirby, MacLeod, & Graham, 2003).

Even a correctly chosen ambulation aid can be used improperly. And an aid that was appropriate for one person may be completely unsuited for use by another individual. In the homes of elders where I have conducted needs assessments, I’ve encountered individuals using aids that are clearly neither fitted nor appropriate for them.

A woman who had sustained a mild stroke but whose mobility remained functional chose to use a quad cane that had belonged to her deceased husband. While quad canes can be very helpful to a person who has sustained a stroke, she was using a device that was too tall for her. Additionally, the base of the quad cane was quite large, and she occasionally caught her feet on it. Switching to a narrow-base quad cane of the appropriate height resulted in her safe ambulation.

Selecting an ambulation aid is usually best done by a physical therapist, in the environment where it will be used. This helps to assess an older adult’s willingness to use an aid and to identify common obstacles not typically seen in a clinician’s office.

— MM

Reference
Tsai, H. A., Kirby, R. L., MacLeod, D. A., & Graham, M. M. (2003). Aided gait of people with lower-limb amputations: Comparison of 4-footed and 2-wheeled walkers. Archives of Physical Medicine and Rehabilitation, 84(4), 584-591.

Resource
United Spinal Association Tech Guide: www.usatechguide.org