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Jun.19.2020

Elsevier Clinical Skills

Assistive Device Training: Walkers (Rehabilitation Therapy)

OVERVIEW

A walker is an assistive device used to provide stability and relieve full or partial weight bearing on a lower extremity. Of the possible assistive devices available (crutches, canes, or walkers), walkers provide the greatest anterior and posterior stability and base of support.1 Walkers are typically made of lightweight aluminum and are easily adjusted using pushpins on the legs. Standard walkers have molded handgrips and rubber tips on all four legs. They come in a variety of sizes, including tall, adult, youth, child, and bariatric. There are a variety of different features available, including folding, reciprocal, stair climbing, and two- and four-wheeled walkers (also known as rollators).1 Selection of the walker type and features depends on the patient's needs (Table 1)Table 1. Use of a walker does not negatively impact rehabilitation or functional outcomes and may boost confidence needed to attain maximum mobility.2

To adjust the height of the walker, the patient should stand upright inside the walker with arms straight at his or her sides. The handgrip should be level with the patient's wrist crease, ulnar styloid process, or greater trochanter of the hip. Adjusting the walker to this height allows sufficient elbow flexion (20 to 25 degrees1) to enable the patient to lift his or her body weight off the floor (Figure 1)Figure 1.

Gait pattern is determined by the required weight-bearing status. When using a standard walker and full weight-bearing status, the patient lifts the walker and moves it forward. Then he or she takes a step forward with one foot and then the other while taking as much support as needed on the walker, and the cycle is repeated.1 Use of a wheeled walker allows for a more natural, reciprocal gait pattern, providing a smoother forward progression. With any walker, but especially a rolling walker, the patient may let the walker get too far forward. This could cause the patient to fall forward. To teach the patient the appropriate forward placement of the walker, the therapist should place a folded towel under each of the patient's arms. The towels should be held in place while using the walker.

When using a walker with a partial weight-bearing status, the patient lifts and advances the walker a comfortable distance. The involved lower extremity is placed on the floor bearing the appropriate amount of weight. Weight is shifted to the arms, and the patient steps forward with the uninvolved lower extremity.

When using a walker with a non–weight-bearing gait, a three-point gait pattern is used where the patient stands on the uninvolved lower extremity and uses both hands to lift and advance the walker. The patient then hops or steps to the walker on the uninvolved lower extremity. If the involved lower extremity is casted or held in knee extension, the involved extremity is lifted off the ground and held slightly in front of the uninvolved lower extremity during gait. If the involved lower extremity is not casted or held in knee extension, patients will typically flex the knee and hold the involved lower extremity in that position during forward progression.

When guarding a patient who is using a walker, the therapist stands on the involved side and slightly behind the patient, with one hand on the transfer belt. When guarding a patient on the stairs, the therapist stands behind him or her when ascending stairs and in front or behind him or her when descending stairs (Figure 2)Figure 2.1

SUPPLIES

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EDUCATION

  • Explain to the patient and caregiver the purpose of using a walker as well as these precautions:
    • Maintain good posture with the head up, looking forward to avoid tripping on objects on the floor.
    • When turning while using a walker, take small steps toward the less-involved side.
    • When sitting down or rising from a chair, be sure to place hands on the arms of the chair, not the walker. Then, while standing with good balance, reach for the walker.
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  5. Assess the patient for pain.
  6. Determine the indications for walker use and confirm the patient's weight-bearing status.
  7. Perform a thorough review of patient's medical history.
  8. Assess the patient's vital signs and laboratory values based on the diagnosis.
  9. In a confident tone using lay language, describe and demonstrate the use of a walker.
    1. During the demonstration, use the walker in the same manner and weight-bearing status that the patient will use.
    2. Demonstrate how the patient should rise from a chair using the walker.
  10. Apply a transfer belt for safety. Inform the patient that the therapist will be guarding him or her by placing one hand on the transfer belt. Stand on the involved side slightly behind the patient so as not interfere with locomotion.
  11. Teach the patient to stand.
    1. Instruct the patient to scoot to the edge of the chair.
    2. Instruct the patient to position the walker comfortably in front of him or her.
    3. Instruct the patient to stand before reaching for the walker. Teach the patient that using his or her arms on the armrests when standing and sitting is permissible.
    4. When the patient is standing with good balance, instruct him or her to place both hands on the walker.
  12. While the patient is standing, examine the walker's height to ensure that it is appropriate. With the patient standing with arms relaxed at his or her sides, the top of the walker should come to his or her wrist (Figure 1)Figure 1.
  13. Teach the patient the appropriate gait pattern (Figure 2)Figure 2.
  14. Teach the patient how to return to a sitting position.
    1. Instruct the patient to take small steps in a circle toward the uninvolved (or less- involved) side.
    2. Instruct the patient to back up until the edge of the chair is felt behind his or her legs.
    3. Instruct the patient to release the walker and reach for the armrests of the chair.
    4. Instruct the patient to lower himself or herself safely to the chair in a controlled manner.
  15. When the patient is safe and confident using a walker on level surfaces, teach him or her how to ascend and descend stairs, if appropriate.
    1. Ensure that the walker will fit on the stairs securely with the front two legs against the back of the stairs.
    2. If the walker does not fit on the stairs, or if the patient is not comfortable using a walker on the stairs, teach him or her to ascend and descend stairs sitting on his or her buttocks.

Ascending and Descending Stairs with a Railing

  1. Teach the patient to ascend stairs with a railing.
    1. Instruct the patient to hold on to the railing on one side and the walker on the other.
    2. Instruct the patient to move the stronger or uninvolved lower extremity up first, followed by the weaker or involved lower extremity, using the railing and the walker to take as much weight as needed.
    3. When the patient is stable, instruct him or her to move the front legs of the walker up onto the stair on which he or she is standing.
    4. Instruct the patient to repeat this cycle to ascend stairs with a railing (Figure 2)Figure 2.
  2. Teach the patient to descend stairs with a railing.
    1. Instruct the patient to hold on to the railing on one side and the walker on the other.
    2. Instruct the patient to descend the stairs by placing the front legs of the walker on the step below him or her with the rear legs on the same step on which he or she is standing.
    3. Instruct the patient to lead with the weaker or involved lower extremity first, followed by the stronger or uninvolved lower extremity.
    4. Instruct the patient to lower the walker to the next step.
    5. Instruct the patient to repeat this cycle to descend stairs with a railing.

Ascending and Descending Stairs without a Railing

  1. Teach the patient to ascend stairs without a railing.
    1. Instruct the patient to step up with his or her stronger or uninvolved lower extremity.
    2. Instruct the patient to place pressure on the walker.
    3. Instruct the patient to step up with his or her weaker or involved lower extremity.
    4. Instruct the patient to bring up the walker.
    5. Instruct the patient to repeat this cycle to ascend stairs without a railing.
  2. Teach the patient to descend stairs without a railing.
    1. Instruct the patient to move the walker down to the next step.
    2. Instruct the patient to move his or her weaker or involved lower extremity.
    3. Instruct the patient to move his or her stronger or uninvolved lower extremity.
    4. Instruct the patient to repeat this cycle to ascend stairs without a railing.

Ascending and Descending Stairs on Buttocks

  1. Teach the patient to ascend stairs on his or her buttocks.
    1. Instruct the patient to use the walker to turn and sit on the step. If the walker folds, the patient may be able to carry it on his or her lap while ascending the steps. If not, another person should carry the walker up the stairs.
    2. Instruct the patient to hold up the involved leg and use his or her arms to lift his or her body up onto the next step. Teach the patient that it may be helpful to push off the step below with his or her stronger leg.
    3. Instruct the patient to repeat this cycle to ascend stairs on his or her buttocks.
    4. When the patient reaches the top, instruct him or her to stand and use the walker as previously instructed.
  2. Teach the patient to descend stairs on his or her buttocks.
    1. Instruct the patient to sit at the top of the stairs. If the walker folds, the patient may be able to carry it on his or her lap while descending the steps. If not, another person should carry the walker down the stairs.
    2. Instruct the patient to hold the involved leg off of the step and to lower himself or herself to the stair below.
    3. Instruct the patient to repeat this cycle to descend stairs on his or her buttocks.
    4. When the patient reaches the bottom, instruct him or her to stand and use the walker as previously instructed.

Completing the Procedure

  1. Perform hand hygiene.
  2. Document the procedure in the patient's record.

MONITORING

  1. Observe the patient for signs and symptoms of pain. If pain is suspected, report it to the authorized practitioner.
  2. Observe the patient for signs of fatigue, dizziness, nausea, or breathlessness. If observed, immediately lower the patient to a chair and take his or her vital signs. Proceed based on findings.
  3. Guard the patient appropriately throughout the treatment session.
  4. Monitor the patient's vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation to be certain his or her condition will allow for the energy expenditure required of a walker.

EXPECTED OUTCOMES

  • Patient is able to sit and stand in a safe manner using the appropriate walker
  • Patient ambulates with a walker on level surfaces in a safe manner
  • Patient is able to ascend and descend stairs in a safe manner with the appropriate walker

UNEXPECTED OUTCOMES

  • Patient falls when using a walker on level surfaces or when going up or down stairs
  • Patient experiences hand or wrist pain

DOCUMENTATION

  • Patient and caregiver education
  • Patient's progress toward goals
  • Level of assistance provided, including verbal instruction
  • Device, gait pattern, and weight-bearing status used
  • Patient's response to treatment
  • Complications and related interventions

OLDER ADULT CONSIDERATIONS

  • Watch for signs of instability or dizziness when the patient changes positions.
  • Before instructing an older adult patient in how to use a walker, assess for impaired cognition, because it may affect communication and influence treatment outcomes.
  • Falls linked to use of walkers have been documented in older adults. Be certain the device has been appropriately adjusted and is being used appropriately on all surfaces.

REFERENCES

  1. Fairchild, S.L., O’Shea, R.K., Washington, R.D. (2018). Chapter 9: Assistive devices, patterns, and activities. In Pierson and Fairchild’s principles & techniques of patient care (6th ed., pp. 211-260). St. Louis: Elsevier.
  2. Vogt, L. and others. (2010). Rollator use and functional outcome of geriatric rehabilitation. Journal of Rehabilitation Research and Development, 47(2), 151-156. doi:10.1682/JRRD.2009.09.0148 (classic reference)* (Level IV)

ADDITIONAL READINGS

Foley, M., Bowen, B. (2014). Comparison of metabolic cost and cardiovascular response to stair ascending and descending with walkers and canes in older persons. Archives of Physical Medicine and Rehabilitation, 95(9), 1742-1749. doi:10.1016/j.apmr.2014.03.032 (classic reference)* (Level V)

*In these skills, a "classic" reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports