Assistive Device: Walkers

There are three major categories of ambulatory assistive devices: canes, crutches, and walkers. This post is the last of the series, and we will talk about walkers. Visit our previous posts about canes and crutches.

Assistive devices are prescribed for a variety of reasons, including problems of balance, pain, fatigue, weakness, joint instability, excessive skeletal loading, and cosmesis.  Another primary function of assistive devices is to eliminate weight bearing fully or partially from a lower limb. This unloading occurs by transmission of force from the upper limbs to the floor by downward pressure on the assistive device.

Walkers

Walkers are used to improve balance and relieve weightbearing either fully or partially on a lower extremity. Of the three categories of ambulatory devices, walkers afford the greatest stability. They provide a wide base of support (BOS), improve anterior and lateral stability, and allow the upper extremities to transfer body weight to the floor.

Walkers are typically made of tubular aluminum with molded vinyl handgrips and rubber tips. They are adjustable in adult sizes from approximately 32 to 37 in., with children`s, youth, and tall sizes available. Several design variations and modifications to the standard design are available and are described below.

Glides

Glides are small, plastic attachments placed on the posterior legs of walkers typically in combination with wheels on the front legs. They promote a smooth forward progression without having to lift and place the walker with each step. They are typically made of high-density plastic in an inverted mushroom-shape. Other common glide designs include a 1-in. diameter “disk” with a central stem that slides into the tubular leg and is tightened into place with a screwdriver; and a fitted cap that is placed directly onto the walker leg (in the same manner the rubber tip is attached). Another style of glide incorporates a tennis ball within a fixed housing.

Folding Mechanism

Folding walkers are particularly useful for patients who travel. These walkers can be easily collapsed to fit in an automobile or other storage space.

Handgrips (Handles)

Enlarged and molded handgrips are available, and may be useful for some patients with arthritis. Some walkers offer a second set of handles to assist with sit-to-stand transitions.

Platform Attachments

This adaptation is used when weight bearing is contraindicated through the wrist and hand (described in the crutch post).

Wheel Attachments

This adaptation to walkers (often called rollators or rolling walkers) includes the addition of wheels (either to the two front wheels only or to all four wheels). The addition of wheels frequently allows functional ambulation for patients who are unable to lift and to move a conventional walker (e.g., frail elderly). Swivel wheels turn freely in a complete circle. Fixed wheels rotate around a central axis. Wheels are generally available in 3-, 5-, and 6-in. diameters. Eight-inch diameter wheels are also available and can be used to add height for tall users.

Swivel wheels

Fixed wheels

Braking Mechanism

A braking system is an essential feature of walkers designed with wheels. Walkers with four wheels frequently include handbrakes that lock the rear wheels. Posterior pressure brakes are effective when wheels are placed only on the front walker legs.

Tripod Rollators 

Three-wheel collators incorporate a tripod design. A major advantage of this device is ease of maneuverability and turning. Height adjustments are made at the handles; the unit folds for storage and travel.

 

Sitting Surface

A variety of seat walker designs are available that fold out of the way when not in use. The structural design of many walkers also includes a contoured back support. Seats are an important consideration for individuals with limited endurance (i.e., post-polio syndrome) as well as for community ambulatory who require periodic rest intervals. Walker seats should be carefully examined for stability and safety with respect to individual patient needs. Patient practice in use the walker seat should be provided.

Reciprocal Walkers

These walkers are designed to allow unilateral forward progression of one side of the walker. A disadvantage of this design is that some inherent stability of the walker is lost. However, they are useful for patients incapable of lifting the walker with both hands and moving it forward (in situations in which a rolling walker might be contraindicated).

Advantages: Conventional walkers provide four points of floor contact with a wide BOS. They provide a high level of stability. They also provide a sense of security for patients fearful of ambulation. They are relatively lightweight and easily adjusted.

Disadvantages: Walkers tend to be cumbersome, are awkward in confined areas, and are difficult to maneuver through doorways and into cars. They eliminate normal arm swing and cannot be used safely on stairs.

Measuring Walkers

The height of a walker is measured in the same way as that of a cane. The handgrip or handle of the walker should come to approximately the greater trochanter and allow for 20 to 30 degrees of elbow flexion.

Gait Patterns: Conventional Walkers

Prior to initiating instruction in gait patterns using a conventional walker (4 points of floor contact without wheel attachments), several points related to use of the walker should be emphasized with the patient:

• The walker should be picked up and placed down on all four legs simultaneously to achieve maximum stability. Rocking from the back to front legs should be avoided because it decreases the effectiveness and safety of the assistive device.
• The patient should be encouraged to hold the head up and to maintain good postural alignment; forward flexion of the trunk, neck, and head should be avoided.
• The patent should be cautioned not to step too close to the front crossbar. This will decrease the overall BOS and may result in a fall.

There are three types of gait patterns used with conventional walkers. These are the full, partial, and non-weightbearing gaits (rolling devices are not recommended for patients with altered weight bearing status). The sequence for each pattern follows.

Full Weightbearing Gait

1. The walker is picked up and moved forward about an arm`s length.
2. The first lower extremity is moved froward.
3. The second lower extremity is moved forward past the first.
4. The cycle is repeated.

Partial Wightbearing Gait

1. The walker is picked up and moved forward about an arm`s length.
2. The involved lower extremity is moved forward, and body weight is transferred partially onto this limb and partially through the upper extremities to the walker.
3. The uninvolved lower extremity is moved forward past the involved limb.
4. The cycle is repeated.

Non-Weightbearing Gait

1. The walker is picked up and moved forward about an arm`s length.
2. Weight is then transferred through the upper extremities to the walker. The involved limb is held anterior to the patient`s body but does not make contact with the floor.
3. The uninvolved limb is moved forward.
4. The cycle is repeated.

Note: Rolling walkers generally allow use of a reciprocal gait pattern as the walker can be rolled forward while walking. As the need to lift the walker forward following each step is eliminated, a smoother forward progression can be achieved.

Assuming Standing and Seated Positions with Walkers

Coming to Standing 

• The patient moves forward in the chair.
• The walker is positioned directly in front of the chair.
• The patient leans forward and pushes down on armrests to come to standing.
• Once in a standing position, the patient reaches for the walker, one hand at a time.

Return to Sitting 

• As the patient approaches the chair, the patient turns in a small circle toward the strong side.
• The patient backs up until the chair can be felt against the patient`s legs.
• The patient then reaches for one armrest at a time.
• The patient lowers to the chair in a controlled manner.

Source: Susan B. O`Sullivan, Thomas J. Schmitz. Physical Rehabilitation.