Locomotion and Assistive Devices

The Importance of Fitting the Client

It is very important to appropriately fit a client for the use of an assistive device. If the device is improperly fitted, it drastically increases the risk for fall and injury. The assistive device is supposed to help the client, not harm them. Having the device fitted properly ensures client safety and reduces the risk of injury. Having the device incorrectly fitted can lead to balance issues which is the reason as to why the risk for fall increases. Properly fitting a client for an assistive device is also important because if the device is incorrectly fitted, it can cause poor posture. Poor posture causes issues with balance. Having difficulties with balance, as stated before, increases the risk for fall and injury which is what we, as therapists, want to avoid. Having good posture allows for muscles to be able to function to the best of their ability. This is important because many of the assistive devices require certain muscles to function properly. Without a client's muscles functioning properly, they are at risk for injury. If a client's assistive device is not fitted properly, it can also cause them to use the device wrong. If the device is used wrong, it defeats the purpose of using a device at all. It can also cause them to get injured or hurt because using the device wrong can cause stability issues. It is also important to fit the client because you do not want them to try to do it themselves and end up doing it incorrectly. 

How to Fit the Client

In order to properly fit a cane, the handle must be at the same height of the client's greater trochanter, ulnar styloid, or wrist crease. If you are fitting a quad cane, the wider legs should be pointed away from the client. When the client is gripping the cane, the elbow should be at approximately 20-30 degrees of flexion. In order to properly fit axillary crutches, the handles must be at the same height of the client's greater trochanter, ulnar styloid, or wrist crease. The axillary rest should be 5 centimeters below the armpit. It can also be measured at about three fingers length when your thumb is pointing up. The elbow should be relaxed with slight flexion. In order to properly fit lofstrand crutches, the hand grip must be at the same height of the client's greater trochanter, ulnar styloid, or wrist crease. The hand grip should be placed forward. The hook must be at the upper third of the clients forearm, or two thirds up the forearm, near the elbow. The hook should be on the posterior aspect of the client's forearm. The elbow should be relaxed with slight flexion. In order to properly fit a rolling walker, the handles, or hand grips, must be at the same height of the client's greater trochanter, ulnar styloid, or wrist crease. The elbow should be relaxed and flexed at about 20-30 degrees. In order to properly fit a platform walker, the walker should be fitted to where the elbow is flexed to a 90 degree right angle when the shoulder is relaxed. The forearm is rested on the platform taking the weight. 

Going from Sit to Stand, Stand to Sit, and Ambulation 

In regards to walkers, when going from sit to stand, it is essential to get to the edge of the surface from which you wish to get up from. The walker should be placed in front of you at a reachable distance. The client should never use the walker to hold onto while standing. The client should use whatever surface they are on to push off of with their arms. The client should put their toes under their knees and use their leg muscles to help them stand. If the client is non-weight bearing, they should extend the involved leg off of the ground. Once they are standing they can then grab onto the walker. When going from stand to sit using a walker, it is essential for the client to go wherever they are trying to sit and back up so that the back of their legs are touching the bed or chair in which they wish to sit. Once they are in this position, the client should reach back using one hand at a time to touch the chair or bed. The client should not use the walker to hold onto when trying to sit down. Once the client is touching the surface that they wish to sit on, then may sit down. If the client is non-weight bearing, they should extend the involved leg in front of them and off the ground. The client should not plop down. They should use their leg muscles to slowly lower themselves into a sitting position. 

During ambulation when using a walker, the walker should be kept close to the body. The client should not be reaching for the walker. Their body should maintain inside of the walker, within the 3-4 points of the walker. When they are ready to walk, they then can lift the walker and place it in front of them while their body is still inside the walker.  The walker should be no more than arms length away from the client. They then can take a step towards the walker using their involved leg. The weight should be transferred into the hands. They should then swing through with the uninvolved leg. If the client is using a rolling walker, they can push the walker in front of them while their body is still within 3-4 points of the walker. If they are non-weight bearing, they should keep the involved leg off the ground. If the client wishes to turn, they should take multiple small controlled steps. 

When using crutches going from sit to stand, if a client is non-weight bearing, they should extend the involved leg in front of them so that it is off the ground. If the client can bear weight, they should keep both of their feet on the ground with their toes under their knees. The client should move to the edge of their seat and place both crutches on the involved side and grasp onto the hand grips. The other hand should be placed on whatever surface they are sitting on. The client should learn forward and push off the surface using their arms and push off the ground using their uninvolved leg. Once they have stood up, they can then adjust the crutches back to their normal positions, under both arms. If the client is using lofstrand crutches, the cuff should be around the forearm after standing and the cuff should be removed before sitting. When using crutches going from stand to sit, the client needs to go to wherever they are trying to sit and back up so that the back of their legs are touching the bed or chair in which they wish to sit on. Once they are in this position, they should place both crutches on the involved side and hold the hand grips. They should reach back with the opposite hand and place it on the surface that they wish to sit on. The client can then sit down slowly. It is essential for the client to not sit down abruptly. If the client is non-weight bearing, the client should keep the involved leg extended in front of them and off the ground.

In regards to ambulation for a client who is using crutches, the client should put the tips of the crutches in a tripod position. As stated before, if the client is non-weight bearing, they should keep the leg off the ground by extending the leg. The client should then transfer their weight into their hands that are holding the hand grips. They should not bear weight on their armpits. This can cause pain and injury to the area. The client should then swing through the crutches. If the client wants to turn, they should take many small controlled steps.  If the client is using lofstrand crutches, the handgrip should be facing forward. 

When going from sit to stand while using a cane, the client needs to get to the edge of whatever they are sitting on. Their feet should be positioned to where their toes are under their knees. The cane should be on the uninvolved side loosely in their hand. The client should put their hands on the surface of whatever they are sitting on, lean forward, and push up to stand up using both their arms and legs. When going from stand to sit while using a cane, the client needs to go to the seat and back up until the back of their legs are touching the seat. They should hold their cane loosely in their hand. The client should reach back with both of their hands for wherever they are trying to sit. They can then sit down slowly. It is essential for the client to not plop down into the seat.

In regards to ambulation for a client who is using a cane, the client should move the cane and the involved leg forwards simultaneously. If the client does not have good balance, they can move the cane forward first and then bring the involved leg forward. The client can then step with the uninvolved leg. The step should be beyond the involved leg. If the client wants to turn, they should take multiple small controlled steps. 

Safety Tips

When using any of the assistive devices listed above, it is essential to keep a clean and clutter free environment. All tripping hazards like loose rugs or stray cords should be removed to avoid falling. All devices should be kept nearby to avoid having to reach far or walk without the device to get it. Supportive shoes should be worn. Shoes that slip off should be avoided. The client should also be cautious of any slippery surfaces. The client should also know their limits and know what they are capable of. When using a walker, keep all legs on the ground. Do not lean on the walker to stand up. This can cause it to slip or tilt over. Stay inside the walker. The brakes should be locked if the walker has them when you are sitting. When using crutches, move slowly and do not get in a rush. Be cautious of the type of surface you are on and watch for uneven ground. When using a cane, keep it close to your body. Do not let it get too far in front of you or too far to the side of you. Be cautious walking on even ground and move slowly. 

Weisser-Pike, O. (2023, June). OT 430: Biomechanical aspects of occupational performance: Lab 10 transfers & adaptive devices [PDF]. Department of Occupational Therapy, The University of Tennessee Health Science Center.