IMPORTANT!

Follow These Rules for Safety and Comfort

Dont look down. Look straight ahead as you normally do when you walk.
Dont use crutches if you feel dizzy or drowsy.

Dont walk on slippery surfaces. Avoid snowy, icy, or rainy conditions.

Dont put any weight on the affected foot if your doctor has so advised.

Do make sure your crutches have rubber tips.

Do wear well-fitting, low-heel shoes (or shoe).

Do position the crutch hand grips correctly (see Sizing Your Crutches)

Do keep the crutch pads 11/2" to 2" below your armpits.

Do call your foot and ankle surgeon if you have any questions or difficulties

Four-Point Crutch Gait

Indication:
Weakness in both legs or poor coordination.
Pattern Sequence:
Left crutch, right foot, right crutch, left foot. Then repeat.
Advantages:
Provides excellent stabilty as there are always three points in contact with the ground

Disadvantages:
Slow walking speed

Three-Point Crutch Gait

Indication:
Inability to bear weight on one leg. (fractures, pain, amputations)
Pattern Sequence:
First move both crutches and the weaker lower limb forward. Then bear all your weight down
through the cruthes, and move the stronger or unaffected lower limb forward. Repeat.
Advantages:
Eliminates all weight bearing on the affected leg.
Disadvantages:
Good balance is required.
Two-Point Crutch Gait

Indication:
Weakness in both legs or poor coordination.
Pattern Sequence:
Left crutch and right foot together, then the right crutch and left foot together. Repeat.
Advantages:
Faster than the four point date.
Disadvantages:
Can be difficult to learn the pattern.
Swing-Through Crutch Gait

Indications:
Inability to fully bear weight on both legs. (fractures, pain, amputations)
Pattern Sequence:
Advance both crutches forward then, while bearing all weight down through both crutches,
swing both legs forward at the same time past the crutches.
Advantage:
Fastest gait pattern of all six.
Disadvantage:
Energy consuming and requires good upper extremity strength.

Swing-To Crutch Gait

Indications:
Patients with weakness of both lower extremities.
Pattern Sequence:
Advance both crutches forward then, while bearing all weight down through both crutches,
swing both legs forward at the same time to (not past) the crutches.
Advantage:
Easy to learn.
Disadvantage:
Requires good upper extremity strength.
Tripod Crutch Gait

Indications:
Initial pattern for patients with paraplegia learning to do swing to gait pattern.
Pattern Sequence:
Advance the left crutch, then the right crutch, then drag both legs to the crutches
Advantage:
Provides good stability.
Disadvantage:
Very energy consuming.

Walking with crutches is not an inherent skill. Thus, techniques on ambulating with crutches
should be taught to the patient. However, since each patient has different learning needs all
patient education should be individualized.
Preparation
Before teaching the client how to ambulate with crutches, the following things should be
instructed to the patient:
P Patient is instructed to wear a sturdy and well-fitting shoe
R Rationalize the intervention of teaching the client to support his or her weight on the hand
pieces not the axilla. The pressure of the crutch can damage the brachial plexus nerves producing
crutch paralysis.
E Explain and demonstrate to the patient the techniques on how to manipulate the crutches
before the patient attempts to do so.
P Prepare the client for maintaining balance by asking him or her to stand on the unaffected leg
by a chair. Holding the patient near the waist or using a transfer belt would be helpful in
promoting balance.
Techniques for Independent Crutch Walking or Ambulation
Before a patient can ambulate using crutches alone, he or she needs to be instructed first on the
different techniques. The following instructions should be given to the patient.
Sitting Down

To sit down, grasp the crutches at the hand pieces. This is to promote control while
mobilizing.
Slightly bend forward while assuming a sitting position.

To prevent weight-bearing and flexion, place the affected leg forward.

Standing Up

With the string leg slightly under the chair, move towards the edge of the seat.
Place both crutches in the hand on the side of the affected extremity.

While raising the body to a standing position, push down on the hand piece.

Going DOWN the stairs

Walk forward as much as possible on the step.

Advance the crutches to the lower step, and then slowly advance the weaker leg first
followed by the stronger one. Using this technique, the stronger extremity shares with the
arms the work of raising and lowering body weight.

Going UP the stairs

Step the strong leg first to the next step.

Advance the crutches with the weaker extremity. An important reminder is to keep in
mind that the strong leg is the one that goes up first and comes down last. Memory device
to avoid confusion is to remember this phrase, up with the good and down with the bad.

Cane
A cane is used to help a patient walk with greater balance and support. Aside from the mentioned
benefits a cane is also used to help relieve pressure on the weight-bearing joints by redistributing
the weight of the body.
Types of cane:
1. Single or straight cane one-footed canes
2. Tripod cane three-footed canes
3. Quadripod cane four-footed canes. This type of cane provides more stability than the
single canes.
For safe cane use, this assistive walking device should be fitted with a gently flaring tip that has
flexible and concentric rings. The tip with its concentric rings provides optimal stability which
functions as a shock absorber and enables the patient to walk with greater speed but less fatigue.
Proper Cane Use:
1. The cane is fitted by instructing the patient to flex the elbow at a 30 degree angle.
2. The patient should hold the handle approximately level with the greater trochanter.
3. The tip of the cane should be placed 15 cm or 16 inches lateral to the base of the fifth toe.
4. The cane is held in the hand OPPOSITE to the affected extremity.
5. In normal walking: the opposite leg and arm move together, a movement called
reciprocal motion. This motion should be carried through when walking with cane.
Nursing Responsibility for Patients with Canes
1. It is one of the crucial responsibilities of the nurse to continually assess the stability of the
patient.
2. The nurse should also keep in mind to consider patient safety all the time (protecting the
patient from falls).

3. When walking with a patient on cane, the nurse walks with the patient while holding at
the waist as needed for balance.
4. Tolerance of walking should also be assessed by the nurse.
5. Rest periods should be provided as necessary.
Ambulating with Cane: Cane-foot sequence
1. The hand opposite to the affected extremity holds the cane to widen the base of support
and to reduce stress on the affected limb.
2. As the cane is advanced, the affected leg is also moved forward at the same time.
3. The cane should be kept fairly close to the body to prevent leaning.
4. When the unaffected extremity begins the swing phase, the client should bear down on
the cane.
Ambulating with Cane: Cane-foot sequence: Going Up the Stairs
1. To go up the stairs, step up on the unaffected extremity.
2. Place the cane and affected extremity up on the step.
Ambulating with Cane: Cane-foot sequence: Going Down the Stairs
1. To go down the stairs, place the cane and affected extremity down on the step.

2. Step down the unaffected extremity.

Walker
When more support and stability is the issue, walkers are better provider of these features than a
cane or a crutch. Unlike canes, walkers do not permit a natural reciprocal pattern which makes its
an ideal walking assistive device for patients who have poor balance or limited cardiovascular
reverse or those who cannot use crutches.
Proper Walker Use
1. The height of the walker is adjusted to the patient. Walkers should be at the hip level of
the patient using it.
2. The patients arm should rest on the walker. The hand grips should exhibit 20 to 30
degrees of flexion at the elbows.
3. The patient should wear sturdy and well-fitting shoes.
Assisting Patients with Walkers
1. The nurse continually assesses the patients stability and protects the patient from falls.
2. The nurse walks with the patient by holding him or her at the waist as needed for balance.
Ambulating with Walkers
1. The walker should be held on the hand grips for stability.
2. Instruct the patient to lift the walker and place it in front by leaning his or her body
slightly forward.
3. When walking with walker, the patients body weight should be supported by the hands
when advancing the patients weaker leg. This permits partial weight bearing or nonweight bearing as prescribed.
4. The patient balances on his or her feet.

5. Lift the walker and place it in front again and continue the same pattern of walking.

Crutches
A crutch is an ambulatory aid that provides support and balance to patients. It is a convenient
method of getting a patient from one place to another. For crutch walking to be possible, good
balance and erect posture are essential.
Who can use crutches?

Patients who are prescribed partial weight-bearing or non-weight bearing ambulation may
use crutches.

Who determines if crutches are appropriate ambulatory aids for the patient?

The nurse or physical therapist determines if crutches are appropriate ambulatory aids for
the patient.

To promote safety when crutch walking the following is important to keep in mind:
1. Crutches should have large rubber suction tips.
2. Patients should wear well-fitting shoes that have firm soles.
3. Crutches must be adjusted to the patient.
Before a patient walks using crutches, preparatory exercises are done. These exercises are aimed
at strengthening the shoulder girdle and the upper extremity muscles which bear the patients
weight when crutch walking. The muscle groups that are vital to crutch walking are the
following:

Shoulder depressor muscles which stabilize the upper extremity and prevent shoulder
hiking.
Shoulder adductor muscles which hold the crutch top against the chest wall.

Arm flexor, extensor and abductor muscles which move crutches forward, backward and
sideward.

Forearm extensor muscles which prevent flexion or buckling and are important in raising
the body in swinging gait.

Wrist extensor muscles which enable weight bearing on hand pieces.

Finger and thumb flexor muscles which grasp the hand piece.

Measuring for Crutches

The patient may be measured standing or lying to determine the approximate crutch length. The
patients height may also be used.
STANDING PATIENT

Position the patient against the wall with feet slightly apart and away from the wall.
Mark out 5 centimeters or 2 inches to the side from the tip of the toe.

Measure fifteen centimeters or 6 inches straight ahead from the first mark. Mark this
point.

Measure 5 centimeters or 2 inches below the axilla to the second mark for the
approximate crutch length.

LYING PATIENT

Measure from the anterior fold of the axilla to the sole of the foot. Add 5 cm or 2 inches
to this measure.

USING THE PATIENTS HEIGHT

Subtract 40 cm or 16 inches to obtain the approximate crutch length.

In general the hand pieces should be adjusted to allow 20 to 30 degrees of flexion at the elbow.
The wrist should be extended and the hand is dorsiflexed. A foam rubber pad on the under arm
piece may be used to relieve pressure of the crutch on the upper arm and thoracic cage.
Ambulating with Crutches
1. Instruct the patient to wear sturdy, well-fitting shoes.
2. The nurse or the physical therapist should explain and demonstrate the proper
manipulation of the crutch.

3. Before a patient attempts on using a crutch, the patient learns standing balance by
standing on the unaffected leg by a chair.
4. To help the patient maintain balance, the nurse should hold the patient near the waist or
uses a transfer belt.
5. Weight of the body is supported by the hand and not borne on the axilla. The pressure of
the crutch on axilla can damage the brachial plexus nerves, producing crutch paralysis.
6. The patient assumes a tripod position, for maximum stability. This is done by placing the
crutches approximately 20 cm to 25 cm (8 to 10 inches) in front and to the side of the
patients toes. The base of support is adjusted to the height of the patient.
Crutch Gaits
After learning how to shift weight and maintain balance, the patient can now be selected with a
crutch gait. The selection of a crutch gait depends on the following:

Patients physical condition

Arm and truck strength

Body balance

Types of Crutch Gaits:

All crutch gaits begin in the tripod position. The patient should be taught two gaits in order to
change from one to another. Each gait requires the use of a different muscle combination, thus,
shifting crutch gaits relieves fatigue. If the patient is in crowded places, a slower gait is used. A
faster gait can be used for distances. The nurse should continually assess the stability of the
patient and protect him or her from falling. When walking with a patient using crutches, the
nurse holds the patients waist for balance.

Four point gait: used for partial weight bearing on both feet. Using this gait, maximal
support is provided and constant shift of weight is required.

1. Advance the right crutch.

2. Advance the left foot.
3. Advance the left crutch.
4. Advance the right foot.

Two point gait: used for partial weight bearing on both feet. This gait provides less
support but is faster than the four point gait.

1. 1. Advance left foot and right crutch.

2. 2. Advance right foot and left crutch.

Three point gait: non-weight bearing gait. This crutch gait requires good balance and
arm strength. It is a faster gait and can be used with walker.

1. 1. Advance left foot and both crutches.

2. 2. Advance right foot.

Swing To Gait: Weight bearing is both feet. This gait provides stability and requires arm
strength. It can also be used with walkers.

1. 1. Advance both crutches.

2. 2. Lift both feet and swing forward.
3. Land the feet next to crutches.

Swing Through Gait: weight bearing. This gait requires arm strength and coordinated
balance. This is the most advanced gait.

1. Advance both crutches.

2. Lift both feet and swing forward.
3. Land the feet in front of crutches.