INTRODUCTION

Assistive devices permit some patients who cannot ambulate without assistance to
ambulate safely. Three major indications for using assistive devices are:

1. Structural deformity or loss, injury, or disease, which decreases the ability to bear
weight on the lower extremities;
2. Muscle weakness or paralysis of the trunk or lower extremities; and
3. Inadequate balance.

Assistive devices increase a patient's base of support and provide additional means of
support. Thus, assistive devices provide a larger area within which the patient's center of
gravity can shift without loss of balance, and a redistribution of support within the wider
base of support.

FATIGUE

Fatigue may occur during gait training as a result of:

1. Performing an activity that has not been performed for a while;

2. Using assistive devices during ambulation;
3. Greater concentration levels while learning a new gait pattern with additional
equipment; and
4. Physiological responses to the stresses of injury or illness.

These factors can cause a patient to fatigue rapidly. Frequent rest periods may be
necessary during initial gait training sessions. Several short sessions of gait training,
rather than one long session, may be more effective.

PATIENT CONCENTRATION

When first using assistive devices, the need to concentrate can be very high. During
initial training sessions, a patient will require greater concentration to learn a gait pattern
properly. Often patients will look at their feet and assistive devices as they learn to walk.
Patients do so because they need input as to where their feet and assistive devices are
with respect to their body. Looking at feet and assistive devices also reduces distractions
of other objects and activities in the immediate area.

High levels of concentration by patients on their feet and assistive devices makes
ambulation an activity requiring active thought, interfering with a patient's ability to
respond to other inputs, such as conversation. A patient may stop walking to answer
questions. Conversation with, and around, a patient not directly related to ambulation
should be avoided during initial gait training. Later in training, however, such additional
inputs can be used to test the degree to which a patient has mastered use of an assistive
device and a new gait pattern. When ambulation has become an automatic activity again,
patients will be able to respond to questions and other activity in the environment without
losing concentration or coordination during ambulation. At this time patients will usually
start to look up and around as they ambulate. When this occurs, patients can take over
the responsibility of monitoring the environment for themselves, and more complex
environments can be used for gait training.

Initial gait training should occur in an environment that is as free of distractions as

possible. The therapist should monitor the environment for the patient. Patient rooms or
therapy departments are usually less distracting than public corridors. When more
complex environments are needed to challenge a patient, public corridors may be used for
gait training.

WEIGHT BEARTNG

When teaching a patient with a restriction of weight bearing, a bathroom scale can be
useful. By placing one lower extremity on the scale, different levels of weight bearing, and
the attendant feeling, can be demonstrated. When using this method, the lower extremity
not placed on the scale must be placed on a solid surface at the same level as the scale to
avoid an uneven supporting surface. In some cases, two scales may be used, with one
lower extremity placed on each scale.

INSTRUCTION

Before a patient begins ambulating, the therapist describes and demonstrates the proper
use of the assistive device and the appropriate gait pattern. A demonstration is the
primary method of instruction, with verbal descriptions reinforcing the demonstration.
Verbal descriptions should be kept simple. Observing other patients who are using
assistive devices correctly can also be a useful method of instruction. A therapist will not
always be available to instruct a patient in how to perform a task outside of a
rehabilitation setting. Therefore patients are assisted in solving problems on their own
when using assistive devices.

Once a patient is proficient in the use of an assistive device and gait pattern on level
surfaces, instruction in the use of stairs, curbs, ramps, elevators, doors, and falling safely,
is provided. The patient should be taught to ascend and descend stairs on the side
appropriate for the country in which they live. In the United States this is the patient's
right side as they face the stairs.

Instruction in sitting down and standing up when using chairs with and without arms, low
or soft sofas and chairs, toilets, and car seats is also necessary. Patients must be taught to
sit in a controlled manner, rather than collapsing into a sitting position.

Uneven surfaces may present specific problems to patients. Gravel, grass, broken
sidewalks and paving, and curb cuts may require additional instruction and practice.
Patients should be cautioned to avoid small throw rugs that may slip or become entangled
with their feet or assistive devices.

Wet or highly polished floors should also be avoided whenever possible. When ambulating
on icy, wet, or highly polished surfaces, smaller movements of assistive devices and
smaller steps should be used. Forces placed on assistive devices should be directed
downward as much as possible to prevent assistive devices from slipping on wet or
unstable surfaces.

Patients must be instructed to check that assistive devices are in safe working condition.
Rubber tips on assistive devices will not grip the floor properly if they become worn
excessively, or dirt fills the grooves. Wing nuts on crutches often loosen with use.
PARALLEL BARS

- Parallel bars are medical devices specifically used in physical and occupational
rehabilitation therapy to assist individuals to re-learn to walk and for gait training,
as well as to regain balance, strength, range of motion, and mobility.

- Being permanent or portable, parallel bars can be platform-mounted, floor-mounted,

or wall-mounted and can be height adjustable with electrical and battery power, or
with manual manipulation.

- They are often used in therapy for individuals recovering from post-surgery, muscle
atrophy, illness, disease, nerve damage, or other disabilities or conditions.

Instruction in a gait pattern often begins in a set of parallel bars.

Parallel bars provide maximum stability, and require the least amount of
coordination by a patient.
A patient can become accustomed to the upright posture and learn a gait pattern in
the relative safety of parallel bars.
Assistive devices can be fitted while a patient stands in parallel bars.
When appropriate, a patient can practice standing or a gait pattern while waiting for
the therapist to adjust assistive devices, providing efficient use of treatment time.
Initial use of assistive devices can be in, or alongside, parallel bars. Patients have
reassurance that the stable parallel bars are readily available.

A patient may, however, become too dependent on the parallel bars. The therapist must
progress a patient to ambulation away from the parallel bars as rapidly as possible.

TYPES OF PARALLEL BARS

1. Platform Mounted Parallel Bars

- The parallel bars are
mounted on a durable
platform with a satin
topcoat, and the platform
has safety treads at both
ends.
- The rail heights can be
adjusted from 26 - 39
inches.
- The Platform Mounted
Parallel Bars are available
in three lengths: 7ft, 10ft
and 12ft.
- Hold up to 350 lbs.

2. Folding Parallel Bars

- Folding Parallel Bars are width adjustable with

double stiffening rails.
- Both handrails are made with 1-1/2" one-piece
stainless steel.
- Easily adjust the height with spring loaded
plungers, and a numbered height strip serves as
a good indicator of how tall the bars are set at.
- A second height knob removes side to side play.

3. Wall Mounted Folding Parallel Bars

- The Wall Mounted Folding Parallel Bars are

the best choice for parallel bars in a smaller
facility or room.
- When not in use, these steel parallel bars fold
up against the wall to save space.
- Some assembly may be required.
- This is not recommended for heavy facility
use.
 4. Electric Platform Mount Parallel Bars
- Electric Platform Mount Parallel Bars are
height-adjustable parallel bars with a digital
display on the control panel that shows the
exact bar height.
- Memory buttons allow the storage and recall
of four separate bar height settings.
- For convenience, this type of parallel bar has
a hand control to make the adjustments.

Parts of a Parallel Bar

Parallel Bar Progression

Upright activities in the parallel bars can be initiated once the patient has progressed
through a program of pre-ambulation exercises. As mentioned earlier, every activity within
the mat sequence will not be appropriate for each patient. Consequently, all mat activities
may not be warranted or feasible before initiating upright activities. Prior to standing, two
important preliminary activities include fitting the patient with a guarding belt and
adjusting the parallel bars. The initial adjustment of the parallel bars is an estimate based
on the patient's height. Ideally the bars should be adjusted to allow 20 to 30 degrees of
elbow flexion and come to about the level of the greater trochanter. Considering individual
variations in body proportions and arm length, the elbow measurement is usually most
accurate. Once the patient is standing, the height of the bars can be checked. If
adjustments are required, the patient should be returned to a sitting position. The
sequence of activities included in the parallel bar progression follows.
1. Wheelchair placement: The patient's wheelchair should be positioned at the end of
the parallel bars. The brakes should be locked, the footrests placed in an upright
position, and the patient's feet should be flat on the floor.

2. Guarding belt. The guarding belt should be fastened securely around the patient's
waist. Guarding belts provide several critical functions. They increase the therapists
effectiveness in controlling or preventing potential loss of balance; they improve
patient safety; they facilitate the therapist's use of proper body mechanics in
untoward circumstances; and finally, they are an important consideration regarding
issues of liability. The safety implications of the guarding belt should be explained to
the patient carefully.

3. Initial instruction/demonstration. In initiating instruction in parallel bar activities, the

entire progression should be presented before breaking it into component parts.
This will include instruction and demonstration in how to assume a standing position
in the parallel bars, guarding techniques to be used by the therapist, the
components of initial standing balance activities, the gait pattern to be used, how to
turn in the parallel bars, and how to return to a sitting position. Demonstrating
these activities by assuming the role of the patient during verbal explanations will
facilitate learning. Each component of the parallel bar progression should then be
reviewed prior to the patient's actual performance of the activity.

4. Assuming the standing position. To prepare for standing, the patient should be
instructed to move forward the chair. The therapist is positioned directly in front of
the patient. A method of guarding should be selected that does not interfere with
the patients use of the upper extremities while moving to standing. One useful
approach is to grasp the guarding belt anteriorly (an underhand grasp will provide
the most security). With unilateral involvement, the therapists opposite wrist
should be placed under the axillary region on the patients stronger or unaffected
side with the hand at the lateral border of the scapula. Care should be taken not to
exert any upward pressure into the axilla. Although the correct position for guarding
is typically on the patients weaker side, the therapist may stand closer to the
unaffected side in order to brace or to guard the patients sound lower extremity
and to ensure one strong supporting limb. For example, this approach would be
indicated in situation in which one lower extremity requires a non-weight-bearing
status. If bilateral involvement exists, the therapist should be positioned more
centrally in order to brace both of the patients knee. If necessary, the patients feet
may be braced (by the therapists feet) to prevent sliding. An alternate hand
placement particularly useful with bilateral involvement is one hand under the
buttock, the opposite hand on the lateral aspect of the guarding belt or below the
axilla onto the scapula and lateral-posterior chest wall.

Having moved forward into the chair with the supporting foot or feet flat on the
floor, the patient should be instructed to come to a standing position by leaning
forward and pushing down on the armrests of the wheelchair. The patient should
not be allowed to stand by pulling up on the parallel bars. As the patient nears an
erect posture, the hands should be released from the armrests one at a time and
placed on the parallel bars. The patients COG should be guided over the BOS to
promote a stable standing posture.
5. Initial parallel bar activities. During the parallel bar activities, the therapist usually
stands inside the bars facing the patient or outside the bas on the patients weaker
side. In guarding the patient from inside the bars, one hand should grasp the
guarding belt anteriorly, and the opposite hand should be in front of, but not
touching, the patients shoulder. From outside the bars one hand should grasp the
belt posteriorly with the opposite hand in front of, but not touching, the patients
shoulder. This method of guarding provides effective hand placement for an
immediate response should the patients balance be lost. It also eliminates the
patients feeling of being held back or pushed forward, which may occur with
manual contacts at the shoulders.

The following initial balancing activities in the parallel bars can be modified relative
to the patients weight-bearing status and specific requirements of a diagnosis (e.g.,
use of a prosthesis or orthosis). Guarding techniques are maintained by the
therapist during these activities.

a. Standing balance. Initially, the patient should be allowed time to become

acclimated to the upright posture. During initial standing activities, the therapist
should be alert to complaints of nausea or lightheadedness, which may indicate
an onset of orthostatic (postural) hypotension caused by a drop in blood
pressure. These symptoms typically disappear as tolerance to the upright
posture improves. However, if the patient has been confined to bed and/or a
wheelchair for a prolonged period, these symptoms may be severe. In these
situations a gradual progression of tilt-table activities and careful monitoring of
vital signs is warranted prior to standing.
b. Lateral weight shift. The patient shifts weight from side to side without altering
the BOS; hand placement on the parallel bars is not altered.
c. Anterior-posterior weight shift. The patient shifts weight forward and backward
without altering the BOS; hand placement on the parallel bars is not altered.
d. Anterior-posterior hand placement and weight shift. The patient moves the
hands forward on the bars and shifts weight anteriorly. This is alternated with a
posterior hand placement, and weight is shifted backward.
e. Single-hand support. The patient balances with support from only one hand on
the parallel bars; hands are alternated. A progression of this activity involves
gradual changes in position of the freed hand and upper extremity. For example,
begin the activity by moving the freed hand several inches above the bar and
gradually progress to alternate positions such as shoulder flexion, abduction,
crossing the midline, and so forth. A progression can be made to balancing with
both hands freed from the bars.
f. Hip hiking. The patient maintains the BOS and alternately hikes one hip at a
time; hand placement on parallel bars is maintained. Resistance can be applied
by manual contacts at the pelvis.
g. Standing pushups. The patients hands are placed just anterior to the thighs on
the parallel bars. Body weight is lifted by simultaneous elbow extension and
shoulder depression. Additional height may be gained by forward flexion of the
head. Return to the starting position is made by a controlled lowering of the
body. This activity requires significant upper extremity strength, using the
controlled mobility developed in perambulation activities. It is usually reserved
for younger patient groups, such as those with paraplegia, and selected patients
with lower extremity amputation.
h. Stepping forward and backward. The patient steps forward with one leg, shifts
weight anteriorly, and returns to the starting position (normal BOS). This is
alternated with stepping backward with one leg, shifting the weight posteriorly,
 and returning to the starting position. Resistance can be applied with manual
contacts at the pelvis.
i. Forward progression. The patient begins ambulation in the parallel bars using
the selected gait pattern and appropriate weight bearing on the affected lower
extremity. The patients should be instructed to push down rather than to pull on
the parallel bars while ambulating, inasmuch as this is the motion that
eventually will be required with an assistive device. This will be easier if the
patient is instructed to use a loose or open grip on the bars rather than a tight
grip, facilitating correct use of the parallel bars and ultimately, the assistive
device.
j. Turning. Once the desired distance in the parallel bars has been reached, the
patient should be instructed to turn toward the stronger side. For example, with
a non-weight-bearing left lower extremity, the turn should be toward the right.
The patient should be instructed to turn by stepping in a small circle and not to
pivot on a single extremity. This technique will carry over to ambulation outside
the bars, when pivoting will always be discouraged because of the potential loss
of balance by movement on a small BOS. Guarding while turning in the parallel
bars can be accomplished two ways. The therapist can remain in front of the
patient, maintain the same hand positions, and turn with the patient. This will
keep the therapist positioned in front of the patient. A second method is not to
turn with the patient but, rather, to guard from behind on the return trip. In this
method hand placements will changed gradually by first placing both hands on
the guarding belt as the patient initiates the turn. One hand then remains on the
posterior aspect of the belt and the freed hand is placed anterior to, but not
touching, the should on the patients weaker side for the return trip toward the
chair. Although both techniques are acceptable, the latter is probably more
practical, considering the limited space available in the parallel bars.

As mentioned earlier, guarding also may be accomplished from outside the

parallel bars. This positioning of the therapist is particularly useful during later
stages of gait training. However, it presents several inherent problems for early
training. If unilateral involvement exists, it is frequently difficult to remain close
to the patients weaker side (especially if the patient is not able to ambulate the
full length of the parallel bars). In addition, the distance between the therapist
and patient imposed by the intervening bar renders the therapist less effective
in guarding and in using appropriate, safe body mechanics to help support the
patient during periods of unsteadiness or loss of balance.
k. Returning to the seated position. When reaching the chair the patient should
again turn as described earlier. Once completely turned, patients are typically
instructed to continue backing up until they feel the seat of the chair on the back
of their legs (this will require substitution with visual or auditory clues for
patients with impaired sensation). At this point the patient releases the stronger
hand from the parallel bar and reaches back for the wheelchair armrest. Once
this hand has securely grasped the armrest, the patient should be instructed to
bend forward slightly, release the opposite hand from the parallel bar and place
it on the other armrest. Keeping the head and trunk forward the patient gently
returns to a seated position.
6. Advanced parallel bar activities. Although not appropriate for every patient,
several more advanced activities also can be incorporated into gait training in the
parallel bars. These include the following.
 a. Resisted forward progression. Resistance can be applied through manual
contacts at the pelvis and/or shoulder as the patient walks forward.
b. Walking backward. Walking backward can be initiated actively and progress to
application of resistance through manual contacts at the pelvis. This activity also
combines hip extension with knee flexion and is particularly useful for patients
with hemiplegia with synergy influence in the lower extremities.
c. Walking sideward. Initially, this activity is performed actively. A progression can
then be made to application of resistance with manual contacts at the pelvis and
thigh. Walking sideward facilitates active abduction of the moving limb combined
with controlled mobility and weight bearing of the opposite supporting extremity.
d. Braiding. This activity requires a side-step progression with the advancing limb
alternately placed anteriorly and posteriorly to the supporting limb. It
incorporates lower trunk rotation as well as crossing the midline.
TILT TABLE

Some patients must be reacclimated to upright posture in a safe manner before sitting,
standing, or ambulation can be initiated. This is usually necessitated by the existence of
orthostatic hypotension in patients who have been in bed for extended periods.
Readjustment of the cardiovascular system may be necessary to avoid dizziness or
fainting as these patients assume an upright posture.

A tilt table is a safe method to provide maximum support for such patients Support
is provided while a patient is raised slowly to an upright position by the tilt table,
leaving the therapist free to control the tilt table and monitor the patient.

Parts of a Tilt Table

Parts of Tilt Table

The padded table top is 24 wide, 80 long, and 34 high and is fitted on heavy duty
square steel tube legs. Mounted on a lockable 4 diameter wheels/casters for
mobility.
2-3 wide straps to hold patient.
Crank with handle/ pedal
Footrest (17/24)
Removable grip bar/Hand rill
 Side bars

Types of Tilt Table

Procedure:

Vital signs are measured, before and during

the process of raising the patient to an upright
posture. The patient should be lowered when
he reports feeling faint. A patient who is
lowered after feeling faint must be monitored
until his vital signs return to normal, and the
patient no longer reports feeling faint. Medical
assistance should be obtained when necessary.

Straps are used to secure a patient to a tilt table. A variety

of styles of straps are available. A bar extends along each
side of the tilt table surface and the straps used to secure
a patient on the tilt table are attached to the bar on one
side of the table.

The straps are passed over the patient and secured to

the bar on the other side. The location of the straps
across the patient depends on the patient's condition. If
upper trunk stability is required, a chest strap, with the
upper extremities free, is used. A strap over the pelvis
stabilizes the lower trunk. A strap at knee level is used if
the patient cannot maintain knee extension.
The angle of table tilt is adjusted to a position the patient
can tolerate safely. Changes in the position of the table
should be performed slowly and steadily. Greater degrees
of tilt may be assumed as the patient's cardiovascular
system adjusts to the demands of upright posture. For
many patients the full upright position provides a
sensation of falling forward; therefore, this position is
usually avoided.

When weight bearing is not permitted on one lower

extremity, a lift can be placed under the uninvolved lower
extremity. This prevents the involved lower extremity
from reaching the supporting surface. Thus, the involved
lower extremity is not weight bearing.

When an exercise program for one of the lower extremities

is to be implemented, the strap across the knees can be
loosened, or placed only around the opposite lower
extremity. This permits the therapist to implement the
patient's lower extremity exercise program.
Gait training can begin on the tilt table with the
fitting of assistive devices. Patients who cannot
sit may find it easier to be brought to an upright
posture on a tilt table, and then to walk off the tilt
table.

STANDING FRAME

Designed for children, particularly those with spina bifida, the standing frame consists of a
broad base, posterior nonarticulated uprights extending from the base to the mid-torso,
anterior leg and chest bands, and a posterior thoracolumbar band. The child wears
ordinary shoes without any special attachments. The shoes are strapped to the base of the
frame. The prefabricated frame is less expensive than custom-made orthoses and
accommodates easily to the child's growth.

It permits the child to stand without crutch support, freeing the hands for play activities.

PARAPODIUM

The parapodium differs from the standing frame by virtue of articulations that permit the
wearer to sit. The stabilizing points on the two orthoses are the same. The newest version
of the parapodium also has provision for keeping the knees stable while the child unlocks
the hips for leaning forward to pick up objects from the floor. Crutchless ambulation in the
parapodium is achieved by rotating the trunk to rock the base along the floor. For walking
longer distances, the parapodium wearer uses crutches or a walker in the swing-to or
swing-through pattern. The parapodium is worn on the outside of the clothing, which most
children older than 6 years find too conspicuous.