FOLLOWING INJURY, SURGERY, or a period of immobility, regaining the ability to walk is an important "step" in your patient's recovery. Your patient most likely won't be able to just hop out of bed and hit the ground running. She'll have to prepare for ambulation by strengthening her muscles, and she may need an assistive device like crutches, a cane, or a walker to get around.
In the next few issues of LPN2005, we'll focus on how you can teach your patients to use these devices. We begin this month by discussing proper crutch use.
First, though, let's look at the strengthening exercises that you and the physical therapist will teach her to help her regain mobility.
Firming the foundation
The quadriceps and gluteal muscles are the primary muscles used when walking, so they must be strengthened through "setting" exercises. To perform the quadriceps-setting exercise, the patient should contract, or "squeeze," her quadriceps muscle by trying to push the back of the leg against the mattress while raising the heel at the same time. Tell the patient to maintain the muscle contraction for 5 seconds, and then relax for 5 seconds. She should repeat this exercise 10 to 15 times each hour. Strengthening this muscle stabilizes the knee.
To set the gluteal muscles, the patient should contract the buttocks together for 5 seconds, and then relax for 5 seconds. This exercise should also be repeated 10 to 15 times each hour.
If she's going to use an ambulatory aid, the patient will need to exercise and strengthen her upper-arm muscles too. Push-up exercises are helpful and can be done in a sitting position, in which the patient raises her body by pushing her hands against the mattress or chair seat. Encourage the patient to do push-up exercises while in a prone position as well.
Another effective conditioning technique is arm pull-up exercises on a trapeze. Using handheld weights increases arm strength too. While holding the weights in her hands, the patient should raise her arms above her head and then lower them in a slow, rhythmic manner. You can gradually increase the weight as tolerated by the patient. She can also strengthen her hands by squeezing a rubber ball.
Once the patient has achieved her sitting and standing goals, she'll typically work with the physical therapist to learn to walk. Using parallel bars for support, she'll practice shifting her weight from side to side and lifting one leg while supporting weight on the other. She'll also walk between the parallel bars to gain strength and confidence.
Don't lean on me
If the primary care provider prescribes crutches for partial weight-bearing or non-weight-bearing ambulation, the physical therapist will determine whether the patient has good balance, adequate cardiovascular reserve, strong arms, and erect posture, which are essential for walking with crutches.
To walk across a room or through her home or to maneuver on the stairs, the patient needs enough arm strength to bear her weight. The muscle groups most important for crutch walking include the shoulder muscles that stabilize the upper extremity and those that hold the top of the crutch against the chest wall. The arm muscles (at the shoulders) must be able to move the crutches forward, backward, and sideways.
Other muscle groups that must be strong enough to support the patient include:
* the forearms, to help prevent flexion or buckling. These muscles are important in raising the body for a swinging gait.
* the wrist muscles, to enable weight-bearing on the hand pieces of the crutches
* the finger and thumb muscles, to grasp the hand piece.
Crutches aren't one-size-fits-all; the patient will need to be measured for the appropriate crutch length. The hand piece on each crutch will be adjusted to allow 20 to 30 degrees of flexion at the elbow. The patient's wrists should be extended and her hands dorsiflexed. Make sure the crutches have large rubber tips for safety, and remind the patient to wear firm-soled, well-fitting shoes when using the crutches.
The patient should be taught to support her weight on the hand pieces. She shouldn't bear weight on the underarm area because the pressure of the crutch can damage the brachial plexus nerves and cause "crutch paralysis." Patients who can't support their weight through the wrist and hand because of arthritis or fracture can use platform crutches.
Easy does it
Before the patient begins walking with crutches, have her get into a tripod position by placing the crutches about 8 to 10 inches in front and to the side of her toes. This position will teach her to shift her weight and maintain balance.
The physical therapist will determine which gait will be best for the patient, depending on the type and severity of her disability and her physical condition and strength. She should be taught two gaits so she can change from one to the other to help relieve fatigue. Tell her to use a faster gait for walking an uninterrupted distance and a slower gait for short distances. Make sure the patient knows how to walk on incline or uneven surfaces and stairs, and warn her to avoid highly polished floors and throw rugs.
As the patient begins to walk with crutches, be sure to walk with her to provide support as needed for balance and to protect her from falls. Assess her stability and stamina; prolonged bed rest and inactivity affect strength and endurance. If you observe the patient sweating or experiencing shortness of breath, have her rest. See Teaching the patient crutch-walking techniques for more information.
With proper instruction and supervision, your patient will be able to ambulate safely and independently. Your skill and knowledge will put her on the path to greater mobility.
Teaching the patient crutch-walking techniques
Before your patient is ready to independently walk with crutches, she'll need to learn to sit down from a standing position while using crutches, stand from a sitting position, and walk up and down stairs. Have the patient follow these steps:
Sitting down
* Grasp the crutches at the hand pieces for control.
* Bend slightly forward while assuming a sitting position.
* Place the affected leg forward to prevent weight bearing and flexion.
Standing up
* Move to the edge of the chair, with the strong leg slightly under the seat.
* Place both crutches in the hand on the side of the affected leg.
* Push down on the hand piece while raising the body to a standing position.
Going down stairs
* Walk forward as far as possible on the step.
* Advance the crutches to the lower step, moving the weaker leg first. This allows the stronger leg to share with the arms the work of raising and lowering the body weight.
Going up stairs
* Move the stronger leg first to the next step.
* Then move the crutches and the weaker leg.
* Remind patients that the strong leg goes up first and comes down last. A good memory jogger for the patient is the phrase, "Up with the good, down with the bad."
On the Web
American Academy of Orthopaedic Surgeons: http://orthoinfo.aaos.org, eMedicine: http://www.emedicinehealth.com/articles/9039-1.asp
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