NHS Training for Physiotherapy Support Workers Workbook 16 Gait re-education
Contents Workbook 16 Gait re-education 1 16.1 Aim 3 16.2 Learning outcomes 3 16.3 Preparation for walking assessment and walking re-education 4 16.4 Gait Patterns 6 16.5 Walking aids and their use 6 16.6 Other walking aids 7 16.7 Measuring the patient for a suitable walking aid 8 16.8 Maintaining the walking aid 9 16.9 Practising walking with patients 10 16.10 Recognising simple gait abnormalities 12 16.11 Identifying when a patient is progressing or regressing 15 16.12 Safety and walking practice 17 16.13 Walking with a patient and two staff 20 16.14 Conducting walking practice with a patient and two staff 22 16.15 Walking re-education workbook completion 25 16.16 Walking re-education reflection 27 NHS Education for Scotland 2012. You can copy or reproduce the information in this document for use within NHSScotland and for non-commercial educational purposes. Use of this document for commercial purposes is permitted only with the written permission of NES.
Workbook 16 Gait re-education 16.1 Aim The aim of this training programme is to provide the Healthcare Support Worker (HCSW) with the knowledge, understanding and skills to safely and effectively re-educate gait. 16.2 Learning outcomes By the end of this workbook you will be able to: Describe and demonstrate the correct patterns of sit to stand and gait with different walking aids. Demonstrate the appropriate preparation of the patient for walking re-education, explain the procedure clearly and correct performance accordingly. Identify when it is appropriate to undertake walking practice with two staff and demonstrate this effectively in a safe co-ordinated manner. Identify when a patient is progressing or regressing and liaise appropriately with the therapist. Identify wear and tear of the walking aid and take appropriate action. Workbook 16 Page 3
16.3 Preparation for walking assessment and walking re-education As with all other activities with patients you need to conduct a risk assessment prior to asking the patient to get up to walk. You may be doing this to assist the therapist to assess the patient, or to practice walking with a patient who has already been assessed. Consider: Does the patient have the appropriate walking aid? Is the patient able to participate in the activity? Does the task require one or two support workers? Can the patient follow commands? Are you adequately trained to assist the patient with this particular task? Whether the patient is wearing appropriate clothing is there anything that might cause the patient to stumble or fall? Does the patient s footwear fit and is it appropriate for walking in? Are there obstacles in the bed space? Do you have plenty of time to enable the patient to work at his own pace? Evidence Describe a risk assessment and preparation for walking practice that you have conducted prior to practicing walking with a patient. What did you find? Describe actions that you took to ensure safety following risk assessment. Workbook 16 Page 4
Assisting the patient to stand up The procedure is explained fully and agreed with the patient. Brakes are on when patient is in a mobile chair. Walking aid is positioned correctly. The patient brings themselves forward to the edge of the chair. Facilitate normal pattern of sit to stand, to include correct positioning of hands and feet, correct sequence of hip and knee movement and trunk extension. Assess when patient requires assistance to stand. Provide appropriate assistance, facilitation or equipment during the assessment. Provide appropriate feedback to the patient. Follow therapist guidelines as to the most appropriate aid and assistance for practice of gait. Remember to provide firm instructions to ensure that the patient turns at the correct time, locates the chair against the back of their legs and uses their arms to control their return to the chair. Evidence Describe how you assisted one of your patients to stand up and return to the chair prior to walking practice. Describe what you did What went well? What could have been better? Anything that you would do differently next time? Workbook 16 Page 5
16.4 Gait Patterns Normal gait patterns It is important to understand normal walking patterns before working with patients Your supervising therapist will demonstrate the phases of gait. Swing phase and stance phase of gait Each leg goes through the same cycle during each step. Swing phase The first part is when the toes come off the ground and the leg swings until the heel strikes the ground. Some patients have difficulty clearing the ground when walking. Stance phase This part is where the heel strikes the ground, the weight is transferred onto the leg and lasts until the toes push off the ground. Some patients have problems with this part of the gait cycle. 16.5 Walking aids and their use Walking aids are selected according to: the patient s balance the required support for weight-bearing Sticks Sticks are selected when a patient has good balance and just a small amount of support is required. The patient would normally be able to bear most of their weight. Two sticks are more stable than one, but the patient still requires good balance in order to be able to use them. Frames Frames are selected when the patient requires greater support, since they have a large base of support to provide stability. You may notice that a patient is struggling to walk with sticks and may benefit from a frame. The frame may have wheels, or may simply have four stoppers. The advantage of wheels is to allow for a more normal gait pattern. Workbook 16 Page 6
Furthermore, it requires less effort to push the frame than it does to lift, thus, it may be better for frail or breathless patients. You may recognise that a patient is easily walking with a frame. They may appear not to require it to provide weight bearing support, or they may be walking quickly. They may benefit from progression to two sticks. If you feel that the patient is ready to progress, or requires more assistance to walk contact the Physiotherapist, who will reassess the patient, and prescribe an appropriate walking aid. 16.6 Other walking aids Auxiliary crutches These are used when weight must be relieved from one leg and can be used to train non-weight bearing. Elbow crutches These are sticks of adjustable length with a horizontal hand grip and a metal forearm rest. These are not as stable as auxiliary crutches but with practice are more flexible to use. Used for partial or full weightbearing. Gutter crutches These provide a gutter splint on top of adjustable crutch legs and are used when weight cannot be taken through the forearms and hands, for example in rheumatoid arthritis or wrist fracture. Workbook 16 Page 7
Activity Your tutor will demonstrate gait patterns with: a walking frame a mobilator two sticks one stick auxiliary crutches elbow crutches gutter crutches You will also learn about: full weight-bearing partial weight-bearing touch weight-bearing non-weight bearing three point swing-to three-point swing-through four-point gait 16.7 Measuring the patient for a suitable walking aid It is important that the walking aid is correctly measured to fit the patient. In the tutorial you will learn about the measurement of: a walking frame a mobilator two sticks one stick auxiliary crutches elbow crutches gutter crutches Measuring the patient Sticks With the patient standing as straight as possible, the stick should be adjusted so that it s handle is level with the patient s wrist crease. When the patient holds the stick, a slight bend at the elbow should be seen. Frames The patient is not normally measured for use of the frame, but should similarly have enough elbow flexion to allow the frame to be moved forward comfortably. The patient should not be stooped, nor should the frame be so high the patient struggles to lift it forward. Auxiliary crutches The height should be measured from the medial malleolus to 5cm below the armpit at the back. The hand piece should be adjusted as for sticks, with 15 flexion at the elbow. Workbook 16 Page 8
Elbow crutches Measurement is as for sticks. Gutter crutches Measurement is conducted by measuring the distance between the elbow when it is flexed to 90 and the floor. Activity Practice measuring the correct height of each of these walking aids on a model. Was there anything that you found difficult when doing this? Describe here what happened when you measured a patient for one of these walking aids. What went well? What could have been better? Anything you would do differently next time? 16.8 Maintaining the walking aid You should always check the walking aid for signs of wear and tear Patients should be instructed to inspect the walking aid for signs of wear and tear Walking aids should be cleaned regularly and where possible wheels can be oiled The ferrules become worn with usage, which may cause the aid to slip on certain surfaces. If the ferrule shows signs of wear it should be replaced Workbook 16 Page 9
Activity Describe how you recognised signs of wear and tear on a walking aid and what action you took. 16.9 Practising walking with patients Activity The therapist may ask you to undertake gait practice with patients. Make a list here of what you should know about the patient before undertaking the task. Workbook 16 Page 10
You might have included information like: What is the patient treatment plan and what goals is the patient expected to achieve? What walking aid does the patient require? How many people are required to assist them walking? What does the therapist require me to do? What should I be helping or encouraging the patient to do when walking? How often and for how long should the patient be practising with the aid? Write here where you would find this information Evidence Select a patient with whom you have undertaken a programme of walking practice as prescribed by the therapist. What walking aid did they use? Describe what you did? What went well? What could have been better? What would you do differently next time? Workbook 16 Page 11
Make sure you can: Safely assist the patient to carry out the gait re-education plan agreed with the therapist. Document the treatment and outcome correctly. For patients using: a walking frame a mobilator two sticks one stick auxiliary crutches elbow crutches gutter crutches 16.10 Recognising simple gait abnormalities and correcting them appropriately With injury and illness, a patient s walking pattern can be very different from normal. The patient may dip down at the hip during stance phase. The patient may find clearing the ground difficult in swing phase. This may lead them to swing the leg round to swing through. If they have had a stroke or neurological disorder, they may not be able to support the weight fully enough to step with the other leg. Some patients may be unable to pull up their toes enough to place the heel on the ground. Patients may lean too far forward on the walking frame. They may push the frame too far forward. They may walk with their weight too far back on their heels. They may walk with one hand on the frame and one on the furniture! Workbook 16 Page 12
Activity With your supervising therapist, look at some of the patients with whom you are practising walking. Try to decide if they are finding swing or stance phase difficult. Your supervising therapist will indicate how to assist this patient to walk better. She may suggest to the patient that they: Brings their heel down to touch the ground at the end of swing phase. Bends their knee to clear the ground. That they straighten their knee and their hip to support their weight better during stance phase. That they slightly flex their knee during stance phase to stop the knee from snapping back. The instructions that the therapist asks you to use to correct the walking pattern of the patient will depend on the individual and the problems that they have. Over time you will become familiar with those encountered on your own unit, and be able to provide patients with feedback that enables them to walk better. Workbook 16 Page 13
Evidence Describe here the details of a patient whose walking you corrected under instruction of the therapist. Describe how you recognised that the patient was walking abnormally. What did you do? What went well and why? What could have been better? What would you do differently next time? Workbook 16 Page 14
16.11 Identifying when a patient is progressing or regressing and liaising appropriately with the therapist Patients change with time and you may notice that a patient is walking better with their frame, sticks or crutches than previously. Evidence Select a patient that you have been working with who has progressed or regressed in their use of a walking aid. Discuss with your supervising therapist and the patient which walking aid would be most suitable. Describe how you recognised that the patient was ready to progress. What action did you take? What was the outcome for the patient? Anything that you might have done differently? Workbook 16 Page 15
Evidence When you have instructed and monitored the patient in the safe use of the new walking aid, it is important that you allow the patient time to practice with the aid before reviewing their progress. Indicate how you would review the progress of the patient with the aid. You should review the patient with the aid again, ensuring that they are confident and comfortable with use of the aid. If the patient is to keep the aid, ensure that you have completed the appropriate paperwork, and that you have correctly documented in the therapy records the change in use of the aid. Your supervising therapist will sign to verify that you can: contribute to selection of the correct walking aid for an individual patient safely progress the patient to a suitable walking aid ensure that the patient is able to use the walking aid safely and effectively in their environment review their progress appropriately complete appropriate documentation Workbook 16 Page 16
16.12 Safety and walking practice When assisting patients with mobility or practising gait re-education, it is most important that you consider patient safety as a priority. Case study Julie is a physio support worker who has been practising walking with Mr Jones in his home for the past few weeks. He walks with a stick and has been safe and co-ordinated until now. Julie speaks to his wife prior to walking Mr Jones. She reports that he is well. When Julie gets him up to stand, she notices that he is less steady than previously. She tries a couple of steps with him, but he becomes more unsteady and holds onto her. Julie shouts for his wife to help her sit him down again. Activity What should Julie have done? Write your answers here. Workbook 16 Page 17
Firstly, Julie should have undertaken a risk assessment before trying to walk with the patient. She should have spoken in detail to the patient himself about how he was feeling. She should have observed that the lack of steadiness was a risk to his safety. When she realised he was less steady than normal, she should have asked him to sit down again. She should have asked him to take a few steps on the spot to assess his balance before proceeding. She could have discussed this change in Mr Jones ability with him and his wife to determine whether anything else had changed and for how long he had felt his walking had been more unsteady. She must then report these changes to the physiotherapist when she returns to base. The therapist would have reassessed Mr Jones and decided on what changes to make to his management. They could have walked him between two. Lastly, they may wish to inform the GP of the change in Mr Jones condition, since this may indicate a change in his medical condition. Workbook 16 Page 18
Evidence Describe here a case in which you safely carried out the physiotherapist s plan for walking practice. What precautions did you take? What instructions did you provide the patient with during practice? What walking aid did you use and how did you correct the patient s walking pattern? What instructions did you provide that patient or carers with for practice when you are not there? What did you document and where? Anything you would do differently next time? Workbook 16 Page 19
16.13 Walking with a patient and two staff When is it appropriate to undertake walking practice with a patient and two helpers? The Physiotherapist may decide from her assessment The physiotherapist will decide following assessment which patients require the assistance of two therapists, support workers, or nurses for walking re-education. They may decide that the patient can walk only with assistance of two. When you recognise that the patient is unsafe as a result of a risk assessment Although you may know the patient and they may have been assessed by the therapist already, you must be aware that patients change day to day and hour to hour. It is possible that following a risk assessment, you realise that there has been a deterioration in what the patient can do and that they are no longer able to practice walking with one person. When working with the patient, therefore, you must assess whether: The patient can move himself out of bed or to stand or more assistance is required. The patient s condition has improved or deteriorated. The patient is confused or can understand what you are asking them to do. A hoist or sliding system is required. You and your co-worker have the capability to perform the task: Have you been trained to handle? Are you fit to handle? Are you familiar with the equipment? Are you familiar with the technique? Are you familiar with the patient? You must also consider the environment Is the space clear, have hazards been removed? Are the brakes on the bed or chair? Is the height of the bed adjusted? Is the correct walking aid available? Is the walking aid in the correct position? It is important that you inform the therapist of any change in condition. She will reassess and may indicate that the patient should practice walking with assistance from two healthcare workers. Workbook 16 Page 20
Evidence With your supervising therapist and a patient in your care, go through the risk assessment process. Discuss you findings with your supervising therapist. Describe here a risk assessment that you performed with a patient, that indicated that they was unable to undertake walking practice with assistance of one person. What did you do and why? What went well? What could have been better? Would you do anything differently next time? What happened as a result of your risk assessment? Your supervisor will verify that you can accurately conduct a risk assessment to indicate when a patient is unsafe or unable to undertake walking practice with only assistance of one. You must inform the therapist promptly if there is a change in the condition of the patient that requires reassessment by the therapist. Workbook 16 Page 21
16.14 Conducting walking practice with a patient and two staff When co-ordinating a manoeuvre such as walking with a patient and two it is very important that everyone knows what to do and when. One of you should be the co-ordinator who gives the commands. Decide in advance who this is to be. The patient should be very clear about each step of the procedure. You should explain to the patient exactly what you are going to do and what the patient should do in each step of the procedure. If using equipment, you should explain exactly what you are going to use, how it works and what you expect the patient to do Of particular importance is clarifying the instruction for standing up and sitting down. Be sure that you, the other therapist and the patient are clear that when you say Ready, steady, stand, that you all know to stand up on Stand. Using this command is clearer than counting 1,2,3, since it is more obvious when to stand or sit. You must ensure that you know where you are going to walk to and that the distance is within the capability of the patient. Once you are certain that the patient is able to weight bear, ensure that the appropriate walking aid is available and to hand. Conducting the procedure You should stand on either side of the chair, facing the same direction as the patient. You should ensure that the patient moves towards the edge of the chair prior to attempting the stand. Your hands should be crossed behind the patient s back, on the pelvic bone, or on a handling belt if you are using one. The tallest therapist or nurse should place her arm across last. You may use rocking to facilitate standing up. The patients hands may be placed flat on the palm of your other hand, so you have a palmto-palm grip. You must never pull the patient up by dragging under the arms. You might use a handling belt, or a walking hoist. Your supervising therapist will assist you to use the appropriate hoist. You must ensure that one of you leads the manoeuvre and explains what you are doing to the patient. The timing of the move must be co-ordinated and everyone must be clear about what is happening and when. Workbook 16 Page 22
It is important to be concerned with the therapy as well as with safe manual handling techniques. Remember to correct the patient in their walking practice, by providing them with feedback as they walk. Evidence Answer the following questions: Where should you stand to assist the patient to stand up with two? What techniques can you use to assist standing up? Where should your hands go to assist the patient to stand up? What equipment might you use? What do you think is particularly important to be clear about when walking with the patient and two therapists? Workbook 16 Page 23
Returning the patient to the chair Again the manoeuvre needs to be co-ordinated between you. Ensure that as you approach the chair that the therapists are behind the patient that you assist the patient to step round to position themselves correctly. The patient should be able to feel the back of the chair with their legs prior to sitting down and if possible should feel for the chair arms with their hands Activity Under supervision with your therapist, go through the steps of walking with a patient and two support workers conducting gait correction returning the patient to the chair Acknowledgements NHS Tayside Workbook 16 Page 24
16.15 Walking re-education workbook completion Your supervising physiotherapist will sign your portfolio to indicate that you have completed this workbook successfully. Objective Physiotherapist s signature Date Demonstrate the correct pattern of sit to stand Describe and demonstrate various gait patterns with different walking aids Safely assist a patient to carry out the gait re-education plan agreed with the therapist Document the treatment and outcome of your treatment correctly Provide a patient with simple instructions to correct his walking pattern according to the plan determined by the physiotherapist Identify when a patient is progressing or regressing and take appropriate action Contribute to selection of the correct walking aid for an individual patient Workbook 16 Page 25
Objective Physiotherapist s signature Date Demonstrate the correct pattern of sit to stand Safely progress the patient to a suitable walking aid Ensure that the patient is able to use the walking aid safely and effectively in their environment Accurately and safely measure appropriate patients for walking aids Recognise signs of wear and tear on the walking aid and take appropriate action when required Accurately conduct a risk assessment to indicate when a patient is unsafe or unable to undertake walking practice with only assistance of one Support worker (name) Support worker s signature Physiotherapist (name) Physiotherapist s signature Date Workbook 16 Page 26
16.16 Walking re-education reflection Suggested KSF Dimensions: C2, HWB2, HBW7 This form should be placed in the appropriate section of your portfolio. What did you learn from this module? How has this influenced your work? Date module completed Date module completed Workbook 16 Page 27
Greater Glasgow and Clyde Tayside