Assistive Devices

Assistive devices Assistive devices for mobility/ambulation can be referred to as ambulatory aids. Ambulatory aids (eg, canes, crutches, walkers) are used to provide an extension of the upper extremities to help transmit body weight and provide support for the patient. The type of ambulatory aid needed depends on how much balance and weight-bearing assistance is needed. Generally, the more disabled the individual is, the greater the complexity required in the walking device. A walker supplies the most support, and a standard cane provides the least. Uses of assistive devices include the following: • Redistribute and unload a weight-bearing lower limb • Improve balance • Reduce lower limb pain • Provide sensory feedback Adequate upper limb strength, coordination, and hand function are required for the proper use of ambulatory aids. Assistive devices for ADL, as well as for self-care and leisure activities, range from simple objects for daily use (eg, plate guards, spoons with built-up handles, elastic shoelaces, doorknobs with rubber levers) to complex electronic devices, such as voice-activated environmental control systems. Batavia and Hammer identified 4 key evaluation and selection criteria for long-term users of assistive devices. • Effectiveness - The extent to which the function of the device improves one's living situation, functional capability, or independence • Affordability - The extent to which the purchase, maintenance, or repair of the device causes financial difficulty • Operability - The extent to which the device is easy to operate and adequately responds to demands • Dependability - The extent to which the device operates with repeatable and predictable levels of accuracy under conditions of reasonable use Assistive devices and their use for impairments Impairments and the associated assistive devices that aid in ambulation and mobility are as follows: • Mildly impaired balance/stability - Single-point cane • Unilateral lower limb pain/mild weakness - Single-point cane; hold with unaffected side • Moderate impaired balance/stability - Quad cane (narrow or wide base) • Moderate-to-severe unilateral weakness/hemiplegia - Walk cane/hemiwalker • Bilateral lower extremity weakness/paralysis - Bilateral crutches or walker (pickup or front-wheeled) • Severely impaired stability - Walker (pickup or front-wheeled) • Impaired wrist or hand function - Platform forearm walker • Difficulty climbing stairs - Stair-climbing walker • Impaired bed mobility - Bed rails (half or full); hospital bed (manual or electrically controlled) • Difficulty with transfer - Transfer (sliding) board • Difficulty getting up from chair - Seat-lift chair or uplift seat assist Impairments and the associated assistive devices that aid in ADL are as follows: • Limited hand function and fine motor control o Eating - Built-up utensils, universal cuff with utensil hold o Dressing - Button hook, zipper hook, Velcro closure, sock aid, long shoe horn, elastic shoe laces o Bathing - Wash mitts, long-handled sponge o Grooming - Built-up combs or brushes, electric toothbrush, electric razor with custom handle • Loss in 1 hand of eating-related functions - Plate guard, rocker knife • Impaired coordination, tremor - Weighted utensils • Impaired range of motion (ROM) of shoulder, proximal weakness - Reacher • Impaired mobility for toileting - Bedside or rolling commode, raised toilet seat, grab bars around toilet • Impaired mobility for bathing - Tub transfer bench, hand-held shower, grab bars on tub or shower; shower chair Impairments and associated assistive devices to aid in communication are as follows: • Difficulty holding pen to write - Built-up pen or pencil • Difficulty typing - Typing stick • Reading difficulty caused by impaired vision - Magnifying glasses, talking clock or watch • Difficulty dialing and using phone - Push-button dialing or 1-touch dialing with speaker phone; voice-activated phone • Difficulty calling for help - Simple buzzers or other signaling devices operated by switches that require minimal pressure; medical alert system, such as Life Alert. Impairments due to complete loss of all 4 limbs or limb motor function: • Brain-computer interface (BCI) devices or motor neuroprosthetic devices are systems that allow individuals to translate in real time the electrical activity of the brain into overt device control such that it reflects the user’s intentions. In essence, these constructs can decode the electrophysiologic signals representing motor intent. They do not rely on muscular activity and can therefore provide communication and control for those who are severely paralyzed due to injury or disease. • Current BCIs differ in how the neural activity of the brain is recorded, how subjects (human or animal) are trained to produce a specific electroencephalographic response, how the signals are translated into device commands, and which application is provided to the user. Patients with any of a variety of conditions, such as locked-in syndrome, spinal cord injury, stroke, limb loss, or a neuromuscular disorder, may benefit from the implantation of these BCIs, which augment the ability of a patient to communicate and interact with his/her environment. Impaired vision and blindness: • Good, older methods of providing sensory substitution for people with severe visual impairment include the use of visual-impairment canes and guide dogs. A more complex aid for the visually impaired, a human-machine interface utilizing an array of electrical stimulators on the tongue, has been developed; the technology was quantified using a standard ophthalmologic test. Using the interface, subjects achieved an average acuity of 20/860 without training; the figure doubled following 9 hours of training. The interface may lead to the development of practical devices for persons with sensory loss, including individuals who are blind Canes Canes widen the base of support and decrease stress on the opposite lower extremity. Canes can unload the lower limb weight by bearing up to 25% of a patient's body weight. Canes can be made of wood or aluminum; tubular aluminum is lighter than wood. Aluminum canes are adjustable, which is a characteristic that facilitates their use by patients of all sizes. Determining the proper cane length is important. A cane that is fitted incorrectly produces an inefficient gait pattern. A short cane reduces support during the stance phase, and it tends to keep the elbow in complete extension. A long cane causes excess elbow flexion, which leads to increased muscle fatigue on the triceps and shoulder muscles. To determine the proper cane length, measure from the tip of the cane to the level of the greater trochanter while the patient is in an upright position. The elbow should be flexed approximately 20°. Types of canes Generally, the following 3 types of canes are used: • C cane - This is the most commonly used cane. Other names used for this device include the crook-top cane, the J cane, and the single-point cane. • Functional-grip cane o This type of cane provides better grip and more controlled balance for patients. o The grip of a functional-grip cane is more comfortable than that of a C cane. o The ortho cane is an example of a functional-grip cane. • Quad cane o Quad canes provide more support than do other standard canes. o Narrow- and wide-based forms of quad canes are available. o Quad canes are especially helpful for patients with hemiplegia. o Slow gait is one disadvantage of quad canes. Other types of canes include the following: • Walk cane (hemiwalker) o This type of cane combines the features of a walker and a quad cane. o Hemiwalkers usually are made of tubular aluminum, are adjustable, and can be folded. o Hemiwalkers provide a wider base and more lateral support than do the regular quad canes. o Indications for a hemiwalker include the following: . Patients with hemiplegia . Individuals who need an intermediate step during gait training; often used during the period after use of the parallel bars and before ambulation, which is a time when the patient needs less restrictive assistive devices • Visual impairment cane o Features . Lightweight . Flexible . Easily collapsible o The distal inches of the cane are red. o To determine the proper length of the cane, measure the distance from the hand to the floor while the shoulder is flexed 90° anteriorly. Biomechanics The cane usually is used on the side opposite the affected lower limb. The cane helps decrease the force generated across the affected hip joint by decreasing the work of the gluteus medius-minimus complex. The force is exerted by the upper extremity through the cane to help minimize pelvic drop on the side opposite the weight-bearing lower limb. If the cane is held on the affected side, the affected hip in turn experiences an increased load of 4 times the body weight during ambulation. Function • Ambulation o The cane usually is held on the patient's unaffected side so that it provides support to the opposite lower limb. o The cane is advanced simultaneously with the opposite, affected lower limb. o The weight is borne through the arm as needed. o The patient always should have the unaffected lower limb assume the first full weight-bearing step on level surfaces. • Stair climbing o The mnemonic "up with the good and down with the bad" can help patients to recall the appropriate step pattern for stair climbing. The cane is used for extra support when ascending/descending stairs. Often, the patient also has a rail to hold on the other side for added safety. o Advance the unaffected lower limb first when going upstairs, and advance the affected lower limb first when coming downstairs. o The patient always should have the unaffected lower limb assume the first full weight-bearing step on level surfaces. Crutches Crutches have 2 points of contact with the body, providing better stability than do canes. Two types of crutches (ie, axillary, nonaxillary) currently are in use. Axillary crutches An axillary crutch is a type of orthosis that provides support from the axilla to the floor. Wood and aluminum axillary crutches, both of which are adjustable, are available.

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