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The Importance of Education Before Using a Walker After Neurological Injury

Usually, when I first meet a client with a recent neurological injury (such as a stroke, brain injury or spinal cord injury) walking is one of their primary physical rehabilitation goals.  Many of these clients do regain the ability to walk, often with the aid of a walker or a cane.

A gait aid can be a useful tool, with the caveat that it is used the right way.  Addressing the way the gait aid is used early on is important since developing good habits will save the client from complications down the road and allow him/her to further improve in function.

For many individuals, gait aids are necessary because they allow for compensations, which can enable them to walk safely.  Compensation is defined as a movement substitution that replaces normal movements to accomplish a functional goal (such as walking).  Compensations can be divided into “appropriate compensations” and “undesirable compensations”.

Appropriate compensations are those, which use movement patterns resembling normal movement.  Undesirable compensations do not teach normal movement patterns the individual may have the potential to learn, but instead lead to atypical movement patterns.

A lot of movement patterns are repeated between differing actions.  For example, a sit-to-stand movement uses the same pattern of trunk and leg muscles as walking.  If an atypical walking movement is learned, then that learned pattern will affect the client’s ability to sit-to-stand as well.   This may limit the client’s ability to get up from a low chair, despite having the muscle strength to do so.  The same normal movement patterns are repeated in a lot of different actions besides walking and sit-to-stand, such as reaching, rolling, lie-to-sit and stair climbing.

Learning atypical movement patterns usually leads to other limitations in the above actions.

A gait aid can result in either appropriate or undesirable compensations depending upon how it is used.  It is undesirable for an individual to use a gait aid by fixating on it with his/her upper body.  A body without fixation is using normal movement patterns.  This includes using different muscles at different times in order to maximize efficiency.

Fixation on a gait-aid occurs when an individual is leaning on the aid, using many of their upper body muscles excessively to help support their weight.  In addition, the person will have poor posture while walking since he/she is leaning forwards on a walker or sideways onto a cane.

These atypical movement patterns are very hard to unlearn.  They often persist, even if the individual recovers muscle function which would otherwise allow for more normal and efficient movement.

Instead, a gait aid should be used in a way that the individual is not fixating upon it, but rather using it as an aid for balance and stability.  It should be used to train normal combinations of leg, trunk and arm movements.  This can be done by ensuring the individual is not leaning on the aid, but rather standing up straight while using it.  In addition, the client should not be using the walking aid to support his/her weight.  When a gait aid is used appropriately, as the individual recovers more muscle function, he/she may eventually be able to walk without the aid.

The timing of when a gait aid is introduced is also important.  Just because an individual can walk using a gait aid, does not mean they should be walking.  As a physiotherapist, if I am working with a client who cannot walk without fixating on a gait aid, that tells me he/she may not be ready to walk.  We work on exercises to improve his/her strength and balance including exercises in standing until they can begin to take steps and walk with the gait aid without fixating on it.

There are always exceptions to every rule and there may be some individuals who may never be able to walk without some degree of fixation.  As a therapist, I work with each client to ensure that fixation is minimized and only used when absolutely necessary.

Submitted by: Farhana Jaffer