Gait re-education

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.

NHS Training for Physiotherapy Support Workers
Workbook 16 | Gait re-education
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:
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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.
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Workbook 16 | Gait re-education
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:
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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.
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Assisting the patient to stand up
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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?
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NHS Training for Physiotherapy Support Workers
Workbook 16 | Gait re-education
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:
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the patient’s balance
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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.
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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.
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Activity
Your tutor will demonstrate gait
patterns with:
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a walking frame
a mobilator
two sticks
one stick
auxiliary crutches
elbow crutches
gutter crutches
You will also learn about:
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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:
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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.
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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
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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
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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.
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You might have included information like:
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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?
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Make sure you can:
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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
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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.
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The patient may dip down at the hip during stance phase.
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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.
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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.
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They may walk with one hand on the frame and one on the furniture!
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NHS Training for Physiotherapy Support Workers
Workbook 16 | Gait re-education
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:
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Brings their heel down to touch the ground at the end of swing phase.
Bends their knee to clear the ground.
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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.
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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?
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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?
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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:
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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
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NHS Training for Physiotherapy Support Workers
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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.
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NHS Training for Physiotherapy Support Workers
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Firstly, Julie should have undertaken a risk assessment before trying to walk with the
patient.
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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.
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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.
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She must then report these changes to the physiotherapist when she returns to base.
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The therapist would have reassessed Mr Jones and decided on what changes to make to
his management.
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They could have walked him between two.
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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.
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NHS Training for Physiotherapy Support Workers
Workbook 16 | Gait re-education
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?
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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:
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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:
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Have you been trained to handle?
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Are you fit to handle?
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Are you familiar with the equipment?
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Are you familiar with the technique?
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Are you familiar with the patient?
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You must also consider the environment
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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.
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NHS Training for Physiotherapy Support Workers
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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.
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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.
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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
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You should stand on either side of the chair, facing the same direction as the patient.
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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.
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You may use ‘rocking’ to facilitate standing up.
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The patients’ hands may be placed flat on the palm of your other hand, so you have a palmto-palm
grip.
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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.
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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?
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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
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walking with a patient and two support workers
conducting gait correction
returning the patient to the chair
Acknowledgements
NHS Tayside
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NHS Training for Physiotherapy Support Workers
Workbook 16 | Gait re-education
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
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Workbook 16 | Gait re-education
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
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Workbook 16 | Gait re-education
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
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Greater Glasgow
and Clyde
Tayside