April 2006

Choosing Mobility

By Alison Kreger, DPT, MS

Wheeled or standard, cane or crutch, selecting the right walking device can ensure smoother ambulation.

Walking is an essential part of life. It is a simple means of mobility, permitting a person to explore their environment. Walking is incorporated into keeping healthy, socializing, and learning. Socializing and learning are much easier when an individual can get around to different places to access what they need and explore their environment. Daily walking may seem simple enough for most, but it is challenging for others. Assistance with balance, weight-bearing, posture, and endurance are only some of the reasons why independent walking can be compromised. Fortunately, there are numerous devices to help one achieve independent or assisted walking ability or ambulation. Some options are canes, crutches, or walkers.

Deciding which device to use can be a daunting task. A common debate is when to use a wheeled versus a standard walker. Here are some factors to consider.

CHOOSING THE RIGHT WALKER
Weight-Bearing: Depending on a person's medical condition, they may sometimes have to limit the amount of weight that travels through the lower extremities (for example, with a fracture, after an amputation, or after surgery, such as a total knee or hip replacement). If a person is given a restricted weight-bearing status (such as non-weight-bearing, partial weight-bearing, or touch-down weight-bearing), a debate on what device is more appropriate may arise. For someone with non-weight-bearing status, a standard walker may be recommended because of the added stability provided by the four legs. This larger base of support stays in contact with the ground and can support the user's body weight, even when they are hopping forward. If one has low endurance or a weak upper body, mobility can be difficult as a result of picking up the walker and advancing it forward. With a different weight-bearing status, the patient may prefer the wheeled walker—unless they are unable to use it. The ease of pushing a walker forward may be better for them as long as their full weight is not expected to pass through their arms, enabling the use to hop on one foot. (In this case, the wheels may slide out from under the patient.)

Balance: This may be an issue with the elderly, people with vertigo/inner ear problems or a history of falls, and children who toe walk or are low tone. When weight-bearing is not necessarily the issue, but added support is necessary for balance, new factors come to mind. When this situation arises, the wheeled walker is good for the ease of advancement because it is being pushed forward. A person is not required to stand on their lower extremities independently, as they would do when picking up a standard walker to advance it forward. The wheeled walker still provides added support, enabling the user to lean forward to distribute weight over a larger support base. Still, some patients feel uncomfortable with a wheeled walker, afraid it will slide out from underneath them. In this case, a person's comfort supersedes my initial preference, and I would proceed with a standard walker.

Endurance: It is not uncommon for patients to present with limited endurance, especially when chronic obstructive pulmonary disease is involved. If their endurance with ambulation is limited due to shortness of breath, the use of a wheeled walker (or a respiratory walker to which an oxygen tank can be attached, if needed) should be encouraged. While the upper body is supported by the wheeled walker, as the user leans forward onto it, the respiratory muscles are also supported—as when they sit down and brace the upper body on extended arms. It also seems to be less physically taxing to roll or push the walker forward rather than to pick it up.

Environment: A person's home environment plays an important role in determining where they want to go. Grass and gravel are not safe or ideal grounds on which to use a wheeled walker. Pavement and carpeting are manageable with a wheeled walker. Climbing stairs is not necessarily the ideal situation with either walker, but if it must be done, a standard walker is more realistic (especially with a railing).

Posture: If a person tends to lean forward with possibly some kyphosis—a forward-head posture and rounded shoulders—a wheeled posterior walker would be a possibility. Due to its design, this walker fits behind the user, forcing a more ideal, erect posture. The user pulls it behind him, and he is still able to use it for balance and support. Besides weight-bearing, balance, endurance, environment, and posture, other factors may come into play when choosing a wheeled walker or a standard walker. These include other equipment to be used and other conditions that are involved, such as amputation or cognitive ability. Many factors play a part in selecting to use a walker rather than another type of assistive device. This decision-making process is not all that simple, and it should be based on knowledge about a person; clinic applications of devices; their environments, expectations, and fears; and physician and medical recommendations.

Essentially, I choose a standard walker for more support and a wheeled walker for more efficient and coordinated ambulation, or if the person is too weak to lift and move a standard walker.

Alison Kreger, DPT, MS, is a pediatric and acute care physical therapist at the Ohio Valley Medical Center, Wheeling, WVa.

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