An elderly patient with a total hip replacement, a young female with a broken leg, and a back pain patient with a sprained ankle would not appear to have much in common—and they probably don't. But they all will very likely need some sort of ambulatory device to get around as their bodies heal. And they could potentially learn to use those devices from the same PT.

Cynthia Bauer, PT, DPT, OCS, director of Musculoskeletal Outpatient Services at Good Shepherd Rehabilitation Network in Allentown, Pa, carries just such a caseload, as do her colleagues in the institution's orthopedic outpatient department. Bauer's staff in the Allentown facility numbers about 15 and includes six PTs (including Bauer), plus one or two PTs in training, and seven PT assistants.

Program specialties include hip, knee, and shoulder replacements; knee injuries, including pain, sprains/strains, and ACL repairs; general sprains and strains; cervical and lumbar pain or injuries; ankle fractures, sprains, or instability; biomechanical foot evaluation and orthotic fabrication; shoulder injuries, including rotator cuff injuries, fractures, tendinitis, impingements, and adhesive capsulitis; thoracic outlet syndrome; reflex sympathetic dystrophy; osteoporosis, rheumatoid arthritis, and osteoarthritis; presurgical education, conditioning, and strengthening programs; comprehensive back care education; lymphedema management; facial pain or paralysis; and myofascial pain and fibromyalgia. Bauer estimates that Good Shepherd's outpatient orthopedic department had more than 19,000 patients in 2007.

Not all of these patients require ambulatory aids, of course, but for those who do, any similarities likely end there. Not only do these patients have different demographics and diagnoses, they also have different lifestyles, tastes, and needs. Subsequently, they will require different types of ambulatory aids, the selection of which will be directed by these parameters as well as rehabilitation goals. "We want to get them to the highest level of function with the least supportive but safest device they need," Bauer says.

THE RIGHT TOOL

Bauer works primarily with crutches, walkers, and canes. Patients in wheelchairs are often referred to Good Shepherd's Assistive Technology program. "Very rarely do our orthopedic therapists order specialized wheelchairs. Our patients usually need a wheelchair as in interim device and use the one they obtained in the inpatient rehabilitation setting or we order a standard type wheelchair for short term use. Specialized wheelchairs for patients that will need them long term and have customizations, such as a motorized wheelchair with controls or adaptations, are fitted by our Assistive Technology department therapists. These therapists are specially trained to fit customized wheelchairs," Bauer says.

Typical patients referred to musculoskeletal rehabilitation include those recovering from orthopedic surgery or trauma as well as those suffering from debilitating conditions, such as rheumatoid arthritis or progressive spinal stenosis. "We see people that have had orthopedic surgeries, such as total hips or knees, or people with ankle sprains or fractures after a motor vehicle accident. We sometimes see elderly patients declining in function who need some sort of support for balance to help ambulate longer distances more safely," Bauer says.

Cynthia Bauer, PT, DPT, OCS, instructs a patient in the correct cane and foot placement using a stylish adjustable single-point cane with a foam grip.

Like many PTs, Bauer will begin patient treatment only after completing a full evaluation and assessment. She seeks to understand not only the ultimate rehabilitation goal but also what the patient is willing to integrate into his or her life. "If you prescribe the wrong device, they will not use it," Bauer says.

Lifestyle and personal preferences must therefore be carefully considered. Questions Bauer asks include: Have they ever used an ambulatory aid before? Where will it rest near them when they sit down so that it is easily accessible but not in the way? How active are they? What hobbies do they enjoy? Where do they live? Are there steps? Do they drive? What type of car do they have? If a walker is going to be prescribed, does it need to fold? Do they have the strength to pick it up to advance it?

The patient's physical condition will play a strong factor in guiding the selection. Those without balance will need more stable devices, such as quad canes or walkers; those with better balance may use single-point canes or crutches. Patients without a lot of upper arm strength or endurance (eg, emphysema sufferers) might need rolling walkers—those with wheels on two of the legs—so they can maneuver the device more easily by pushing rather than lifting.

For example, Bauer might start an older person that has had total hip and also has poor balance with a walker, but a school-age student with good balance and strength might use axillary or underarm crutches. A 30-year-old female who fractured her ankle in a car accident would likely get axillary crutches, while an MS patient with a broken bone and bad balance would start with a walker.

"It generally depends on function, though I have learned over time that what I recommend needs to be in agreement with what the patient wants," Bauer says. Even if she believes there is one device that would be best, Bauer will compromise to be certain the patient will use it. Sometimes, however, compromise is difficult, such as when a patient who needs a walker insists on a cane.

"You definitely don't want to agree to a device that won't help them or is unsafe. For instance, patients may insist on a cane but don't have the right balance to use one. I might tell the physician about the difference in opinion, and we have to go from there," Bauer says. She worries about community residents with inappropriate devices and notes that patients frequently come in to the clinic with unsafe items they have purchased from yard sales.

Generally, however, agreement is reached, often after the patient has had the opportunity to experiment with the options. The orthopedic outpatient department maintains its own inventory of ambulatory aids to use as samples and educational and training tools. "We keep various devices in the department to try them out and show patients how to use them, including family members," Bauer says. Samples, which have all been purchased, include bariatric canes and walkers, regular and tall standard walkers, rolling walkers, quad canes, wooden canes, and standard single-point canes, with and without arthritic grips. "We work with patients to see what they are safe with. How is their stability? Can they climb stairs and curbs? Can they walk on grass?" Bauer says.

Using this information, Bauer will make a recommendation. In some cases, Good Shepherd will place the order as well, providing insurance information to the patient-preferred vendor.

THE RIGHT TIME

According to Bauer, insurance companies do not cover multiple devices in a short period of time, so it is extremely important that the first item selected be the right device. PTs and patients must look ahead to be certain that the recommendation will work for future needs as well as for the current ones.

Bauer explains the importance of setting all four prongs of a quad cane on the ground when walking for optimal stability.

"It's important to make sure the device selected will progress with the patient. You want to know if the diagnosis is progressive or debilitating, or if the patient is expected to recover fully or in part. Once insurance invests in a device, they don't want to buy another," Bauer says. Fixing a mistake can therefore be a challenge. Bauer states that many times the insurance companies do rent devices with the intent to purchase after a period of time. This may provide an interim solution.

Bauer finds that prescribing an appropriate device at the time is important. Generally, Bauer notes it isn't likely that a person with a total joint or ankle fracture will use a walker for the rest of his or her days. At the same time, there are patients who will not fully recover and may have to permanently rely on an ambulatory aid. Therefore, it becomes important to select a device that may become less supportive or more supportive as the needs change.

Bauer finds that with her caseload, the single-point cane is one of the most common ambulatory aids she recommends; among walkers, she prefers those that roll. "I find that most patients with chronic back pain and shoulder conditions that require a more supportive ambulatory aide do much better with a rolling walker than a standard walker. As patients improve and their injuries heal and more weight bearing is possible, I then progress patients to a lesser supportive device such as a quad cane, then a single-point cane, and eventually no cane if their balance is good enough. Some patients will skip the quad, while others will use it forever and that is the most improvement they will achieve," Bauer says.

Bauer recalls one such patient who sustained debilitating fractures to both heels along with muscular injuries. "This type of injury is very hard to recover from. The pain and weakness in the lower extremities is significant, and the patient may not be able to advance," Bauer says, noting the challenges he experiences in balancing, pushing his weight forward when walking, and stepping over objects. However, if he does progress, Bauer expects to move to Lofstrand crutches first, also known as forearm or Canadian crutches.

THE RIGHT FIT

Even as the devices become less cumbersome, they must still be properly fit. "A lot of times, patients come to the clinic with a device already. They have been sent home from the ER or a surgical room and provided with the device they need. Our role is to make sure it fits them correctly and that they understand how to walk appropriately," Bauer says. She worries about community residents with inappropriate devices and notes that patients frequently come in to the clinic with unsafe items they have purchased from yard sales or they had belonged to a family member or neighbor. These devices frequently are the wrong height or are worn and are in need of repair and may be unsafe. Many times patients think they know how to use them and are using them incorrectly.

Often, ambulatory aids are specific to the patient's height, width, and weight. Few devices will telescope to fit patients ranging in height from 5 feet 1 inch to 6 feet 6 inches and greater, so it's important that the initial device be ordered in the appropriate size. "If I have a woman who is 5 feet tall but a walker designed for patients at least 5 feet 4 [inches] or 5 feet 5 [inches] tall, we'll need a new walker," Bauer says.

Pediatric patients will require pediatric devices. Heavier patients will also require specialized devices. Ambulatory aids typically load up to 250 pounds; larger patients will require bariatric models, which can support up to 500 pounds and there may be some that support heavier patients.

Comorbidities also must be considered when ordering, since they can impact smaller details and options, such as grips. "When we order from a vendor we designate the type of grip we want. Hands with rheumatoid arthritis need a different grip so the cane doesn't lead to hand or shoulder problems," Bauer says. Grips are most often made of wood, rubber, plastic, or soft foam. Even Lofstrand crutches or walkers with platform attachments offer options to prevent weight-bearing on the hands if needed, such as in cases of multiple fractures.

THE RIGHT LOOK

Though function is the primary concern, it isn't everything, particularly for patients for whom the devices are permanent fixtures. "Times have changed for ambulatory aids. They are not just the typical wooden or silver devices. They are colorful and stylish," Bauer says.

Many patients possess multiple canes from which they match their formal and recreational outfits. "People buy them to match what they are going to wear to church or other activities and functions," Bauer marvels.

In addition to the fashion benefits, well-designed devices tend to make patients—particularly pediatric users—more comfortable with their aids. "They are able to integrate their personality into their assistive device," Bauer says, who recalls seeing camouflage wheel covers on a wheelchair recently. She expects the market will support more "high-end designer gear" in the future.

THE RIGHT ACCESSORIES

Another burgeoning market is that for ambulatory aid accessories. "There are many people using lots of devices, and they have become very creative in inventing things to improve performance, so out of a need have come inventions for this market," Bauer says.

Some of these have come from manufacturers. For instance, there are quad canes today that feature wheels. "The device may compresses to the floor when you stop it," Bauer says.

Another cane is built with a step to allow patients to maneuver tall stairs or awkward climbs. Still another offers a seat that folds out when rest is needed. "If you have an endurance problem, such as an emphysema patient might, you can rest when you get tired," Bauer says. However, she suggests these users should be lightweight. "I'm not sure how taller people weighing 200 pounds would feel about the seat," Bauer says.

Folding canes are great for travel while cane attachments can expand functionality. Bauer has seen ice grippers (though she doesn't recommend patients with canes spend much time walking on ice), attached reachers ("these are great for patients with total hips who can't bend over at the waist to pick items up off the floor," Bauer says), slings from which to dangle a cane from a wrist while fetching something with one's hands, and grippers that hold a cane resting in place. Bauer has even seen an attachment to turn a single-point cane into a tripod cane. "It adds stability," Bauer says.

Walkers also have a host of accessories, many of which target the back legs. Decorative balls help to reduce noise and friction, gliders shaped like mini-skis make the device easier to push, as do circular ones resembling those used to move large furniture (and often seen as the subject of television infomercials). Lights, baskets, bags, and cup holders can all be added to a walker to make the completion of other tasks more convenient.

These extra devices are generally added over time and do not require formal prescriptions. Often they are only a few dollars and so are easily affordable. Bauer will not necessarily direct a patient to accessories but will make suggestions in response to specific complaints. "If a patient is not using a cane because it keeps falling to the ground whenever they rest it against a table or wall, I can let them know I've seen a gripper adaptation to alleviate that problem," Bauer says.

Bauer's patients can often find these items in Good Shepherd's store, which was opened recently to serve clinicians and customers with unique product needs. Previously, orders were placed over the phone or the Internet by the patient for an item seen in a catalog. The store, however, offers the ability to see the item and speak with an educated individual that can assist in selection. It also carries items that may be suggested by the clinicians. This takes the guesswork out of ordering the correct item as the therapist is already familiar with the item and knows it will work with the patients needs. It also offers a wide selection that benefits the institution and its patients as much as the clinicians. Its inventory helps to provide the right device at the right time with the right fit and look.

Renee DiIulio is a contributing writer for Physical Therapy Products. For more information, contact .