Walkers

Original Editor - The Open Physio project.

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Introduction

A walker is a walking aid that has four points of contact with the ground and usually has three sides with the side closest to the patient being open. It provides a wider base of support than a walking stick and so is used more to stabilise patients with poor balance and mobility. Having a caregiver and being unable to walk more than one metre per second has been significantly associated with walking frame use. Paradoxically, walker or frame use has been associated with an increased risk of falls in both the community-dwellers and those who live in residential care. Using a walker can also increase metabolic and musculoskeletal demands so prescription and education is key to helping the user maintain their balance, minimise their falls risk and optimise their activity levels.

People may be resistant to use walkers due to social stigma and peer pressure, particularly so in minority groups. By having positive peers models, greater physician input, more visually pleasing walkers, lower cost walkers and user friendly walkers would aid in greater acceptance.

In 2009 in Australia the percentage of people with disabilities using aids was 15% [ 6.6% using walking frames, 6.7% walking sticks].

A study in the USA, reported on on 2015, found that 11.6% of those over 65 used walking frames. The use of walking aids it also reported had jumped up by 50% in the last 10 years.

In a Canadian study using 2012 data 4.1% of the population, 15 years and older, used a walking frame, stick or crutch. Approximately 50% of these used a walker. Since 2004 there has been a 2% increase of walking aid use in the community.

Types of Walkers 

Many walkers exists on the market and a physiotherapist is well placed to be instrumental in choosing the correct walker for the differing needs of users.

4 wheeled walker

• Wheel size: large wheels for outdoors, small wheels for indoors
• Push down brakes or grip on brakes
• Ability to be folded and lightweight material such as carbon fibre, which makes travelling with the frame easier
• Trays, seats and baskets may be attached
• Other modifications such as a light that projects a red line on the ground in order to guide step length in individuals with Parkinsons

• High or gutter frames for users who need more support. The user weight bears through their forearms on gutter-shaped supports, with the elbows flexed to approximately 90 degrees.

• Pulpit frames where the user also weight bears through their forearms and hands on a padded U-shaped support, similar to leaning on a pulpit.

Variations on 4 wheel walkers

• Two front legs with two rear casters
• Two front legs and two rear wheels
• "Square" wheels
• A modular kit with interchangeable parts to make frames and other mobility devices. This is a great innovation made by a final year engineering student aimed at the worlds poorest communities. Such a kit helps these communities make there own mobility aids at a realist price.
• 4 wheeled walker and transport chair all in one

Prescription

There is no one walker that should be used. Walker choice is dependent on what activities the user will use it for, where the walker will be used, how much support the user requires and the user's confidence with a walker.

It is also worth noting the funding source for the walker. If the walker can be sourced through government funding there may be an established range from which to choose from.

There is recent, preliminary evidence that suggests that the stability of a user and their walker can be measured "as one". The methodology considered a combined (user plus walker) centre of pressure and combined base of support (again created by user and walker, not two separate bases of support). This may not be so practical for physiotherapists, particularly those assessing users in their homes, but the physics behind the methodology is useful to consider.

Walkers should be adjustable in height, which is measured in the same way as one would measure for a walking stick. Shoes should be taken into account during prescription as shoe height can significantly affect walker use.

Factors to take into account when prescribing a walking frame:

• Height of the frame
• Weight of the frame when user propels and manoeuvres it
• Base area
• Manoeuvrability including wheel design e.g. fixed versus swivel
• Wheel placement
• Hand grip design
• Arm support design
• Folding versus unfolding
• Attachments e.g. trays and seats

Assessing the user with a walking aid should be done using an appropriate outcome measure such as the 10 Metre Walk Test or Timed Up and Go.

Usage

Users should have a smooth gait pattern that is unimpeded by the frame. There should be adequate space for step placement.

Users should never attempt to use a frame, by pulling on it, to help them sit or stand.

A frame with four legs and a wide base, known as a Zimmer frame is used in the following way if weight-bearing on both legs.The user:

• Picks it up
• Moves it forwards
• Places it in front of them
• Leans on the frame, taking weight through the upper limbs
• Walks into it (the patient should be encouraged to take two small, even steps to avoid a disordered gait pattern)

A 4 wheeled walker

• Make sure walker is completely opened and hinges locked
• Keep close to the frame at all times, near the back wheels
• For downhill ramp use gently squeeze on brakes at all times
• Ensure that brakes are locked before sitting on the seat of frame, with frame on level ground, preferably with wall or fence behind.

Maintenance

Brakes should be checked regularly to ensure they are working correctly. Wheels should be checked regularly and when the user reports tracking issues, e.g. frame pulling to one side. Wheels should also be checked as sometimes hard and repeated braking can distort the shape of the wheel making it lose its roundness. Ferrules should be checked regularly and replaced if worn. Wear may occur more quickly if the walker is used outdoors.

The height of the frame should also be checked periodically to ensure it is the optimal height for the user's posture. This is especially important if the user is undergoing rehabilitation and changes in their balance, strength and posture are expected or observed on assessment.