Gait Training
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Direct answer
"Up with the good, down with the bad" — the stairs rule carries the logic of all gait training: the sound limb leads while climbing, the affected limb leads while descending, and the walking aid always travels with the affected limb. Training begins away from walking altogether — sitting balance, standing balance, weight-shifting and transfers — then progresses through parallel bars to a walker, crutches or a cane according to the surgeon's weight-bearing order and the patient's strength. An aid is fitted, never borrowed: axillary crutches sit two to three finger-widths below the armpit with elbows bent 20 to 30 degrees, because resting weight in the axilla compresses the radial nerve.
What you must remember
- Pre-gait prerequisites: adequate range and strength in hip and knee extensors and plantarflexors, sitting and standing balance, adequate cardiovascular reserve — the sequence runs bed mobility, sitting, standing, weight-shift, parallel bars, aid, independence.
- Weight-bearing orders decoded: non-weight-bearing, touch-down or toe-touch (foot rests for balance only), partial weight-bearing (a set percentage), weight-bearing as tolerated, and full weight-bearing.
- Axillary crutch fitting: pad about 5 cm below the axilla (two to three finger-widths), tip 10–15 cm lateral to the foot, elbows flexed 20–30 degrees; weight goes through the hands, not the armpits — axillary pressure causes radial nerve palsy and wrist drop.
- Crutch gaits: four-point (right crutch, left foot, left crutch, right foot — always three points down, slowest, most stable), two-point (crutch and opposite foot advance together, near-normal rhythm), three-point (both crutches and the affected limb move together, then the sound limb — for non-weight-bearing orders), swing-to (feet swing up to the crutches) and swing-through (feet pass beyond them — fastest, needs strong arms and trunk, as in paraplegics with orthoses).
- The cane is held in the hand opposite the affected limb and advances with it; it widens the base of support and reduces the load through the affected hip.
- Walkers give maximum stability for frail or elderly patients; rollator frames suit those who cannot lift safely but brake reliably.
- Safety kit: dry floor, firm footwear, gait belt, therapist positioned on the affected side and slightly behind.
Gait training after total hip replacement
Take a patient on day two after a right total hip replacement, posterior approach, weight-bearing as tolerated and three precautions: no hip flexion beyond 90 degrees, no adduction past midline, no internal rotation. Pre-gait work comes first — sitting edge-of-bed with the hip extended, standing with the frame in the bar, side-stepping weight onto the left leg, small right knee lifts within precaution limits.
Parallel bars next: the sequence is taught as three words — lift the frame (or both crutches), step the affected right leg, step the left. The frame moves first, always, and never farther than arm's length; the patient counts aloud to stop the shuffle. Watch the right hip for any crossing of the midline, and place a pillow between the knees in bed.
Progression to a rollator frame, then to a cane in the left hand within two to three weeks, always opposite the operated side. Stairs arrive before discharge because most Indian homes have them: with a rail on the left and cane in the right hand, ascend leading with the left (good) leg, descend leading with the right (bad) — "good goes to heaven, bad goes to heaven's gate first on the way down", or simply: up with the good, down with the bad. Sessions twice daily, ten minutes each, tolerated pain guiding speed, with Trendelenburg watching as the abductors recover.
Where students slip
The cane's side is the most wrongly answered fact in mobility training — opposite the affected limb, not beside it. Gait-pattern definitions get scrambled: three-point does not mean three limbs down but crutches-plus-affected-limb moving as one unit. Students forget that axillary pads must never touch the armpit, and they reverse the stairs rule under exam pressure. Weight-bearing order matching — touch-down allowing the toes to rest for balance only — also separates marks in scenario questions.
Frequently asked questions
In which hand is a cane held, and why?
Opposite the affected limb; it widens the base of support and reduces force through the affected hip by shifting the line of loading.
Which crutch gait suits a patient forbidden to bear weight on one limb?
Three-point gait — both crutches and the affected limb advance together, then the sound limb steps through.
How are axillary crutches fitted?
With the pad 5 cm below the axilla, tip 10–15 cm lateral to the foot, and elbows in 20–30 degrees of flexion.
What is the stairs rule with a cane?
Up with the good, down with the bad — the sound limb leads ascending, the affected limb leads descending, cane always with the affected limb.
What injury follows resting body weight on axillary crutch pads?
Compression of the radial nerve in the axilla — crutch palsy with wrist drop.