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newSchoolWorks.com › VoTechWorks › Health & Personal Services › Physical Therapy / Rehab Aide › Patient Transfer and Mobility Assistance › Lesson 5
HLT-PHYS81-04 · Lesson 5 · 14 clock hours · practice

Gait Training Assistance and Assistive Device Fitting

Objective. Students will measure and fit a walker, standard axillary crutches, and a quad cane to a peer patient according to established fitting criteria, then provide correct verbal and physical guarding during ambulation on level surface and stairs.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

VoTechWorks program approval and accreditation are still in progress. Credentials are issued only by the certifying bodies named in each program, after their own exams.

Why Assistive Device Fitting and Guarding Matter

An ill-fitted walker or crutch places patients at immediate risk of falls, nerve injury, and ineffective ambulation. As a rehab aide, you are not prescribing devices — that is the physical therapist's role — but you will be directed to set up, verify fit, and assist patients during ambulation under a therapist's supervision. Accuracy and safety awareness are non-negotiable parts of your scope of practice.

Anatomical Landmarks Used in Fitting

All three devices in this lesson are fitted while the patient stands upright in non-skid shoes with arms relaxed at the sides.

Walker and quad cane handle height: The handle should align with the patient's greater trochanter (the bony prominence on the outer hip). When the patient grips the handle, the elbow should flex approximately 20–30 degrees. A straight-arm grip means the device is too tall; an elbow bent beyond 30 degrees means it is too short.

Axillary crutch length (overall): The crutch tip is placed approximately 2 inches (about 5 cm) to the side and 6 inches (about 15 cm) in front of the patient's foot. The top of the crutch should sit approximately 2–3 finger-widths (about 1.5–2 inches) below the axilla. The axilla must never bear weight on the crutch pad — prolonged axillary pressure can compress the brachial plexus, causing radial nerve palsy ("crutch palsy").

Axillary crutch handgrip height: Same landmark as the walker — the handgrip should align with the greater trochanter, producing 20–30 degrees of elbow flexion when the patient grips it.

Step-by-Step Fitting Procedure

1. Confirm the therapist's order and the patient's weight-bearing status before handling any device.

2. Place the patient in standing with good posture and non-skid shoes.

3. Use a tape measure to assess each landmark; record the measurement.

4. Adjust the device to the measured setting; all push-button pins must be fully seated and all wing-nuts tightened.

5. Verify fit visually and with the patient: ask whether the grip height feels comfortable, and re-check elbow angle.

6. Complete the fitting criteria checklist before any ambulation begins.

Gait Patterns for Crutches

Non-weight-bearing (NWB): The involved limb does not touch the floor. The patient advances both crutches together, then swings the body through, bearing all weight on the uninvolved leg. As an aide, cue: "Crutches forward together, then step through with your good leg."

Partial-weight-bearing (PWB): The involved limb may touch the floor and bear a limited, therapist-specified amount of weight. The patient advances both crutches and the involved foot simultaneously, then steps through with the uninvolved foot. Cue: "Crutches and your weaker foot move together, then step with your strong leg."

Never advance a patient beyond the weight-bearing status documented in the care plan. If a patient reports increased pain, refuses to follow the pattern, or you observe anything unsafe, stop ambulation and notify the supervising therapist immediately.

Walker Ambulation Pattern

The standard pick-up walker pattern: advance the walker, then step with the more-involved leg, then step with the less-involved leg. The walker should not be advanced so far that the patient has to reach forward or lean dangerously. The patient's wrists, not the forearms, bear the load.

Quad Cane Use

A quad cane provides more lateral stability than a standard cane. The four-point base is always placed with all four tips flat on the floor before the patient transfers weight. The cane is held on the side opposite the weaker leg. Fit and grip-height criteria are identical to the walker.

Guarding Technique

Correct guard position keeps the patient safe without restricting movement.

If a patient begins to fall: do not try to prevent the fall entirely — guide the patient to the floor in a controlled manner, protecting the head, then call for help.

Stair Negotiation: "Up with the Good, Down with the Bad"

This mnemonic describes which leg leads on stairs:

When guarding on stairs, stand one step below the patient when ascending and one step above when descending, maintaining gait-belt contact throughout. Always verify that a railing is present and that the patient grips it. Alert the therapist if stairs are not yet appropriate for the patient's current status.

Escalation and Scope of Practice

You must report to the supervising therapist when: a patient reports new pain or dizziness, when fitting adjustments exceed your confidence, when a patient refuses to follow the prescribed pattern, or after any near-fall or fall. Documentation of these events is the therapist's responsibility, but your verbal report must be timely and accurate.

Key terms9

Greater trochanterThe bony prominence on the outer upper thigh used as the primary landmark for setting handle height on walkers, crutches, and canes.
AxillaThe armpit; the padded top of an axillary crutch must rest 2–3 finger-widths below this point — never bear weight on it — to prevent brachial plexus injury.
Non-weight-bearing (NWB)A weight-bearing status in which the involved limb makes no contact with the floor during ambulation.
Partial-weight-bearing (PWB)A weight-bearing status in which the involved limb may contact the floor and bear a limited amount of weight as specified by the physical therapist.
Gait beltA sturdy belt fastened around the patient's waist that the aide grips to provide safe manual support during ambulation and transfers.
Guard positionThe aide's stance during assisted ambulation: slightly behind and to the weaker side of the patient, with an underhand grip on the gait belt.
"Up with the good, down with the bad"A mnemonic for stair negotiation meaning the stronger leg leads going up stairs and the weaker leg (with the assistive device) leads going down.
Brachial plexusA network of nerves running through the axilla; compression from improper crutch use can cause weakness or numbness in the hand and arm.
Elbow flexion angleWhen a patient grips an assistive device handle set at the correct height, the elbow should be flexed approximately 20–30 degrees — used to confirm proper fit.

Worked examples4

1. A patient stands 5 feet 8 inches tall (68 inches). You want to estimate the correct walker handle height using the greater trochanter method. The patient's greater trochanter measures 38 inches from the floor. What height should you set the walker handles, and how do you verify the fit?
  1. Step 1: The handle height target equals the floor-to-greater-trochanter measurement: 38 inches.
  2. Step 2: Adjust both walker handles to the 38-inch setting, ensuring all push-button pins click fully into their holes.
  3. Step 3: Have the patient stand inside the walker, gripping the handles with arms relaxed. Observe elbow angle.
  4. Step 4: Confirm elbow flexion is approximately 20–30 degrees. If the elbows are nearly straight, the handles are too high and must be lowered. If elbows are bent more than 30 degrees, the handles are too low and must be raised.
  5. Step 5: Record the final setting and check the fitting criteria checklist before ambulation begins.
Answer: Set both handles to 38 inches (equal to floor-to-greater-trochanter height); verify by confirming approximately 20–30 degrees of elbow flexion when the patient grips the handles standing upright.
2. You are fitting axillary crutches for a patient. After placing the crutch tip 2 inches to the side and 6 inches in front of the foot, you check the space between the axillary pad and the patient's armpit. You can fit only one finger-width in the gap. What should you do and why?
  1. Step 1: Recognize that one finger-width of clearance is less than the required 2–3 finger-widths (approximately 1.5–2 inches).
  2. Step 2: The crutch is too long. Stop — do not allow the patient to ambulate with this fit.
  3. Step 3: Shorten the overall crutch length by pressing the push-button and moving the lower extension tube to a shorter setting.
  4. Step 4: Re-check: confirm 2–3 finger-widths of clearance below the axilla and 20–30 degrees of elbow flexion at the handgrip.
  5. Step 5: Document the adjusted measurement and verify with the fitting criteria checklist before proceeding.
Answer: Shorten the crutch length until 2–3 finger-widths of clearance exist below the axilla. A gap of only one finger-width means the crutch pad presses into the axilla, risking brachial plexus compression and crutch palsy.
3. A patient's floor-to-greater-trochanter measurement is 35 inches. The quad cane you have is adjustable from 28 to 38 inches in 1-inch increments. What is the correct handle height setting in inches, and what elbow angle confirms good fit?
  1. Step 1: The target handle height equals the floor-to-greater-trochanter distance: 35 inches.
  2. Step 2: Check that 35 inches falls within the cane's range (28–38 inches). It does.
  3. Step 3: Set the cane handle to 35 inches; confirm the adjustment pin is fully seated.
  4. Step 4: Have the patient hold the cane on the side opposite the weaker leg and stand upright in non-skid shoes.
  5. Step 5: Observe elbow angle — 20–30 degrees of flexion confirms correct fit.
Answer: Set the handle to 35 inches. Correct fit is confirmed when the patient's elbow flexes approximately 20–30 degrees while gripping the handle in a natural standing position.
4. During stair training, a patient with a right knee replacement is descending three steps using a crutch and railing. The student aide is unsure which leg goes down first and where to stand. Walk through the correct sequence.
  1. Step 1: Apply the mnemonic 'down with the bad': the weaker (right, post-surgical) leg and the crutch descend to the lower step first.
  2. Step 2: The stronger left leg then steps down to join the right leg on the same step.
  3. Step 3: The patient grips the railing with one hand and the crutch with the other for bilateral support.
  4. Step 4: The aide stands one step below the patient (in the direction of descent), maintaining an underhand grip on the gait belt throughout.
  5. Step 5: The aide verbalizes each phase: 'Crutch and right foot down, now left foot down' for every step, watching for balance loss.
Answer: The right (weaker) leg and crutch go down first, then the left (stronger) leg follows. The aide stands one step below the patient, holding the gait belt, and cues each movement aloud.
In class: Demonstration and measurement lab: instructor shows fitting protocol for each device using anatomical landmarks; students measure three peers of differing heights, record measurements, adjust devices, and verify fit using the textbook criteria checklist · Guarding technique practice: pairs ambulate the length of the gym at least four times—walker, crutches (non-weight-bearing pattern), crutches (partial-weight-bearing pattern), and quad cane—while the aide student practices correct guard position, gait cueing, and verbal encouragement; instructor provides real-time corrections · Stair negotiation drill using a three-step practice stair unit: instructor demonstrates 'up with the good, down with the bad' and bilateral rail technique; students practice guarding a peer patient ascending and descending while verbalizing the sequence; class debriefs on when to escalate to therapist
Materials: Standard aluminum walker, axillary crutches (adjustable), quad cane, tape measure, fitting criteria reference card, three-step practice stair unit with rail, gait belt, non-skid shoes, student workbook Chapter 5
Check: Structured observation: each student fits all three devices and guards ambulation and one stair cycle; pass requires all fitting measurements within accepted range (verified by instructor re-measure) and correct guard position maintained throughout; zero unsafe guarding positions to pass

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Patient Care and Safety
1. When fitting axillary crutches, the top pad should be placed how far below the patient's axilla?
Patient Care and Safety
2. A patient is prescribed non-weight-bearing status for the left leg. Which instruction best describes the correct two-point swing-through crutch pattern?
Patient Care and Safety
3. A rehab aide is guarding a patient ambulating with a walker. Which guard position is correct?
Anatomy and Kinesiology
4. Which anatomical landmark is used as the primary reference to set handle height for a walker, axillary crutch handgrip, and quad cane?
Patient Care and Safety
5. A patient with a left hip fracture is ascending stairs with a cane. According to the 'up with the good, down with the bad' rule, which leg leads going up?
Emergency Response and Safety
6. During crutch-assisted ambulation, a patient reports sudden dizziness and begins to sway. What should the rehab aide do FIRST?
Professional and Legal Standards
7. When would it be OUTSIDE the scope of practice for a rehab aide to proceed with gait training without consulting the supervising physical therapist?
Patient Care and Safety
8. After fitting axillary crutches, you verify fit by checking elbow angle when the patient grips the handgrips. Which angle confirms correct fit?
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