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How to explain gait when pt. Is using stick or walker for mobilisation

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clinical documentation gait walking stick walker terminology physiotherapy

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Document gait by stating the walking aid, level of assistance, distance, gait quality, balance, and safety.
Simple format
Ambulates [distance] with [stick/walker type] and [assistance level]. Gait is [steady/unsteady/antalgic/etc.], with [specific observed features]. Requires [cueing/supervision] for safety.
Use “ambulates with” rather than simply “uses walker.”

Examples

  • Independent with stick
    Ambulates independently with a single-point stick. Gait steady with reduced speed; no loss of balance.
  • Stick with assistance
    Ambulates 20 m with a single-point stick and contact-guard assist. Mildly antalgic gait, reduced weight-bearing through the left lower limb, and requires verbal cues for safe turning.
  • Standard walker/frame
    Ambulates 10 m using a wheeled walker with one-person assist. Slow, short-stepped gait with forward-flexed posture; unsteady during turns.
  • Rollator
    Mobilises with a four-wheeled rollator under supervision. Gait slow but stable on level surface; requires reminders to apply brakes before sitting.
  • High falls risk
    Ambulates only with a walking frame and minimal assistance of one due to poor balance. Shuffling gait with reduced foot clearance and intermittent loss of balance.
  • If unable to walk safely
    Unable to safely ambulate with walker today due to dizziness/unsteadiness; transfers with one-person assist.

Useful terms for gait quality

  • Steady / unsteady
  • Antalgic: limping or shortened stance on a painful leg
  • Shuffling
  • Short-stepped
  • Wide-based
  • Slow pace / reduced cadence
  • Reduced step length
  • Reduced foot clearance
  • Forward-flexed posture
  • Difficulty turning
  • Loss of balance or no loss of balance
Also specify the exact device when relevant: single-point cane/stick, quad cane, standard walking frame, two-wheeled walker, or four-wheeled rollator. Observation of walking and turning is a core part of gait assessment, since gait reflects integrated strength, sensation, balance, and coordination (Harrison’s Principles of Internal Medicine, 22nd ed., Gait Examination). Documentation should also record the type and amount of help or cueing provided, as recommended by APTA documentation guidance.
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