The cue to walk is an internal cue. When given a command or asked a question, the response time is 10 to 15 seconds.

The internal cue to stand and walk is followed by an effort to get up that cannot be inhibited by the person. They do not learn from repeated falls. They will accept the support of two people to protect their balance and enjoy walking. They are able to evaluate their experience of walking and can tell caregivers when they are getting tired. They can choose when to stop and when to continue doing what they are doing.

The urge to walk is probably programmed into the human DNA and stimulated by internal cues.

While sitting on the edge of the bed with good head control, the person is able to extend their arm to prevent falling when gently pushed to the side.

To Verify

The person should be able to hold their head up without head supports for at least 30 minutes and extend their arms to prevent a fall when pushed before walking is attempted.

The internal need to step forward within ACL 2.2 is as strong as the need to stand-up within ACL 2.0. Wanting to step forward makes a standing table intolerable. The constant urge to stand and walk can be satisfied by guided and physically supported walking using a forearm support frame, with two people to provide assistance with poor balance. When the opportunity to walk is not provided, the urge to walk cannot be inhibited and they will keep trying.

Their attention to doing seated activities can be sustained for 30 to 45 minutes. At least three different hand-over-hand activities will probably be needed and frequent rest periods should be expected. With nothing to do, their attention drifts away and they slump down and start to slide out of their chairs in about 10 minutes.

Upper extremity range of motion (UE ROM) exercises are bilateral and require hand-over-hand assistance, as described above. One hand / arm may be exercised with hand-over-hand assistance and an attractive object.

Being able to stand and the sensation of joint compression is quite rewarding for the person. A common schedule includes two sessions in the standing frame every day, one in the morning and one in the afternoon. 30 minutes is the usual length of time that they can tolerate without becoming exhausted.

Standing Frame

Standing frames prevent falls associated with poor balance and bending knees. The person is aware of the frame and is generally grateful for the support.

The person has no understanding that it is unsafe for them to stand up when they are unable to weight bear due to a medical condition. They do not retain in their memory that it is unsafe for them to stand up on their own. Asking them to wait for assistance has poor compliance. When they are stopped from standing up they are likely to yell and engage in other negative behaviors. Work with the physical therapist on ways of getting the person upright and still comply with their non-weight bearing orders.

They are able to recognize and respond to many universal, non-verbal signals including: helplessness, scolding, warnings, puzzlement, angry fixed stares, submission, avoidance, and modesty.

Gestural communications that they can understand include: pointing to the direction they are going to move to, waving, shrugging your shoulders, clasping and shaking their hand, and their recognition of OK when you give the OK sign.

The urge to stand tends to run nursing assistants ragged. The value of the standing frame is very apparent to them, but exhaustion may affect the next shift if they are left in the standing frame too long.

The flip side is not standing or sitting, but the consequences need to be made clear. Yelling is not excusable if the opportunities to use a standing frame and be guided with hand-over-hand assistance while sitting are not provided. Regulators need to be educated about yelling and restraints because the current lifestyle within ACL 2.0 is grim, and it does not need to continue.