Canes

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Introduction

Canes or walking sticks are designed to:

• Provide balance support in standing and walking
• Take some pressure off one or both legs
• Improve sensory feedback for safety and security when walking

There are lots of canes for users to choose from. There are wood and metal canes, as well as state-of-the-art carbon fibre canes. They can be traditional or come in a range of modern colours and patterns. There are some sticks that fold up to fit in a carrying case or handbag and some are adjustable to make it easier to get the correct length.

Other aspects, such as the handle, can also be customized for the individual user. A range of styles are available including t-shaped, offset, crook, swan neck and ergonomic (or arthritic) handles, which are designed to provide additional support under the palm.

For those needing more support, four-point canes (also known as quad canes) provide a wider base, and can act as an intermediary between the single point cane and the walker. However, quad canes may not be appropriate for all as the the user must have the ability to ensure, and a gait pattern that allows, all four points of the cane to be in contact with the ground while weight is put through the cane. If this is not possible, this type of cane may pose a safety risk.

As with any assistive device, it is important to ensure that a patient is using it properly. Even for something as simple as a cane, proper gait should be practiced in the clinic, and education should be provided regarding points of safety and concerns regarding negotiation of certain riskier areas such as stairs. Canes are very commonly used incorrectly, and as such, practitioners should always take the time to address these particular aspects.

Handgrips

Type of Hand Grip	Benefit
Anatomical Handle	Stable and comfortable; force through handle kept directly over shaft
Crook handle	Allows for fluid movement of cane; typically one piece construction offering great strength
Derby Handle	Stable; similar to anatomical handle; often separate from shaft allowing customizability
Fritz Handle	Flatter handle intended to be be more comfortable for those with arthritis of the hand
Contour Handle	Handle is contoured to the hand of the user offering stability and greater ease of holding
Palm Grip / Fisher	Wide flat handle that offers greater comfort for those with pain or arthritis of the hand

Types of Canes

A detailed understanding of the different types of ambulatory assistive devices and their types, modifications, fitting, stability and indications is essential when prescribing a cane. The type of cane that is best for a patient is often dependent the specific gait characteristics they present with. That being said, it is important to understand that no one type of cane is "best" for improving mobility and preventing falls, the the best cane is one that is chosen specifically for the individual.

Three major varieties of canes are available and offer a range of support.

• Standard cane
• Offset cane
• Quadriped cane

Single Point Canes

Of the three types of canes, two types are considered "single point" canes; the standard cane and the offset cane. Additionally, single point canes provide the least amount of stability, but are also the least restrictive assistive device.

Standard Canes

Standard canes (also known as straight canes) are generally made of wood or aluminium. They are lightweight and inexpensive. The shaft of a standard cane is typically straight, meaning that depending on the type of handle, the force applied by the user may not be positioned directly over the tip. This, in turn, causes the line of force from the body to be at a very slight angle compared with the cane's shaft, reducing the overall stability of the standard cane.

Wooden standard canes can be fitted to the user by permanently removing length from the tip, while aluminium standard canes are often adjustable, utilizing a pin or ring system to allow the height to be easily changed without permanent modification.

These standard canes are useful for patients who need just an additional point of contact with the floor for balance, have minor lower extremity weakness, or who need a small amount of weight bearing reduction. This being said, standard canes provide only limited support.

Offset Canes

Offset canes are usually made from aluminium. Their length is adjustable, so there is no need for custom fittings. The major advantage of the offset cane is a bend that allows the handle to be placed directly over the main shaft of the cane. By doing so, a straight line of force can be created through the cane that is positioned directly over it's tip, thus creating greater stability.

Individuals who would benefit from an offset cane are those who need slightly more stability than a standard cane or require an intermediate amount of weight bearing reduction. This may include those who have a diagnosised with hip or knee osteoarthritis,which can create a mild to moderate antalgic gait pattern.

Multiple-Legged Canes

Quadruped (Quad) Cane

Quadriped canes can have a structure similar to either a standard or offset cane, but their defining feature is their enlarged base that features not one, but four tips. This four legged design creates a larger contact area with the ground, allowing the quad cane to provide greater stability than a single point cane.

Quad canes also permit greater weight bearing, as well as an increase base of support for the user. Their self-supporting design can make them easier to manage, especially for those with limited use of one upper extremity or hand.

A disadvantage is that all four legs of the cane must be in contact with the floor during gait to provide stability, which hinders fast gait.

Quad canes can be prescribed for hemiplegic patients or patients with moderate to severe antalgic gait from osteoarthritis.

Hemi Walker

A hemi walker is also known as a walk cane. It is made of aluminium and has a vertical component with a handle and two legs, as well as another component with two additional legs angled away from the patient.

This cane provides a more broad based support than the other canes. It is used by patients requiring continuous weight bearing through one upper extremity like stroke patients with hemiparesis who have moderate to severe lower extremity disability.

Measuring Canes

To measure the height of any walking stick, the base of the stick should be placed approximately 15cm from the outside of the foot and the handle height should be set at the wrist crease height. The elbow should be bent slightly (generally between 15 and 30 degrees) when holding the stick and standing upright.

• Put on the user's walking shoes
• Have the user stand naturally upright as much as possible
• Have their arms fall to their sides naturally with a normal relaxed bend at the elbow
• Using a tape measure, measure the distance from their wrist joint (bottom crease at the wrist) down to the floor. Round up to the nearest half cm
• Adjust the stick according to the measurement

How to use a Cane

Gait

Walking sticks are usually used on the unaffected/strongest side of the body (the “good leg”). However, this may depend on individual preference and abilities. The stick should be placed forward at the same time as the affected leg and then the unaffected leg follows.

• If using two sticks at the same time, a four-point gait may be used by bringing one stick forward, then the opposite leg, then the other stick, followed by the other opposite leg.
• Four-point sticks with an offset base should be positioned so that the straight side of the base is nearest to the body. All points of the stick should maintain contact with the ground when the stick is placed down.

Stairs

To negotiate going up steps and stairs, lift the unaffected leg up first, then the stick and the affected leg onto the same step. To travel down, the stick and the affected leg should be lowered first, then the unaffected leg down to the same step.

Sit to Stand

From sitting to standing:

1. Position the cane on the unaffected side of the user
2.  Ask the user to move to the edge of the seat, hold the cane handle and bear weight on the unaffected leg and cane to come up to the standing position
3. Make sure the height of the cane is appropriate (level of greater trochanter), ensure elbow flexion is 20° to 30° and that the cane is 2 inches in front of the affected leg and 6 inches to the side of the affected leg.

Standing to sitting:

1. Instruct the user to approach the chair (or bed), and turn in small circles toward the stronger side until the back is facing the chair or bed
2. Assist the user to back up to the chair until the chair can be felt against the back of their legs
3. Instruct the user to reach for one arm rest at a time
4. The user then lowers themselves into the chair in a controlled manner

Safety Tips

Inspect the cane on a regular basis. Make sure the cane has a rubber top for shock absorption and grip to prevent slipping. Always check the cane for worn tips and handles. Always make sure that the cane is at proper height to avoid imbalance and bad posture.

Conclusion

Many people have disabilities that require an ambulatory assistive device in order to ambulate independently. Some people may "self-treat" as canes are easily accessible and do not require a prescription before being purchased. This increases the risks of falls, especially in elderly patients. There is also a risk of musculoskeletal injuries or postural adaptations if individuals use / hold the assistive device incorrectly.

Many of the pharmacies and stores selling canes / assistive devices do not employ health professionals equipped with the knowledge to choose the appropriate device or fit them properly for the user. One study has shown that pharmacists do not feel they have sufficient knowledge to fit a device for a patient.

Ambulatory assistive devices should be sold where appropriate health professionals can advise the buyers on the proper way to use them. Health professionals like pharmacists can be trained in this area as they also sell such in their pharmacies. This would help to ensure that users learn the proper way to ambulate with these assistive devices.