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== Introduction  ==
== Introduction  ==
[[File:Walking stick 3.jpeg|right|frameless|405x405px]]
Canes or walking sticks are designed to:
* Provide [[balance]] support in standing and [[Walking - Muscles Used|walking]]<ref>Haddas R, Villarreal J, Lieberman IH. [https://link.springer.com/article/10.1007/s43390-020-00084-7 Kinematic comparison of the use of walking sticks versus a rolling walker during gait in adult degenerative scoliosis patients]. Spine deformity. 2020 Aug;8(4):717-23.</ref><ref>Bradley SM, Hernandez CR. [https://pubmed.ncbi.nlm.nih.gov/21842786/ Geriatric assistive devices.] American family physician. 2011 Aug 15;84(4):405-11.</ref><ref name=":4">Arefin, Paroma, et al. [https://www.researchgate.net/profile/Paroma-Arefin/publication/341463954_A_comparison_of_mobility_assistive_devices_for_elderly_and_patients_with_lower_limb_injury_Narrative_Review/links/5ed4d923299bf1c67d322934/A-comparison-of-mobility-assistive-devices-for-elderly-and-patients-with-lower-limb-injury-Narrative-Review.pdf A comparison of mobility assistive devices for elderly and patients with lower limb injury: Narrative Review]. Int J Aging Health Mov 2.1 (2020): 13-7.</ref><ref name=":5">Bateni H, Maki BE. [https://www.archives-pmr.org/article/S0003-9993(04)00474-5/fulltext Assistive devices for balance and mobility: benefits, demands, and adverse consequences.] Arch Phys Med Rehabil. 2005 Jan;86(1):134-45</ref><ref>Prajapati G, Sharmila K. [http://gerontologyindia.com/pdf/vol34-3.pdf#page=118 Role of assistive devices in wellbeing of elderly: A review]. Indian journal of Gerontology. 2020;34(3):394-402.</ref>
* Take some pressure off one or both legs<ref name=":4" /><ref name=":5" />
* Improve sensory feedback for safety and security when walking<ref name=":4" /><ref name=":5" /><ref>Oxford health Walking Sticks Available from:https://www.oxfordhealth.nhs.uk/wp-content/uploads/2014/08/OP-103.15-Safety-information-leaflet-walking-sticks.pdf (accessed 9.4.2021)</ref>
<br>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.<ref>Home instead [https://homeinstead.com.au/news/how-to-choose-and-use-a-walking-stick/ Walking stick]s Available from:https://homeinstead.com.au/news/how-to-choose-and-use-a-walking-stick/ (accessed 9.4.2021)</ref>


Canes are ambulatory assistive devices used for improving postural stability. It is generally prescribed for people with moderate levels of mobility impairment, It is typically used when minimal stability is needed<ref>Mon SB, Amir P, MSAdams T. Gait changes with walking devices in persons with parkinson’s disease. Disabil Rehabil Assist Technol 2012;7(2):149–152.</ref>. Canes in common day to day usage are known as walking sticks. A cane can either be made of wood or a light metal such as aluminium.
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.<ref name=":4" />
The wooden sticks usually have a crook handle and cannot easily have multi point tips. Aluminium walking sticks can either have a flat or "swan-neck" top and have the advantage of being adjustable in length and are able to have multiple points e.g. a tripod.


Multi point walking sticks include tripods and quadripods, both of which can have either flat, swan-neck or ergonomic handles.  
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 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.<ref name=":4" />


== Handgrips ==
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.<ref>Sheehan NJ, Millicheap P. [https://pubmed.ncbi.nlm.nih.gov/17973269/ Talk the walk: the importance of teaching patients how to use their walking stick effectively and safely]. Musculoskeletal care. 2008 Sep;6(3):150-4.</ref>


A variety of styles and sizes are available<ref>O'Sullivan S, Schmitz T, Fulk G. Physical rehabilitation. FA Davis; 2013 Jul 23.</ref>. The type of hand grip prescribed or used depends on two important factors<ref>Jones A, Alves ACM, de Oliveira LM, Saad M, Natour J. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664218/ Energy Expenditure During Cane-Assisted Gait in Patients with Knee Osteoarthritis]. Clinics. 2008; 63(2): 197–200. Accessed 31 January 2019.
== Handgrips ==
</ref>: firstly, the comfort of the patient and secondly, the grip's ability to provide adequate surface area to allow effective transfer of weight from the upper extremity to the floor. There are many types of hand grips available like the shotgun handle, crook handle, piston handle etc.
A wide variety of handgrips are available, each with characteristics that may be beneficial to a given patient.
{| class="wikitable"
!Type of Hand Grip
!Benefit<ref>Hovallo, O. Art Walking Sticks: Walking cane handle types. Available from: https://artwalkingsticks.com/blogs/blog/walking-cane-handle-types-1 (accessed 6/14/2023).</ref>
|-
|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 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 ==
== Types of Canes ==
A detailed understanding of the different types of ambulatory assistive devices and their types, modifications, fitting, stability and indications is essential in prescribing one<ref name=":12">Faruqui SR, Jaeblon T. Ambulatory assistive devices in orthopaedics: uses and modifications. American Academy of Orthopaedic Surgeon 2010;18(1):41–50.</ref>. Though they are useful, mobility aids such as canes also have increased demands on metabolism and the musculoskeletal system<ref>Bradley SM, Hernandez CR. Geriatric Assistive Devices. Am Fam Physician. 2011;84(4):405-411.</ref>. There are different types of canes which can be classified based on the number of legs it has and the amount of body weight it can support or its use. The type used is dependent on the type of gait disturbance.
A detailed understanding of the different types of [[Walking Aids|ambulatory assistive devices]] and their types, modifications, fitting, stability and indications is essential when prescribing a cane.<ref name=":12">Faruqui SR, Jaeblon T. [https://pubmed.ncbi.nlm.nih.gov/20044491/ Ambulatory assistive devices in orthopaedics: uses and modifications.] JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2010 Jan 1;18(1):41-50.</ref> The type of cane that is best for a patient is often dependent upon 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 best cane is one that is chosen specifically for the individual. <ref name=":12" />


Gait disturbances can be divided into three useful categories<ref name=":02">Robert Lam. Choosing the correct walking aid for patients. Can Fam Physician 2007;53(12):2115–2116</ref>:   
Three major varieties of canes are available and offer a range of support.<ref name=":6">Sehgal M, Jacobs J, Biggs WS. M[https://www.aafp.org/pubs/afp/issues/2021/0615/p737.html obility Assistive Device Use in Older Adults.] Am Fam Physician. 2021; 15;103(12): 737-744.</ref>
* Balance (including sensory and cerebellar systems),
* Motor (including cerebral initiation of walking and muscular strength), and
* Joint or skeletal problems.
'''1.'''      '''Single canes:'''


These are canes with only one leg. They include:
* Standard cane
*    Standard canes: This can also be called a straight cane and it is generally made of wood or aluminum. They are lightweight and inexpensive. The length of the wooden standard canes must be custom fitted to the specific patient while the aluminum standard cane have pins for length adjustment so there is no need for custom fitting. These standard canes are useful for patients that need just an additional point of contact with the floor for balance with little or no weight bearing needed, therefore, increasing the base of support. This cane can be used for patients with.mild sensory or coordination problems found in visual, auditory, vestibular, peripheral proprioceptive, or central cerebellar disease
* Offset cane
*   Offset canes: These canes are usually made from aluminum and the lengths are also adjustable with no need for custom fittings. These canes allow for the patient's weight to be displaced over the shaft of the cane. This cane provides more stability and can be used for occasional weight bearing. The type of patients in need of this cane are those with painful gait disorders like that of mild to moderate antalgic gait gotten from hip or knee osteoarthritis.
* Quadriped cane
'''2.'''      '''Multiple-legged canes:'''


These are canes with multiple legs. They include:
=== Single Point Canes ===
*    Quadripod (quad) cane: This is a four-legged cane usually made of aluminium. This cane permits more weight bearing, increases base of support and provides more stability for the patient. It can also stand by itself freeing the patient to use his or her hands. The only 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. It is also not suitable for stair climbing. It can be prescribed for hemiplegic patients or patients with moderate to severe antalgic gait from osteoarthritis.
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.<ref name=":6" />
* Hemi walker<ref name=":1">Van Hook FW, Weiss BD. Ambulatory devices for chronic gait disorders in the elderly.  Am Fam Physician 2003;67(8):1717-1724</ref>: This is also known as a walk cane. It is made of aluminum and has a vertical component with a handle and two legs, and another component with two additional legs angled away from the patient. This cane provides 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.
==== Standard Canes ====
{{#ev:youtube|8nvPeXIglI8|300}}
[[File:Walking stick 2 .jpeg|right|frameless]]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.
<ref>physicaltherapyvideo. Walking Canes: How to choose, measure and use. Available from: http://www.youtube.com/watch?v=8nvPeXIglI8</ref>
 
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.  
 
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.<ref name=":6" /><ref name=":7">Minor MA, Minor SD. Patient Care Skills. 7th Edition. Boston. Pearson, 2010. p.289-419</ref>  


==Patient Assessment==
==== Offset Canes ====
There are many factors involved in prescribing the appropriate ambulatory assistive device<ref name=":0">Sadowski  C, Jones A. Ambulatory assistive devices. How to appropriately measure and use canes, crutches and walkers. Pharmacy Practice 2014;1(10):24-31.</ref>. The patient’s upper body strength, balance and coordination, overall physical strength and endurance,  level of impairment, cognitive function, vision and living environment must be taken into account.
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 its tip, thus creating greater stability.<ref name=":6" /><ref name=":7" />  


The patient’s upper body strength should be evaluated to determine whether one or both of the upper extremities would be needed to bear weight or achieve balance.  If only one upper extremity is needed then a cane would be the proper device, while those needing two upper extremities would benefit from a walker or a pair of crutches. Also the degree or amount of the patient’s weight needed to be borne by the device would aid the Physiotherapist in choosing the appropriate device<ref name=":1" />.
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 diagnosis of hip or knee [[Osteoarthritis|osteoarthritis,]] which  creates a mild to moderate antalgic gait pattern.<ref name=":4" /><ref name=":6" />
===='''Gait Analysis'''====
Most people in need of canes have pain or injuries (like in the case of an antalgic gait due to  hip osteoarthritis) that make them avoid weight bearing on the affected side or limb and decrease the stance phase on that limb in an attempt to unload the mechanical stress on the painful hip joint<ref>Malanga G, DeLisa JA. Clinical Observation: Gait Analysis in the Science of Rehabilitation.  Available from <nowiki>https://www.rehab.research.va.gov/mono/gait/malanga.pdf</nowiki> (Accessed 22nd June 2018)</ref>. A cane can increase stability during the single-limb support phase<ref>Yocheved Laufer. The effect of walking aids on balance and weight-bearing patterns of patients with hemiparesis in various stance positions. Physical Therapy 2003;83(2):112–122.</ref>.


Therefore, a sound knowledge of the normal [[gait]] pattern and cadence is of utmost importance in evaluating and understanding the limitations of the patient with abnormal gait patterns and in prescribing the appropriate ambulatory assistive device<ref name=":12" />.
=== Multiple-Legged Canes ===
==== Quadruped (Quad) Cane ====
[[File:Quad stick.jpeg|right|frameless]]Quadruped 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. <ref name=":4" /><ref name=":7" />  


== Measuring Canes ==
Quad canes also permit greater weight bearing, as well as an increased base of support for the user. Their self-supporting design can also make them easier to manage, especially for those with limited use of the hand or upper extremity on one side.<ref name=":7" />


In measuring a cane height, the cane is placed approximately 6 inches (15.24cm) from the lateral border of the toes.The patient should be wearing appropriate, comfortable shoes during measurement.
One disadvantage is that all four legs of a quad cane must be in contact with the floor during use in order to provide proper stability.  From a practical standpoint, this can  greatly limit gait speed, but it can also create a major safety concern for those who cannot, or inadvertently do not, use the cane correctly.<ref name=":4" /> <ref name=":6" />


These are the various ways to determine the appropriate cane length:
Quad canes can be prescribed for patients with hemiplegia, or those with a moderate to severe antalgic gait from osteoarthritis.<ref name=":6" />
# Elbow Angle: The patient should stand erect and hold the cane with the elbow flexed at 20 to 30 degrees. The angle of elbow flexion is measured using a goniometer. There should be 20 to 30 degrees of elbow flexion in the elbow while holding the cane approximately 15 cm (6“) from the lateral border of the toes<ref name=":2">Lam R. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2231545/ Choosing the correct walking aid for patients.] Can Fam Physician. 2007 Dec; 53(12): 2115–2116. Accessed 31 January 2019.
</ref>. This degree of flexion allows efficient elbow movement while walking with the cane<ref name=":2" />, and allows the arm to shorten and lengthen during different phases of the gait cycle, and provides a shock absorption mechanism.
# The floor to the greater trochanter<ref name=":4">Jones A. Alves ACM, Magalhães de Oliveira L, Saad M, Natour J. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664218/#b8-cln63_2p0197 Energy expenditure during cane-assisted gait in patients with knee osteoarthritis]. Clinics 2008; 63(2). Accessed 31 January 2019.</ref>: The patient should stand erect and the distance from the floor to the greater trochanter measured to give the length of the cane. That means the top of the cane is at the same level of the greater trochanter  when the patient is standing upright with the arms hanging loosely by the side as shown below.
# The distal wrist crease to the floor<ref name=":4" />: The patient should stand erect with arms hanging loosely by the side and the distance from the distal wrist crease to the floor measured to get the cane length.
# Use a formula: Length of cane = height of the individual (meters) x 0.45 + 0.87 m. (L = H x 0.45 + 0.87 m)<ref name=":4" /><ref>Kumar R, MC Roe, Scremin OU. Methods for estimating the proper length of a cane. Arch Phys Med Rehabil. 1995. 76; 12: 1173-1175.
</ref>


== Gait Pattern With a Cane ==
== Hemi Walker / Walk Cane ==
Hemi walkers are a unique type of walker that is intended for us by individuals who have weakness or loss of function on <u>ONE</u> side of the body.  The traditional instance for hemi walker use is with patient's who have hemiplegia post stroke. Hemi walkers can also be considered a type of quadruped or mulit-leged cane with an extra wide base of support, hence the name walk cane. <ref name=":7" /><ref name=":1">Van Hook FW, Demonbreun D, Weiss BD. [https://pubmed.ncbi.nlm.nih.gov/12725450/ Ambulatory devices for chronic gait disorders in the elderly.] American family physician. 2003 Apr 15;67(8):1717-24.</ref>


A cane is held in the upper extremity opposite the affected limb. When teaching the patient we should instruct the patient to move the cane and involved lower extremity followed by the unaffected lower extremity. The cane should be relatively close to the body and should not be placed ahead of the toe of involved extremity. When bilateral involvement is there, a clinical decision has to be made as to which side of the body the cane will be held or a bilateral use of cane is necessary or a walker needs to be prescribed.  
Hemi walkers provide a much broader base of support than even a quadruped cane. They are also uniquely designed to allow patients with weakness or loss of function of one upper extremity to maintain continuous weight bearing in a safe a stably manor.<ref name=":1" />


==How to Ambulate With a Cane==
==Measuring/Fitting Canes==
Ambulation is defined as the ability to walk from place to place independently with or without assistive device<ref>Moorhead  S, Johnson  M,  Maas M. Nursing Outcomes Classification (NOC) 3rd ed. St. Louis, MO: Mosby, 2004.</ref>.
To measure the height of any cane the following procedure should be used:<ref name=":7" />
Many people self-treat and go on to purchase ambulatory assistive devices without any assistance from an appropriate health professional. They choose the improper device for their conditions and have no knowledge on the proper way to use them.


The first thing to know in [[Proper Ambulation with a Cane|ambulating with a cane]] is that the cane must be on the opposite side of the affected leg  and in tandem with it so as to simulate normal gait and to increase balance and aid in weight distribution (canes can easily support up to 25% of a patient’s body weight<ref name=":0" />). This means that if the right leg is the one with the disability then the walking cane would be held in the left hand.
# Have the patient stand upright, with a normal stance, arms at the sides, and shoulders relaxed
# The tip of the cane is positioned touching the floor, next to the small toe, OPPOSITE the involved or weaker side
# The height of the cane is adjusted so the handle sits at the level of the ulnar styloid process (fold of the wrist) with the arm still at the side


'''A. From Sitting to Standing'''<ref name=":3">Visiting Nurse Associations of American (VNAA) 2010-2011 Edition Nursing Procedure Manual (NPM) Rehabilitation Therapy - [http://www.meridianathome.com/MAH/upload/Section-26-RehabilitationTherapy.pdf Ambulation with a cane]. Section 26.01. Accessed 31 January 2019.</ref>
<nowiki>**</nowiki>When fitting a quad cane, be sure to orient it properly - the shorter legs are ALWAYS closer to the body to reduce tripping risk{{#ev:youtube|8nvPeXIglI8|300}}
# Position the cane on the unaffected side of the patient.
<ref>physicaltherapyvideo. Walking Canes: How to choose, measure and use. Available from: http://www.youtube.com/watch?v=8nvPeXIglI8</ref>
#  Advise the patient 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.
# 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” in front of the affected leg and 6” to the side of the affected leg.
'''B. Walking'''


Instruct the patient to position the cane on the unaffected side<ref name=":3" />.
==How to use a Cane==


'''Three Point Gait'''
==== Gait ====
# Instruct the patient to balance the body weight on the strong or unaffected limb while moving the cane forward approximately 12-18 inches. Make sure the cane is close to the patient’s body
Canes should be used on the unaffected/strongest side of the body, so that support can be provided while the weaker side is bearing weight. The one instance where this does not apply is if there is a specific therapy goal of promoting increased weight bearing on the weaker or affected side. This instance will be initiated and guided by a physical therapist.<ref name=":7" />
# The patient then moves the weak or affected foot forward.
# The patient transfers the weight from the unaffected foot to the affected foot and cane, and then brings the unaffected foot forward to join the affected foot.
# Repeat the steps 1 to 3 while shadowing the patient closely and alertly.
'''Two Point Gait'''
# Instruct the patient to balance body weight on the strong or unaffected foot.
# Instruct the patient to move the cane and the weak or affected foot forward in unison (i.e at the same time), keeping the cane close to the body to prevent leaning to the side.
# Instruct the patient to transfer their body weight forward to the cane and move the unaffected leg forward.
# Repeat steps 1 to 3 while shadowing the patient closely and alertly.
'''C. Standing to Sitting'''<ref name=":3" />
# Instruct the patient to approach the chair (or bed), and turn in small circles toward the stronger side till the back is facing the chair or bed.
# Assist the patient to back up to the chair until the chair can be felt against the back of the patient’s legs.
# Instruct the patient to reach for one arm rest at a time.
# The patient lowers to the chair in a controlled manner.
'''D. Stair climbing'''


Canes can be used for stair climbing if proper instructions are followed (Up with the good leg, down with the affected one).
Basic gait pattern with a cane:<ref name=":7" />


'''Going up the stairs'''
* Advance the cane approximately one step length
* Advance the affected/weaker leg, placing it in line with the cane
* Shift weight to the cane and affected/weaker leg, and then advance the unaffected/stronger leg
** Begin with a step-to pattern, advancing the unaffected/stronger leg to a point in line with the cane and other leg
** Progress to step-through pattern, where the unaffected/stronger leg is advanced past the cane and other leg


As usual the cane shall be opposite the affected limb.
==== Stairs ====
#      At the bottom of the stairs, instruct the patient to lift the strong or unaffected leg onto the first step.
Ascending stairs with a handrail:<ref name=":7" />
#     Transfer body weight to the unaffected leg on the step while  lifting the cane and the affected leg onto the same step.
#      Repeat steps 1 and 2.
'''Going down the stairs'''


As usual the cane shall be opposite the affected limb.
* Grasp the handrail with the hand opposite the cane
#      At the top of the stairs, instruct patient to transfer body weight to the strong or unaffected leg while lifting the cane and the affected leg simultaneously to land on the step below it.
* Raise the unaffected/stronger leg to the next step
#      Instruct patient to lift unaffected limb to land on the same step.
* Step up, bringing the affected/weaker leg and cane up to the step with the other
#      Repeat steps 1 and 2.{{#ev:youtube|fRn8ZZJMzno|300}}<ref>CAREGIVERSTRAINING. How to use a cane. Available from: http://www.youtube.com/watch?v=fRn8ZZJMzno</ref>


Descending stairs with a handrail:<ref name=":7" />


* Grasp the handrail with the hand opposite the cane
* Place the cane on the next lower step
* Lower the affected/weaker leg to the same step as the cane
* Shift weight to the cane, affected/weaker leg, and handrail before bringing the remaining leg down to the lower step


'''Safety tips'''
==== Sit to Stand ====
From sitting to standing:<ref name=":7" /><ref name=":3">Visiting Nurse Associations of American (VNAA) 2010-2011 Edition Nursing Procedure Manual (NPM) Rehabilitation Therapy - [http://www.meridianathome.com/MAH/upload/Section-26-RehabilitationTherapy.pdf Ambulation with a cane]. Section 26.01. Accessed 31 January 2019.</ref>
# Position the cane on the unaffected side of the user
# Ask the user to move to the edge of the seat before
# One hand is placed on the armrest/seat and the other holds the cane
# Use the hand on the chair and the cane to provide support to come up to the standing position
# Make sure the cane is 2 inches in front of the affected leg and 6 inches to the side of the affected leg


Inspect 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 cane is at proper height to avoid imbalance and bad postures<ref name=":0" />


==Conclusion==
Standing to sitting:<ref name=":7" /><ref name=":3" />
Many people have disabilities that require an ambulatory assistive device in order to ambulate independently. Some people are prone to 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, and risk of musculoskeletal injuries or adaptations due to bad posture gotten from incorrect way of using or holding the assistive devices.
# Instruct the user to approach the chair (or bed), and turn toward the stronger side until the back is facing the chair or bed
# Assist the user to back up to the chair until the chair can be felt against the back of their legs
# Instruct the user to reach for the armrest, chair seat, or bed with the free hand
# The user then lowers themselves into the chair in a controlled manner using the cane and chair/bed surface for support
{{#ev:youtube|fRn8ZZJMzno|300}}<ref>CAREGIVERSTRAINING. How to use a cane. Available from: http://www.youtube.com/watch?v=fRn8ZZJMzno</ref>


Many of the pharmacies and stores selling these equipment do not have health professionals that are equipped with the knowledge to choose the appropriate device, fit them properly and specifically to the patient. One study has shown that pharmacists do not feel equipped with the knowledge to fit a device for a patient<ref name=":0" />.
=== '''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.<ref name=":0">Sadowski CA, Jones CA. [https://www.researchgate.net/publication/282130699_Ambulatory_assistive_devices_How_to_appropriately_measure_and_use_canes_crutches_and_walkers Ambulatory assistive devices: how to appropriately measure and safely use canes, crutches and walkers.] Pharmacy Practice. 2014;1:24-31.</ref>


Therefore, 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 aid in ensuring that people learn the proper way to ambulate with these assistive devices.  
==Conclusion==
[[File:Walking stick.jpeg|right|frameless]]
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 [[Older People - An Introduction|elderly patients]]. There is also a risk of musculoskeletal injuries or postural adaptations if individuals use / hold the assistive device incorrectly.<ref name=":4" /><ref name=":5" />


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.<ref name=":0" />


[[Assistive Devices|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.


== References  ==
== References  ==
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[[Category:Open_Physio]]
[[Category:Open_Physio]]
[[Category:Assistive devices]]
[[Category:Assistive Technology]]
[[Category:Older People/Geriatrics]]
[[Category:Older People/Geriatrics]]
[[Category:Acute Care]]
[[Category:Older People/Geriatrics - Interventions]]
[[Category:Course Pages]]

Latest revision as of 22:35, 19 June 2023

Original Editor - The Open Physio project.

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Introduction[edit | edit source]

Walking stick 3.jpeg

Canes or walking sticks are designed to:


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.[7]

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.[3]

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 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.[3]

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.[8]

Handgrips[edit | edit source]

A wide variety of handgrips are available, each with characteristics that may be beneficial to a given patient.

Type of Hand Grip Benefit[9]
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 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[edit | edit source]

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.[10] The type of cane that is best for a patient is often dependent upon 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 best cane is one that is chosen specifically for the individual. [10]

Three major varieties of canes are available and offer a range of support.[11]

  • Standard cane
  • Offset cane
  • Quadriped cane

Single Point Canes[edit | edit source]

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.[11]

Standard Canes[edit | edit source]

Walking stick 2 .jpeg

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.

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.[11][12]

Offset Canes[edit | edit source]

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 its tip, thus creating greater stability.[11][12]

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 diagnosis of hip or knee osteoarthritis, which creates a mild to moderate antalgic gait pattern.[3][11]

Multiple-Legged Canes[edit | edit source]

Quadruped (Quad) Cane[edit | edit source]

Quad stick.jpeg

Quadruped 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. [3][12]

Quad canes also permit greater weight bearing, as well as an increased base of support for the user. Their self-supporting design can also make them easier to manage, especially for those with limited use of the hand or upper extremity on one side.[12]

One disadvantage is that all four legs of a quad cane must be in contact with the floor during use in order to provide proper stability. From a practical standpoint, this can greatly limit gait speed, but it can also create a major safety concern for those who cannot, or inadvertently do not, use the cane correctly.[3] [11]

Quad canes can be prescribed for patients with hemiplegia, or those with a moderate to severe antalgic gait from osteoarthritis.[11]

Hemi Walker / Walk Cane[edit | edit source]

Hemi walkers are a unique type of walker that is intended for us by individuals who have weakness or loss of function on ONE side of the body. The traditional instance for hemi walker use is with patient's who have hemiplegia post stroke. Hemi walkers can also be considered a type of quadruped or mulit-leged cane with an extra wide base of support, hence the name walk cane. [12][13]

Hemi walkers provide a much broader base of support than even a quadruped cane. They are also uniquely designed to allow patients with weakness or loss of function of one upper extremity to maintain continuous weight bearing in a safe a stably manor.[13]

Measuring/Fitting Canes[edit | edit source]

To measure the height of any cane the following procedure should be used:[12]

  1. Have the patient stand upright, with a normal stance, arms at the sides, and shoulders relaxed
  2. The tip of the cane is positioned touching the floor, next to the small toe, OPPOSITE the involved or weaker side
  3. The height of the cane is adjusted so the handle sits at the level of the ulnar styloid process (fold of the wrist) with the arm still at the side

**When fitting a quad cane, be sure to orient it properly - the shorter legs are ALWAYS closer to the body to reduce tripping risk

[14]

How to use a Cane[edit | edit source]

Gait[edit | edit source]

Canes should be used on the unaffected/strongest side of the body, so that support can be provided while the weaker side is bearing weight. The one instance where this does not apply is if there is a specific therapy goal of promoting increased weight bearing on the weaker or affected side. This instance will be initiated and guided by a physical therapist.[12]

Basic gait pattern with a cane:[12]

  • Advance the cane approximately one step length
  • Advance the affected/weaker leg, placing it in line with the cane
  • Shift weight to the cane and affected/weaker leg, and then advance the unaffected/stronger leg
    • Begin with a step-to pattern, advancing the unaffected/stronger leg to a point in line with the cane and other leg
    • Progress to step-through pattern, where the unaffected/stronger leg is advanced past the cane and other leg

Stairs[edit | edit source]

Ascending stairs with a handrail:[12]

  • Grasp the handrail with the hand opposite the cane
  • Raise the unaffected/stronger leg to the next step
  • Step up, bringing the affected/weaker leg and cane up to the step with the other

Descending stairs with a handrail:[12]

  • Grasp the handrail with the hand opposite the cane
  • Place the cane on the next lower step
  • Lower the affected/weaker leg to the same step as the cane
  • Shift weight to the cane, affected/weaker leg, and handrail before bringing the remaining leg down to the lower step

Sit to Stand[edit | edit source]

From sitting to standing:[12][15]

  1. Position the cane on the unaffected side of the user
  2. Ask the user to move to the edge of the seat before
  3. One hand is placed on the armrest/seat and the other holds the cane
  4. Use the hand on the chair and the cane to provide support to come up to the standing position
  5. Make sure the cane is 2 inches in front of the affected leg and 6 inches to the side of the affected leg


Standing to sitting:[12][15]

  1. Instruct the user to approach the chair (or bed), and turn 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 the armrest, chair seat, or bed with the free hand
  4. The user then lowers themselves into the chair in a controlled manner using the cane and chair/bed surface for support

[16]

Safety Tips[edit | edit source]

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.[17]

Conclusion[edit | edit source]

Walking stick.jpeg

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.[3][4]

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.[17]

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.

References[edit | edit source]

  1. ↑ Haddas R, Villarreal J, Lieberman IH. Kinematic comparison of the use of walking sticks versus a rolling walker during gait in adult degenerative scoliosis patients. Spine deformity. 2020 Aug;8(4):717-23.
  2. ↑ Bradley SM, Hernandez CR. Geriatric assistive devices. American family physician. 2011 Aug 15;84(4):405-11.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Arefin, Paroma, et al. A comparison of mobility assistive devices for elderly and patients with lower limb injury: Narrative Review. Int J Aging Health Mov 2.1 (2020): 13-7.
  4. ↑ 4.0 4.1 4.2 4.3 Bateni H, Maki BE. Assistive devices for balance and mobility: benefits, demands, and adverse consequences. Arch Phys Med Rehabil. 2005 Jan;86(1):134-45
  5. ↑ Prajapati G, Sharmila K. Role of assistive devices in wellbeing of elderly: A review. Indian journal of Gerontology. 2020;34(3):394-402.
  6. ↑ Oxford health Walking Sticks Available from:https://www.oxfordhealth.nhs.uk/wp-content/uploads/2014/08/OP-103.15-Safety-information-leaflet-walking-sticks.pdf (accessed 9.4.2021)
  7. ↑ Home instead Walking sticks Available from:https://homeinstead.com.au/news/how-to-choose-and-use-a-walking-stick/ (accessed 9.4.2021)
  8. ↑ Sheehan NJ, Millicheap P. Talk the walk: the importance of teaching patients how to use their walking stick effectively and safely. Musculoskeletal care. 2008 Sep;6(3):150-4.
  9. ↑ Hovallo, O. Art Walking Sticks: Walking cane handle types. Available from: https://artwalkingsticks.com/blogs/blog/walking-cane-handle-types-1 (accessed 6/14/2023).
  10. ↑ 10.0 10.1 Faruqui SR, Jaeblon T. Ambulatory assistive devices in orthopaedics: uses and modifications. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2010 Jan 1;18(1):41-50.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 11.6 Sehgal M, Jacobs J, Biggs WS. Mobility Assistive Device Use in Older Adults. Am Fam Physician. 2021; 15;103(12): 737-744.
  12. ↑ 12.00 12.01 12.02 12.03 12.04 12.05 12.06 12.07 12.08 12.09 12.10 12.11 Minor MA, Minor SD. Patient Care Skills. 7th Edition. Boston. Pearson, 2010. p.289-419
  13. ↑ 13.0 13.1 Van Hook FW, Demonbreun D, Weiss BD. Ambulatory devices for chronic gait disorders in the elderly. American family physician. 2003 Apr 15;67(8):1717-24.
  14. ↑ physicaltherapyvideo. Walking Canes: How to choose, measure and use. Available from: http://www.youtube.com/watch?v=8nvPeXIglI8
  15. ↑ 15.0 15.1 Visiting Nurse Associations of American (VNAA) 2010-2011 Edition Nursing Procedure Manual (NPM) Rehabilitation Therapy - Ambulation with a cane. Section 26.01. Accessed 31 January 2019.
  16. ↑ CAREGIVERSTRAINING. How to use a cane. Available from: http://www.youtube.com/watch?v=fRn8ZZJMzno
  17. ↑ 17.0 17.1 Sadowski CA, Jones CA. Ambulatory assistive devices: how to appropriately measure and safely use canes, crutches and walkers. Pharmacy Practice. 2014;1:24-31.
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