Canes

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Introduction

Walking sticks are designed to:

• provide balance support in standing and walking
• take some pressure off one or both legs
• improve feeling of safety and security when walking

A range of handle 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. Four-point sticks (also known as quad sticks) provide a wider base of support than the more common single point walking stick, however, they can also create a potential tripping hazard due to their increased side width.

Walking sticks are used widely, principally to reduce pain and improve stability and balance. However, they are frequently used incorrectly and can be dangerous if not properly maintained. It is important to educate patients on how to obtain greatest benefit from their walking stick and of the necessity to check it regularly for defects to ensure safe usage.

Handgrips

A variety of styles and sizes are available. The type of hand grip prescribed or used depends on two important factors: 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.

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. Though they are useful, mobility aids such as canes also have increased demands on metabolism and the musculoskeletal system. 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.

Gait disturbances can be divided into three useful categories:   

• 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 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 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.

2.      Multiple-legged canes:

These are canes with multiple legs. They include:

•    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.
• Hemi walker: 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.

Patient Assessment

There are many factors involved in prescribing the appropriate ambulatory assistive device. 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.

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. A cane can increase stability during the single-limb support phase.

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.

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 the sides naturally with a normal relaxed bend at the elbow. (Please see Diagram A for correct posture)
• 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.

Gait Pattern With a Cane

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.

How to Ambulate With a Cane

Walking sticks are usually used on the unaffected or strongest side of the body (the “good leg”) but 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.
• 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.
• From Sitting to Standing
  1. Position the cane on the unaffected side of the patient.
  2.  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.
  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” in front of the affected leg and 6” to the side of the affected leg.

• Standing to Sitting
  1. 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.
  2. Assist the patient to back up to the chair until the chair can be felt against the back of the patient’s legs.
  3. Instruct the patient to reach for one arm rest at a time.
  4. The patient lowers to the chair in a controlled manner

Safety tips

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

Conclusion

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.

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.

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.