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Jun.19.2020View related content

Assistive Device Training: Canes (Rehabilitation Therapy)

ALERT

Canes should not be used for patients who have a partial–weight-bearing or non-weight–bearing status because they cannot provide sufficient stability and support to be used safely.

Oxygen consumption is increased when using canes to ascend and descend stairs; therefore, use additional care when guiding patients with cardiac dysfunction who are using canes.1

OVERVIEW

Canes are used to assist with walking in a variety of reasons, which may include impaired balance, joint instability, pain, fatigue, and a need to reduce weight bearing in the lower extremity. Canes are available in many shapes and sizes: single-point canes (also called straight or standard canes), large- and small-based quad canes, freestanding canes such as the "hurry cane" or "trusty cane," hemi canes, rolling canes, and canes with laser lights to assist in an episode of freezing of gait.3 Canes are typically made from lightweight aluminum and are adjustable via push buttons. Those made from wood can be adjusted by cutting them to the desired length.

The handgrip on a cane should be selected based on patient comfort. There should be adequate surface area on the hand to allow for transfer of weight from the upper extremity to the floor.

Clinicians must provide careful instruction regarding use, fit, and safety with canes because of the risk of falls. Canes that are of improper height can cause disturbances to the walking pattern and can increase the risk for falls. Canes that are too short in length can cause stooped posture, and those that are too long in length do not provide the intended support.

Patients typically are instructed to hold the cane in the hand opposite of (contralateral to) the involved lower extremity. When used in this fashion, canes reduce the biomechanical load on the involved lower extremity, provide a more natural reciprocal gait pattern with the opposite arm and leg moving together, and provide an increased base of support. When the cane is placed in the contralateral hand, there is a reduction in the lateral shifting of the center of mass compared to using the cane on the same side (ipsilateral) as the involved lower extremity.3

There are a variety of commonly used canes, and each type has advantages and disadvantages (Table 1)Table 1. Selection of the appropriate cane is determined by the patient's diagnosis and needs. This can include the need to reduce forces on the involved lower extremity and the need to provide increased stability. The number of points of contact with the floor determines the cane's stability level. Large-based (or broad-based) quad canes provide the greatest stability, whereas single-tip canes provide the least. Walking with a single-tip cane is more efficient, but less stable than using either a tripod or quad cane. Use of a quad cane is the most stable but least efficient choice. Single-tip canes have also been found to relieve the pain of osteoarthritis2 and are useful before and after joint replacements.

The typical method for determining appropriate cane height begins with the patient standing with his or her feet comfortably apart and shoulders relaxed. The cane tip or the center of the broad-based cane is placed 15 cm (6 in) laterally from the toes. The top of the cane should reach the level of the greater trochanter of the hip, and the elbow should be flexed to approximately 20 to 30 degrees. Because of the differences in trunk and limb length, elbow flexion is the most important determinant of cane height. Having the elbow in 20 to 30 degrees of flexion allows for arm length to change during the different phases of the gait and absorbs forces from the floor.3

Gait Patterns

Most patients hold the cane on the contralateral side and move it forward simultaneously with the involved lower extremity, followed by the uninvolved lower extremity. For patients with bilateral weakness, the use of two canes may be desired. In this instance, either a two- or four-point gait can be used. In a two-point gait, one cane and the more involved lower extremity are moved forward simultaneously followed by the other cane and the less involved lower extremity. In a four-point gait pattern, the cane is moved forward followed by the most involved lower extremity, then the other cane, followed by the less involved lower extremity (e.g., right cane, left lower extremity, left cane, right lower extremity).

SUPPLIES

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EDUCATION

  • Explain to the patient and caregiver the purpose for using a cane and provide recommendations:
    • Maintain good posture with the head up and look forward to avoid tripping on objects on the floor.
    • Be sure the cane is out of the way but within reach when sitting down or rising from a chair.
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient, and ensure that he or she agrees to treatment.
  5. Assess the patient for pain.
  6. Determine the indications for cane use and confirm weight-bearing status.
  7. Perform a thorough review of the patient's medical history.
  8. Assess the patient's vital signs and laboratory values.
  9. Apply a transfer belt for safety.
  10. In a confident tone using lay language, describe and demonstrate the use of a cane.
    1. Use the cane on the same side and with the same gait pattern the patient will use.
    2. Demonstrate how the patient will rise from a chair using the cane.
  11. Inform the patient that you will be guarding him or her by placing one hand on the transfer belt. In the majority of instances, stand on the patient's involved side slightly behind him or her so as not interfere with locomotion. Use clinical judgment regarding which location is the most appropriate place to stand, depending on the patient.

Rising to a Standing Position

  1. Instruct the patient to scoot to the edge of the chair.
  2. Instruct the patient to position the cane on the uninvolved side (if it is a broad-based cane) or leaning against the armrest (if it is a straight cane).
  3. If the patient is using a broad-based cane, instruct him or her to come to standing before reaching for the cane.
  4. If the patient is using a straight cane, instruct him or her to hold it loosely with the fingers before standing.
  5. Once the patient is standing, instruct him or her to place the cane on the contralateral side.
  6. While the patient is standing, examine the cane length to ensure that it is the appropriate height for him or her. With the patient standing with arms relaxed at his or her sides, the top of the cane should come to his or her wrist (Figure 1)Figure 1.
  7. Review the gait pattern to be performed and allow the patient to practice it with the cane (Figure 2)Figure 2.

Returning to a Sitting Position

  1. After the patient practices with the cane, instruct him or her to approach the chair and take steps in a circle toward the uninvolved (or less involved) side.
  2. Instruct the patient to back up until the edge of the chair is felt behind his or her legs.
  3. If the patient is using a broad-based cane, instruct him or her to release the cane and reach for the opposite armrests of the chair.
  4. If the patient is using a straight cane, instruct him or her to lean the cane against the chair and then to reach for the armrests.
  5. Instruct the patient to lower himself or herself safely to the chair in a controlled manner.

Ascending and Descending Stairs

  1. After the patient is safe and confident using a cane on level surfaces, teach him or her to use it ascending and descending stairs, if appropriate.
  2. Instruct the patient to use a railing if one is available, even if it requires putting the cane on the side on which it is not typically used.

Stairs with Railings

  1. Ascending: Instruct the patient to hold on to the railing and to move the stronger or uninvolved lower extremity up first, followed by the weaker or involved lower extremity and the cane.
  2. Descending: Instruct the patient to lead with the weaker or involved lower extremity and cane first, followed by the stronger or uninvolved lower extremity.

Stairs without Railings

  1. Ascending: Instruct the patient to step up with the stronger or uninvolved lower extremity, placing pressure on the cane, followed by placing pressure on the weaker or involved lower extremity, and finally bringing up the cane.
  2. Descending: Instruct the patient to place the cane down first, then the weaker or involved lower extremity, followed by the stronger or uninvolved lower extremity.

Completing the Procedure

  1. Perform hand hygiene.
  2. Document the procedure in the patient's record.

MONITORING

  1. Observe the patient for signs and symptoms of pain. If pain is suspected, report it to the authorized practitioner.
  2. Observe the patient for signs of fatigue, dizziness, nausea, and breathlessness. If observed, immediately lower the patient to a chair and take his or her vital signs. Proceed based on findings.
  3. Guard the patient appropriately throughout the treatment session.
  4. Monitor the patient's vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation to be certain his or her condition will allow for the energy expenditure required of using a cane.
  5. Observe the height of the cane while in use and adjust it as needed.
  6. Examine the cane tip to be sure it is on securely and is not worn. Replace it as needed.

EXPECTED OUTCOMES

  • Patient is able to sit and stand in a safe manner using the appropriate cane
  • Patient ambulates with the cane on level surfaces in a safe manner
  • Patient is able to ascend and descend stairs in a safe manner with the appropriate cane

UNEXPECTED OUTCOMES

  • Patient falls while using a cane
  • Stooped posture
  • Impaired gait

DOCUMENTATION

  • Patient and caregiver education
  • Level of assistance provided, including verbal instruction
  • Device, gait pattern, and weight-bearing status used
  • Response to treatment
  • Patient's progress toward goals
  • Complications and related interventions

OLDER ADULT CONSIDERATIONS

  • Watch older adult patients for signs of instability or dizziness when changing positions.
  • Before instructing the patient in the use of a cane, assess him or her for decreased cognition, as this may affect communication and influence treatment outcomes.
  • Falls may be of particular concern among older adult patients. Be certain that the cane has been appropriately adjusted and is being used appropriately on all surfaces.

REFERENCES

  1. Foley, M., Bowen, B. (2014). Comparison of metabolic cost and cardiovascular response to stair ascending and descending with walkers and canes in older adults. Archives of Physical Medicine and Rehabilitation, 95(9), 1742-1749. (classic reference)* (Level V)
  2. Jones, A. and others. (2012). Impact of cane use on pain, function, general health and energy expenditure during gait in patients with knee osteoarthritis: A randomised controlled trial. Annals of Rheumatic Diseases, 71(2), 172-179. doi:10.1136/ard.2010.140178 (classic reference)* (Level II)
  3. Fairchild, S.L., O’Shea, R.K., Washington, R.D. (2017). Chapter 9: Assistive devices, patterns, and activities. In Pierson and Fairchild’s principles & techniques of patient care (6th ed.). St. Louis: Elsevier.

*In these skills, a "classic" reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports