WALKERS VS. CANES
Knowing Which Is Best For Optimum Mobility
By Christine McLaughlin
As PTs know, patients are prescribed walkers and canes to help stabilize their ambulation and/or progress them to full independence. Even though the physical differences between traditional walkers and canes are obvious, recognizing the differences between patients who are ready for a walker or a cane takes thought, physical assessment and visual observation by the therapist.
Due to its wide base of support, the most commonly prescribed initial assistive ambulation device for patients who recently experienced surgery, illness or injury to the lower extremities is the traditional walker. Diagnoses common among adults who use walkers include lower extremity fractures, post total knee or hip replacement surgery, general deconditioning and--depending on the severity--stroke and traumatic brain injury.
"A WALKER ALLOWS the patient to put a [significant amount] of their weight on it. So those who have a leg fracture and are weak, or nonweight bearing [in one leg] can use it effectively. Plus, most patients feel secure because they can hold on to it with both hands and because it is something in front of them with four bases of support," explained Debbie Walter, PT, senior therapist of the spinal cord, amputee and orthopedic team at the Rehabilitation Institute of Chicago.
As stable as walkers may be, they are bulky and sometimes difficult to maneuver, especially in small areas and on stairs (although there are walkers designed for use on stairs).
In addition, unless they come equipped with a basket, it can be next to impossible for the user to carry objects, which can be of primary concern when used at home in places like the kitchen, Walter commented.
Other concerns are the abnormal gait pattern and the additional exertion that can result from advancing the walker intermittently.
To be able to advance the walker in between steps, patients need to have bilateral upper extremity hand function as well as standing strength and balance, according to Walter. "Patients should have enough standing balance to pick up the walker and not [have to] put all of their weight on the walker."
BECAUSE MOVEMENT of both extremities is necessary to use the walker, the patient cannot be severely contracted in either leg and should have "good" range of motion, according to Sheila Haddad, PT, rehab director at King City Rehabilitation and Living Center in King City, OR.
Cognitive abilities are also a consideration when determining which patient is right for a walker. Haddad noted that if patients have cognitive problems with sequencing, they may not know what to do with a walker. "As a result, the patient [who is prescribed a walker] will need to be able to follow directions."
In addition to sound cognition, the patient must have the necessary strength to use the walker. As an initial test of strength, Walter mentioned performing manual muscle tests of the lower extremity. She tests strength and balance by having the patient stand in the parallel bars to determine if they need to lean on them to be able to balance themselves. If the patient is able to balance himself without pulling on the parallel bars, most likely that person is ready to stand with a walker.
Haddad explained that she uses a manual muscle test strength scale of zero to five, with five being the highest, to gauge a patient's ability to use an assistive device. If a patient has a three out of five in strength, then that patient can handle the "little bit of resistance" that is required to use a walker. Yet if the patient has a higher score then they might do better with a cane, she said.
PATIENT MOBILITY can also be assessed while the patient is in bed moving from supine to sitting, and then standing and transferring to the walker. "Even if patients are shaky sitting on the edge of the bed, that doesn't mean they cannot use a walker," commented Walter. "I'll have patients stand up and try to walk with it to see if they are using their legs on their own, or if they're putting too much weight on the walker."
Conversely, if a patient doesn't need assistance with weight bearing and has good balance, but feels more secure with a walker in front of them, Walter said that she prescribes a rolling walker. Rolling walkers can have wheels on all four points or only two points. These walkers increase the speed of movement, but give patients the additional security of having something to hold on to with both hands.
If a patient shows even more strength and balance, and doesn't need to hold on with both hands, that person may be progressed to a cane. Haddad mentioned that to be able to use a cane the patient should have "good weight shift from one leg to the other" and cannot have any weight bearing precautions.
CANES CAN be wooden or metal with curved, rounded or grip handles and can be single-, triple- or quad-footed, which can provide a variety of stability levels. But for the purpose of this article, the traditional, single-pointed cane is addressed.
When determining if a patient is ready for a cane, balance testing is even more comprehensive than with a walker. Haddad told ADVANCE that she uses the Tinetti balance assessment tool, which ranks patients with a score from 0 to 28. It assesses the patient's ability to sit, stand, turn and walk. Patients are also tested in the single leg stance, in which they stand on one leg while holding on to the wall and then release to see if they can maintain balance. Haddad noted that she also looks for balance problems while having patients walk with their eyes open and closed, and looking left and right.
"In order to use a cane, patients should be able to step forward and backward, walk on uneven surfaces, step up on and down from a curb, reach forward while standing and be able to recover their balance if someone steps in their path," Haddad said.
Walter pointed out that the patient should also be able to bend over and pick up the cane, if it is dropped, from a sitting and standing position.
The advantages of using a cane are patients have a more normalized gait pattern and have a free arm to carry and pick up objects. In addition, canes are lighter and less cumbersome than walkers, and are easier to transport.
Of course, the leading difference in using a cane over a walker is that it is not as stable. "If patients lose their balance with a cane, it can't be corrected as easily," commented Haddad.
Patients' prior level of function before surgery or illness can also be a consideration to determine if they are ready for a cane. For example, if the patient was totally independent before and now has a slight balance problem and needs additional support, that person probably would do well with a cane, noted Haddad. But if the patient has a history of falls prior to surgery, then a cane may not be the best choice.
Even if patients have the balance necessary to use a cane, that doesn't necessarily mean that they can use one. For instance, if they have complicating factors like respiratory problems or diabetes, which can drain strength, they may need the additional support that a walker provides.
Moreover, if patients have a progressive condition and have developed trouble using a cane, Walter told ADVANCE that she will prescribe a rolling walker first. "I don't want to make a huge jump from a cane to a standard walker. Instead, I want them to have some of the freedom of movement they were used to with the cane, but the stability of a walker," she said. If patients show that they need even more stability, Walter will then suggest a standard walker.
Walter emphasized, therapists who work with patients with orthopedic problems should remember to progress the patient once their weight-bearing status changes. "A lot of times, I see patients who were given a walker initially after surgery and continue to use it even after they've improved. These are patients who are strong enough to use a cane," she said. As a result of using the walker for so long, they may have "forgotten" how to walk fluidly and swing the arms, and may have developed trunk weakness.
Finally, both therapists stressed how important it is to take the entire patient (i.e., their function, and both professional and personal goals) into consideration when prescribing either a walker or a cane to ensure the best possible fit.
http://physical-therapy.advanceweb.com/Article/Walkers-vs-Canes.aspx
Canes & Walkers
Table of Contents:
As people grow older, important daily activities, like walking, dressing, bathing, and eating, may become increasingly difficult to manage alone. Many older persons depend on helpful products or devices to help carry out these activities.
Millions of Americans rely on devices to help them walk and move around. The most common devices used for walking are canes and walkers, which provide support and balance. This booklet describes several types of canes and walkers and general instructions for their use.
For help in selecting and using canes and walkers, always consult a professional, such as your doctor or a physical therapist. Canes and walkers are reimbursable under Medicare and many other third party payers.
The cane is the most widely used assistive device. In the United States alone, over 4 million people use canes. People who have difficulty walking use canes for support and balance. Canes support up to 25% of a person’s weight and may prevent many falls.
Canes are found in many stores for fairly inexpensive prices, ranging from $5 to $100. Because of their availability, people often acquire canes without the help of a qualified professional. This may result in an improper choice of a cane. For example, the cane may be too short or too long for the user. To guarantee a proper fit and good performance, a health professional, such as a physical therapist should help select the cane.
Important Considerations for Effective Cane Use
Do not use canes on stairs without using a handrail or the support of another person on the opposite side. Most quad canes and other wide base canes are not safe for use on stairs.
Canes consist of four components: the handle (a), the shaft (b), the base (c), and the tip (d).
The handle of the cane should be as high as the wrist of the hand opposite the weak side. While standing and holding the handle of the cane, the elbow should be at a 20 to 30 degree angle, as pictured on the next page (figure e).
There are many different types of cane handles. Choose the style that makes you feel most secure.
Types of cane handles include the crooked handle (a), the ball-topped handle (b), the straight (or offset) handle (c), and the shovel handle (d). For a person with weak grasp, a pistol handle (e), which contours to the hand, may be more comfortable. To increase comfort and improve grasp, foam (f) or other materials can be added to the cane handle.
Different materials used in the shaft change the weight and feel of canes. Traditional wood (a) is relatively heavy. Aluminum (b) is very common and lighter than wood. Newer, lightweight materials, like carbon fiber, are beginning to be used in the cane designs. Height adjustment buttons on metal canes raise and lower the height of the cane, to guarantee a perfect fit for each user.
Some companies sell "designer" canes (c) with painted or decorated shafts. Many people prefer using canes that look "special".
In a single shaft design, the base is simply the end of the shaft. Greater support can be achieved by adding more legs, and making the base of the cane higher and wider. However, as legs are added and bases are widened, canes become heavier. They may become too heavy for people with decreased strength. Furthermore, multi-legged canes may be too wide for use on stairs.
Multi-legged canes include the quad high profile cane (a) and the quad narrow cane (b). A quad wide base cane is also available.
Tips on the end of cane legs provide traction and absorb shock, thereby cushioning the hand. A suction tip (a) grips the floor for extra protection against falling. Stabilizers (b) can be added to a cane to help the user maintain balance and equilibrium while walking. Because they slip easily, do not, in general, use canes on snowy or icy surfaces. However, metal or rubber tips (c & d) that grip the ice may give more protection against slipping and falling.
Many special features are available for canes. Some canes fold down to form a convenient tripod seat (a). Cane holders (b) keep the cane upright when leaned against a counter or table. Wrist straps (c) allow the hand to be free without having to set down the cane. They also prevent a person from dropping the cane. Forearm cuffs and platforms (d & e) help people with limited hand or wrist strength because they shift weight to the forearm or upper arm. The reacher accessory (f) is useful for picking up items off the floor.
Walkers rank second behind canes in amount of users, numbering almost two million people in the United States. Since their introduction over 200 years ago, walkers have changed greatly. Originally designed as a temporary rehabilitation device, walkers have been modified for use in the home, adding features like wheels, brakes, and accessories.
Able to support up to 50% of a person's weight, walkers are more stable than canes. Walkers are helpful for people with arthritis, weak knees or ankles, or balance problems. Prices range from $30 for a basic rigid walker, to $600 for a wheeled walker with accessories.
Important Considerations for Effective Walker Use
A professional, such as a physician or physical therapist, should help choose or prescribe the walker. The physician or physical therapist should demonstrate how to walk correctly with the walker on different types of surfaces.
Walker height is best when the users’ shoulders are level, and the arm bends at the elbow in a 20 to 30 degree angle.
Many people use walkers for several years. Extended walker use may cause side effects such as a stooped posture.
To prevent tripping or falling, always look ahead, not at the feet, when walking and use walkers only in well-lit areas. Beware of crowded, cluttered areas. Avoid throw rugs and wires running across the floor, which may catch the wheels of the walker. Footwear is also important when using a walker. Properly fitting shoes with rubber soles are best. Do not wear loose fitting footwear such as slippers, high heels, or slippery soled shoes.
When coming to a standing position from sitting, use the arms of the chair, not the walker, to help in lifting. Once up, be sure there is no dizziness before beginning to walk. When sitting, reach back to the arms of the chair to provide a safe descent to the seat.
Avoid using the walker on stairs. In two or three story homes, it may be necessary to have a walker at each level. Small rooms, like bathrooms, may prevent proper use of the walker. A solution is to install appropriately placed grab bars.
The most basic walker design, the rigid walker (a) is the type most often used in therapy. The frame of the rigid walker is typically made of aluminum. The width can sometimes be adjusted. Other components of the rigid walker include crutch or cane tip legs, and handles. Handles come in a variety of styles, and can be modified for comfort with materials such as sheepskin (b).
To operate, a person lifts the walker, moves it forward, and puts it back down with each step. Because they require lifting, extended use may cause strain on the wrists, shoulders, and arms. It is important to have a therapist determine if this is the best type of walker for you.
The side walker (a) is a variation of the rigid walker design. Often, it has two grasp bars at different heights. Grab the lower bar when rising from a seated position. Use the upper bar for walking.
The folding walker (b) has the same components and is used in the same manner as the rigid walker. However, it folds into a flat object so that it can be carried or transported easily when not in use.
Unlike the rigid walker, the user merely pushes the two-wheeled walker (a) forward. No lifting is necessary, so the walking style is more natural. Two-wheeled walkers have automatic brakes that work when you push down on the walker. Some have auto-glide features (a) that allow the rear legs to skim the surface.
Three or four wheeled walkers (b) & (c) require less energy and strength to use. Gliding over carpets and thresholds is easier, and they may provide better performance in turning. Three and four wheeled walkers often have hand brakes (c).
Wheel size and walker weight vary greatly in different models of wheeled walkers. All are heavier than rigid or folding walkers. Because many wheeled walkers do not fold, they may be more difficult to transport.
Convenient accessories are available, such as detachable baskets (a), and seats (a) and trays (b). Walker bags (c) allow you to carry small items while keeping your hands free to hold the walker. Clips can attach other accessories to rigid walkers, such as a platform arm support (d)
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