I. Background

  1. In U.S., 10% of pts > 65yo use canes, and 4.6% use walkers
  2. Most obtain and use these devices without any advice or instructions from a health care provider

II. Indications, benefits and risks

  1. Indicated when weakness, poor balance, and/or pain impede mobility and/or create risk of falls
  2. Benefits:
    1. Improve balance by providing wider base of support
    2. Improve pain by redistributing weight off lower extremities
  3. Risks
    1. Can increase risk of falls if patient not properly instructed or has cognitive, attentional, or physical impairments that preclude safe use.

III. Devices

  1. Canes
    1. Appropriate when only one upper extremity is needed for balance or to reduce weight bearing on lower extremities
    2. Correct height: At level of pt's wrist crease with pt standing up straight with arms relaxed at their sides
    3. Various types are available; little evidence to favor one type over another.  "Quad canes" have a wider base with four feet and can stand freely if patient needs to let go and use hands for something else, but all four points much touch the ground for proper use.
  2. Walkers
    1. Useful when both upper extremities are needed to stabilize or relieve weight on lower extremities, such that a cane is not adequate.
    2. Can be difficult to maneuver and can result in poor back posture; also hard to navigate stairs with one
    3. Same guideline for height as canes
    4. If need for weight-bearing, then "shotgun" (straight, not curved) handle may result in less risk of carpal tunnel syndrome (due to less pressure on palm)
    5. Subtypes:
      1. "Standard" (no wheels)-Most stable, but must be completely lifted off the ground with each step, so requires substantial effort.
      2. Front-wheeled-Less stable than standard, but allows for more normal gait, and requires less effort than a standard walker.  May be associated with less "freezing" in pts with Parkinson's than a standard walker.
      3. Four-wheeled (aka "rollator")-Often have built-in seats; Requires least effort but risk of falls for pts with balance problems.
  3. Crutches
    1. Helpful when pt needs to use UE's for weight bearing and propulsion (not just balance)
    2. Ambulating with crutches takes a lot of energy, as well as significant UE strength.
    3. Subtypes:
      1. Axillary crutches-If fit is bad, can cause nerve compression
      2. Forearm ("Lofstrand") crutches-have a cuff that fits around the upper forearm; difficult to use on stairs

IV. Considerations in selecting optimal device

  1. Strength
  2. Endurance
  3. Balance
  4. Cognitive and attentional ability
  5. Vision
  6. Environmental demands

V. Management of assistive devices

  1. Confirm correct height
  2. Check for loose rubber caps or hand grips
  3. Check for proper use
    1. Canes with "shotgun" grip are commonly held backwards; the end of the grip should be pointing backward.
    2. Canes should be held on the side of the less weak/painful lower extremity and advanced simultaneously with the contralateral lower extremity.
    3. Posture with canes and walkers should be upright, not leaning forward or to the side
    4. Keep device on the ground while turning
    5. On stairs: going up, stronger leg first; going down, weaker leg first ("up with the good, down with the bad")
  4. Consider physical therapy referral if patient is having difficulty

(Sources include: AFP 84:405, 2011)