Walkers vs. Canes
Making an Informed Choice
By Christine McLaughlin
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 isn't. As such, there's no substitute for a thorough patient assessment.
Careful patient observation will help you decide whether to prescribe a cane or a walker, the latter of which is the most commonly prescribed assistive ambulation device. Due to its wide base of support, a traditional walker works well for patients recovering from recent surgery, illness or injury to the lower extremities. Diagnoses common among adults who use walkers include lower extremity fractures, total knee or hip replacements, general deconditioning and--depending on the severity--stroke and traumatic brain injury.
Most of these patients feel secure using a traditional walker because they can hold on to it with both hands, says Debbie Walter, PT, senior therapist of the spinal cord, amputee and orthopedic team at the Rehabilitation Institute of Chicago. Patients also appreciate the stability a walker's four legs provide, she adds.
Yet, despite their stability, walkers are bulky and sometimes difficult to maneuver, especially in small areas and on stairs. Without a basket, they also interfere with a patient's ability to carry objects--a primary concern when they use walkers at home in places like the kitchen, Walter says.
Other disadvantages are the abnormal gait pattern and the additional exertion that results from advancing the walker intermittently. To advance the walker evenly between steps, patients need bilateral upper extremity hand function as well as standing strength and balance, Walter says.
As an initial test of strength, consider manual lower extremity muscle tests, says Sheila Haddad, PT, rehab director at King City Rehabilitation and Living Center, King City, Ore. She uses a 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 he can handle the "little bit of resistance" required for walker use, Haddad says.
You can also assess mobility 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," Walter says.
Conversely, if a patient doesn't need weight-bearing assistance and has good balance, but feels more secure with a walker in front of him, Walter prescribes a rolling walker. Rolling walkers, which have either two or four wheels, increase speed while giving patients the additional security of having something to hold on to with both hands, Walter explains.
If a patient shows even more strength and balance, and doesn't need to hold on with both hands, he may progress to a cane. To use a cane, the patient needs "good weight shift from one leg to the other" and no weight-bearing precautions, Haddad says.
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.
To assess patients for traditional single-pointed cane use, Haddad uses the Tinetti balance assessment tool, which ranks patients with a score from 0 to 28. It assesses their ability to sit, stand, turn and walk. In addition, it tests their balance in a single leg stance. Haddad also looks for balance problems while having patients walk with their eyes open and closed, and looking left and right.
Patients who can step forward and backward, walk on uneven surfaces, step up on and down from a curb, reach forward while standing and recover their balance if someone steps in their path are good candidates for cane use, Haddad says.
These patients should also be able to bend over and pick up the cane, if they drop it while sitting or standing--even if the cane has a wrist loop, Walter says.
Canes give patients a more normalized gait pattern and a free arm to carry and pick up objects. In addition, they are lighter and less cumbersome than walkers and are easier to transport.
Of course, the disadvantage of using a cane instead of a walker is instability. "If patients lose their balance with a cane, it can't be corrected as easily," Haddad says.
Patients' prior level of function before surgery or illness can also be a consideration. For example, if the patient was totally independent but now has a slight balance problem and needs additional support, that person probably would do well with a cane, Haddad says. But, if the patient has a history of falls prior to surgery, a cane may not be the best choice, she adds.
Similarly, patients with complications, such as respiratory problems, diabetes or other fatiguing conditions, may not have sufficient strength for cane use. Patients with progressive conditions may also have difficulty. So Walter prescribes a rolling walker first.
"I don't want to make a huge jump from a cane to a standard walker," she says. "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." If patients show that they need even more stability, Walter suggests a standard walker.
You must consider individual patient needs when choosing between a cane and a walker, says Haddad. "Some patients have a hard time accepting that they have to use a walker, because they think they're just for old people. But we really try to take their personal goals into consideration, as long as they're safe." *
Christine McLaughlin is on staff at ADVANCE.