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.