An elderly patient enters your office with complaints of low back pain. She is using an assisted device (e.g., cane, walker, crutches). As you watch her walk, you think to yourself, "She looks like Yoda from Star Wars, and I would hurt also if I were walking like that."
Or your patient asks, "Dr. Bones, am I using my cane correctly?" or "Dr. Bones, do you think my walker is at the right height for me?"
Can you answer any of these questions with certainty? After reading this article, you should be able to give your patients an educated answer.
Traditionally, as Doctors of Chiropractic, we do not prescribe or recommend the use of canes, crutches, or walkers. The patient usually has them from a previous condition such as stroke, fractures, and other neuromusculoskeletal conditions. Sometimes they just purchased or rented them to allow them to get to our offices.
We will address some of the most common recommendations for the use of canes, crutches and walkers. Today these devices are referred to as "assisted devices." First, we will talk about how to properly determine the correct height of our patients’ devices and then discuss their proper use.
Our basic goal for the use of an "assisted device" is to help the patient with ambulation. But, even more, it is to have the patient walk as normally as possible without sacrificing safety. As chiropractors, we understand the importance of a normal gait pattern. We have discussed this phenomenon in previous articles. Commonly, our elderly patients present a forward-flexed posture with the head carried in an anterior translation, while the thoracic spine follows with an opposite kyphosis. These postural changes are the results of poor posture, ankylosing, muscle imbalances and degenerative changes. If our patients are using their assisted devices incorrectly, they will develop other compensatory complications throughout the entire musculoskeletal system.
The patient should stand in an upright, straight posture, shoulders relaxed, with one hand on the cane. Make sure she is holding the cane in a good weightbearing position. Place the cane approximately six inches ahead and to the outside of the patient’s foot. The hand holding the top of the cane should rest so the elbow is about 160 degrees in extension or about even with the greater trochanter on that side.
With patient standing, place the walker in front of her, so that it is also partially around her on the sides. The patient should stand in an upright, straight posture with shoulders relaxed. Elbows should be almost straight. Once the patient feels comfortable, see if she can apply a push and pull on the walker without having to bend over.
The patient should position the crutches with the tips touching the floor about six inches from each foot and out to the sides, in a comfortable, weightbearing position. The patient again needs to assume an upright, straight posture with shoulders relaxed. The axillary pads (top of the crutch) should lie against the ribs about three to four finger widths from the axila (armpit). The handles of the crutches should be positioned so the elbows are about 160 degrees extended or about even with the greater trochanter. This positioning is the same as the cane. Instruct your patient not to press down on the axillary pads. Weight bearing needs to be on the hands and not the axillary (armpit) areas. Axillary pads should be placing pressure into the body.
Walking with a Cane
The patient must understand that she is forming a "triangle foundation" with her feet and the cane. This is for stability. The cane should always be used in the hand opposite the involved leg. The function of the cane is to assist with lateral stability.
Move the cane forward and out to the side. Have patient put her weight onto the cane, shifting the weight off the involved leg. Have her move her involved leg up even with the cane. Make sure patient keeps a good center of gravity for balance. This can be assisted by having her assume a little wider stance, then press on the cane with as much weight as possible on the involved leg. Have her step past the cane with her non-involved leg. Continue this sequence.
With consideration to the different types of canes that are available, the best cane for a patient to use for general ambulatory needs is the basic "straight cane." Other canes, such as the quad cane or hemi cane, are designed for specific patients with specific gait deficiencies. They are designed for patients with limited weightbearing abilities (due to conditions such as stroke, cerebral palsy, fractures), where partial- to non-weightbearing is necessary. What commonly happens for a patient who uses a quad cane for normal ambulation, when they place the cane down, it is usually placed on one or two of the supporting legs, which now creates a rock mechanism as the weight is shifted forward onto the other legs of the cane. This is unlike a straight cane that has only one contact point to allow easy pivoting for better ambulation.
Using the Walker
Instruct the patient to pick the walker up and place it forward a little. Step into the walker, first with the involved leg and then with the other. Have the patient put the involved foot or leg forward and place it on the floor. For non-weightbearing gait or partial weight bearing, the patient now needs to push on her hands and, lifting her weight, step forward with involved leg, then uninvolved leg, placing it next to the involved leg. Repeat this sequence with each step. Place only weight bearing on the involved leg.
Keep reminding the patient of the importance of maintaining as normal of a heel-to-toe gait as possible and avoid limping.
Using the Crutches
The patient must keep in mind the proper positioning of the crutches. A triangle position of the feet and crutches makes her more stabile. When walking, maintain weight bearing on one leg and put both crutches forward. Place all pressure on the hands, and step past the crutches with her opposite foot landing on the heel first (heel strike) for balance.
Now the patient’s position should present as a backward triangle. If patient can put weight on the involved foot, we would have her try to place the crutches forward and then step forward with the involved foot up to the crutches, followed by having her step past the crutches with her uninvolved foot, placing her uninvolved foot on the ground with a heel-first landing. This maneuver is commonly used for weak legs and restricted weight bearing.
When your patient is able to bear considerable weight on the involved leg and foot, the gait pattern will resemble the pattern used for cane walking. Move one crutch, or one foot at a time (4 point) or move one crutch and one foot together (2 point).
Ultimately, the important issue with our patients and walking devices is that they are comfortable with both their use of the device and are maintaining as upright and stable posture as possible. This includes walking with as close to a normal gait pattern as possible so we do not elicit compensatory stresses throughout the musculoskeletal chain, thus allowing our patients to maintain their chiropractic adjustments for better patient outcomes.
I would like to thank my wonderful wife Terri for her advice and assistance in writing this article.
A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan. He is very active with the Michigan Chiropractic Society serving on the legal and government affairs committees.