See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/282130699

Ambulatory assistive devices. How to appropriately measure and use

canes, crutches and walkers

Article  in  Pharmacy Practice · January 2014

CITATION READS
1 14,073

2 authors:

Cheryl Sadowski Allyson Jones

University of Alberta University of Alberta
102 PUBLICATIONS   1,147 CITATIONS    162 PUBLICATIONS   4,309 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

International education View project

Prescribing Project View project

All content following this page was uploaded by Allyson Jones on 24 September 2015.

The user has requested enhancement of the downloaded file.

Clinical Feature

Ambulatory
Assistive
Devices
How to appropriately measure and safely use
canes, crutches and walkers

by Cheryl A Sadowski, BSc(Pharm), PharmD, FCSHP

and C. Allyson Jones, PT, PhD

T
he use of ambulatory assistive devices (AAD) is becoming increas-
ingly common as the population ages and individuals who have
chronic conditions and mobility challenges maintain their inde-
pendence in the community. AADs, which include canes, crutches
and walkers, are most commonly used by older individuals,(1,2) to decrease
weight bearing on the lower limbs, compensate for muscular weakness and
aid in improving balance. These devices can improve mobility and balance,
thus increasing independence and confidence for users.(2-4) Some studies have
also shown that AAD use reduces falls,(5-7) while other studies have shown
an increased risk of falls, possibly due to changes in the types of steps taken,
or tripping through interference with the feet and the device.(8-10) Up to 50%
of people discontinue AAD use because the device is difficult to use or the
patient perceives the AAD to be risky.(2,7-9,11,12) Many pharmacies sell AADs,
yet research has shown that only 5% of pharmacists feel that their training
for AADs is ‘definitely sufficient.’ More than 70% could not describe how to
fit a patient for an AAD, and more than 50% could not describe how to use
an AAD for ambulation(13)
This article provides basic guidance on the measurement, use and safety of
canes, crutches and walkers.

24 November 2014 [Vol.1 No.10] pharmacy practice +


Patient assessment
When a patient presents for an AAD, the pharmacist may be in a situa-
tion where another health professional has not written a prescription or
made a recommendation, as some patients choose to self-diagnose or treat.
When this occurs, pharmacists can inquire about management of other
chronic conditions (e.g., Parkinson disease, osteoarthritis) and ensure that
treatment of these conditions is optimized to prevent decreased mobility.
Experts recommend two screening questions related to mobility(11):
1. For health or physical reasons, do you have difficulty climbing
up 10 steps? Walking 0.25 mile?
2. Because of underlying health or physical reasons, have you
modified the way you climb 10 steps or walk 0.25 mile, either
by changing the method or frequency of these activities?
Box 1(11) provides a checklist pharmacists can use when first interact-
ing with a patient asking for an AAD. Box 2(11) outlines situations that
may require additional assessment by a physiotherapist. When assessing
patients for an AAD, physiotherapists consider neurologic, cardiopul-
monary, orthopedic, home and funding/support factors.(14)
Safety and referral
Unsafe use of an AAD can result in significant harm to patients, with
contusions, abrasions, punctures and lacerations being the most
common injuries.(15) Trauma from canes, crutches and walkers made
up 15% of adverse events from medical devices in a large US study
examining more than 450,000 cases.(15) In another study of patients age
65 years and older, 87% of fall-related injuries were related to walkers,
12% to canes, and less than 1% to both walker and cane; one-third of
walker injuries resulted in hospitalization.(7)
While each device is unique, certain safety principles apply to all
three types of AADs. A patient should never use an AAD to tackle or
go over obstacles; obstacles should always be avoided. Footwear should
always be worn when being measured for and when using an AAD.
A device that has been properly fitted should be used to avoid falls or
other accidents. Box 3(11) summarizes AAD safety concerns (red flags)
that require referral to a physiotherapist.
pharmacy practice +
Feature
Pharmacists may be confronted with a
situation where a patient’s concern cannot
be adequately addressed in the pharmacy.
The patient may be at greater risk for
falls, or the pharmacist may have diffi-
culty estimating the effort and metabolic
demands some AADs require of users.(2)
A physiotherapist may be able to provide
education and training regarding use of
the AAD, or guidance on another form of
intervention.
Pharmacists should also keep in mind that
patients require support from other health
professionals, in additional to physiotherapy.
For example, referring to a social worker
or other community agency may assist with
transportation concerns or engaging an
occupational therapist or homecare worker
could ensure a safety assessment and im-
proved mobility in the home (Box 4[16]).(11)
Specific AADs
CANES
A cane is typically used when minimal
stability is needed. Canes can support up to
25% of a patient’s weight.(8) They widen a
person’s base of support, thereby providing
increased balance. Canes have customarily
been used only for balance but modified de-
signs may permit various degrees of weight
bearing throughout the cane.
Target population Canes are used for a
wide variety of conditions, depending on
the patient’s balance. For instance, they are
useful for patients who have vestibular dys-
function, mild visual impairment, sensory
ataxia or painful gait. Canes may also be
[Vol.1 No.10] November 2014 25
 Feature
useful for patients who have had a stroke and require more
support when walking.(11,17)
Caution Although canes provide an additional point of
BOX 1
contact to help balance, they are the least stable of the three
INITIAL QUESTIONS TO ASK PATIENTS
types of AADs mentioned in this article. They may not be the INQUIRING ABOUT AADs(11)
most appropriate device for persons who have severe balance ✔ The indication (reason for purchasing an AAD)
disturbances or impaired cognition affecting safety judg- ✔ Previous assessment/consultation by other health
professionals
ment. If any of these factors are noted, the patient should be ✔ Parts of the body that cannot weight bear
referred to their family physician or a physiotherapist. ✔ Issues in using hands for support on the AAD
✔ Conditions that could impair mobility (e.g., cognitive
or sensory impairment)
Types of canes
AAD–ambulatory assistive device
Various types of canes exist, with different styles, shapes and
handgrips. Table 1(3,11,17,18) outlines the preferred use of each type. BOX 2
Box 5(3,14,17,19) outlines how to measure a patient for a cane, tips SITUATIONS THAT MAY REQUIRE ADDITIONAL
for use (including stairs and other terrain) and safety tips. ASSESSMENT BY A PHYSIOTHERAPIST(11)
› Compromised upper extremity function (cannot
weight-bear through hands, wrist)
CRUTCHES › Extremely poor balance
The axillary crutch is commonly used to offload a limb. One › Cognitive impairment (e.g., lack of
crutch can bear 80% of body weight, and two crutches can understanding, lack of judgment)
› Visual impairment
bear 100% of body weight.(18) Although crutches require con- › Poor overall strength and endurance
siderable energy expenditure for propulsion, as well as arm › Unable to safely transfer (e.g., supine to sit,
and shoulder strength,(18) they provide greater maneuverability sit to stand, to/from toilet)

than a walker. Good balance and coordination are required to

BOX 3
use crutches. They are typically used for temporary purposes
AAD SAFETY CONCERNS REQUIRING
(e.g., leg fractures/sprains).(3) Axillary crutches should fit and PHYSIOTHERAPIST REFERRAL(11)
be used properly to avoid circulatory and nerve damage to 1. Orthopedic-related signs and symptoms:
the upper extremities. Leaning on crutches and placing too › Pain in wrist/hand
› Numbness or tingling in hands and fingers
much weight through the arms rather than the wrists/hands › Bruising/tenderness in upper arm and elbow
can cause prolonged pressure in the axillary/ribcage region › Shoulder pain
and temporary or permanent damage to the nerves in that › Cramping in triceps muscles
› Pain and cramping in the weight-bearing leg
area.(20-22) This can cause tingling and numbness in the arm 2. Poor balance coordination with use of device
and shoulder region. In addition, vascular or orthopedic AAD–ambulatory assistive device
trauma can occur if crutches are not fitted or used prop-
erly.(23-26) Proper fitting of the crutch and instructions for
correct use are important to prevent such injuries.
TABLE 1
Target population Injuries to the lower extremities (e.g.,
TYPES OF CANES (3,11,17,18)
fractures, postoperative recovery after orthopedic surgery to
SINGLE CANES MULTIPLE-LEGGED CANES
the hip or knee, pulled muscles [strains], ankle sprains) are
STANDARD OFF-SET QUAD HEMI-WALKER
quite common. Depending on the severity of the injury, a tem-
porary period of partial weight-bearing or nonweight-bearing Helpful for Weight of Permits more For patients
balance by the patient weight-bearing requiring
of the limb may be required to allow healing time. This should providing an can be and provides continuous
be determined by the patient’s physician or physiotherapist. additional point displaced increased base of weight-bearing
Crutches may also be used for patients with chronic condi- of contact with over the support with only one
the floor shaft of arm
tions (e.g., post-polio syndrome), for travelling short distances the cane May be awkward
within the house or community or for short periods of time. Aluminum canes for greater to use because Cannot be
Caution Crutches may not be the most appropriate device are easy to stability all legs of the used on stairs
adjust cane need to be
for persons who have visual impairment, severe balance in contact with
disturbance or impaired cognition affecting safety judgment. Wooden canes the ground and
Patients should be referred to their family physician or a need to be cane may be
custom-fitted heavier
physiotherapist if any of these factors are noted. for length
Not very practical
Types of crutches on stairs unless
the cane is
In addition to axillary crutches, a variety of other crutch types turned sideways
are available through specialty medical stores. Gutter crutches to fit the step
(platform attachments or troughs) may be used when weight-

pharmacy practice + [Vol.1 No.10] November 2014 27


bearing through the hand is contraindicated (e.g., arthritis af-
fecting the wrist and hands, fractured wrist). Forearm crutches
(Loftstrand or Canadian crutches) have forearm cuffs with
either a medial or anterior opening and handgrip. This type
of crutch may be useful for patients with weak triceps muscle,
spinal cord injury, cerebral palsy or those who ambulate while
wearing bilateral knee-ankle-foot orthosis.
Box 6(3,14,17) outlines how to measure a patient for crutches,
tips for use (including stairs and other terrain) and safety tips.
WALKERS
Walkers were originally introduced approximately 200
years ago to assist with rehabilitation, but are now also
used for daily activities.(9) They are typically used to im-
prove balance and/or decrease weight-bearing through the
legs. Weight can be offloaded either partially or fully from
the affected limb, with walkers bearing up to 50% of a
patient’s weight.(27) Walkers provide greater stability than
crutches or canes. They allow a wider base of support, im-
prove both anterior and lateral stability, and allow the arms
to transfer body weight through to the floor.
Target population Walkers are recommended for condi-
tions such as poor balance, generalized weakness, restricted
lower-limb weight bearing (e.g., post-hip surgery) and debili-
tating conditions.(7)
Caution Walkers may not be the most appropriate device
for persons who have visual impairment, severe balance
disturbances or impaired cognition affecting safety judgment.
They are not appropriate for rough terrain or stairs and pose
a hazard in a crowded or cluttered setting. Some individu-
als find certain features challenging to master (e.g., folding
the walker to make it flat can be physically demanding and
awkward for frailer patients). If any of these factors are
noted, the patient should be referred to a physiotherapist or
occupational therapist.(11)
Types of walkers
Walkers vary in style and design. The most common types are
the standard walker, 2-wheeled walker and 4-wheeled walker.
Pharmacists should be aware that an occupational therapist,
physiotherapist or physician can make modifications to these
devices to best suit individual patients. These altered devices are
often ordered from specialty medical stores and are not necessary
for the pharmacist to carry or prescribe. For example, platform
attachments (gutters) can be attached if the client is unable to
grip the handles of the walkers due to pain, muscle weakness/
paralysis or restricted hand joint movement (e.g., osteoarthritis of
the wrist/hand) or if they are unable to weight bear through their
hands (e.g., wrist fractures). Other special order features include
hand grips that are larger or smaller or of a different texture
for those with arthritis. A 2-wheeled walker may provide more
support and stability than a 4-wheeled version, but may be more
difficult to maneuver on carpeted surfaces.(9) Box 7(3,14,17) outlines
how to measure a patient for a walker, tips for use (including
stairs and other terrain) and safety tips.
pharmacy practice +
BOX 4
PATIENT EDUCATION REGARDING FLOOR
Feature
SURFACES FOR HOME SAFETY WITH AADs(16)
✔ Watch for uneven, slippery and icy surfaces
✔ Keep floors clean, dry and well-lit
✔ Remove throw rugs and fix any loose carpet edges
✔ Keep traffic areas and floors free of clutter
✔ Wipe up floor spills quickly to prevent a fall
AAD–ambulatory assistive device
BOX 5
CANE MEASUREMENT, TIPS FOR USE AND
SAFETY TIPS(3,14,17,19)
= Measurement
1. Ask patient to stand tall looking straight ahead with
arms loosely at side
2. Adjust cane handle to level or wrist crease
(alternatively, adjust to height of the greater
trochanter of the femur)
3. When holding cane, elbow should be flexed ~ 20–30
degrees to allow the arm to shorten and lengthen
during different phases of the gait cycle, as well as
to provide a shock absorption mechanism
4. Ensure measurements are taken with the individual
wearing shoes. Ideal footwear includes a neutral
heel, with proper heel support and nonslip sole (no
crepe soles)
1. Place cane in hand on unaffected
side as this provides the greatest
base of support and simulates
TIPS
normal gait
se 2. If bilateral involvement, hold the
u
for cane in the hand that offers the
most grip strength and comfort
3. Hold cane close to body
4. Tip of cane should be placed ~ 2”
in front and ~ 6” lateral to the foot
q Use on stairs and other terrain
Canes can be used on stairs with the appropriate
instruction. The stronger foot should ascend the
stairs, followed by the weak leg, then the cane. When
descending the stairs, the cane should go down first,
followed by the weak leg, then the strong leg. If a
railing is available on the side opposite to the hand
holding the cane, the patient may be advised to use it
for increased stability and safety.
SAFETY TIPS
1. Inspect cane on a regular basis; watch for cracking
or worn tips, handles.
2. If walking in a region where walking surfaces could be
icy, consider attaching ‘ice tips’ to provide extra grip.
3. Can be used for ascending and descending stairs (use
cane with handrail, if available, for maximum safety)
4. Use a rubber tip on the end of the cane to help
prevent slipping and provide some shock absorption
5. If patient continues to reach for supporting surfaces
(e.g., a wall, counters or railings) while walking, the
healthcare professional should refer to a physician
or physiotherapist for further assessment in order to
determine the proper gait aid.
6. If the cane is too short, the patient will have to
lean too far forward during the walking cycle,
compromising stability and energy usage
[Vol.1 No.10] November 2014 29
 Summary
As AADs are sold in community pharmacies, pharma-
Feature

cists can play an important role in ensuring their safe BOX 6

and appropriate use by establishing the patient’s need, CRUTCH MEASUREMENT, TIPS FOR USE
ensuring a proper fitting and providing patient educa- AND SAFETY TIPS(3,14,17)
tion. A helpful online resource is available from the = Measurement
American Academy of Orthopaedic Surgeons (http:// To adjust height:
1. Position axillary pad ~ 3” (3–5 finger
orthoinfo.aaos.org/topic.cfm?topic=a00181). Pharma- widths) below the axilla
cists can work with rehabilitation specialists and physi- 2. Tip of the crutch should be ~ 2” anterior
cians to ensure that patients receive the best care. and 6” lateral to the foot
To position hand grip:
3. Ask patient to relax arm at side
Cheryl Sadowski (cherylas@ualberta.ca) is a clinical pharmacist 4. Adjust hand grip to the level of wrist
in the interprofessional Geriatric Outpatient Assessment Clinic at crease (alternatively, adjust to height of the
the Misericordia Community Hospital (Edmonton), and an associate greater trochanter of the femur)
professor at the Faculty of Pharmacy & Pharmaceutical Sciences, 5. Elbow angle should be ~ 20–30 degrees
University of Alberta in Edmonton.
Ensure measurements are taken with the
Allyson Jones is a professor in the Department of Physical Therapy, individual wearing shoes. Ideal footwear
Faculty of Rehabilitation Medicine, University of Alberta. includes a neutral heel, with proper heel
support and nonslip sole (no crepe soles)
References can be found at Canadian
FIND IT HealthcareNetwork.ca. Click on
ONLINE the Pharmacy Practice+ logo for online 1. When using crutches, the
content from this issue. top of the crutch should
be placed against the rib

TIPS
cage with the majority of
se the weight bearing through
u
for the hands.
2. Step with an upright
BOX 7
posture; do not walk too
WALKER MEASUREMENT, TIPS FOR far behind or lean too far
USE AND SAFETY TIPS(3,14,17) forward with the crutches
3. Look straight ahead rather
= Measurement than down at your feet
1. Note patient’s position - measure 4. Your weak leg should move with the
in standing position with shoulder crutches
girdle and arms relaxed by side. Ask 5. Apply only the prescribed weight-bearing
the patient to stand tall and look status (e.g., full, partial, feather or non-
straight ahead. weight-bearing)
2. Adjust the walker handles to the level
of the wrist crease.
3. Elbow angle should be ~ 20–30 degrees.
4. Ensure adequate width and depth to allow patient to comfortably q Use on stairs and other terrain
walk inside walker. Crutches are safe to use on stairs. When ascending, the
stronger (‘good’) leg should go up the stairs first, followed by
1. Step into the walker and maintain an upright the weak (‘bad’) leg, then the crutches. When descending, the
posture; do not walk too far behind or too close crutch should be placed down first, followed by the weaker
to the front of the walker. TIPS leg, then the strong leg. When going up or down stairs with
2. Patients should look straight ahead rather for crutches, the crutches should always be on the step below to
than down at their feet to maintain an upright u se prevent the axillary pads from jamming into the axilla. Patients
posture and navigate. are encouraged to use hand railings when available. In general
3. Never use on stairs or rough terrain. patients using crutches can also attempt inclines or declines by
using an approach similar to using stairs.

q Use on stairs and other terrain

NOT appropriate for use on stairs or rough terrain.
SAFETY TIPS
1. Before each use, inspect the walker to make certain that
components such as the hand grips are securely attached.
2. Do not use walker to stand (e.g., pulling up from sitting to a
standing position).
3. Do no use walker on stairs.
4. Wear non-skid well-fitting shoes.
5. If small items are carried on the walker, ensure that they do not
affect walker stability or interfere with gait pattern; recommend
using a walker with a basket attached.
6. Regularly check rubber tips and wheels; replace if worn or torn.
7. Do not try to walk if feeling dizzy; a walker will not reduce dizziness.
SAFETY TIPS
1. Never rest axilla on top of crutches; this can lead to nerve injury.
2. Do not use crutches positioned in the axilla to sit or stand,
always place crutches in one hand and use the unaffected
arm/leg to assist with sitting and standing.
3. Avoid obstacles; do not attempt to go over them, rather go
around them.
4. Wear flat shoes to provide a good base of support.
5. Avoid bending too far forward or too far backward.
6. In poor weather, go slowly and use smaller steps to help
prevent slipping on slick surfaces.
7. Wipe tips of crutches if wet from rain or snow when going inside.
8. Consider purchasing “ice tips” to help provide extra grip on icy
sidewalks.

30 November 2014 [Vol.1 No.10] pharmacy practice +

Online
References
1. Hartke RJ, Prohaska TR, Furner S. Older adults and assistive devices: Use, multiple-device use, and need. J Aging Health
1998;10:99-116.
2. Bateni H, Maki BE. Assistive devices for balance and mobility: benefits, demands, and adverse consequences. Arch Phys Med
Rehabil 2005;86:134-45.
3. Bradley SM, Hernandez CR. Geriatric assistive devices. Am Fam Physician 2011;84:405-11.
4. Salminen AL, Brandt A, Samuelsson K, et al. Mobility devices to promote activity and participation: a systematic review. J
Rehabil Med 2009;41:697-706.
5. Graafmans WC, Lips P, Wijlhuizen GJ, et al. Daily physical activity and the use of a walking aid in relation to falls in elderly
people in a residential care setting. Z Gerontol Geriatr 2003;36:23-8.
6. Jensen J, Lundin-Olsson L, Nyberg L, et al. Fall and injury prevention in older people living in residential care facilities. A cluster
randomized trial. Ann Intern Med 2002;136:733-41.
7. Stevens JA, Thomas K, Teh L, et al. Unintentional fall injuries associated with walkers and canes in older adults treated in U.S.
emergency departments. J Am Geriatr Soc 2009;57:1464-9.
8. Mann WC, Granger C, Hurren D, et al. An analysis of problems with canes encountered by elderly persons. Physical and Oc-
cupational Therapy in Geriatrics 1995;13:25-49.
9. Mann WC, Hurren D, Tomita M, et al. An analysis of problems with walkers encountered by elderly persons. Physical and Oc-
cupational Therapy in Geriatrics 1995;13:1-23.
10. Bateni H, Heung E, Zettel J, et al. Can use of walkers or canes impede lateral compensatory stepping movements? Gait
Posture 2004;20:74-83.
11. Brown CJ. Flood KL. Mobility limitation in the older patient: a clinical review. JAMA 2013;310:1168-77.
12. Dean E, Ross J. Relationships among cane fitting, function, and falls. Phys Ther 1993;73:494-500 and discussion 501-4.
13. Lam A, Molnar R, Vu T, et al. Online continuing education module for community pharmacists: assisting clients with
ambulatory devices. Currents in Pharmacy Teaching and Learning 2009;1:87-92.
14. Edelstein JE. Assistive devices for ambulation. Phys Med Rehabil Clin N Am 2013;24:291-303.
15. Hefflin BJ, Gross TP, Schroeder TJ. Estimates of medical device-associated adverse events from emergency departments.
Am J Prev Med 2004;27:246-53.
16. Safer Healthcare Now. Reducing falls and injuries from falls - getting started kit. June 2013. www.saferhealthcarenow.ca/
EN/Interventions/Falls/Documents/Falls%20Getting%20Started%20Kit.pdf (accessed August 17, 2014).
17. Van Hook FW, Demonbreun D, Weiss BD. Ambulatory devices for chronic gait disorders in the elderly. Am Fam Physician
2003;67:1717-24.
18. Faruqui SR, Jaeblon T. Ambulatory assistive devices in orthopaedics: uses and modifications. J Am Acad Orthop Surg
2010;18:41-50.
19. Kumar R, Roe MC, Scremin OU. Methods for estimating the proper length of a cane. Arch Phys Med Rehabil 1995;76:1173-5.
20. Murphy MT, Journeaux SF. Case reports: long thoracic nerve palsy after using a single axillary crutch. Clin Orthop Relat Res
2006;447:267-9.
21. Raikin S, Froimson MI. Bilateral brachial plexus compressive neuropathy (crutch palsy). J Orthop Trauma 1997;11:136-8.
22. Poddar SB, Gitelis S, Heydemann PT, et al. Bilateral predominant radial nerve crutch palsy: a case report. Clin Orthop Relat
Res 1993;297:245-6.
23. Moon IS, Hwang JK, Kim JI. Recurrent upper extremity embolism due to a crutch-induced arterial injury: a different cause of
upper extremity embolism. Ann Vasc Surg 2010;24:554.e7-554.e12.
24. Garcia Suarez G, Garcia Garcia J, Perez Carro L. Stress fracture of the ulna associated with crutch use. J Orthop Trauma
2001;15:524-5.
25. McFall B, Arya N, Soong C, et al. Crutch induced axillary artery injury. Ulster Med J 2004;73:50-2.
26. Feldman DR, Vujic I, McKay D, et al. Crutch-induced axillary artery injury. Cardiovasc Intervent Radiol 1995;18:296-9.
27. Elmamoun M, Mulley G. Walking sticks and frames for patients with neurological disorders. Pract Neurol 2007;7(1):24-31.

pharmacy practice + [Vol.1 No.10] November 2014 31

View publication stats