Ambulação adequada com cana Ir para: navegação, pesquisa

Introduction

Ambulation is defined as the ability to walk from place to place independently with or without assistive device^[1]. There are many different cases or instances in which mobility is impaired and ambulation with an assistive device (canes, walkers, crutches, etc.) is needed.

Cane

A cane is an ambulatory assistive device generally prescribed for people with moderate levels of mobility impairment, It is typically used when minimal stability is needed^[2]. A cane can also be known as a walking stick.

Types of Canes and their uses.

A detailed understanding of the different types of ambulatory assistive devices and their types, modifications, fitting, stability and indications is essential in prescribing one^[3]. There are different types of canes and the type used is dependent on the type of gait disturbance.

Gait disturbances can be divided into 3 useful categories^[4]:

1. a.      Balance (including sensory and cerebellar systems),
2. b.     Motor (including cerebral initiation of walking and muscular strength), and
3. c.      Joint or skeletal problems.

The types of canes include^[4]:

1. 1        The standard cane: This is generally used for mild sensory or coordination problems found in visual, auditory, vestibular, peripheral proprioceptive, or central cerebellar disease. It can help stabilize a patient’s gait by providing an extra contact point with the ground, therefore, increasing the base of support.
2. 2        Offset cane: This is used for patients that cannot bear weight on the affected side or limb and need to transfer weight to the cane, like those with osteoarthritic hip or knee pain. This cane will provide greater stability, as it allows force to be placed directly along the cane’s shaft.
3. 3        Offset 4-legged quad cane: This type of cane is prescribed when there is substantial weight bearing required, such as in a hemiplegic patient.

Patient assessment

There are many factors involved in prescribing the appropriate ambulatory assistive device. The patient’s upper body strength, balance and coordination, overall physical strength and endurance,  level of impairment, cognitive function, vision and living environment must be taken into account.

The patient’s upper body strength should be evaluated to determine whether one or both of the upper extremities would be needed to bear weight or achieve balance.  If only one upper extremity is needed then a cane would be the proper device, while those needing two upper extremities would benefit from a walker or a pair of crutches. Also the degree or amount of the patient’s weight needed to be borne by the device would aid the Physiotherapist in choosing the appropriate device^[5].

Gait analysis

Most people in need of canes have pain or injuries (like in the case of an antalgic gait due to  hip osteoarthritis) that make them avoid weight bearing on the affected side or limb and decrease the stance phase on that limb in an attempt to unload the mechanical stress on the painful hip joint^[6]. A cane can increase stability during the single-limb support phase^[7].

Therefore, a sound knowledge of the normal gait pattern and cadence is of utmost importance in evaluating and understanding the limitations of the patient with abnormal gait patterns and in prescribing the appropriate ambulatory assistive device^[3]. 

A test can be done to determine if a cane is the appropriate device. Walk with the patient while assisting with a hand or both hands. If the patient can walk with only a single assisting hand then a cane would be the appropriate choice. If the patient needs both hands being held to walk then a walker would be a better choice^[4].

Measuring the cane^[8]

There are different ways of adjusting the cane to fit the specific patient. Elbow flexion could be used as a guide. Ideally, there should be 20 to 30 degrees of elbow flexion in the elbow while holding the cane approximately 15 cm (6“) from the lateral border of the toes.This degree of flexion allows efficient elbow movement while walking with the cane, allows the arm to shorten and lengthen during different phases of the gait cycle, and provides a shock absorption mechanism. The degree of elbow flexion can be measured using a goniometer.

Another way of fitting the cane to the patient is to make certain that the top of the cane is at the same level of the greater trochanter or wrist crease when the patient is standing upright with the arms hanging loosely by the side as shown below. That means the cane length should be the same as the distance from the ground to the greater trochanter or elbow crease when the patient’s arm is in the anatomical position.

The patient should be wearing appropriate, comfortable shoes during measurement.

How to ambulate with a cane

Many people self-treat and go on to purchase ambulatory assistive devices without any assistance from an appropriate health professional. They choose the improper device for their conditions and have no knowledge on the proper way to use them.

The first thing to know in ambulating with a cane is that the cane must be on the opposite side of the affected leg  and in tandem with it so as to simulate normal gait and to increase balance and aid in weight distribution (canes can easily support up to 25% of a patient’s body weight^[8]). This means that if the right leg is the one with the disability then the walking cane would be held in the left hand.

A. From Sitting to Standing^[9]

1. 1. Position the cane on the unaffected side of the patient.
2. 2.  Advise the patient to move to the edge of the seat, hold the cane handle and bear weight on the unaffected leg and cane to come up to the standing position.
3. 3. Make sure the height of the cane is appropriate (level of greater trochanter), ensure elbow flexion is 20° to 30° and that the cane is 2” in front of the affected leg and 6” to the side of the affected leg.

B. Walking^[9]

Instruct the patient to position the cane on the unaffected side.

Three Point Gait

1. 1. Instruct the patient to balance the body weight on the strong or unaffected limb while moving the cane forward approximately 12-18 inches. Make sure the cane is close to the patient’s body
2. 2. The patient then moves the weak or affected foot forward.
3. 3. The patient transfers the weight from the unaffected foot to the affected foot and cane, and then brings the unaffected foot forward to join the affected foot.
4. 4. Repeat the steps 1 to 3 while shadowing the patient closely and alertly.

Two Point Gait

1. 1. Instruct the patient to balance body weight on the strong or unaffected foot.
2. 2. Instruct the patient to move the cane and the weak or affected foot forward in unison (i.e at the same time), keeping the cane close to the body to prevent leaning to the side.
3. 3. Instruct the patient to transfer their body weight forward to the cane and move the unaffected leg forward.
4. 4. Repeat steps 1 to 3 while shadowing the patient closely and alertly.

C. Standing to Sitting^[9]

1. 1. Instruct the patient to approach the chair (or bed), and turn in small circles toward the stronger side till the back is facing the chair or bed.
2. 2. Assist the patient to back up to the chair until the chair can be felt against the back of the patient’s legs.
3. 3. Instruct the patient to reach for one arm rest at a time.
4. 4. The patient lowers to the chair in a controlled manner.

D. Stair climbing

Canes can be used for stair climbing if proper instructions are followed (Up with the good leg, down with the affected one).

Going up the stairs

As usual the cane shall be opposite the affected limb.

1. 1.      At the bottom of the stairs, instruct the patient to lift the strong or unaffected leg onto the first step.
2. 2.     Transfer body weight to the unaffected leg on the step while  lifting the cane and the affected leg onto the same step.
3. 3.      Repeat steps 1 and 2.

Going down the stairs

As usual the cane shall be opposite the affected limb.

1. 1.      At the top of the stairs, instruct patient to transfer body weight to the strong or unaffected leg while lifting the cane and the affected leg simultaneously to land on the step below it.
2. 2.      Instruct patient to lift unaffected limb to land on the same step.
3. 3.      Repeat steps 1 and 2.

^[10]

Safety tips^[8]

1. 1.      Inspect cane on a regular basis. Make sure the cane has a rubber top for shock absorption and grip to prevent slipping.
2. 2.      Always check the cane for worn tips and handles

Always make sure that cane is at proper height to avoid imbalance and bad postures.

Conclusion

A lot of people have disabilities that require an ambulatory assistive device in order to ambulate independently. Many people are prone to self-treat maybe due to lack of funds or the ease of access to these assistive devices as they are sold almost everywhere, are easily accessible and do not require a prescription before being purchased. This increases the risks of falls, especially in elderly patients, and risk of musculoskeletal injuries or adaptations due to bad posture gotten from incorrect way of using or holding the assistive devices.

Many of the pharmacies and stores selling these equipment do not have health professionals that are equipped with the knowledge to choose the appropriate device, fit them properly and specifically to the patient. A study has shown that Pharmacists don’t feel equipped with the knowledge to fit a device for a patient^[8].

Therefore, ambulatory assistive devices should be sold where appropriate health professionals can advise the buyers on the proper way to use them. Health professionals like Pharmacists can be trained in this area as they also sell such in their pharmacies. This would aid in ensuring that people learn the proper way to ambulate with these assistive devices.

References

1. ↑ Moorhead  S, Johnson  M,  Maas M. Nursing Outcomes Classification (NOC) 3rd ed. St. Louis, MO: Mosby, 2004.
2. ↑ Mon SB, Amir P, MSAdams T. Gait changes with walking devices in persons with parkinson’s disease. Disabil Rehabil Assist Technol 2012;7(2):149–152.
3. ↑ ^3.03.1 Faruqui SR, Jaeblon T. Ambulatory assistive devices in orthopaedics: uses and modifications. American Academy of Orthopaedic Surgeon 2010;18(1):41–50.
4. ↑ ^4.04.14.2 Robert Lam. Choosing the correct walking aid for patients. Can Fam Physician 2007;53(12):2115–2116
5. ↑ Van Hook FW, Weiss BD. Ambulatory devices for chronic gait disorders in the elderly.  Am Fam Physician 2003;67(8):1717-1724.
6. ↑ Malanga G, DeLisa JA. Clinical Observation: Gait Analysis in the Science of Rehabilitation.  Available from https://www.rehab.research.va.gov/mono/gait/malanga.pdf (Accessed 22nd June 2018)
7. ↑ Yocheved Laufer. The effect of walking aids on balance and weight-bearing patterns of patients with hemiparesis in various stance positions. Physical Therapy 2003;83(2):112–122.
8. ↑ ^8.08.18.28.3 Sadowski  C, Jones A. Ambulatory assistive devices. How to appropriately measure and use canes, crutches and walkers. Pharmacy Practice 2014;1(10):24-31.
9. ↑ ^9.09.19.2 Visiting Nurse Associations of American (VNAA) 2010-2011 Edition Nursing Procedure Manual (NPM) Rehabilitation Therapy – Ambulation with a cane. Section 26.01 http://www.meridianathome.com/MAH/upload/Section-26-RehabilitationTherapy.pdf
10. ↑ CAREGIVERSTRAINING. How to use a cane. Available from: