Abstract
BACKGROUND:
Various types of canes are frequently utilised in stroke rehabilitation to support walking ability by compensating for hemiplegic gait. However, Randomised Controlled Trial (RCT) design varies considerably in the area of cane use following stroke and there is no scoping review published to date on this topic. Thus, it is crucial for better evidence informed clinical care and future research that RCT evidence regarding specific assistive walking devices is examined.
OBJECTIVES:
Identify and map the types of canes that currently exist and review their impact on the rehabilitation of functional mobility post-stroke.
METHOD:
The following databases were searched: PubMed/MEDLINE, Web of Science, and CINAHL in Ebsco. Two authors independently screened 425 titles, identifying 16 RCT studies for inclusion in the review.
RESULTS:
16 studies were selected for review. Five different cane designs were identified, including one-point cane, three-point cane, quad cane, weight-supported feedback cane, and rolling cane. Twelve studies were crossover RCT and four were parallel RCT. Stroke phase varied widely among subjects included in the studies and outcome measures utilised and resultant findings are heterogeneous.
CONCLUSION:
More evidence is required to clearly indicate the effect of canes on people who have had a stroke and parallel long-term RCTs with follow-up assessment are lacking. Furthermore, there is a lack of research examining variations in new cane designs that specifically target motor function in people who have had a stroke at specific stages. Future research should aim to address the identified inconsistencies and knowledge gaps to facilitate novel and evidence-informed clinical care regarding assistive walking devices for post stroke rehabilitation.
Introduction
The 2022 WHO Global Stroke Factsheet estimates that people who have had a stroke worldwide numbered 101 million [1]. Stroke remains the second leading cause of death and the third leading combined cause of death and disability in the world [2]. It has been observed that 65% of people who have had a stroke have reduced ambulation during the acute stage of stroke [3]. Only 30–50% of stroke survivors are capable of community ambulation [4].
Ambulation after stroke is altered by balance deficits, reduced sensation, decreased ability to properly time and grade normal levels of voluntary muscle contractions, involuntary increases in muscle tone, and changes in muscle mechanical properties [5]. These changes result in a hemiplegic gait characterised by reduced walking velocity, asymmetrical movement, shortened stride length, reduced standing phase and prolonged swing phase on the affected side [6]. Hemiplegic gait is associated with high instability and falls [7], decreasing cardiovascular fitness, and increased energy demand [8]. Thus, walking aids are frequently utilised to support walking ability by compensating for hemiplegic gait [9]. Approximately 32% to 76% of people with hemiplegia use at least one walking aid within three months post stroke [10].
In clinical practice, various walking aids, such as parallel bars, walkers, and different types of cane (single-point cane, 3-point or 4-point cane, weight-support feedback cane, cane with laser illuminators), are used for balance and gait training in people who have had a stroke [11]. Investigation of walking aids in stroke survivors have focused on cane use, as canes can help to increase the base of support for stroke survivors to provide postural stability and improve weight transfer ability in the standing position and walking. Moreover, canes are less detrimental to the temporal-distance characteristics of gait, more functional for ambulation in a challenging environment, and are less cumbersome and more aesthetically pleasing compared to other walking aids [11]. Additionally, walking frames demand bilateral upper-extremity function, which may be impaired in people who have had a stroke [12].
To date, the evidence on the effectiveness of cane use in stroke survivors is inconsistent. Laufer et al. reported that walking with a cane reduces postural sway and the chance of falling and improves independent walking [13]. According to the Choi et al. incorporating a cane into post-stroke gait training can improve muscle activation in the lower limbs [14]. In contrast, Neumann et al. demonstrated that the use of a cane increased weight-bearing in the nonparalyzed lower extremity by 40%, which interfered with weight training on the affected side and led to long-term gait asymmetry and inefficient gait [15]. Hamzat et al. showed that stroke survivors who used canes on a long-term basis had lower balance scores and less social participation than those who did not [16]. Due to broad study characteristic variations, there is little consensus or guidelines on how the prescription of canes should be individualised for patients at different stages of stroke [10].
A recent systematic review by Avelino and colleagues examined the immediate effects of canes on spatiotemporal parameters of walking [47]. However, study inclusion for this review was limited to cross-sectional within-group design, with outcomes primarily concentrating on the spatiotemporal parameters of walking. This review was also primarily focused on assessing study findings. Consequently, specific Randomised Controlled Trial (RCT) evidence was not assessed and the longitudinal effects and other aspects of cane research on walking remain indeterminate. To the author’s knowledge, no prior scoping review has been published regarding the incorporation of RCTs assessing cane use. Given that scoping reviews are designed to identify and broadly map a topic area [41], the current scoping review objectives are to assess the extent of parallel and cross-over RCT literature on the topic to identify and map the types of canes that currently exist and review their impact on the rehabilitation of functional mobility post-stroke. The following research question was investigated: What are the key characteristics of included studies regarding cane type, participant rehabilitation phase, outcome measures and resultant findings?
Methods
This scoping review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review (PRISMA-ScR), which was developed according to published guidance by the EQUATOR (Enhancing the Quality and Transparency Of health Research) Network for the development of reporting guidelines [17].
Search strategy and eligibility criteria
Searches were conducted in PubMed/MEDLINE (1965 to February 2024), Web of Science (1993 to February 2024), and CINAHL in Ebsco (1989 to February 2024). The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for CINAHL (see Table 1). The search strategy, including all identified keywords and index terms, was adapted for each included database. The reference list of all included sources of evidence were screened for additional studies.
Example search strategy (CINHAL /EBSCO)
Example search strategy (CINHAL /EBSCO)
The titles, abstract, and then full texts were screened for articles which met the following selection criteria: Related to the use of canes in people who have had a stroke; Published randomised controlled trials (RCTs), including crossover RCTs; Published in English.
Papers were excluded if they failed to meet any of the mentioned inclusion criteria.
Following the search, all identified citations were collated and uploaded into EndNote20 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts were then screened by two independent reviewers (RA, PB) for assessment against the inclusion criteria for the review. Following this, full text of selected citations was assessed in detail against the inclusion criteria by the two reviewers. The results of the search and the study inclusion process are presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review (PRISMA-ScR) flow diagram (Fig. 1)
PRISMA-ScR Flow chart illustrating the screening process.
The full text of each included article was read, and key information was noted. Descriptive data from included studies were tabulated to compare content. Data was extracted on study design, study population, stroke phase of the patient, intervention and duration, inclusion/exclusion criteria, types of cane, height of cane, outcome measures and main findings. Following data extraction, a single reviewer independently synthesized data. All data were initially tabulated and subsequently reported descriptively to answer the key research questions of the review.
Results
All databases retrieved 206 potentially relevant articles after removing duplicates. After screening the titles and abstracts, 121 papers were excluded based on the inclusion criteria, and 85 full-text searchable papers were identified. Following this, another 68 papers were excluded, and 1 relevant paper was found from screening references of eligible articles, a total of 16 papers were included in the final scoping review. Full details regarding study characteristics of all included studies are included in(Table 2).
Overview of selected studies
Overview of selected studies
Three studies used one-point canes [20, 32], while one study [27] compared the differences between three-point canes and one-point canes, and five reported the differences between one-point canes and quad canes [18, 28], weight supported feedback canes (WSFC) designed with a pressure sensor that detects the peak vertical force on the cane during gait for enhancement of weight-bearing on the affected lower limb were used in five studies [19, 33], and one used a Wheeleo® rolling cane [25] which has four small wheels allowing the patient to roll the cane instead of lifting it. Four different cane heights were used in the studies, four studies adjusted the height of cane at the level of each subject’s radial styloid process of the nonparetic hand with the arm hanging straight down [23, 29]; three studies adjusted to the height of the ulnar process of each participant when in a standing position with the elbow extended [26, 32], three studies adjusted at the level of the participants’ greater trochanter [20, 33], three experiments in which the height of the cane was dependent on patient [18, 25]. Three studies failed to provide the height of cane used [21,22, 31].
Study design and intervention
Among the sixteen selected RCT studies, twelve [18–29] were crossover and four were parallel [30–33]. Nine crossover studies [18–24, 29] implemented one-day interventions to assess walking ability with or without a cane and under different types of cane conditions. One crossover study [25] implemented a two-day intervention, and two [26, 28] crossover studies used three consecutive days assessment. All four included parallel RCTs [30–33] implemented a 4-week intervention. The experimental groups in three parallel studies used weight supported feedback canes (WSFC), while the control group used ordinary canes without feedback. All three studies used cane training sessions lasting 30 minutes per day, 3–5 times per week, for 4 weeks for both experimental and control groups with no follow-up assessment [30–31, 33]. One study was an attention controlled randomised trial with 2-month follow-up, the experimental intervention was to provide a single-point cane at any time when walking was required for a period of one month, while the control group engaged in stretching exercises of the affected lower-limb muscles daily for one month at home [32].
Participant characteristics
The mean age of subjects recruited in all studies was greater than 55 years. Nine studies [19–21, 33] included participants who were regular users of canes, six [22–24, 32] included non-regular users, and one study [18] did not report whether participants were non-regular or regular users. According to Julie et al. [34], time points for stroke recovery are defined as: Hyper acute (0–24 hours), Acute (1–7 days), Early sub-acute (7 days–3 month), Late sub-acute (3–6 months), Chronic (>6 months). One study recruited subjects with acute to sub-acute stroke [19], four [20, 29] with sub-acute stroke, seven [18, 33] with sub-acute to chronic, three [21, 32] with chronic stroke, and one study [23] with all the stages of stroke (from acute to chronic).
Outcome measures
Twelve studies measured gait related outcomes that included spatiotemporal gait parameters (speed, step length, cadence, symmetry, etc.) and kinematic as well as kinetic gait parameters [20–28, 30–32]. Balance assessment included trunk and pelvic stability as well as the number of times the therapist assisted the subjects to maintain balance while walking [19, 27]. Trunk control was evaluated using Trunk Impairment Scale (TIS) [33]. In addition, the peak vertical cane force [18, 23], muscle activation patterns (amplitudes and timing) were measured using surface electromyography (sEMG) [19, 33], energy expenditure and energy cost were reported [26]. Only four of sixteen studies included psychological tests in their outcome measures. Assessment of walking confidence through perceived exertion utilising the modified Gait-Efficacy Scale, as well as participant satisfaction and opinions regarding the ease of use and safety of the cane. [20, 32].
Effectiveness of canes
(a) Walking speed
Six studies [20–22, 29] examined walking speed, when walking with either a single-point cane, three-points cane, or quad cane versus walking without a cane. One study [21] showed the use of a one-point cane resulted in significant increases in gait speed during both fast and comfortable walking compared to walking without a cane. Four studies [20, 29] reported no significant difference in walking speed between walking with and without a cane. One study [22] showed that mean walking speed significantly decreased during the quad cane task. Four studies conducted comparative analyses of walking speed utilising various cane types. Three studies [24, 28] showed a significantly lower walking speed when walking with a quad cane compared to walking with a one-point cane. One study [27] reported no significant differences in walking speed between a one-point cane and a three-point cane. One study [25] reported the significant improvement in walking speed and distance during a 6-min walk test with the use of Wheeleo rolling cane compared to a quad cane. Three studies [30, 33] showed significant improvement in walking speed with the use of WSFC compared to ordinary canes. Two studies [19, 23] that examined two methods of cane use, light touch contact which required subjects to exert less than 4 N of force through a cane and force contact, where the subject was instructed to exert as much force on the cane as needed, reported that walking speed did not differ between the force contact and touch contact condition.
(b) Symmetry
Three studies [22, 29] examined symmetry when walking with canes versus walking without canes. One study reported [22] that compared to walking without a cane, the use of a one-point cane significantly improved symmetry in stroke survivors with asymmetry, while the quad cane did not improve symmetry. One study showed [27] that no significant differences in symmetry were found between the conditions. One study [29] demonstrated that both spatial asymmetry (calculated as step length asymmetry ratio), and temporal asymmetry (calculated as mean single limb support time ratio) reduced during one-point cane use. Two studies [27, 28] reported that there was no significant difference in symmetry between a one-point cane and a quad cane. One study [31] showed a significant improvement in symmetry index with the use of WSFC.
(c) Muscle activation
Two studies [24, 29] examined muscle activation, when walking with canes versus walking without canes. Both studies showed that cane use significantly reduced EMG activity in gluteus medius, tensor fascia lata [29], erector spinae, tibialis anterior, vastus lateralis [24]. One study [24] reported that the EMG activities (amplitudes and burst duration) were significantly lower in erector spinae, tibialis anterior, vastus lateralis when compared to walking with a quad cane and walking with a one-point cane. Two studies [19, 23] reported that muscles (bilateral tensor fascia latae, vastus medialis) on the paretic side during stance phase were activated more in the light touch contact condition than in the force contact condition. Three studies [30, 31] reported that muscle activation was significantly higher in the WSFC group compared to the ordinary cane group in the affected lamb.
(d) Single limb support phase
One study [19] reported that the duration of the single-limb support phase of the paretic leg in the light touch contact cane condition was significantly longer than in the force contact condition. While one [23] showed that stance-swing durations did not differ among the two conditions. Two studies [30, 31] demonstrated the significantly greater improvement in the affected single-limb support with the use of WSFC compared to ordinary canes.
(e) Trunk and pelvic movements
Two studies [23, 27] examined trunk movements, when walking with canes versus walking without canes. One study [27] found that there was no significant difference in trunk movements when using a cane or no aids. While another study [23] reported trunk stability was significantly greater when walking with a one point-cane. One study [30] reported no significant difference in trunk stability between the WSFC group and an ordinary cane group. A significant improvement was also observed for the dynamic balance in the WSFC group compared to the ordinary cane group. One study [19] demonstrated that the comparison of the average peak-to-peak pelvic acceleration showed no difference between the force contact and light touch contactcondition.
(f) Additional outcomes
One study [20] examined step length when walking with a single-point cane versus walking without a cane. Additionally, one study [26] showed that energy cost was significantly lower for the single-point cane compared to a quad cane. One study [30] reported the significant improvement in the peak vertical force on the cane during gait with the use of WSFC.
Discussion
This scoping review has demonstrated that the RCT research literature on cane use in post-stroke rehabilitation is heterogeneous in nature regarding varied research and cane design, varied subject characteristics, and mixed results.
This review has also identified specific knowledge gaps in the current literature. The impact and practical implications of these review findings for clinical care or future research are discussed in detail below. Among the sixteen included studies, only three studies [30, 33] examined evolutions of traditional cane design, utilising biofeedback canes and one study reported the effects of a rolling cane [25]. The biofeedback studies evaluated the effect of weight support feedback cane gait training. The results demonstrated greater improvement in the experimental group in lower limb muscle activity and gait ability compared to the traditional cane group. This potentially promising approach to novel cane design utilising technological application would benefit from further RCT research. Individuals with poor balance are frequently required to use a quad cane, which has a larger base of support and reduces sway and increases stability during the stance phase [40]. However, the cane must be lifted and advanced. This pattern causes a 3-step gait, which slows walking speed [13]. Deltombe et al added wheels to a quad cane, thus the participants rolled the cane instead of lifting it and this study found that the rolling cane improved walking speed and distance without additional risk of falls and patient satisfaction was increased compared to a quad cane [25]. Taking this evidence into account, the development of new types of canes that can prevent patients from developing abnormal gait and potentially improve neuromuscular control or recovery of balance and gait has the potential to be explored further due to the small number of RCT studies currently published in the area. Additionally, two studies [19, 23] suggested that light touch cue can be provided during walking with a cane, this augmented somatosensory information provides lateral stability during walking for people who have had a stroke by facilitating the activations of weight-bearing muscles on the paretic leg during the stance phase. Regarding overall study design, only four of the sixteen RCTs presented in this review were parallel studies, with each intervention lasting four weeks [30–33], and only one study implemented a follow-up assessment process [32]. The remaining twelve crossover trials had intervention periods of one to three days. In short-term crossover trials, reduced intervention dosage and potential carry-over effects can impact treatment responses [39]. Recent clinical guidelines [45] emphasise 150–300 minutes of moderate-intensity aerobic activity per week for adults with chronic conditions like stroke. To enhance clinical understanding, future research should conduct more RCTs exploring higher therapy dosages and long-term outcomes with extended follow-up assessments.
Early walking is crucial in stroke rehabilitation, addressing psychological well-being, cardiovascular fitness, and preventing secondary muscle weakness and abnormal muscle tone [29]. However, limited research [46] focuses on the acute to sub-acute phase, a critical period for post-stroke clinical care. Study criteria are diverse, encompassing individuals who have experienced a stroke, from acute to chronic phases [18, 30–33]. Limited RCT research on acute or subacute stroke phases underscores the need for further investigation. Current findings on cane impact on stroke patients’ mobility are mixed, with many studies reporting neutral (no change) or positive conclusions. Up-to-date statistical analysis in a systematic review with meta-analysis is recommended for a clearer understanding.
The Biopsychosocial model, the foundation of the International Classification of Function (ICF) [35], underscores the importance of biological, psychological, and social aspects in defining health and disability [44]. However, studies on walking aids primarily focus on kinetic, kinematic, and neuromuscular effects, neglecting satisfaction and quality of life impact. Given the psychological importance in device acceptance [43], future research should explore the psychological effects of cane types on stroke survivors for improved clinical care.
In conclusion, this scoping review has mapped cane use for people who have had a stroke to assess study characteristics, design and device variations and to identify potential knowledge gaps. The impact and practical implications of this review for clinical care and future research include the identification that parallel trials, long-term crossover trials and follow-up assessments are lacking. Furthermore, more RCT research is required to examine variations in novel cane design that specifically target motor function in stroke patients at specific stages due to the potential of such devices to improve mobility and motor function. As well as this, the current scoping review may act as an important precursor to more specific future systematic reviews by enhancing the clarification of research in the area. Future research should aim to address the identified inconsistencies and knowledge gaps to facilitate novel and evidence-informed clinical care regarding assistive walking devices for post stroke rehabilitation.
Conflict of interest
The authors have no conflict of interest to report.