Hey, what's up everyone, Doctor Zeshan here.
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and out. So again, thank you all so much
and good luck. So let's talk about Keynes.
The different topics that we're going to cover with Keynes are
the different types of Keynes. They're indications for use,
proper use of the cane and then safety and patient education.
So there's different levels of exactly what we can ask on the
boards regarding canes. The first one is identifying
what type of a cane it is. So we've got what's called a
single point cane and we've got a quad cane.
And if you just look at exactly what they're saying when they
define the type of cane it is, single point is one of those
ones that's just a stick. It's only got the one end to it,
whereas the quad cane, it has four little legs, quad being
four and then the cane being the portion of it that holds.
So this one offers more stability.
So the single point cane has minimal stability and it's good
for balance and support. But if you think about just the
actual structure of that cane, a single point is one leg that
you're holding on, whereas the quad cane has much more
stability than the single point because it's got 4 legs at the
base. When do we use it?
Well, we need it for patients that have balance issues.
And when we talk about balance issues or need balance
assistance, we're looking at unilateral weakness.
Unilateral weakness. So in what patients are Keynes
indicated, think of patients that develop a unilateral
weakness. So patients such as strokes is a
big one. What other balance issues or
not? Not just balance, how about just
unilateral weakness and what other situations do you see?
And so when we think about unilateral weakness, we think of
different types of populations, populations like stroke
patients, patients that have balance issues like Vertigo.
How about people that have that unilateral weakness with age and
degeneration? How about arthritis?
We don't want to mix up crutch with cane.
Now let me explain the difference real quick.
So that way we understand when we use one over the other in a
cane, we have weakness or balance issues.
Whereas a crutch is going to be for more severe injuries,
surgery on the leg or a fracture of the leg.
So 1 is going to be for a more severe injury.
The other one is a little bit more milder, mild weakness or
balance issues, crutch. We need to be able to have that
support because we have a broken leg, we've been we are unable to
use that leg, whereas the cane offers more stability, whether
it be single point or quad cane. It's therefore stability in mild
balance issues, mild weakness as well too, such as stroke
victims, people that are recovering from strokes and or
people that have arthritis. So things of that nature.
So that's between crutch and cane.
So moving on with cane, we must look at educating on the proper
use of a cane. So the proper use of cane starts
with fitting. What are we looking at?
What parameters are we looking at when we're dealing with a
patient that needs to be fitted for a cane?
Well, first and foremost, we've got to look at their height
because the length of the cane is going to be dependent on
their height because ultimately the cane should align with the
wrist when the patient is standing with their arms down,
standing with arms down. So if I'm fitting a cane, what
I'm looking at is the height. So ultimately, how am I going to
determine the length of the cane?
Well, I want them to stand up and I want them to put their
hands by their side. And where the wrist falls next
to the side of the body is where I want the height of the cane to
be. When we talk about technique of
canes, we're going to be talking about what hand to hold it in,
how we're going to walk with it, and how we're going to take
steps moving forward. And then the use of a cane going
up the stairs and also going down South.
With technique, we want to start with what hand do we want to
hold it in? And the hand that we're going to
hold it in is the hand opposite of the affected leg.
So with the cane, we hold it on the hand opposite of the
affected side or we hold it on the side of the good leg.
Well, we know what hand to hold it in, but how do we walk with
it? So let's talk about walking with
a cane. First we want to move the cane
forward. We then take the weaker leg and
we align it forward with the cane and then we bring that
stronger leg up or forward. So technique, we start with what
hand we hold the cane in and it is in fact the hand opposite of
the affected leg or the hand that is in fact the stronger leg
or the hand that is the same as the stronger leg.
Then we have to learn how to walk with the cane.
So when we educate our patients, select all that apply, we're
going to move the cane forward, step one, Step 2, bring the
weaker leg aligned to that cane and then Step 3, bring the
strong leg forward. So in order move the cane
forward first, then the weaker leg, we align to the cane and
then we bring the stronger leg forward.
Now we're going to talk about using a cane going up and down
stairs with stairs. Remember the quick tip, we go up
with the strong, down with the weak.
So what does that mean? When we go up the stairs, we
start with the strong leg and then we bring up the cane and
then we bring up the weak leg. Whereas when we go down, we go
down with the weak. But when we go down with the
weak, we start with the cane first, then the weaker leg, then
the strong leg. So recap with stairs.
When we go up the stairs, we go up with the strong, down with
the weak, up with the strong, down with the weak, go up the
stairs with the strong leg first, cane second, weak leg
last. I'm going to go down the stairs.
We go down with the weaker leg. We start with the cane, then the
weaker leg, then the stronger leg.
So there's in each one of these, it's a three-step process.
So just remember up with the stairs or I'm sorry, up with the
strong, down with the weak. Each one is going to have three
steps. So when you go up strong leg,
cane, weak leg. When we go down cane, weak leg,
strong leg. Another part of Canes that gets
overlooked that I think is important, that we should know
that's very, very fair game for the boards is safety
considerations regarding canes. Because ultimately the problem
with patients that have the necessity for Canes is that they
are a fall risk. That's the biggest thing.
A lot of these people, they will end up hurting themselves
severely because of a fall in elderly patients.
What are we concerned about fall in patients that have arthritis,
in elderly patients, stroke. We're worried about falls
because recovering from a fall, especially as we age, is one of
the biggest risk factors for not recovering and actually becoming
debilitated is false. So we must consider the safety
precautions when we're dealing with canes.
So what is the first thing we're going to look at?
What's simple? Inspect the device.
So inspect the device. What does that mean?
Well, we want to regularly check the cane and look for wear and
tear, right? We want to make sure that the
rubber tips, because on the bottom is a rubber tip in order
to prevent slipping, so we get good traction, make sure that is
intact so that we we're not overlooking something that can
be detrimental to their safety. The second is called
environment. So safety with a cane, we must
look at environment. So again, loose rugs, cords,
clutter, clear pathways, Night Lights, fall risks, make sure
there's no leaks or any wet damp areas, no dusty areas.
Anything that can cause slipping or getting in the way or
tripping is considered environmental safety.
The next two for safety precautions are going to be are
they able to wear bear the weight on that cane?
Is it sturdy enough or is it a little flimsy?
Are there any cracks in it? Are they able to balance on it?
So again, we want to just do a little bit more safety
precautions when it comes to cane use and cane safety.
So for crutches, which obviously can be compared to canes, but
the difference being that one is going to be for something more
severe like we talked about as far as fractures, as far as post
surgery things where we need to be able to to recover.
And these patients, they require non weight bearing or partial
weight bearing on one or both legs.
So we really can't use the legs in this situation.
And the other situation with canes, we had weaker legs or we
had weakness or we had balance issues.
In this situation we have non weight bearing leg or a partial
weight bearing leg or legs. That's when we need crutches.
That is going to take the weight off of that leg completely.
So what are some parameters that we're going to look at?
What are some sections that the boards like to talk about when
it comes to crutches? Well, we just talked about the
purpose of it where we have a non weight bearing or a partial
weight bearing leg or legs. Then we're going to talk about
the types of crutches. We're going to talk about weight
distribution. We'll talk about positioning.
We'll talk about gait patterns, which is that 2.3 point, 4 point
gait. We'll talk about stability and
patient population. So let's talk about the
different types of crutches. When we talk about the different
types of crutches, the two that we're going to see for the sake
of the boards that I want you to know, is an axillary crutch.
And where's our axilla? It is our armpit, right?
So an axillary crutch and a forearm crutch.
When do we use which and how do we use them?
Well, the axillary crutch is the standard crutch that you think
about that has the handle and then there's a pad right
underneath the arm, right underneath the armpit and we're
able to put pressure on it. Now the thing about axillary
crutches is that it can compress the axillary nerve.
So educating them on proper use of a crutch is very important.
Then our forearm crutch is going to be used for long term
disabilities, people that have chronic conditions.
And these are the ones that you would see that potentially both
legs are not able to be used and they're placing their forearms
into that crutch. And now they're using that
crutch as a means of replacing or stabilizing their leg.
And that's what a forearm crutch is.
So with crutches, again, we talked about the the indications
for the uses, whether it be non weight bearing or partial weight
bearing situations where you cannot put any type of weight or
a little bit of weight on either one or both legs.
So a situation that we'll see that in things like fractures,
sprains, dislocations, surgical recovery, hip or knee surgeries
or severe severe joint pain, severe joint pain.
Then we went into the types of crutches.
The two different types of crutches that we're going to see
are the axillary crutches, which are again underneath the arm in
the axillary area or the armpit area.
This is good for short term mobility.
Then we've got our forearm crutches or loft strand
crutches. These are used for long term
mobility in patients with chronic conditions because the
cuff fits around the forearm and it gives more freedom of the
hands, whereas under the axillary we're kind of bound to
our hands not being as free. So these are grade 4 things like
or these are great for patients that have potentially cerebral
palsy or other neurological conditions where they're unable
to utilize both legs. So now we're going to talk about
proper fitting of crutches. So education, education.
The reason why we're going to properly fit these is 1, So we
utilize them properly, second, so they're comfortable, and 3rd,
so we don't obtain any injuries. So with axillary crutches, we're
going to adjust the height so that there's two to three finger
widths of space between the top of the crutch and the armpit.
So one to two inches or two to three finger widths between the
top of the crutch and the actual armpit or the axillary area.
So you don't want them resting on it.
You want space so that you have that two to three finger width
or one to two inches in between that top and the armpit.
Because again, what are we trying to prevent?
Axillary nerve damage? The hand grips should be at the
wrist level. The hand grips should be at the
wrist level. When the patient's arms are
hanging naturally, so as they stand, let their hands dangle.
The wrist is where the hand grips should be at.
This allows for our elbow to bend, as most literature would
say, in that 30° angle. So again, hand grips should be
positioned where the wrist is hanging naturally gangly at the
side of the body. This allows for the elbow to
bend at that 30° angle, which is going to provide control and
comfort, control and comfort with the forearm crutch.
The cuff should fit snugly around the forearm, so about one
to two inches below the elbow. And again, the hand grip should
be at the wrist level when the arms are hanging naturally.
So again, just a little quick, quick point.
When we're dealing with where we should have the grips at, it
should always be for crutches in this situation, accelerator,
forearm, it should always be when you dangle your hands to
the side at the level of the wrist.
Now we get into arguably the the topic with crutches that gets
tested the most in this situation.
We're going to talk about walking with crutches.
Walking with crutches, which is in fact A2 point gate, a
three-point gate, and a four point gate.
We'll start with the non weight bearing and then we'll get into
partial weight bearing. You've got the option of partial
weight bearing and non weight bearing.
With partial weight bearing you can use A2 point or a four
point. With partial weight bearing you
can use A2 point or a four point, whereas with non weight
bearing we're going to use that 3 point gate.
So what is a three-point gate? First and foremost, we must
understand that we're going to use this with non weight bearing
crutches. So 3 point gate is non weight
bearing. With this, the patient cannot
bear weight with one leg. So what are the steps?
Step one, move both crutches forward together.
So let's just think about this. If I've got one leg that cannot
bear weight, I've got 2 crutches and one leg.
How many points is that with non weight bearing?
3 point gait is we've got two crutch legs and one good leg
that is your three points. So now step by step, what are we
going to do? Move both crutches forward
together, then move the injured non weight bearing leg forward.
Without placing any weight on it and then step forward with the
unaffected leg one more time. 3 point gait.
We have a non weight bearing leg.
So the three points are in fact the crutches and the weight
bearing leg. The steps of moving forward in
the three-point gait is move the crutches forward followed by the
non weight bearing leg without placing weight on it and then
step forward with the unaffected leg.
That is your 3 point gate. Our four point gate and our two
point gate again are going to be with partial weight bearing.
Partial weight bearing, which means that we can put a little
bit of weight on that fourth point or that second point
depending on what the situation is.
So the four point gate is with partial weight bearing on both
legs. In this situation we have 4
steps, 4 point gate, 4 steps. If we're able to put partial
weight on both the legs, then we're going to move the right
crutch forward, then the left leg forward, left crutch
forward, right leg forward. Again, 4 point gate with partial
weight bearing, we're going to move the right crutch forward,
left leg forward, left crutch forward, right leg forward.
So we alternate. It's a slow gate, but it's
steady and it's stable. So this is great for people that
have bilateral weakness. Then the last one is our two
point gate, again using impartial weight bearing.
And in this situation we have two steps.
Move the left crutch and right leg forward together.
Step 2 Move the right crutch and left leg forward together. 2
steps 2 point gate again move the left crutch and right leg
forward together. Step 2.
Move the right crutch and the left leg forward together and
that is crutches.