The Paradox of Walking Aids

Not falling is an integral part of our atmasvasth quest to live long healthy. The three pillars of falls prevention include physical activity and exercise to improve muscle strength and balance, personal measures such as taking care of poor vision, reduced hearing and polypharmacy and measures at home that reduce the risk of falls, including better lighting, provision of hand-rails, etc.

The use of walking aids such as canes, sticks and walkers is an intuitive personal measure that can apparently help us walk with more confidence and reduce our risk of falling.

However, in a recent Indian study on the prevalence of falls in a rural Kolar population by Bhoomika Ventakeshappa and colleagues [1], which showed a falls prevalence of 46.8%, the use of walking aids paradoxically increased the risk of falls - this was not such a big surprise for the authors. A study by Judy Stevens and colleagues [2] in 2009, that looked at US data from 2001 to 2006 showed that 47,000 odd patients were treated annually for walking aids related falls (87.3% with walkers, 12.3% with canes and 0.4% with both). While these were just 2.6% of all falls related emergency injuries, they happened  in the most frail and vulnerable adults.

Association does not always imply causality. Those who use walking aids are typically older, weaker, have impairment of balance and other risk factors for falling [3]. Perhaps those who use walking aids are at such a high risk of falling that despite the use of walking aids, they fall anyway, making it appear that the walking aids are responsible for the fall.

Another study [4] found that most people use walking aids improperly, increasing their risk of falls.  For example, using a cane on the wrong side or at the wrong height can throw a person off balance and increase the risk of tripping. Using a walker that is too tall or too short can also increase the risk of falls. In addition, using a walking aid when it is not needed can increase the risk of falls by creating a false sense of security and leading to overconfidence.

The quality of walking aids also differs depending on geography and price and there are no specific standards they have to meet - it is possible that poorly designed walking aids also contribute to an increased falls risk.

What does this mean for you and I? If you are at increased risk for falls or if you have difficulty walking or getting around, it is important to sit with an expert, a physiotherapist or occupational therapist, to understand the extent of disability and to try and see if this can be corrected with exercise, physical activity, improved vision and hearing and a review of the daily medicine intake. If after all this, there is still a problem with walking and balance, a high-quality walking aid should be chosen. The use of the cane or walker should be monitored to make sure that the person using it is in control and understands how to use the walking aid properly.

The bottom line is that the use of a walking aid is not an obvious or natural falls prevention solution in the elderly and frail and its use has to be judicious and monitored carefully.

Footnotes

1. Bhoomika V et al. Prevalence of fall and associated risk factors among the elderly living in a rural area of Kolar. J Family Med Prim Care. 2022 Jul;11(7):3956-3960.

2. Stevens JA et al. Unintentional fall injuries associated with walkers and canes in older adults treated in U.S. emergency departments. J Am Geriatr Soc. 2009 Aug;57(8):1464-9.

3. Stubbs B. The provision of walking aids to the overtly aggressive older adult who is a high risk of falls: a careful balancing act. Int Psychogeriatr. 2010 Feb;22(1):161-2. doi:

4. Thies SB et al. Are older people putting themselves at risk when using their walking frames? BMC Geriatr. 2020 Mar 4;20(1):90.