Stages of Learning to Use a Cane
by Dona Sauerburger, COMS
Original version was published in the Spring 2005 Newsletter, AER Orientation and Mobility Division

(Click here for full JVIB article by Sauerburger and Bourquin)
(Click here for workshop explaining the implications of these stages of learning -- free ACVREP credit)
(Click here for consumer's version)

It took me many years to realize that while beginners are learning to use a cane (actually practicing the cane itself), I cannot ask them to also notice sounds or work on orientation strategies or anything else until they achieve what I call the "third level of learning the cane." And for people who have little motivation to use the cane, I no longer suggest that they have a few sessions to learn to use it "just in case." This is because I now realize that learners cannot rely on their cane for protection until they reach the fourth level of learning the cane (which means they can notice what the cane detects, even when they are distracted with misleading vision or expectations), AND they can maintain that level of attention and proficiency (which is not always possible without using the cane regularly).

Here I share with you what I have observed as the "four levels of learning the cane;" and explain what can be accomplished in each stage as well as some ideas for intervention to help achieve the fourth level.

First level of learning the cane -- Beginning to learn:

At this level of learning the cane, the cane does not reliably provide the independent traveler with adequate protection under any circumstances.

Second level of learning the cane -- Concentration required:

At this level of learning the cane, the cane does not reliably provide the independent traveler with adequate protection,
because whenever the learner is in a situation that is stressful or distracting
(or even just daydreaming or lost in deep thought!),
THE CANE TECHNIQUE DETERIORATES.

Third level of learning the cane -- Correct movement is maintained without concentration:

At this level of learning the cane, the cane does provide some learners with adequate, reliable protection in many circumstances. However, many learners with functional vision (and even some of those with no vision) are not yet adequately protected because
THEY DO NOT RELIABLY RESPOND WHEN THE CANE GOES OVER AN EDGE
(click here for ideas to teach this).

Fourth level of learning the cane -- Learner responds to cane information reliably:

NOTE:

Examples of Strategies for Teaching Non-Visual Skills and Use of Non-Visual Information

Once learners have achieved this level of learning the cane, the cane will provide them reliable protection in all situations because they maintain correct cane technique even when distracted, and they notice drop-offs and obstacles.

Suggestions for training / intervention
to reach the Fourth Level of learning the cane

Usually lots of practice is all that's needed to advance beyond the Third Level of learning the cane. Once learners have had enough experience walking with the cane on flat surfaces, they develop a kinesthetic understanding of what it feels like when the tip is on the same level as they are, and they notice the difference when the tip has dropped below or raised above the level they're walking on.

However sometimes practice is not enough -- special training or intervention is needed to reach the Fourth Level. I have found that with learners who struggle to achieve the Fourth Level, usually it's one of the following issues:

the level of attention required to notice this information;
being able to override visual information;
being able to use the proprioceptive information from the cane.

1) Level of attention: Even though it's important to be able to move the cane correctly without concentrating, the user should always pay enough attention to the cane that any deviation from flat surface will be noticed.

Intervention:

unexpected

2) Override visual information: People who have a lifetime of using vision do not readily switch to relying on other sensory information. Although some people can make this switch without special intervention, many people cannot. When their vision indicates that the ground is flat and the cane drops over an edge, they will often believe the vision and not even notice the cane information.

Intervention:

Partial occlusion

partial occlusion

3) Proprioception information: Good proprioception is required in order to be able to notice changes in the level of the cane tip. This is especially true when using the touch cane technique, because usually the only clue to a drop-off is that the cane tip has landed below the surface level that they're walking on.

Intervention:

If learners are having difficulty noticing a change in surface level, make sure they are moving the cane only with the wrist, and not the arm -- a slight change in the angle of the cane is much more noticeable in the wrist than it is in the elbow or shoulder.
I have found the following intervention to be very successful for those who have normal proprioception but still cannot notice a change in level even though they are moving the cane correctly (i.e. with wrist movement only).
- Have them stand on top of a curb with the side of their feet next to the edge, and hold the cane out ahead in the normal position with the tip on top of the curb.
- Have them keep their arm still while they move the cane slightly so the tip drops over the edge of the curb.
- Have them notice that they can feel the change in their wrist -- there is a stretch along the top of the wrist when the cane drops below the surface.
  If they don't notice it, do it at a deeper drop-off, such as a stair, so they notice the change, then do it again at a curb.
- Once they notice that stretch, explain that the wrist stretch is their only cue to a drop-off, and that they can learn to notice it with practice.
- Have them continue to stand on the curb and repeat moving the cane tip up to the top of the curb and then drop it down over the edge of the curb until they are satisfied that they can notice the wrist stretch readily.
- Finally, have them approach curbs and notice when the tip goes over the edge.
The proprioception of some learners is insufficient to be able to notice the change in the cane tip's surface level no matter how much practice they get. For example some people with severe diabetic neuropathy may have insufficient proprioception. Anyone having difficulty noticing changes in the cane tip's level because of impaired proprioception can use the constant-contact cane technique because the edge can then be detected when the cane drops over or bumps into it.

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