JVIB - April, 2010
Teaching the Use of a Long Cane Step by Step:
Suggestions for Progressive, Methodical Instruction
Dona Sauerburger and Eugene Bourquin
Abstract: A fundamental part of the orientation and mobility curriculum is the acquisition and retention of skills in using a long cane automatically and proficiently to detect and negotiate obstacles and drop-offs. Using practitioners' experiences and the principles of learning theory, instructors can monitor students' advancement and adapt teaching strategies to optimize the results.
One of the important skills of orientation and mobility (O&M) instruction is the use of the long cane for anticipating what is ahead of the user and negotiating obstacles and changes in surface elevation (such as steps and curbs). However, use of the cane will not ensure the safety of students unless they reach a sufficient level of proficiency in the skills of moving the cane correctly without having to concentrate, being able to notice unexpected obstacles and steps even when distracted, and knowing how to negotiate obstacles and steps safely.
For example, a man who learned how to use a cane fell off a curb because he was not able to move the cane correctly when distracted. A woman who could move the cane well even when distracted fell off a transit platform because she did not notice when the cane went over the edge. An intern at a nursing home who was proficient with the cane had not learned how to negotiate obstacles, so she knocked over a patient because she sidestepped to get around a medicine cart she had contacted with her cane. These people all needed further instruction and practice before their ability to use the cane to notice and negotiate hazards was proficient enough to provide for their safety. This article presents ideas and information that may help facilitate instruction in and practice with using a cane, drawn from extended observations in professional practice and the results of research from physical therapy, neuroscience, and psychology.
Appropriate practice and instruction
According to Ackerman (2007, p. 238), "Although practice is the primary determinant of individual differences in skilled performance of tasks with significant motor requirements, the sheer amount of practice provides only a moderate amount of explanatory power." Practice can be made more efficient with careful consideration of the principles of learning.
Students go through a series of stages as they learn any skill, and instruction should vary according to the stage of learning. For example, the beginning stages of learning require the student to concentrate on the task, whereas advanced students can perform the task with little or no effort (psychologists call this "autonomous performance"; Ackerman, 2007, p. 236). According to Adi-Japha, Karni, Parnes, Loewenschuss, and Vakil (2008, p. 1544), improvements in performance "are related to transitions between two types of processing modes: an initial, controlled, more effortful mode and eventually a more automatic mode."
In 1911, mathematician Whitehead noted:
It is a profoundly erroneous truism, repeated by all copy-books and by eminent people when they are making speeches, that we should cultivate the habit of thinking of what we are doing. The precise opposite is the case. Civilization advances by extending the number of important operations which we can perform without thinking about them. (p. 61)
Likewise, it is an advantage to students with visual impairments to reach a level of proficiency where they do not have to "think" about their canes or the details of the techniques they are using but, rather, perform in a manner that is independent of cognitive control. Some aspects of successful travel, such as learning to use landmarks in the environment for traveling routes, require conscious cognitive effort (Martinsen, Tellevik, Elmerskog, & Storlilokken, 2007); we suggest that effective use of a cane need not be one of these components that require such cognitive effort.
Retention of skills is the goal of practice, as described by Maas et al. (2008, p. 278): "The distinction between performance during acquisition (practice) and retention or transfer implies that learning, a permanent change in the capability of skilled movement, must be measured by retention and/or transfer tests. Retention refers to performance levels after the completion of practice." For cane skills, which are motor related, the student will follow through the acquisition and retention stages; note, however, that learning how to negotiate obstacles can be done at any time, even when the student is in the beginning stages of learning to use a cane.
The retention of skills depends on temporal factors, including the human sleep cycle. Studies have shown that after practicing a task and undergoing another practice session "between 10 minutes and 6 hours later, without intervening sleep, the memory undergoes the first, stabilization phase of consolidation, making it resistant to interference from a competing memory" (Walker, Brakefield, Hobson, & Stickgold, 2003, p. 618). However, even though spacing practice sessions apart can help consolidate the skill memory, it does not necessarily improve speed or accuracy for performance. In experiments published in 2003, Walker et al. reported that "following practice of a specific motor sequence, delayed performance improvements only occur across a night of sleep [emphasis added], while waking periods of 4, 8 or even 12 hours offer no such performance enhancements" (p. 617). An awareness of timing and scheduling for practice can be used in each stage of cane mastery.
The practice of cane techniques can also be maximized with appropriate feedback from the instructor. Studies have consistently shown that too much feedback can impede learning. Sullivan, Kantak, and Burtner (2008) found that when participants received feedback on their performance only 62% of the time, beginning with frequent input and fading to less input, they performed motor skills more consistently and accurately when tested later, as opposed to those who always received feedback. The authors hypothesized that "educed feedback practice conditions … increase information-processing demands during practice that are advantageous to the relatively permanent effects associated with motor learning observed in a delayed retention test" (p. 721). Jacobson and Bradley (1997) also suggested that after providing continuous reinforcement in the beginning of instruction, providing less frequent praise later will encourage a student to continue to engage in high levels of effort. Instructors should monitor and consider the amount and timing of the correction and input they provide as students pass through the stages of acquiring cane skills.
Stages of learning
It may be helpful to understand what expectations and teaching strategies could be appropriate as students move through the various phases of acquiring cane skills. We propose, on the basis of the results of empirical studies (Walker et al., 2003; Sullivan et al., 2008), the following model of how students pass through stages of learning to use a cane:
Stage 1: Beginner--acquiring manual performance skills. The student is learning how to move the cane and requires feedback and correction.
Stage 2: Concentration--maintaining independent movement. The student can maintain the correct cane technique without correction but only with concentration.
Stage 3: Consolidation--performance without concentration. The student can maintain the correct cane technique without conscious concentration; movement of the cane has become natural for the student and is done correctly even when the student is distracted. However, the student may not notice when the cane drops over an edge that was not expected.
Stage 4: Proficiency--noticing and using information provided by the cane. The student moves the cane correctly without having to concentrate and notices when the cane contacts any unexpected edges or obstacles even when the ground seems flat. At this stage, the cane provides the student with a reliable warning of hazards in all situations (see Box 1).
Stage 1
In the first stage of learning to use a cane, the student learns the mechanics of moving it correctly. Moving the cane correctly involves several skills (maintaining the correct hand position and movement and the correct arc of the cane tip, moving the cane in rhythm with the feet, and staying in step). Feedback from the instructor can be frequent at the beginning and fade out as the student improves.
Because the first and second stages of learning require students' full concentration, students in these stages need a sufficient amount of time to practice without having to perform other tasks simultaneously, such as noticing sensory information or finding destinations. The goal is for the student to establish muscle memory until using a long cane "becomes increasingly resistant to interference from competing or disrupting factors with the continued passage of time" (Walker et al., 2003, p. 616). As Jacobson (1993) explains, "Motor skills need to become ingrained before students can be expected to concentrate on higher-level orientation skills" (p. 12).
To prevent tedium and improve the quality and quantity of skills that are acquired, practice can be interrupted with activities to work on skills and concepts that are dissimilar, such as how to negotiate obstacles or locate dropped objects, or to develop students' kinesthetic sense or echolocation skills. The instructor should also be aware that pacing practice of similar skills is critical for long-term retention. The term massed practice refers to rehearsal without intermittent pauses, as opposed to distributed practice, which is rehearsal with breaks. Schilling, Marangoni, Vidal, and Rajan (2000, p. 3) claimed, "Abundant research indicates that distributed practice improves learning rates over massed practice, presumably because it gives the learner time to do the kind of deep, elaborative processing that enables development of the knowledge structures." By using a distributed schedule for learning, O&M specialists can effectively relieve boredom that is associated with repetitive tasks and provide students with time to recoup and reflect on the instruction.
With the exception of the skill of maintaining rhythm, it may be helpful to isolate one skill at a time until the student can at least demonstrate it correctly and then add other skills later. As Walker et al. (2003, p. 617) demonstrated, instruction in more than one similar task can impede acquisition. The phenomenon is called interference. Walker stated that "when subjects … were trained on a second motor sequence immediately after the first, interference was seen, so that overnight improvement in accuracy only occurred for the second sequence, and not the first" (p. 617). Instructors should be aware of the effect of interference; when they observe it, they can focus on a single skill or subset of a skill (such as hand position and movement of the cane) during that day's lesson and wait until another day to practice other skills (such as moving the cane in rhythm with the feet).
When students have difficulty learning the skill of maintaining the rhythm of the cane, the instructor can temporarily suspend work on skills they may have already mastered, such as arc and hand position, and work only on developing a sense of moving the cane in rhythm with the feet. Often students will acquire that sense of rhythm if the instructor moves the cane for them while they walk. If that strategy does not work, students may get the sense of moving something in rhythm with their feet by tapping their hand on their hip in time with their steps while the instructor guides them (with no cane) and then taps the cane in rhythm with their steps (ignoring the arc and hand position until they can gain a sense of what it feels like to move the cane in rhythm with their feet). Once they are able to coordinate the rhythm of the cane movement with that of their feet, they can work on moving the cane with the correct arc and hand position.
Stage 2
When students have mastered the correct cane technique and can maintain it without any prompting if they are concentrating, they are in the second stage of learning to use a cane. In this stage, students still need sufficient practice without interference because they still need to concentrate on the skill. Any distraction, such as a question or statement, may result in the student's cane technique deteriorating or cause the student to deviate from the correct technique. At one time, we thought it was simply coincidence that whenever we complemented students on their technique, they momentarily lost their ability to use the cane properly. Now we suspect that we were distracting the students during a period of their training in which they still needed to concentrate. The instructor's constant presence is not necessary in this stage, except perhaps to ask the students periodically to check themselves to see if they are in step.
By the end of the second stage, students do not walk out of step for long before they notice and automatically correct themselves because it just does not feel right to them. To determine whether students have passed through the second stage of learning and have achieved the third stage, the instructor may ask them a question while they are using the cane. If the students are still in the second stage, their cane technique will deteriorate while they ponder the question; for example, they will get out of step, the arc will shift to one side, or they may even stop walking.
Stage 3
The process of solidifying skills, known to neuroscientists as "consolidation" is achieved by the third stage of learning to use a cane. As Diekelmann and Born (2007, p. 1085) noted:
As with other types of memories, once skill memories (such as riding a bike) are acquired, they pass through a phase in which the newly encoded neuronal memory representation is labile, and thus vulnerable to disruption and interference. Building a memory that is remembered forever requires that memory traces be transformed into a robust, stable form that is resistant to disruption.
When students have achieved consolidation, their cane skills are stabilized to the point that they no longer have to concentrate to move the cane correctly and consistently. Students can be expected to maintain an effective cane technique while paying attention to sensory information and work on other tasks, such as orientation. Jacobson (1993) noted that when this stage is complete, motor skills become "second nature."
As students enter the third stage, execution of the cane technique may still occasionally falter if the cane tip jams, but this situation improves with practice. In this stage, students often need prompting or correcting soon after they first use the cane outside because the cane jams so often, but before long the technique remains consistent even in rough terrain.
Even though students in this stage move the cane correctly and consistently, many of them (especially those with functional vision) do not respond reliably to the information provided by the cane. They sometimes trip or fall on a stair or obstacle even when using the cane correctly because they continue to walk forward unaware that the cane has dropped over an edge or contacted an obstacle.
Therefore, when students have reached the third stage of learning to use a cane, the instructor needs to assess whether they can reliably and consistently notice and react to the information that the cane provides about drop-offs and obstacles, even when the students are distracted. Individuals who have functional vision must be assessed to be sure they can reliably notice hazards even when their vision misleads them to think that the ground is clear and flat.
Stage 4