Note: For information related to cane use, see
  • How do I learn to use a cane? (published in the online newsletter of VisionAWARE)
  • Examples of Strategies for Teaching Non-Visual Skills/ Information to People with Functional Vision
  • Things that the cane may not detect
  • Walking in Step: Why Does It Matter?

    Stages of Learning to Use a Cane
    by Dona Sauerburger, COMS
    Spring 2005 Newsletter, AER Orientation and Mobility Division

    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 mastering the use of 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” because I now realize that learners cannot rely on their cane for protection until they reach the “fourth level” or stage of proficiency and attention (they must also 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 stages of learning to use a cane;” and explain what can be accomplished in each stage as well as some ideas for intervention to help achieve the fourth level.

    Stage 1 -- Beginning to learn:

    The learner is beginning to understand how to move and use the cane, and requires prompting to maintain a correct technique.

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

    Stage 2 -- Concentration required:

    The learner in this stage can maintain a correct technique without any prompting, but only when concentrating on it. If distracted with anything, such as a question, another task, or sometimes even a thought, the cane technique will deteriorate or deviate from correct technique. I used to think it was a coincidence that whenever I complemented them on their technique, they momentarily lost it -- now I know that I was distracting them while they were still in the stage when any distraction will make the cane technique deteriorate. I can even tell when they start thinking hard about something by watching the cane -- whenever it suddenly deviates, I find out they had started thinking about something else.

    Once learners can maintain the correct technique consistently without prompting (end of Stage One), I’ll test whether they’re ready for additional tasks by asking them a question while they’re using the cane (“What are you planning for dinner?” “Tell me about your children?”). Often people who are still in this second stage will get out of step or the arc will shift to one side while they ponder the question, and I’ll know they need more practice before they’re ready to do anything in addition to moving the cane (such as noticing sounds or textures, or maintaining a straight line of travel)

    To give the learner (and me!) a break, I’ll interrupt the cane practice with short episodes of learning other skills, such as locating dropped objects, exercises to develop their kinesthetic sense, using echolocation to determine room sizes and which walls are nearest, etc. I don’t expect the learner to use the cane during these activities -- either they use it with the understanding that I’m not going to correct the technique, or I guide them.

    At this stage, 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.

    Stage 3 -- Correct movement is maintained without concentration:

    In this stage, the learner no longer has to concentrate on the cane in order to consistently move it correctly. At the beginning of this stage, the technique occasionally falters if the cane jams, but this improves with practice (learners in this stage often need some prompting / correcting when first using the cane outside because the cane jams so often, but soon the technique remains consistent even in rough terrain).

    Once they have achieved this third stage, learners can use the cane while working on various tasks without jeopardizing correct cane technique. The O&M specialist can have them learn more skills and concepts while using the cane.

    At this stage, 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.

    Stage 4 -- Learner responds to cane information reliably:

    This is the final stage of learning to use the cane. At this stage, the learner always notices when the cane drops over an edge or contacts an obstacle. Until learners reach this stage, they will sometimes trip or fall because they continue to walk after the cane has dropped over an edge or contacted an obstacle.

    Once learners have achieved this stage, 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.

    NOTE: Once they notice the obstacle or stair, some learners will rely on visual information to negotiate it. If the vision is sufficient, this is satisfactory but if not, they may need to learn to augment the insufficient vision with cane information – see Examples of Strategies for Teaching Non-Visual Skills and Use of Non-Visual Information.



    Training / intervention suggestions for reaching the fourth level:

    I believe that there are three issues involved in achieving this final stage of proficiency:
  • 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.
    Practice is required to address all of these, and sometimes after reaching the third stage, training or intervention in addition to practice is needed to reach the fourth stage, as explained below:

    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:
    The only intervention I’ve found necessary for learners to overcome insufficient attention is lots and lots of practice, including approaching and detecting lots of unexpected drop-offs (with appropriate monitoring for safety, of course). When opportunities are present, I sometimes also try to make them aware of how important it is to notice the cane information by pointing out any severe, unbarricaded drop-offs or holes they pass.

    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 is very effective for helping the learner notice cane information while distracted or misled with visual information. Occlude the bottom half of the vision (for example, place paper on the bottom half of their glasses or have them wear goggles with the bottom half occluded) so the ground cannot be seen for about 10 feet ahead (see partial occlusion), and have the learner approach obstacles and drop-offs while performing a visual task (such as counting how many doors have handles on the right, or counting poles, etc.). Be sure to monitor closely for safety.

    Partial occlusion has a secondary benefit for those who customarily walk with head down, watching the ground (often without being aware of what they are doing). It helps them realize how dependent they are on looking down, and they may learn that looking down is not necessary if they have a reliable cane technique (note that if they haven’t learned to use the cane information yet, the cane technique will not be reliable).

    3) Proprioception information: People need lots of experience with the cane on flat surfaces to get an understanding of what it feels like when the tip is on the same level as they are, and what it feels like when the tip is slightly dropped or raised. This requires good proprioception.

    This ability to notice changes in the level of the cane tip is important for people using the touch cane technique because often, their only clue that they’re approaching a step is when the cane tip has landed slightly above or below the level they’re walking on. 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.

    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.

    One intervention that has been 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) is to have them stand with the side of their feet next to the edge of a curb and hold the cane out ahead in the normal position such that the tip is at the edge. Have them move the cane slightly so it goes over the edge, and 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 beside the curb and repeat moving the cane up and down to the top and bottom of the curb until they are satisfied that they can notice the wrist stretch readily, then have them approach curbs and notice the drop.

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