Key messages

• The use of a contralateral cane in patients with knee osteoarthritis probably reduces pain (certainty of moderate evidence).

• It is not possible to establish clearly if the use of contralateral cane increases walking speed, because the certainty of the existing evidence has been evaluated as very low.

• The use of a contralateral cane could slightly increase the function (certainty of the low evidence).

What is the evidence

See evidence matrix in Epistemonikos later

We found three systematic reviews[2],[3],[4], which included four primary studies[5],[6],[7],[8] of which one corresponds to a randomized trial[7].

All the studies reported interesting outcomes, for which reason this table and the summary, in general, are based on these.

What types of patients were included*

All the studies[5],[6],[7],[8] included adult patients with a diagnosis of knee osteoarthritis, based on the American College of Rheumatology criteria, all of which presented symptoms (pain).

The average age ranged from 53.6 to 65 years.

76.5% of the patients were women.

What types of interventions were included*

One study[5] evaluated the use of a contralateral walking pole, one trial[7] analyzed the use of a wooden cane with a contralateral T-shaped handle, the other two studies[6],[8] used contralateral cane not specifying the type.

Three studies[5],[6], [8] compared the same patients without the use of canes, while one trial[7] compared a control group with knee osteoarthritis. 

What types of outcomes were measured

Of the multiple outcomes measured by the trials, the systematic reviews presented in a grouped manner the following: pain, function, quality of life, walking speed, moment of adduction of the knee and vertical reaction force to the ground.

The average follow-up of the trials was one month (range between 0 and 2 months).

To whom this evidence does and does not apply 

• The evidence contained in this summary is applicable to adult patients with symptomatic knee osteoarthritis.
• It is not applicable to patients with acute or chronic knee pain from another cause, or to patients with symptomatic osteoarthritis of other joints.

• The outcomes included in the results summary table are those considered critical for decision making by the authors of this summary.
• Although some systematic reviews considered peak knee adduction moment as a relevant outcome and some clinicians might think in the same way, these outcomes are now known as surrogate outcomes[10]. The report of these outcomes is made when there is an absence of information on clinically relevant outcomes, since the use of surrogate outcomes in decision making entails a risk of incorrect decisions. However, the authors of this summary decided to analyze it, obtaining a certainty of the very low evidence, since the outcome presented limitations due to the risk of bias, imprecision, and inconsistency.

• Among the benefits of cane use, it is highlighted that it probably decreases the pain (moderate certainty) and could have a slight effect on function (low certainty).
• In turn, the adverse effects of cane use have not been systematically evaluated, and although there are theories showing kinetic and kinematic changes in other joints of the lower extremities, the clinical implications of these changes are not defined.
• Due to the absence of the measurement of adverse effects, it is difficult to make an adequate risk/benefit balance.

• No studies were found that evaluated the cost-benefit of this intervention. However, it is a low-cost and widely available technical aid. 

• Faced with the available evidence, it is expected to find variability in the decision of the different patients and physicians. Although there may be pain reduction and there are clinical guidelines that recommend its use, there is uncertainty about the adverse effects, so its indication should be individualized and supervised.
• One study[9] evaluated the factors that influence the use of a cane in patients with osteoarthritis of the knee. This study, which uses a behavioral change approach, found that older people, with a higher body mass index, a longer duration of knee pain and more intense pain when walking, tend to prefer using the cane.
• It could be considered as an option in patients in whom other therapeutic options are not being considered, or as a complement to other therapeutic options with greater evidence.

• The revised systematic reviews do not make specific recommendations regarding the use of canes due to the limited available evidence, which is consistent with the results obtained.
• The International Society for the Study of Osteoarthritis (OARSI)[11] recommends the use of a cane in patients with osteoarthritis of the knee, without osteoarthritis in other joints based on the results of the mentioned randomized trial[5]. The American Academy of Orthopedic Surgery (AAOS) does not refer to the use of canes[12].

• The probability that the conclusions of this summary will change in the future varies depending on each outcome, with the probability of walking speed and adverse effects being high. On the other hand, the probability that the results change is less in function and pain.
• We identified an ongoing systematic review in International Prospective Register of Systematic Registries (PROSPERO) that assesses changes in maximum moment of adduction of the knee from interventions that modify gait, including the use of a cane[13].
• We identified two randomized trials underway in the International Clinical Trials Registry Platform of the World Health Organization, one that evaluates maximum vertical force in patients with osteoarthritis of the knee[14] and another in relation to pain and function with the use of walking sticks[15].