One really cannot understand how much we use our vision to help us balance until it is taken away. That is why a standardized test for balance is to stand with feet together and eyes closed. The test is called the Romberg test, and the goal for most adults regardless of their age is to stand for at least 30 seconds with good balance.
Last week, my patients with balance problems were tested in a more functional way. Equinox Physical Therapy is located in Sarasota, Florida and what became Hurricane Hermine was approaching our shores. It was around 1 pm when the brunt of the storm rolled into Sarasota. The sky became pitch black. Looking outside my office window, one would think it was midnight! The patients who were coming in for afternoon appointments were used to coming in the daylight, not in conditions where the sky was dark as night. This made negotiating the parking lot much more challenging. Then the electric when out, and the hallway was almost completely dark. Everyone could clearly see how much we rely on our vision to help us balance and walk, and we were all grateful when the electric was restored. In the dark, some patients did better than others. The ones that did the best were the patients whose brains had learned how to use inner ear balance information and somatosensory information (the information from our joints and muscles that that tells the brain what position our body is in). The patients with damaged inner ear systems, or the patients that were not good at using their inner ear information, had the greatest trouble in the dark.
Understanding this problem, and why it happens, allows us as physical therapists to create exercises that will force the brain to practice using inner ear information. One such exercise is based on the Romberg test that I described at the beginning of this article. The patient stands in a corner with a chair in front for safety. If they are very unsteady, a family member stands by, ready to assist them if need be. They stand with their feet shoulder width apart, hands at their sides, and they close their eyes and try not to sway. They will stand for 2 minutes, unless they are too dizzy or become tired. As the exercise gets easier over the next few days, they gradually move their feet closer together to make it more challenging. Over time, they become less dependent on their vision, and better able to use their inner ear balance information and somatosensory information to balance. In real life, this helps in conditions where they must walk in a darkened setting or in the case of Hurricane Hermine when the lights went out…
Included image: In The Light Of The Setting Sun, painting by Victor Borisov-Musatov 1904
This week is Balance Awareness Week, Sept 12-18th, 2016. Please join me and others in our fight to stop dizziness in its tracks. If you would like to learn more about your specific type of inner ear balance problem, the Vestibular Disorders Association website has very good patient information. Let’s continue working together to defeat dizziness!!!
VOR stands for the Vestibular Ocular Reflex. This is basically the coordination that one has between head and eye movements. The way it works is this: when a person is moving their head, the ears send information to the brain to tell the brain how the head is moving. The brain then uses this information to coordinate the eye movements so that the person can stabilize their gaze on an object even though their head is in motion. We do this all the time! For instance, if I am talking to someone, and nodding my head yes or no, then I am using my VOR.
When a person has a weakness in one ear following an inner ear infection, for example, the brain that was used to getting the same amount of information from each ear, realizes that the information from the two ears is no longer balanced. The affected side is not sending the same amount of information as the healthy ear anymore. Initially, this can cause dizziness, nausea, and imbalance. To avoid these symptoms, patients will often avoid head motions. While this may seem logical at first, to continue avoiding head motions only makes the problem worse. You see, the brain needs to learn the difference that now exists between the two ears, and the only way the brain can do this is by experiencing the movement! The brain won’t learn how to recalibrate itself if the person continues to avoid moving their head. By doing the VOR exercise, we force the brain to pay attention to the inner ear information when the head is moving, because the brain must in order to coordinate the eye motions and allow the person to keep their eyes fixed on the target without the target looking blurry, double, or as if it is jumping around…
Initially, this exercise may cause dizziness, or increase the person’s baseline dizziness. The patient should first do this exercise at a slow speed, and for a short duration (30 seconds). That way if the exercise causes dizziness, the dizziness should dissipate in a few minutes after stopping the exercise. With practice, the exercise will no longer cause dizziness or nausea. Once this happens, then we work on increasing the duration of the exercise little by little until eventually they can do it for 2 minutes and feel fine afterwards. At that point, we work on increasing the speed of the head motion, so that the brain learns how to process faster and faster head motions, and not feel dizzy. After that, we move on to other variations. You see, there is a progression to the exercise, and a vestibular specialist will be able to teach you how to do the exercise correctly, and guide you in your journey toward recovery.
Man with His Head Full of Clouds- Painting by Salvador Dali, 1936
Levanna Doing Exercise, painting by Maria Primachenko
The Vestibular Ocular Reflex (VOR) is the mechanism that allows a person to keep their eyes on a fixed target while their head is moving, for instance when you are looking at your friend and nodding your head “yes” or “no”. The reason we are able to do this is because our inner ear system acts like little gyroscopes that tells our brain when our head is in motion. Your brain then takes that information, and tells the eye muscles what to do to keep your eyes on the target.
The VOR exercise is especially important when a person has had damage to their inner ear system. The brain, which was used to getting normal inner ear information previously, will have to relearn how to use the information that has lessened due to illness or injury.
I’ll give you a common example. Let’s say that a person has an inner ear infection that affects their Left inner ear system, and decreases responsiveness of the Left vestibular system (the balance part of the ear) to send information during head motions. When the person now moves their head, the left ear is sending less information than the healthy right ear. This difference in input to the brain being sent from the two ears can result in symptoms of dizziness, nausea, or unsteadiness. Ironically, some patients will avoid moving their head so that they don’t get dizzy, but movement is the only way for the brain to learn how to use the inner ear information again!
Vestibular Ocular Reflex exercises help the brain through this retraining process, because the exercise forces the brain to receive inner ear information and practice using it to keep the eyes on a fixed target. Patients start with slow head turns, keeping the eyes on a fixed target placed on the wall at eye level 4 feet away. They start in a seated position and move the head 20 degrees to each side in a back and forth head motion. They also do the exercise in an up and down head motion as if nodding “yes”. As they are able to do the exercise symptom free, we increase the duration of the exercise to 2 minutes.
The next step is to gradually increase the speed of the head motion. If you are doing the exercise correctly, your symptoms will decrease over the next few weeks. If you aren’t doing the exercise correctly, you may think the exercises don’t work! This is why working with a vestibular specialist is so important. If you are not improving, they can figure out what you are doing wrong and help you learn how to perform the exercise correctly, and hence, recover as much inner ear function as your body will allow.
Connoisseurs of Books (Knowledge is Power), by Nikolay Bogdanov-Belsky, 1920
My physical therapy practice in Sarasota, Florida, is devoted to helping people with balance and inner ear problems. So you may be wondering why I am writing about visual problems The reason is: vision is extremely important in maintaining good balance! We use our vision to understand where we are in space, and how to negotiate obstacles in our environment. As adults, we have an idea of what good vision is, and we are likely to notice if our vision changes. But what if the person we are talking about is a small child, maybe even an infant who may not be able to communicate or recognize that he/she is having a visual problem? This child, in addition to a visual problem, could also be experiencing a balance problem, because we know that good vision and good balance are closely connected.
I was lucky to be talking about this problem with my friend and associate Dr. Mohamad S. Jaafar. Dr. Jaafar is Professor of Ophthalmology and Pediatrics at the George Washington University, and Chief of the Division of Ophthalmology at the Children’s National Health System, Washington, DC. He is passionate about training young doctors to be experts in his field and is the Past-Director of Washington’s Pediatric Ophthalmology Fellowship Program, which is the oldest, largest, and most renowned such program in the world.
Dr. Jaafar and I want to help parents recognize visual problems in their children, so that they know when to seek help. Bear in mind that there is an association of eye diseases in some children who have hearing loss (such as retinal dystrophy, cataract and misalignment of the eyes). Dr. Jaafar was kind enough to provide this top 5 list, so that parents know what to look for if they suspect their child may have a visual problem.
TOP 5 Signs of Visual Problems in Children
1. Bumping into things or acting clumsy.
2. Always sitting close to the TV or holding books and I-pads too close to their face.
3. Crossed or wandering eyes.
4. Tilting or turning the head, or assuming a chin-up or chin-down posture (ocular torticollis).
5. Disliking having one eye covered but not the other (may indicate a “lazy eye” – amblyopia).
If your child is showing these signs, was born prematurely, has multiple health problems or a family history of eye diseases in childhood, it is a good idea to consult an eye doctor who is experienced in treating infants/children. Please remember, a TOP 5 list is not all inclusive. If you have questions about your child’s vision, go and see a specialist or ask your Pediatrician. Dr. Jaafar suggests that you could find a qualified doctor in your area by going to the following website: https://aaosso.aapos.org/ebusaapos/FindanEyeMD
Strangled by Growth, by Emily Carr 1931
Acoustic Neuromas are nerve sheath tumors surrounding the vestibular or cochlear nerves. The vestibular nerve is the balance nerve that goes from the inner ear to the brain. The cochlear nerve is the hearing nerve that goes from the cochlea to the brain. When the tumor grows, it can press on the nerves as they travel through a boney canal to reach the brain. This is how the tumor can damage a person’s balance and hearing. Also in this boney canal is the facial nerve. Damage to the facial nerve can result in facial paralysis.
At Equinox Physical Therapy, we specialize in treating people who have balance problems or facial paralysis as a result of acoustic neuromas. The majority of these patients come to see me following surgery, or radiation to the tumor. A few months ago, I had the pleasure of speaking to the members of the Acoustic Neuroma Association in Sarasota, Florida. They had the idea to videotape the talk for the members who were unable to attend the meeting. They were so pleased with the video, that they asked me if they could post it on their national website. The title of the talk was “The Vestibular System and How it is Affected by Acoustic Neuroma”. If you would like to learn more about this topic, you too can watch the video below.
The New Labyrinth with Black Holes by George Saru, 1996.
Last year I wrote an article for my blog about anxiety and inner ear problems based on the research by Dr. P. Ashley Wackym. It turns out that it has been one of my most frequently visited blog posts! Last October 2015, I saw Dr. Wackym again when we were both attending the 7th International Symposium on Meniere’s Disease and Inner Ear Problems in Rome, Italy. During our discussions, I learned of a recent research article of his that was published in the ENT Journal (Ear, Nose and Throat) that studied people with a type of inner ear problem called Superior Semi Circular Canal Dehiscence (SSCD). This is a condition where the bone between the inner ear system and the brain erodes causing symptoms of imbalance, headache, dizziness, tinnitus, cognitive dysfunction, nausea, subjective hearing loss, visual disturbance, aural fullness, objective hearing loss, hyperacusis, and vomiting.
Although I don’t usually post scientific articles on my blog because I want the information to be easy for the average lay person to understand, for those of you with SSCD, you may find the information interesting… If so, feel free to read Dr. Wackym’s research paper!
Do you like to learn by listening and watching? If so, you may enjoy coming to a free lecture that I am giving next week. The title of the talk is “Understanding and Treating Dizziness and Balance Disorders with Vestibular Rehabilitation”. I will be co lecturing with Dr. Jack Wazen, MD. Spaces are limited, so if you would like to attend, please register online here, or call 941-556-4219.
Hope to see you there!
It’s that time a year for the annual trip to the Christmas tree lot. When a person has Benign Paroxysmal Positional Vertigo (BPPV), bending the head down, or tipping the head back, can trigger a vertigo spell. It goes without saying, that if you are standing on a ladder and reaching overhead to hang something on a tree, you definitely don’t want the world to spin!
So this is a tip for those with holiday cheer and vertigo, let someone else do the ladders, and the reaching overhead and bending over! If you have positional vertigo, aim for the ornaments in the middle of the tree where you can keep your head level. This way you won’t have to worry about triggering the vertigo, and potentially falling and getting hurt during the holiday session. Or, if you live alone, you could get a smaller tree this year that is 3 feet tall, and place it on a small table so that you can decorate it without having to tip you head back or bend over too much…
For those of you with balance problems or BPPV, give yourself the present you deserve, and go and see a trained vestibular specialist and get treated for your problem. That would be the best present of all!
Happy Holidays! - Dr. Laura Wazen, Equinox Physical Therapy 941-404-4567
LOCAL SUPPORT GROUP MEETING INVITATION
Please plan to join us at the next meeting of your local Acoustic Neuroma Support Group. We welcome you to learn about the latest treatment options,
network with other acoustic neuroma patients and find encouragement and support.
Saturday, November 7, 2015
1:00 – 3:30 p.m.
Fruitville Public Library - Meeting Room
100 Coburn Road
Sarasota, FL 34240
The Vestibular System and How it is Affected by Acoustic Neuroma
Presented by Dr. Laura J. Wazen, DPT
Equinox Physical Therapy
"Woman Tying Her Shoe", Painting by Pierre-August Renoir, 1918
Do the shoes you are wearing matter when you have a balance problem or a history of falling? The answer to this question is ABSOLUTELY!
I still remember the lady who came to see me for balance therapy in Sarasota, Florida with complaints of falling. She was wearing 5-inch stilettos that didn’t even have an ankle strap! Now I ask you, do you have to be a balance specialist to know that maybe this is not such a good idea?
So what is a good idea?
1. A FLAT shoe is the best, avoid shoes with a high heel if you can tolerate a flatter shoe.
2. A shoe with a flat WIDE HEEL is better than a small pointy heel. The wide heel provides a more stable foundation when shifting your weight.
3. NO FLIP FLOPS or SLIDE style shoes. These loose shoes can cause a trip and fall.
4. A shoe with a SNUG FIT around the HEEL is important.
5. STRAPS or LACES that tighten- Don’t just slide your feet in and out of your shoes. If they have Velcro straps or laces, use them to make your shoe secure. Ankle straps should fit snuggly.
6. For people with peripheral neuropathy, avoid shoes that are too cushioning as they decrease your already limited ability to feel the ground.
7. Make sure that your toes are comfortable in the shoe, as you use your toes to stabilize your balance.
BPPV (Benign Paroxysmal Positional Vertigo) is the most common type of inner ear problem, comprising approximately 25% of all inner ear problems. It is caused when crystals in the ear that are supposed to sit on top of the nerve fibers in a jelly like matrix, become loose and start floating in the semi-circular canals of the ear. When this happens, the person can experience a spinning sensation (vertigo) that lasts for seconds and is triggered by changes in head or body position. For instance, it happens when getting in/out of bed, bending over, or tipping your head back.
In answer to the question, “Can people have BPPV in both ears?” the answer is YES. About 40% of people can have it in both ears at the same time. The good news is that if the condition does not go away on its own, it can be treated with maneuvers to guide the crystals back into the part of the ear where they belong.
If you think you have BPPV, I encourage you to find a qualified doctor or physical therapist, who can test to see if BPPV is your problem, and if it is in one ear or both ears. The proper testing leads to the proper treatment, and to the proper cure…
Painting entitled, A Serious Question, by Sergey Solomko
Money Matters (Selected Part of Letters from Aunt Evelyn), conceptual art by Barton Lidice Benes, 1982.
This is an article that I thought I would never write. When I first started working as a physical therapist, I worked for a big hospital in Manhattan. I never had to think about insurance, because basically the hospital accepted every type of insurance there was! In fact, these were the days when there was no such thing as a co-payment. When co-pays did come along, for many years the hospital never attempted to collect the 5 to 10 dollars per visit. But that was 17 years ago, and a lot has changed now.
Things really started to change after Obama care. I not saying that I am either for or against Obama care, I am just saying that things are very different now. For example, in order to have insurance, many families are choosing insurance where the deductible is 5 to 6 thousand dollars per year! This means that the patient has to pay the first 5 or 6 thousand dollars in medical services, thus meeting their deductible, before their physical therapy services are covered. In addition, the person usually has a co-pay required at each physical therapy session, which can be as high as 50 to 75 dollars per visit with some plans. Take the time to consider these factors when choosing your insurance needs.
At Equinox Physical Therapy, we check a patient’s insurance benefits before they even arrive for their first visit. I am a standard Medicare Part B provider for out-patient physical therapy services. That means that I accept standard Medicare Part B because I am committed to treating people over 65 years of age who have balance problems, dizziness, vertigo, falls, inner ear problems, concussion, or facial paralysis. I don’t want my Medicare patients to fall and break a hip, when I know that I can help them to enjoy their retirement in sunny Sarasota, Florida, and live a long and healthy life! Medicare pays 80% for out patient physical therapy services, and most people have a secondary insurance that covers all or part of the remaining 20% of the bill.
As far as other types of insurance, I see patients who do not have Medicare, but some other type of insurance, and in these cases I am classified as an “out-of-network” physical therapy provider. Because I am not a major hospital, I cannot accept every insurance under the sun, because it would be too much for my small practice to manage.
Why would someone come to me, an out-of-network provider, when they could see someone in-network instead? That should be your next question. The reasons are probably many. When I see a private insurance patient, they pay me, and then I give them the papers they need to submit their physical therapy bills to their insurance company. Then, their insurance company will reimburse the patient directly for whatever their out-of-network physical therapy benefits are. The patient calls their insurance company to verify their benefits before they even step inside my door. They know exactly the percentage that their insurance company will reimburse them, and the percentage that they will have to pay of the remaining bill.
Again, why would someone come to me instead of going to his or her “in-network” provider? For one thing, many of these patients have BPPV, a condition that causes vertigo and seriously interferes with their ability to work, or function properly. With this condition, it usually goes away if treated properly in 2-6 sessions. So, it is not such a big expense to come see me. If they have a big deductible, they will have to pay either way. At least if they come to see me, they know they are being seen by someone who treats this problem 3-4 times a day, as opposed to someone who has little experience, or only treats this problem occasionally. For patients with conditions that take longer to treat, they come to me because they know that their chances of having a good outcome are enhanced if they have the best possible therapist that their money can buy, because again, they still have to pay the large deductible either way. Other patients come to me because I am a specialist in treating inner ear disorders, concussion, falls, dizziness, and facial paralysis, and their “in-network” therapists are not.
Another point to consider is the co-payment. Because I am out of network, I do not collect a co-payment. For those patients whose co-payments are 50 to 75 dollars per visit, the difference between their co-payment and what they have to pay me may be the same, or not much more.
If you are considering going out of network for your out-patient physical therapy services, here are a list a questions that you should ask your insurance company to help you decide if going out of network is right for you or your loved one. One thing to remember is that you, the patient, have the right to receive services from any physical therapist you choose.
TOP 4 QUESTIONS REGARDING OUT-OF-NETWORK PHYSICAL THERAPY BENEFITS
1. Do I have out-of-network physical therapy benefits? If not, what does that mean?
2. Am I eligible to receive direct reimbursement from the insurance company for my physical therapy visits?
3. What percentage of the money I paid at my physical therapy visit will you, the insurance company, reimburse?
4. Do I have an out-of-network deductible to meet first?
Artwork: Here is a Sign by Forrest Best, 1970
How do you know if you or someone you love, such as an elderly parent, may need balance therapy? Below are 5 signs that balance therapy could be right for you. If it is, contact a physical therapist that specializes in balance therapy so that you can improve your health and decrease your risk of falling.
The bottom line is we want you around for a long time! A fall could cause an injury that would jeopardize your livelihood, and your functional independence. For those older folks, it could mean the difference between living independently on your own, or having to go to a nursing home- so take it seriously!
5 signs that a Person needs Balance Therapy:
1. Any fall that created a serious injury in the last 12 months.
2. Two or more falls without injury in the last 12 months.
3. Needing more that 1 attempt to rise from a chair.
4. Walking touching the walls & furniture for support.
5. Having a fear of falling is a significant risk factor for falls.
If you answered “yes” to any of these 5 signs, don’t wait to do something about it. Find a qualified vestibular specialist who can help you improve your balance. You can use these web sites to look for vestibular specialists in your area.
1. The Vestibular Disorders Association website
2. The American Physical Therapy Association Neurology section has a Vestibular Rehabilitation Section where you can search for vestibular specialists state by state.
Be empowered. Balance therapy CAN change your life!
Prospective Chromatique, Abstract art by Martha Boto 1972
Several years ago I was working at a hospital in Manhattan, and I was trying to get a patient out of bed. They didn’t want to get up, or do their exercises, even though that was what they needed to do to get better. I remember the patient, because I was working on the open heart surgery floor at the time. The patient got really mad, and demanded to know how I could I possibly help them, because I had not had open heart surgery and therefore didn’t know what they were going through.
Thank goodness for all the physical therapists, doctors, and nurses in this world that we do not need to have every disorder there is under the sun before we can help patients! Yet, I understand how the patient feels at the same time. Sometimes it is comforting to know that you are not the only one who knows what it feels like to have a condition. My vertigo patients sometimes ask if I have had vertigo. Luckily, I have not, but I work with people who have vertigo every day. One of my patients offered to tell her story of how vertigo and BPPV was affecting her life. I hope her story helps those of you out there who do not know someone with vertigo, and that it gives you comfort that you are not alone, and that there is hope that things can get better.
Flying People by Karel Appel, 1971
From a medical terminology stand point, vertigo is the sensation that the world is spinning around you, or that the world is still and you are spinning. But what’s it really like?
From a personal standpoint, everyone experiences vertigo differently. I have had many patients who seem to have a mild case, and find it to be mainly an annoyance. In the case of BPPV (Benign Paroxysmal Positional Vertigo), there are some patients who only experience the spinning when getting in and out of bed, and since the spinning only lasts less than a minute, the person finds it to be more of a nuisance than anything else.
I have also had patients who complain of dizziness and imbalance only (not a spinning sensation), and then when I test them for BPPV it turns out they have BPPV after all. There have even been times when the nystagmus (spinning of the eyes) is extremely strong, and the patient denies feeling dizziness or spinning at all!
On the other hand, I have some BPPV patients who have an incredibly strong case of BPPV, and the vertigo sensation feels incredibly violent and awful. Sometimes it causes nausea, and can be very frightening. One of my new BPPV patients last week had such a strong sensation of spinning that she said she would rather get her other hip replaced than have to have vertigo again. She felt like she could control her pain with a hip replacement, but she couldn’t control her vertigo.
I have also had BPPV patients who are so afraid of their vertigo, that they don’t want to do the repositioning maneuver because they might feel the spinning again. Of course, this is not a logical or viable option, because if they don’t get treated they are very likely to have continued vertigo, but if they do get treated they are very likely to make the vertigo stop. What would you choose? So far, no one has refused treatment once they really understand that this is their best alternative.
Luckily for those with BPPV, the vertigo only lasts for seconds. And again, luckily for BPPV, most people respond to the repositioning maneuvers, and we are able to stop their vertigo.
Painting: Le golf by Emilio Grau Sala, 1961
BPPV hit the international stage this last week at the 2015 US Open Golf Tournament in Chambers Bay when Australian golfer Jason Day suffered an attack of vertigo and fell to the ground. It’s not every day that people all over the world are talking about and witnessing the debilitating effects of a vertigo attack...
I have been surfing the net, looking at the video footage, and listening to and reading the various commentaries that people are posting. The bottom line is that BPPV is a real drag, and it is horrible in general, but especially difficult if you are trying to play golf. Why do I say that? It is because we know that head or body motions trigger BPPV. The crystals in the inner ear become out of place, and when we bend over, tip our head down or back, or turn quickly, it can trigger the vertigo. Needless to say, it is pretty difficult to play golf without bending over or turning your head quickly, not to mention playing championship level golf and competing with people who are not having this problem.
The good news is that BPPV can be treated! Living in South Florida, I treat a lot of golfers who have this condition. All they want is for the vertigo to go away so that they can get back on the golf course. My BPPV patients in Sarasota, Florida couldn’t stop talking about Jason Day, because they knew how he felt, and hoped that this international exposure of the condition might help others understand what they are going through.
The most common treatment for BPPV is a repositioning maneuver where the head is moved in a certain way in order to put the crystals back in the part of the ear where they belong so that the person no longer has vertigo. There are several treatments that will do this, including the Epley Maneuver, Semont Maneuver, or the Foster Maneuver. These 3 treatments are for the Posterior canal. (The inner ear has 3 canals and each canal requires a different treatment). If maneuvers do not work, there is a surgery to occlude the canal where the crystals are floating, but this surgery is only done in the worst of cases and for very few people since most people respond to the repositioning maneuvers. Also, sometimes BPPV goes away on it’s own.
If you are having vertigo, you need the proper diagnosis in order to get the proper cure. Some of the people who were commenting on the Internet were talking about other causes of vertigo, such as Meniere’s Disease, and offering advice on what they do to control their vertigo. The treatments for BPPV and Meniere’s Disease are completely different, and what works to help Meniere’s Disease does not work to treat BPPV (and vice versa). I would recommend that if you are having vertigo, do not take antidotal advise from a layman with no medical training. Go and see an Otologist (an ENT physician who specializes in treating inner ear problems), or a vestibular therapist (a physical therapist who specializes in treating inner ear problems) who can test you for this problem and get down to business in helping you find the correct answer to your problem.
A former patient recently came back to see me due to an article he received from the Harvard Health Letter. I thought it was a good article, and wanted to share it with you. Maybe you, or your parent, or loved one, need to think about how using a rolling walker could improve safety and independence. An evaluation by a physical therapist would help in determining if you could benefit from balance therapy, and if using a rolling walker is a good idea. In the case of my patient, he was so happy with the walker because now he is able to walk without assistance of another person, and he can walk for much longer distances than he ever could with his cane alone.
Click here to read the article.