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Standing 101 is for Physical Therapists, Occupational Therapists, and Assistive Technology Professionals. It covers the history of standing therapy for the disabled, including research studies on standing programs. It also discusses the different types of standing frames including: prone standers, supine standers, and sit to stand standers. It concludes with information on funding and documentation for standing equipment and writing a letter of medical necessity for standing.
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StandingMobilityAlternative positioningRehabTechnology
Standing 101 Educational Seminar
Register
Welcoming remarks & overview of seminar content
History of standing and weight bearing
Early literature identifying secondary complications associated with
immobilization syndrome.
Evolution of standing technology, device types and their current applications
• Long leg braces• Tilt table/supine standers• Standing boxes• Prone standers• Multi-position standers• Standing wheelchairs• Sit-to-stand standers
Program Agenda
Break
Current Clinical Practices• Indication and Contraindications for standing • Accepted Medical Benefits for standing• Current clinical studies and research
Video Case Studies
1720
1500 19701500 1980
History of
Standing
Taylor et al (3) The effect of bed rest
on the blood volumeof normal young men
Cristobal Mendez (1) Book of bodily exercise
Treatise on the physiologic responses to exercise and its therapeutic indications Exercise therapy History of exercise
1533
1940’S
19291500 1900 1950
Tied to prolonged immobilization
• Cuthbertson (2) • The influence of prolonged
muscular rest on metabolism
Dietrick et al (4) Effects of immobilization upon
various metabolic and physiologicfunctions of normal man
Widdowson (5) Effects of rest in bed on plasma
volume as indicated by hemoglobinand hematocrit
Miller, Johnson and Lamb (7) Effects of four weeks absolute bed rest
on circulatory functions in man
1960’s
19671965 1980
Space exploration resulted in a flurry of research with goal of measuring adaptation of human body to weightlessness
Graybiel and Clark (6) Symptoms resulting from prolonged immersion in water The problem of zero G asthenia
• Gemini (9)Summary Conference
1970
1975
1977
• Space medicine (8)in project mercury
• Biomedical results of Apollo (10)
• Biomedical (11)results of Skylab
1960
1960’s
1965
Simultaneously, rehabilitation researchers documented the pathophysiologic changes exhibited by patients with extensive paralysis
19701970’s
• Browse (12)• The physiology and
pathology of bed rest
1960
• Spencer (13)• Physiology concepts of
immobilization • Kottke (14)
• The effects of limitation of activity upon the human body
• Long and Bonilla (15)• Metabolic effects of
inactivity and injury
StandingDevices
• Different types & manufacturers• Made locally with variations within types
• KAFO- (Knee-Ankle Foot Orthosis)
• RGO- (Reciprocal Gait Orthosis) Louisiana State University
• HGO- (Hip Guidance Orthosis) Para-Walker, Adult• Often driven by desire to walk
• Impractical
• Expensive
• Therapy time intensive
• Usually cannot be utilized independently
• Poor compliance
• Minimal support on anterior and posterior surface of body• Earliest example of assisted standing devices
• Often homemade• Inexpensive
• Often requires two attendants• Does not include a lifting mechanism• Adult and pediatric sizes• Minimal positioning or alignment options• Usually cannot be used independently
• Full support along posterior surface of body• Two-three straps to secure body to support surface • Platform to secure feet• Horizontal to vertical transition in supine position• Developed for cardiovascular testing
• To evaluate how body regulates blood pressure in
response to simple stress• Orthostatic hypotension• Rarely seen outside hospital environment
• Adult sizes• Manual or power lift mechanism• Minimal positioning or alignment options• Cannot be used independently
• Posterior surface support from head, thoracic
area, pelvis, knees and feet• Stander angle accommodates from horizontal to
vertical in supine position• Often prescribed for lack of head control• May have a lift mechanism • Available in sizes from pediatric to adult• Usually will accommodate options for growth,
positioning and alignment• Usually cannot be used independently
• Support on anterior surface of the body• Contact at upper thoracic area, pelvis, knees and feet
• Used to promote head control• Gravity assist for full extension of hips• Usually accommodates 30º of prone positioning to upright• May have a lift mechanism• Available in sizes from pediatric to adult• Options for growth, positioning and alignment• Usually cannot be used independently
• Prone, Supine, and Upright• Primary supports can be interchangeable
• Between anterior and posterior surfaces of the body• For positioning in prone, supine, or upright position
• Usually accommodates 30º of supine positioning to upright,
and 30º of prone to upright• Available in sizes from pediatric to adult
• Traditionally used with pediatric clients• Options for growth, positioning and alignment • Usually cannot be used independently
• Power and/or manual wheelchair• Main support on posterior surfaces of body
• Anterior support at knees• Hip belt and chest belt
• Usually includes lift mechanism• Available in sizes from pediatric to adult, including baratric• Power wheelchair may be able to move in the standing
position• Standing mechanism transitions person from sitting to
standing approximately (80º of supine)• Integrated lift mechanism is independently operated• Heavy and expensive
• Anterior and posterior variable support• Minimal support
• Anterior (mid-thoracic, knees, feet)• Posterior (PSIS to popliteal)
• Maximum support• Anterior (head, shoulder, thoracic, knees, feet)• Posterior (head to popliteal, feet)
• Transitions person from sitting to standing upright• Stop at any point from sitting to standing• Supported during incremental weight bearing
• Usually includes a lift mechanism• Available in sizes from pediatric to adult, including bariatrics• Options for growth, positioning and alignment• Usually can be used independently
CurrentResearchStudies
Does prolonged standing improve bone mineral density in non-ambulatory children with spastic quadriplegia?
• Principal Investigator(s)• Brian Snyder, MD • Antion Dodek, MD
• Co-Investigator(s)• Danielle Katz, MD • Maria Fragala, PT• Laura Freeman, PT
• Site(s)• Franciscan Children’s Hospital, Boston, MA• Kennedy Day School, Boston, MA• Mass. Hospital School, Canton, MA
• Purpose• This study will test the hypothesis that non-ambulatory children
with spastic quadriplegia who participate in two hours of lower
extremity weight bearing a day, will have an increase in bone
density.
Does prolonged standing improve bone mineral density in non-ambulatory children with spastic quadriplegia?
• Pilot finished
• Pilot Conclusions: It is feasible to have non-ambulatory children
participate in a rigorous standing program. The weight bearing “dose”
affects BMD at the calcaneous but the benefits appear to be transient if
the intensive standing program is not sustained
• Significance: The intensive use of standing devices (10hrs a week)
may have a beneficial effect on BMD of weight bearing bones in
non-ambulatory children
• Full study underway
The effects of passive standing on health-related areas for individuals with spinal cord injuries.
• Principal Investigator• Ronald Davis, PhD
• Co-Investigator• Leonard Kaminsky, PhD
• Site• Ball State University, Muncie, IN
• Purpose• This study is to assess the effects of prolonged passive
standing on bone mineral density (BMD) and health-related
factors in individuals with spinal cord injury.• Pilot Finished
• Conclusion • Standing must be longer than 30 minutes per day to
have effect on BMD
Working on weight bearing and gait with functional electric stimulation.
• Investigator• Dr. Richard Sheilds
• NIH Grants• Site
• University of Iowa Hospitals & Clinics, Iowa City, IA• Purpose
• To assess the use of the EasyStand 6000 Glider
and its potential with patients in their grant study.
Keep Moving: Technologies to enhance mobility and function for the individual with spinal cord injury.
• Principal Investigator(s)• Samuel Landsberger, ScD • Robert Waters, MD
• Site• California State University, Los Angeles, CA
• Purpose• To enhance the beneficial effects of therapeutic exercise
programs developed for individuals with spinal cord injury by
improving the equipment to make it more clinically effective
and easy to use, while minimizing the risk of injury. Our
strategy is to evaluate existing devices during one-on-one
training sessions with spinal cord injury subjects.
Health Parameters in Standing and Non-Standing, Non-Ambulatory Adults with Cerebral Palsy.
• Principal Investigator(s)• Kevin Murphy, MD • Kevin Sheridan, MD
• Site• Gillette Children’s Specialty Healthcare (Lifetime Clinic)
• Purpose• To describe health parameters of a population of standing
and non-standing, non-ambulatory adults with cerebral palsy
with a focus on measures of bone mineral density.
Parameters include bone mineral content and density, and
changes in bone metabolic parameters such as anabolic and
catabolic function. Other physical health parameters including
bowel and bladder function, upper extremity strength and
subjects report of pain.
The effects of passive and dynamic standing in multiple sclerosis.
• Director• Christine Martin, PhD• Pat Provance, PT
• Site• University of Maryland Medical School, Baltimore, MD• Veteran's Administration Multiple Sclerosis Center of
Excellence, East, Baltimore, MD• Purpose
• Enhance functions for individuals with multiple sclerosis• Pilot Finished
The effects of passive and dynamic standing in multiple sclerosis.
• Conclusion • This small pilot study compared static and dynamic standing to
no standing on multiple measurements. Statistical significance
was not reached due to the small sample size, however,
important trends were observed.
• We hypothesized that subjects in Group B (dynamic standing)
would demonstrate the greatest improvement in outcome
measurements. However, results (thus far) indicate Group A
(static standing) had more consistent and positive outcomes.
The effects of passive and dynamic standing in multiple sclerosis.
• Conclusion
• Subjects in Group B with higher functional ability to baseline
indicate the greatest individual improvement mid-way through
the study.
• Observations (thus far) indicate that active upper and lower
extremity movements required of Group B are too vigorous for
subjects with greater functional impairment.
• Based upon the trends seen in the treatment phase of this
pilot, a larger trial is warranted. The trial is currently in the
follow-up phase to assess any carry-over benefit
of passive or dynamic standing.
PendingResearchStudies
Prototype pediatric active stander pilot study for clients with cerebral palsy.
• Principal Investigator• Thomas Polisoto, MD
• Site(s)• Children’s Hospital, Erie County Medical Center, Buffalo, NY• Elmwood Health Center, Buffalo, NY
• Purpose• Treatment of risk/development of osteoporosis in kids with
cerebral palsy using the prototype pediatric active stander with
and without supplemental vitamin D and calcium with controls.• Influence of the use of the prototype pediatric active stander on
hip/acetabular development in the same population.
Indications/Contraindications
• Individuals at risk for immobilization syndrome • Restricted neuromuscular activity due to paralysis• Individuals who stay in a given position
• i.e. sitting in a wheelchair for continuous
or prolonged periods of time • Impaired mobilization due to disease, illness, or disability
• Physician referral• Therapist evaluation and program set up• Therapeutic follow up
Clinical Indications
• Physician declined referral • Orthostatic intolerance syndrome
• Orthostatic hypotension• Postural tachycardia syndrome
• Impaired skeletal structure that will not tolerate weight bearing• Osteogenesis imperfecta, osteoporosis, or other
forms of brittle bone disease• Certain orthopedic disorders
• Hip and/or knee flexion contractures greater
than 20º and non reducible
Clinical Contraindications
AcceptedMedicalBenefits
of Standing
• Prevention of contractures and improvement of joint range of motion • Reduction of spasticity• Prevention or reversal of osteoporosis and resultant hypercalciuria• Improvement in renal function, drainage of the urinary tract, and
reduction in urinary calculi• Prevention of pressure ulcers• Improvement in circulation as it relates to orthostatic
hypotension and other benefits of good circulation• Improvement of bowel function
Passive standing has been demonstrated to prevent, reverse, or
improve many of the adverse affects of prolonged immobilization.
Musculoskeletal System
• Immobilization has dramatic effects on the musculoskeletal system.• It has been demonstrated that the immobilization of muscles and
lack of weight bearing on bones causes bone demineralization and
true osteoporosis.
The immobilized patient: Functional pathology and management,Steinberg, F.U. et al (16)
Musculoskeletal System
• Experiment demonstrated healthy men immobilized by complete
bed rest reversed increased calcium excretion by quiet standing
three hours per day.
Effects of prolonged bed rest on urinary calcium output. Issekutz et al (17)
Musculoskeletal System
• Investigators found that muscle stretch by weight load in standing
was able to reduce spasticity 26%-32% depending on the flexion of
the feet.
Evaluation of the effects of muscle stretch and weight load in patients
with spastic paraplegia. Odeen and Knutsson (18)
• After a period of weight load with calf muscle stretch, this spastic
restraint may be reduced by up to 70% and the effect may be sustained
for several hours.• The standing procedure is easily managed and may therefore be used
in a home program if the patient is supplied with supported standing.
Effects of Muscle Stretch. Odeen and E. Knutsson (18)
Musculoskeletal System
Loss of Strength
• Muscles at rest lose strength at a rate of about 10-15% per week, at 4 weeks the patient will have only 50 to 60% of their strength remaining.
The malignant effects of bed rest. Richardson, J.K. (19)
Loss of Skeletal Mass
• Bones need the stress of gravity and tendons to maintain their mass. Patients who have been immobilized for several weeks or more will not re-gain their pre-morbid bone density for several months and so are at an increased risk for fracture should they fall during that time.
Musculoskeletal System
• Since osteoporosis is a major risk factor, patients with cerebral
palsy should bear weight to prevent pathological fractures.• Any stiffness of major joints and extended periods of immobilization
should be avoided.
Pathological fractures in patients with cerebral palsy. Brunner, R.D et al (20)
Pulmonary
• The patient needs to be turned, sat (the lungs dangled), percussed and
generally mobilized; avoiding these treatments is as detrimental as
choosing the wrong antibiotic.
The malignant effects of bed rest. Richardson, J.K. (19)
Renal and Urinary Tract
• Hypercalciuria resulting from bone changes induced by
immobilization predisposes the patient to urinary tract calculi and
infection. This is especially true for spinal cord injured that also have
impaired bladder function and inhibited bladder emptying.
The physiology and pathology of bed rest. Browse, N.L. (21)
• Urine may stagnate in the kidneys since gravity cannot assist
in drainage. The result is stasis or stagnation of urine in
bladder with subsequent formation of calculi.
Renal and Urinary Tract
• Hypercalciuria associated with immobilization is thought to be due to
reduced axial weight bearing on the long bone of the skeletal
system causing loss of large amounts of bone calcium, which is
excreted in the urinary tract.
A long-term survey of the incidence of renal calculosisin paraplegia. Browse, N.L. (21)
Renal and Urinary Tract
• Suggests weight bearing within 18 months of injury would
significantly reduce incidence of urinary calculi.
The metabolism of calcium in patients with spinal cord injuries.Freeman, L.W. (22)
Renal and Urinary Tract
• Quiet standing for two or more hours per day appears to reverse the
changes in mineral metabolism induced by bed rest.• Evidence of this type supports the concept that it is the absence of
pressure forces on the skeleton which if primarily responsible for disuse
osteopenia.
Effects of prolonged bed rest on bone mineral. Donaldson, C.L. (23)
Renal and Urinary Tract
• Standing programs have been shown to have an effect on bone
development in humans and animals. Bone mineral density has
been demonstrated to increase with exercise programs that
provide a physiologic stimulus for bone modeling.
Considerations related to weight bearing programs in children with
developmental disabilities. Stuberg, W.A. (24)
Skin and Underlying Tissue
• The prevention and treatment of these ulcers require pressure relief
that may be accomplished by postural changes.• Passive standing provides pressure relief to the seated or supine
individual by shifting the pressure from the ischial tuberosities,
trochanters, and sacrum to the long bones of the legs.
Pressure sore prevention for the wheelchair bound spinal injury patient.Fergusion-Pell, M. et al (25)
Skin and Underlying Tissue
• The average number of hospitalization days for pressure ulcer
treatment was 150 days, with an average cost of $150,000 per
patient hospitalized.
Pressure ulcers in veterans with spinal cord injury; A retrospective study.Garber, S.L. (26)
Cardiovascular System
• After a period of immobilization, if an individual attempts to sit or stand,
there is a marked pooling of blood in the lower extremities causing a
decrease in the circulating blood volume. Blood pressure drops and the
brain is depleted of blood and oxygen, which may lead to fainting.
Effects of immobilization upon various metabolic and physiologic
functions of normal men. Deitrick, J.E. (27)
Cardiovascular System
• The problem of orthostatic hypotension caused by immobilization
can be improved by repeated standing.
Cardiovascular and hemodynamic response to tilting and to
standing in tetraplegic patients. Figonia, S. (28)
Digestive System
The digestive system is affected by prolonged immobilization. Valibona, C.
(29)
• There is a general decrease in gastrointestinal activity. The decrease in mobility leads to constipation. Prolonged constipation may lead to fecal impaction and serious intestinal dysfunction.
Conclusion
Many of the documented pathological changes that occur due to
immobilization may be prevented, reversed or improved by a regular
standing regimen.
Funding andDocumentationfor Standing
Achieving Effective Documentation
• Detail the client: Who is this person medically (brief specific history)?• Provide the client’s history of compliance.• Explain how the stander will help achieve functional goals/outcomes.• Describe trial use of the proposed standers.• List alternatives that were considered & rejected (include less/most
costly medical alternative).• If possible, present photos & videos to convey the information along with
documentation.• Be complete, but concise; reviewers do not have time to read a novel.• Include supporting material: clinical studies, papers, etc.• Re-submit and appeal when necessary.
Letter of Medical Necessity Outline
Personal Information
• Name• Date of birth• Diagnosis• Onset of disability• Height• Weight• Funding (primary/secondary)• Brief medical history (specific to the need of the device)
Current Function
• This section should draw a complete picture of the client with words.• Ambulation: Type and how much assist• Transfers: Type and how much assist• Activities of daily living: How independent or dependent• Living environment (brief description)• Mobility: Home and community (brief description)• School/Employment (brief description)• Transportation (i.e. own car, van, public transportation)
Physical/Medical Condition
• Concentrate on a medical overview. Give specific medical factors that
will be affected by standing technology and how they will change.• Facilitating symmetrical posture• Developing/improving head, neck, and upper body muscle control• Inhibiting abnormal muscle tone and reflexes• Preventing loss of range of motion (ROM)• Improving systemic functions (i.e. bladder, respiratory, circulatory,
and digestive)• Preventing loss of bone density• Developing standing tolerance and endurance• Aid in normal skeletal development• Aid in balance restoration through upright posture• Other
Current Program
• What is the client’s current therapy program at home, school, work &
their history of compliance?• What are client’s functional goals?• What other less costly alternatives were considered (ROM, splints,
other methods of weight bearing)?• What other medical interventions may be necessary if client cannot
receive a stander (surgeries, bracing, etc. approximate cost of other
interventions)?
Equipment Trail
• What equipment was considered and/or tried for how long
(least to most costly)?• What were the outcomes of each trial and why was each trail either
accepted or rejected?
Recommendations
• What equipment is being recommended and why?• What is the prescribed standing program (what setting, describe
protocol, minutes/hours/day, times/week)?• What are the expected outcomes?
CurrentTechnology
Standing Technology Providers
• Altimate Medical - Sit to Stand• Levo - Standing Wheelchair• Life Stand - Standing Wheelchair• Mulholland- Prone• Permobil - Standing Wheelchair• Prime Engineering - Sit to Stand• Sammons Preston - Prone, Multi-positioning, Supine • Snug Seat - Prone, Multi-positioning, Supine• Stand Aid of Iowa- Sit to Stand• DavisMade Inc. - Standing Wheelchair• Rifton - Prone, Multi-positioning, Supine• Theradapt - Supine, Prone• Vertran - Standing Wheelchair
www.easystand.com