There are many children and adults with disabilities who cannot stand independently. This can be caused by injuries and diseases such as spinal cord or head injuries, cerebral palsy, spina bifida, and multiple sclerosis. The use of standing systems can benefit these individuals both while undergoing therapy and in their daily lives. Anyone who cannot independently stand can benefit from the use of a stander. Significant research has been conducted to establish the benefits of standing. While the levels of evidence for standing are not as high as for some other therapeutic interventions, the need for standing is well established.1
Benefits of Standing
Standing has been shown to delay the appearance of contractures and improve those that already exist.2,3 For individuals who lack the strength to stand, the standing frame keeps them in a good position to stretch their lower extremity and trunk muscles for extended periods. This stretch can help to maintain and improve lower extremity range of motion.
Standing has a positive effect on spasticity. It has been shown to decrease spasticity in children with cerebral palsy.4 It also lessens spasticity in individuals with spinal cord injuries.5 Decreasing spasticity assists in maintaining and improving range of motion and improving overall level of function.
Children without disabilities stand between 8 and 10 months of age. This standing helps with the forming of the acetabulum.6,7 It is very important for children with disabilities to get them standing at as young an age as possible. Children who stand late and have significant spasticity are at increased risk of developing hip subluxation as they grow. Standing will increase the depth of the acetabulum and decrease the risk of subluxation.
People who cannot stand independently are at increased risk of developing osteoporosis.8,9 Standing can improve bone mineral density. Research has shown that dynamic weight bearing results in less loss in bone mineral density.10 When vibration is added to standing, the benefits are increased as compared to static standing.11
People who cannot stand have an increased risk of developing decubitus ulcers.12 People who stand for at least 30 minutes per day have fewer pressure sores than those who do not stand.5 As decubitus ulcers can be costly and result in significant loss of activity, this is especially important.
The use of a stander can benefit people psychologically.5,13 Most people report improved quality of life after beginning a standing program. It can also increase self-esteem by allowing eye-to-eye conversations with peers. This decreases the risk of developing depression over time.
Standing has been shown to improve motor function in both adults and children.14-16 Gains in gross motor function and balance in children with cerebral palsy, and ambulation in nursing home patients with various diagnoses, have been documented.
Standing also facilitates better emptying of the bladder, which can decrease the risk of developing urinary tract infections.12 The other benefits of standing are well established. Standing has been shown to improve circulatory, gastrointestinal, bowel control, and respiratory functions.6,12,17
It is clear from the research that standing is beneficial for all populations who are nonambulatory.
There are a few contraindications and precautions to beginning a standing program. The majority of the risks of a standing program are only precautions. The one main contraindication would be any condition, such as a healing fracture or severe osteoporosis, that precludes weight bearing of any kind. For some individuals with a healing fracture in one limb, a stander can be adjusted to prevent weight bearing on one limb if necessary.
Individuals with significant hip or knee flexion, or ankle plantarflexion contractures, may not be able to use a stander. Caution should be taken to ensure that the stander does not place too much stretch or that surfaces such as the knees do not have too much pressure due to a contracture. If this is the case, standing may be contraindicated until more motion is obtained.
For individuals with compromised cardiovascular or respiratory systems, close monitoring of circulation and function while in a stander is necessary to prevent serious complications. This would include blood pressure, heart rate, and any signs of orthostatic hypertension.
TYPES OF STANDERS
There are three styles of independent standing systems: prone, supine, and sit-to-stand. Within those three types, there are dynamic, static, and mobile standers. Additionally, there are standing systems that are integrated into wheelchairs.
Supine Versus Prone Versus Sit to Stand—Supine standers are most appropriate for medically fragile individuals who have very poor head control and those who have tracheotomies and G-tubes. Supine standers are thought to be the least stressful of all of the types of standers because most of the weight is taken through the back rather than through the legs. For children, this type of stander is usually easy for a family to use because the child is placed into the stander in supine. The more upright the individual is positioned, the more weight bearing that they will do through their legs.
Prone standers usually are used only for children who are alert and interactive and who have fair to good head control. They can be used to help improve head control if the caregiver can closely supervise the child in the stander. A prone stander can also help facilitate weight shifting because the child is leaning forward while in the stander. One problem with prone standers is that they can make it difficult to position the child. This is because the child must be placed in the stander in standing. This can be a challenge for a parent who is home alone and has to hold the child in the correct position as the straps are adjusted and tightened.
Sit-to-stand standers work best for the same patient population as the prone standers and are commonly used for adults. This stander allows the individual to be placed into it in a sitting position. This is a somewhat easier position in which to secure the individual. Additionally, many higher functioning adults can transfer themselves into the device independently. The other benefit of this type of stander is that some of these designs can be used in sitting. It has an adjustable height and adjustable depth tray so it can be used well in both positions.
Dynamic, Static, or Mobile
Static standers are the most commonly used type. The person is fully supported at all times, and the leg muscles are basically inactive. The person and the stander do not move.
Dynamic standers allow and encourage movement. The person weighs and unweighs their legs, as well as flexes and extends their joints. These can also be referred to as gliders.
Mobile standers let the person move around their environment while in a standing position. There are pediatric and adult models of this type of stander. For children, it can be used both in the classroom and at home. For adults, it can let them be more functional at home and at work.
Wheelchairs that have integrated standers are manufactured in both manual and power styles. The benefit of these systems is that the person does not have to transfer out of the wheelchair to use the device so they can use it more frequently. It also assists in completing their activities of daily living and can increase their independence throughout the day.
These systems are more expensive than similar manual and power wheelchairs without the standing features. Consequently, the funding and justification for these may be more difficult. However, some private payor sources that will not fund static standing will fund wheelchair standers, as they improve function and independence.
There is little evidence about how frequently and how long a person needs to stand to achieve the positive medical benefits of standing. By reading the research, it is clear that different amounts of standing are necessary to achieve different benefits of standing. Consequently, there is not currently one agreed upon program. The best recommendation is for patients to stand daily for at least 45 minutes and up to 2 hours. As with many other therapeutic interventions, more is likely better so encouraging patients to stand as frequently as possible will ensure that they get the most benefit.
Funding for standers is varied based on state of residence, patient’s age, and funding source. Many practitioners believe that standers are difficult to obtain so they do not recommend them for their patients. However, with a few exceptions, this is not the case and most standers can be funded.
It is important to note the few exceptions. The largest funding source that does not currently fund standers is Medicare. Additionally, a few private insurance companies have published policies that prohibit the funding of standers. Both groups base their policies on outdated research. Hopefully, with the more recent publications, they will change their policies.
For Medicaid and other private payor sources, the documentation necessary is usually similar to what is required for obtaining a wheelchair. It is important to document the patient’s current function, goals, and the medical necessity for the stander and all needed accessories.
Most of the major standing system manufacturers have funding guides to assist practitioners in properly justifying their equipment. These can usually be downloaded from the company’s Web site. They are very helpful and usually include sample letters. Additionally, for wheelchair standers, there is a position paper published by the Rehabilitation Engineering and Assistive Technology Society of North America.18 This paper contains both published research and best clinical practice guidelines for the provision of these products.
Standing is beneficial for all individuals and should be encouraged for everyone who cannot do so independently. There are a variety of products available to help almost everyone achieve upright standing, and for most individuals, there is some type of funding available to assist them in obtaining this equipment.
Lauren Rosen, PT, MPT, ATP, is the Motion Analysis Center program coordinator for St Joseph’s Children’s Hospital, Tampa, Fla. For further information, please contact .
- Sackett DL, Strauss SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. Philadelphia: Churchill-Livingstone; 2000.
- Vignos P, Wagner M, Karlinchak B, Katirji B. Evaluation of a program for long-term treatment of Duchenne muscular dystrophy. J Bone Joint Surg Am. 1996;78:1844-1852.
- Baker K, Cassidy E, Rone-Adams S. Therapeutic standing for people with multiple sclerosis: efficacy and feasibility. Int J Ther Rehabil. 2007;14:104-9.
- Tremblay F, Malouin F, Richards CL, Dumas F. Effects of prolonged muscle stretch on reflex and voluntary muscle activations in children with spastic cerebral palsy. Scand J Rehabil Med. 1990;22:171-180.
- Walter JS, Sola PG, Sacks J, Lucero Y, Langbein E, Weaver F. Indications for a home standing program for individuals with spinal cord injury. J Spinal Cord Med. 1999;22:152-8.
- Stuberg WA. Considerations related to weight-bearing programs in children with developmental disabilities. Phys Ther. 1992;72:35-40.
- Macias LM. The effects of the standing programs with abduction for children with spastic diplegia. Pediatr Phys Ther. 2005;17:96.
- Whedon GD. Changes in weightlessness in calcium metabolism and in the musculoskeletal system. Physiologist. 1982;25:S41-4.
- Henderson R, Kiaralla J, Abbas A, Stevenson R. Predicting low bone density in children and young adults with quadriplegic cerebral palsy. Dev Med Child Neurol. 2004;46:416-19.
- Thompson CR, Figoni SF, Devocelle HA, Fifer-Moeller TM, Lockhart TL, Lockhart TA. From the field. Effect of dynamic weight bearing on lower extremity bone mineral density in children with neuromuscular impairment. Clinical Kinesiology. 2000;54:13-8.
- Ward K, Alsop C, Caulton J, Rubin C, Adams J, Mughal Z. Low magnitude mechanical loading is osteogenic in children with disabling conditions. J Bone Miner Res. 2004;19:360-9.
- Dunn RB, Walter JS, Lucero Y, et al. Follow-up assessment of standing mobility device users. Assist Technol. 1998;10:84-93.
- Huston G. Use of prolonged standing for individuals with spinal cord injuries. Phys Ther. 2001;81:1392-9.
- Ahlborg L, Andersson C, Julin P. Whole-body vibration training compared with resistance training: effect on spasticity, muscle strength and motor performance in adults with cerebral palsy. J Rehabil Med. 2006;38:302-8.
- Netz Y, Argov E, Burstin A, et al. Use of a device to support standing during a physical activity program to improve function of individuals with disabilities who reside in a nursing home. Clin Rehabil. 2007;21:977-986.
- Garrett ML, Hinman M, Curry T, Jowers C. The effects of whole-body vibration on spasticity in children with cerebral palsy: case reports. Poster session presented at: annual meeting of the American Physical Therapy Association; 2006; San Antonio.
- Edwards LC, Layne CS. Effect of dynamic weight bearing on neuromuscular activation after spinal cord injury. Am J Phys Med Rehabil. 2007;86:499-506.
- Arva J, Paleg G, Lange M, et al. RESNA Position on the Application of Wheelchair Standing Devices. Assist Technol. In press.