by Caitriona S. Modoono, DPT, Lisa M. Perkins, DPT, CSCS, and Melissa H. Agrimanakis, DPT
Standing is an essential part of daily life, and the vertical position lends itself to numerous physiologic and psychologic benefits. Those who suffer spinal cord injuries are affected not only by mobility restrictions, but also by a sequela of autonomic and metabolic impairments due to primarily being wheelchair bound. Some of these complications include: decreased bone mass, poor circulation, disuse atrophy, contractures, spasticity, pressure sores, impaired bowel and bladder function, and depression.1 The greatest degree of bone loss occurs within the first year after injury due to significant reduction in weight bearing, resulting in an imbalance in which bone resorption occurs at a faster rate than bone formation, thus increasing risk for lower extremity fractures.2 Early intervention is essential to delay these processes from occurring. Luckily, due to advanced technology, these opportunities are available for individuals of all disabilities to safely assist with obtaining a vertical position.
Initial transition to upright can be limited secondary to autonomic dysfunction, resulting in impaired hemodynamic response. Therefore, we have developed this systematic approach with utilization of a variety of technologies to successfully transition individuals who have suffered spinal cord injuries into a vertical position for prolonged periods of time. Prior to initiating such interventions, patients have been cleared by medical professionals and do not have fractures, skin impairments, and/or range of motion limitations. All of these interventions are also initially performed with full compression garments donned, including TEDS, ace wraps, and abdominal binders as appropriate.
Early Rehabilitation Robotic Device
Within a few days of admission at our acute rehabilitation hospital, it is a priority to get patients hemodynamically stable in an upright position. This allows them to tolerate more aggressive therapy and participate in a standing program as soon as possible. One of the earliest neuro re-education interventions we incorporate is utilizing an early rehabilitation robotic device: a vertically adjustable platform that provides cyclic leg loading and synchronized functional electrical stimulation (FES). It has been found that stepping movements in combination with loading of the legs have been associated with a patterned leg muscle activation in both persons with complete paraplegia and tetraplegia.3 The early rehabilitation robotic device allows for slowly increased verticalization of a patient, while the cyclic leg movement allows for increased cardiovascular stability. Also, this device allows prevention of secondary damage such as contractures and muscle atrophy while having a positive influence on neuroplasticity and spasm management.?
Due to the increased set-up time and requirement of a skilled physical therapist to perform the intervention, patients will participate in sessions using the early rehabilitation robotic device one to two times weekly, with an initial duration of 15 to 20 minutes and progressing to 45 to 60 minutes, depending on their hemodynamic response and individual goals. Due to the dynamic movement associated with this device, achieving success in a more upright position is achieved faster than with a static device. With time, as the patient’s tolerance to upright increases, we increase the verticalization and decrease the cadence of the stepping in preparation for progression to a static tilt table.
With successful tolerance of full upright on the early rehabilitation robotic device, it is necessary to continue hemodynamically challenging the patient’s autonomic system with progression to a static tilt table. Unlike other devices, the static tilt table also allows freedom to accommodate special needs a patient may have, such as prepositioning the table at an incline if supine is not tolerable, as well as prone use if a patient has skin breakdown on the sacrum or coccyx. As the patient maintains hemodynamic stability, the increment of tilt can be increased gradually as well as the duration spent in an upright position. Ideally, the patient should spend 30 to 60 minutes three to five times per week.? Due to the simplicity of setup, patients are able to participate in a “tilt table program” with a rehabilitation aide outside of physical therapy sessions to allow for an increased frequency of use.
As a patient gets closer to transitioning home, therapists educate them about the benefits and importance of their continued participation in a regular standing program. Oftentimes the safest and most appropriate way for independent participation is with a standing frame. Trials of the device begin as soon as the patient has demonstrated tolerance of the static tilt table at an increased vertical angle, such as 60 degrees or higher. The standing frame allows the patient to achieve vertical from a more natural sit-to-stand transition versus a supine-to-stand that occurs with use of the early rehabilitation robotic device or tilt table. The therapist will trial a variety of devices, including both static frames and dynamic standing gliders, to determine which device meets the need of the patient to participate in the prescribed standing program. Evidence suggests that patients should stand for at least 30 minutes, 7 days per week, to slow or even stop the decrease in bone mineral density, and also to prevent the previously mentioned complications.?
For static standing frames therapists and caregivers may find multi-position standers that can have adjustments made without the use of tools a useful convenience. Accessories such as multi-position trays and shoe holders may be desirable for some users, in addition to height-adjustable pommels that can help keep lower extremities in the desired position. Standing systems that can be adjusted to accommodate growth are important for pediatric users who may use a standing frame at home.
Dynamic standing systems are designed to provide clinical benefits associated with activity. Among the design features that provide these benefits are handles that the user’s arms can move back and forth across the sagittal plane, simultaneously creating reciprocal movement in the lower limbs. Other important features for this type of device are padded knee, seat, and chest supports that provide safe positioning without straps coming into contact with the skin. For facilities where standing systems are used by multiple individuals of various sizes, adjustable-width knee blocks may be a desirable feature. For some individuals post-SCI, a standing frame may be recommended for home use. In these cases, flip-down knee pads are a design feature that can enable users to self-transfer from a wheelchair.
Robot-Assisted Treadmill Training
A robot-assisted treadmill designed to provide body weight support is an excellent adjunct therapy for those patients who have incomplete spinal cord injuries and have a goal of ambulation. There are several articles with good evidence that reveals robot-assisted ambulation can change neural activation in the spinal cord and improve gait biomechanics. It is thought that use of the robot-assisted treadmill can assist with the corticospinal reorganization7,8 as well as activation of the central pattern generators within the spinal cord that assist with ambulation.? There are limited studies which focus on usage parameters; however, it is thought that reducing the body weight support, increasing the duration of ambulation, increasing speed, and reducing guidance force will improve functional outcomes on this device.10
Prior to use of the robot-assisted treadmill, we ensure that patients are able to tolerate 30 minutes in full vertical stance with stable hemodynamic response. This is due to the increased time required to complete the initial set-up of the patient within the locomotor system. The robot-assisted treadmill is ideal for the patient who has normal range of motion at the knees, hips, and ankles, no skin breakdown, minimal to no spasticity, and fair to good tolerance to strenuous exercise. Once the optimal patient settings have been determined by the clinician, subsequent sessions will be focused on increasing weight bearing, time performing in active-assisted ambulation, increasing speed, and reduction of guidance force. Pending availability, the robot-assisted treadmill should be utilized at least once per week in conjunction with pre-gait and gait training over-ground and in a pool.
Individuals with spinal cord injuries in the early phases of their rehabilitation are commonly limited by orthostatic hypotension which impacts their ability to participate in vertical activities. With use of the previously mentioned technology in our recommended systematic approach, early mobilization is possible. The ability to get individuals up on their feet at a faster rate for a longer duration delays the onset of secondary complications that occur with SCI. We not only recommend utilization of equipment within the hospital setting, but also ensuring patients can perform such interventions independently post-discharge with use of standing frames. RM
Caitriona S. Modoono received her DPT from Simmons College (Boston) in 2012. Since 2012 she has practiced in the acute rehab setting working with patients of all ages. Modoono is currently an advanced clinician and practice leader on the Spinal Cord Injury Inpatient Unit at Spaulding Rehabilitation Hospital, Boston.
Lisa M. Perkins received her DPT and CSCS certification from Northeastern University (Boston) in 2014. Since 2014 she has practiced in the acute rehab setting, initially with a variety of diagnoses prior to specializing in Spinal Cord Injury. Lisa is currently an advanced clinician on the Spinal Cord Injury Unit at Spaulding Rehabilitation Hospital, Boston.
Melissa H. Agrimanakis received her DPT from MGH Institute of Health Professions (Boston) in 2010. Since 2010 she has practiced in the acute care and rehab settings working with adults and children. Agrimanakis is currently a clinical specialist on the Spinal Cord Injury Unit at Spaulding Rehab Hospital, Boston, and specializes in wound care. For more information, contact [email protected].
1. Kunkel CF, Scremin E, Eisenberg B, Garcia JF, Roberts S, Martinez S. Effect of “standing” on spasticity, contracture, and osteoporosis in paralyzed males. Arch Phys Med Rehabil. 1993;74:73-78.
2. Edwards WB, Schnitzer TJ, Troy KL. Reduction in proximal femoral strength in patients with acute spinal cord injury. J Bone Min Res. 2014;29(9):2074-2079.
3. Dietz V. Spinal cord pattern generators for locomotion. Clin Neurophysiol. 2003;114:1379-1389.
4. Craven CTD, Gollee H, Coupaud S, Purcell MA, Allan DB. Investigation of robotic-assisted tilt-table therapy for early-stage spinal cord injury rehabilitation. J Rehabil Res Dev. 2013;50(3):367-378.
5. Bohannon RW. Tilt Table standing for reducing spasticity after spinal cord injury. Arch Phys Med Rehabil. 1993; 74: 1121-1122.
6. Dionyssiotis Y, Lyritis GP, Mavrogenis AF, Papagelopoulos PJ. Factors influencing bone loss in paraplegia. Hippokratia. 2011;15:54-59.
7. Shin JC, Kim JY, Park HK, Kim NY. The effects of robotic-assisted gait training in patients with incomplete spinal cord injury. Ann Rehab Med. Dec 2014;38(6):719-25.
8. Hajela N, Mummidisetty CK, Smith AC, Knikou M. Corticospinal reorganization after locomotor training in a person with motor incomplete paraplegia. Biomed Res Int. 2013;2013:516427. doi: 10.1155/2013/516427. Epub 2012 Dec 26.
9. Minassian K, Hofstoetter U, Dzeladini F, Guertin P, Ijspeert A. The human central pattern generator for locomotion: does it exist and contribute to walking. Neuroscientist. 2017;23(6):649-663.
10. Mayr A, Kofler M, Quirbach E, Matzak H, Frohlich K, Saltuari L. Prospective, blinded, randomized crossover study of gait rehabilitation in stroke patients using the lokomat gait orthosis. Neurorehabil Neural Repair. 2007;21(4):307-314.
Letter of Medical Necessity
What funders should know about the stander your client needs
Prior to discharge, it is recommended that the client and primary physical therapist meet with a vendor to ensure the appropriate specifications for the standing frame are ordered. When writing a Letter of Medical Necessity (LMN), there are key points to include to assist with insurance approval to fund a standing device for home. It is necessary to provide documentation which demonstrates:
• Patient’s ability to tolerate standing for 30 minutes with hemodynamic stability.
• Patient’s current participation in a standing program.
• Patient’s ability to independently transfer (or direct a transfer).
• Patient’s ability to independently use the device or direct a caregiver in how to assist.
• The need for a standing device.
• Health benefits of standing.
• Prevention of medical complications.
Providing complete and thorough documentation will decrease denials from insurance companies. This, in turn, expedites the process to receive the standing frame and, thus, allow the patients earlier participation in a home standing program and a decrease in the risk of complications associated with prolonged sitting.