by Jillian Cacopardo, MPT, ATP/SMS
PHOTO ABOVE: Jillian Cacopardo, MPT, ATP/SMS, performs a standing system evaluation with an outpatient at Gaylord Specialty Healthcare.
As an adult, can you remember a time when you had to think about the steps it takes to get out of bed in the morning? Or get up out of a chair? To accomplish either of these tasks, two similar actions must occur: one must stand. As I age, it is becoming more difficult to attain a standing position as a result of stiffness that sets in overnight or after sitting for a long period. Despite these minor difficulties, I can still roll out of bed, place my feet on the floor, and stand up. Those actions are not possible, however, for many of the patients I see at Gaylord Specialty Healthcare, a rehabilitation-focused healthcare system headquartered in Wallingford, Conn.
More standing tips in this interview with Jillian Cacopardo!
Among individuals affected by a spinal cord injury, the benefits of standing are substantial but achieving a standing position can be problematic. There is not a great deal of literature regarding standing, but firsthand reports from patients indicate standing has truly positive effects. The benefits range from decreasing spasticity, to improving the ability to breathe, and improving bowel regularity. Standing on a daily basis can have profoundly positive effects. At Gaylord Specialty Healthcare our patients, no matter their diagnosis, are required to put considerable thought and effort into standing. Many cannot stand at all without some sort of support such as an ambulation device or a standing device. Whatever the case may be, the importance of standing cannot be minimized, and if therapists can help a person acquire a device that enables him or her to stand it is crucial that clinicians possess a keen understanding of the process.
How Can One Stand?
Standing systems have evolved over the years with the tried-and-true sit-to-stand as the most common type of system. A sit-to-stand device allows the patient to transfer into the equipment and begin from a seated position to be raised to an upright standing position. There is also a type of sit-to-stand device that uses a harness placed under the patient to raise him or her up to a tray table in front of the patient. Although these are the most popular models, there are disadvantages to this type of system. For example, if someone relies on a mechanical lift for transfers, it can be difficult for a single caregiver to place the person in the standing frame and then position all the accessories that are necessary to achieve a standing position. If a person is unable to assist in weight shifting and/or requires a mechanical lift for transfers, it may be difficult to place a harness underneath that person.
A supine stander is another type of device that functions similarly to a tilt table that supports an individual anteriorly and laterally and angles the equipment upward until upright. For a patient affected by significant issues with orthostatic hypotension, this design facilitates a more gradual elevation to upright and allow for blood pressure acclimation. These devices tend to be large, however, and storage may be difficult.
Perhaps the easiest way to facilitate standing is to use a device that enables a person to stand from a wheelchair. Manual standing wheelchairs facilitate this type of standing and utilize hydraulics or gas springs to assist the user to an upright position. However, the weight of these devices can hinder their use, and the need for users to lower themselves for propulsion wheel access if they need to move may be another disadvantage.
Among power wheelchairs, front-wheel drive models historically have accepted a power standing actuator while, more recently, some manufacturers have fitted mid-wheel drive chairs with a power standing actuator. Advantages and disadvantages exist for both approaches. For example, some may find mid-wheel drive devices more maneuverable than front-wheel drive models, typical of standard power chairs. Having the seating system placed over the drive wheel provides mid-wheel models with a shorter overall length and a smaller turning radius.
The front-wheel drive power standing wheelchair can offer the advantage of superior outdoor maneuverability, and some bases can be programmed to provide a sit-to-supine-to-stand transition. Its larger turning radius and the cost of a longer chair length, however, are disadvantages.
There are many indications for which a client should stand, and chief among them is to preserve bone density. Weight-bearing has been shown to slow the progression of osteoporosis, a high-risk disease for much of the patient population we treat.1,2 Another musculoskeletal benefit of standing is to assist in contracture prevention or to enhance existing range of motion. In the pediatric population, standing is important for skeletal development.3 It can also help lessen the progression of scoliosis. Standing can off-load pressures from the high load surfaces which may assist in wound management or skin preservation. Likewise, standing can support the cardiovascular system, assist in blood pressure regulation, improve circulation, and develop activity tolerance.1 Enhanced respiration can also be achieved by increasing diaphragmatic excursion and thoracic expansion when standing. An upright position can support improved gastric motility throughout the digestive system, support kidney function, and prevent constipation.1 Perhaps one of the most overlooked indications—certainly not one considered by third-party payors—is the psychological benefit derived from looking a peer or family member in the eye or being able to hug in an upright position.
There seem to be nearly endless benefits to standing but, unfortunately, not everyone is a standing candidate. If a patient suffers from orthostatic intolerance syndrome, where they experience a combination of a blood pressure drop and/or elevated heart rate, they may be inappropriate to stand.
Impaired skeletal structure is also a contraindication, particularly with osteogenesis imperfecta. Depending on its severity, osteoporosis, too, may rule out standing for some patients. It may be said, however, that standing can help increase bone density. Other contraindications include impaired range of motion or severe joint contractures that could cause excess pressure on key points of support or contribute to muscle tear if stretched excessively. Hip subluxation can also be considered a contraindication, but, again, it can be argued that standing may help improve hip socket development.4 It is imperative to use clinical judgement and work together with the patient, the caregiver, and the medical team, to determine whether standing offers greater benefit than risk.
As part of my ongoing practice at Gaylord Specialty Healthcare I have implemented strategies to best serve my patients. These strategies have evolved over the years but continue to prove beneficial. They ensure patients obtain equipment that best meets their medical and functional needs while reducing the potential for equipment abandonment.
When requesting a standing device the most important consideration is medical clearance to stand. The client’s primary care physician or physiatrist can provide this clearance, which may be based on an x-ray with bloodwork or a bone density scan. There have been times when the licensed/certified medical professional has also referred to an endocrinologist for further assessment. If results are inconclusive or not optimal, the medical professional can document this and clear a person to stand based on available information.
Once clearance has been obtained, a standing program is initiated. This works best under the guidance of a therapist with access to equipment that most closely matches the patient’s preferences. This may take place in the home or clinic. It has been found that if a patient has shown progress toward upright, third-party payors are more likely to approve the equipment. Of course, this is only if standing is covered under the patient’s policy. It is recommended that patients research their coverage for standing devices so they know what is and is not covered and the costs for which they may be responsible.
Equipment abandonment seems to be high, particularly with stationary standing frames. This seems to stem from a difference in the type of lift equipment available within the clinic versus the home setting. Abandonment also seems to be related to the potential need for multiple caregiver assistance for set-up in a standing frame. Caregiver coverage similarly seems to play a role in the frequency with which a patient can use the equipment. Caregivers are stretched thin and need to complete numerous other tasks, which may mean the patient who requires standing frame set-up and supervision may fall by the wayside.
In an attempt to reduce equipment abandonment, clinic practice standards have changed over the past few years. The patient and their caregiver are now expected to demonstrate their transfer ability to/from the equipment using the same type of transfer that will be used in the home.
Experience has shown that a gradual increase in angle and duration spent in a given position is more advantageous than attempting to bring a person upright too fast, as this may cause orthostasis, pain, and even injury.
Sample Standing Program
A sample standing program for a patient who has supportive caregivers and does not have range of motion limitations could look something like this:
• Week 1 of stance: Stand for a duration of 15-25 minutes, 1-2x/day. Stop ½ way to upright positioning (approximately 45-50 degrees) for 10-15 minutes. If there are no signs of orthostasis or pain, then increase the angle to 70 degrees, remaining in this position for the next 10-15 minutes.
• Week 2 of stance: Stand for a duration of 30 minutes, 1-2x/day. Stop ½ way to upright positioning (approximately 45 to 50 degrees) for 10-15 minutes. If she is without signs of pain or discomfort, then increase upright position to 75 degrees for the next 20 minutes.
• Week 3 of stance: Stand for a duration of 30-45 minutes, 1-2x/day. Stop ½ way to upright positioning (approximately 45 to 50 degrees) for 5 minutes. If she is without signs of pain or discomfort, then increase upright position to 75-80 degrees for the next 25-30 minutes.
• Week 4 of stance: Stand for a duration of 45-60 minutes per day. Stop ½ way to upright positioning (approximately 45 to 50 degrees) for 2 minutes. If she is without signs of pain or discomfort, then increase upright position to 75-80 degrees for the next 15 minutes.
In conclusion, why sit when you can stand? If possible, therapists should educate their patients about the benefits of standing and help them obtain a standing device. The justification for standing and its key benefits are fairly straightforward and perhaps best summed in a passage authored by one of the leading clinical thinkers in this area: “Standing 30 minutes per day, 5 times per week can provide positive impacts on areas, including self-care, range of motion, cardiorespiratory function, strength, spasticity, pain, skin, and bladder and bowel function, while standing 60 minutes per day, 4–6 times per week may provide positive impacts on bone mineral density.”5 RM
Jillian Cacopardo, MPT, ATP/SMS, is the Clinical Program Coordinator for Wheelchair Assessment Services for Gaylord Specialty Healthcare, Wallingford, Conn, a provider of complex medical care and rehabilitative services. Cacopardo, who specializes in wheelchair assessment and inpatient rehabilitation, received her Bachelor of Health Science and her Master’s Degree in Physical Therapy from Quinnipiac University. She is certified as an Assistive Technology Professional and as a Seating and Mobility Specialist. For more information, contact RehabEditor@medqor.com.
- Goktepe A. Does standing protect bone density in patients with chronic spinal cord injury? J Spinal Cord Med. 2008;31(2):197-201.
- Pin TW. Effectiveness of static weight-bearing exercises in children with cerebral palsy. Ped Phys Ther. 2007;19(1):62-73.
- Macias-Merlo L, Bagur-Calafat C, Girabent-Farres M, Stuberg WA. Standing programs to promote hip flexibility in children with spastic diplegic cerebral palsy. Ped Phys Ther. 2015 Fall;27(3):243-9.
- Paleg G, Livingstone R. Systematic review and clinical recommendations for dosage of supported home-based standing programs for adults with stroke, spinal cord injury, and other neurological conditions. BMC Musculoskeletal Disorders. November 2015.