In Good Standing

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November 2003

By Rachael G. Finke, PT, and Kristeen Muldoon, MSPT

The market for durable medical equipment for individuals who are not ambulatory is a diverse one. Standing frame chairs are just one of many options that also include manual wheelchairs, power scooters, electric chairs, and chairs with power-assisted wheels.

Our world is primarily set up for individuals who are able to stand at will. This fact does not make it easy for an individual whose primary mode of mobility is a wheelchair. Examples of tasks that will be easier to accomplish via the use of a standing frame chair are:

Reach a sink and paper towel dispenser to wash your hands
Pay cashiers
Achieve appropriate height for eye contact, handshake, or hug
Potential to take advantage of job opportunities
Hang clothes
Reach food on high shelves
Put away dishes
Reach a changing table to care for a baby
Close the trunk of a car or the hatch on a mini van
Pay less for home or office modifications due to the ability to stand and reach.

For those of us who are able to stand, we take these things for granted. For those who are not able, this list is too short; given 2 minutes, they could add at least 20 more practical applications that could enhance their day-to-day life. However, it is not just about being able to access common items throughout the course of a day; maybe the most important thing of all to consider is how the ability to stand affects someone’s self-esteem.

Standing frame chairs offer physical and medical as well as emotional and social benefits. Standing offers a change in position that is useful in aiding digestion, assisting with bowel and bladder programs, decreasing the risk of skin breakdown by unloading the buttocks, aiding in respiration, and decreasing the risk of orthostatic hypertension. Another thing to consider is that standing allows for weight bearing, which will promote muscle-pumping action to improve circulation and thus decrease the risk of circulatory problems. Weight bearing is known to help control abnormal muscle tone and decrease the risk of contractures, most notably at the hip flexors and heel cords.

Stander Precautions

However, some of the benefits listed above are also contraindications or precautions. Factors to think about before recommending a standing frame chair include:

Will existing contractures prevent an optimal standing position?
What is the mechanism of sit to stand in the chair and will it cause repetitive shear (thus increasing the risk of skin breakdown)?
What is the length of time that has passed since the client has stood? Are the muscles and bones able to tolerate the stress of standing without the risk of a fracture? Should a bone mineral density test be conducted first?
Does the client have orthostasis?
Is the client at risk for seizures?
Will existing tone be exacerbated by weight bearing?
What is the client’s self-perception? Standing via a standing frame wheelchair is very different from what they remember of themselves as a stander. There is potential to not like the new self-image.
Will it meet all of the client’s seating and mobility needs, not just their standing needs?

For all of these reasons, it is imperative to have a physician’s approval prior to a trial with a standing frame wheelchair. The physician will need to decide if it is medically sound for the client’s limbs to sustain the trial or if further testing is indicated first. Assuming that the doctor clears the client for use of a standing frame wheelchair, it is best to trial new equipment with a licensed physical therapist who is well versed in the various types of seating systems as well as a vendor who knows the assortment of products that are available.

Patient Populations

Standing frame chairs can be used for many patient populations including those with post-polio syndrome, spinal cord injuries, muscular dystrophies, multiple sclerosis, stroke, and head injury. It is important to note that this class of chair may be beneficial to clients who are able to stand, but who are not capable of sustaining the standing position long enough to successfully manage a functional task due to lack of balance and safety, lack of strength, medical need to use energy conservation techniques, lack of motor control, or inability to control tone. It should not be used for anyone for whom weight-bearing or standing is contra- indicated, or who is unable to physically, mentally, or emotionally manage the equipment.

Choices, choices

There are many traits that vary across models and brands and are important to consider when choosing a standing frame chair. First and foremost, should the client choose a manual or an electric standing frame chair? Generally speaking, to successfully use a manual standing frame chair, the client needs to have full use of both upper extremities. The purpose of this is twofold: to propel the chair in the seated position, and to engage the sit-to-stand mechanism. This also assumes that the client will not need to mobilize the system while in the standing position.

The electric or power version allows the client to propel the chair with an adaptive control (joystick, head control, etc) in the seated or standing position. In addition, the sit-to-stand mechanism is fully powered. If clients have a condition where it is deemed medically necessary to conserve energy, or they lack the ability to propel a manual wheelchair, have significant neurological or orthopedic findings in their spine, or have upper extremities that will undergo further overuse strain from repetitive use of a manual chair, then an electric chair can often be justified.

Further considerations for standing frame chairs include:

Will the client need the chair to recline? Some chairs recline, some tilt and recline, and some will bring the client from the supine position into the standing position.
Will the chair allow for a van/car tie-down so that the client can drive while seated?
Will the chair allow for appropriate seat and back adaptations to allow for postural accommodations that will not interfere with the sit-to-stand mechanism?
Where are the contact points of the standing frame? Are they appropriate for the client?
Will the chair travel on all terrain (curbs, ramps, gravel, grass) the client intends to use it on?
What is the turning radius?
Will the chair let the client come to a partial standing position (in order to close the trunk of a car, reach a low shelf)?
What is the time that the chair takes to change from sit to stand?
What types of steering controls are offered?

Other Considerations

While the following two devices are not standing frame chairs, they are appropriate to mention for their unique applications.

There is a class of chair known as the vertical lift chair. It is a power wheelchair that lifts the client vertically instead of bringing them into standing. This would be appropriate for a client who perhaps has orthostatic hypotension, or for whom weight-bearing is contraindicated or impossible (double amputee, high spinal cord injury). Another device worth mentioning is technically classified as a mobility device and not a wheelchair, but it is being marketed as a sit-to-stand unit able to ascend and descend stairs. The options for standing frame wheelchairs are highly varied, and clients depend on the knowledge and skill of the doctor, physical therapist, and wheelchair vendor to provide them with accurate information to allow them to make a safe, practical decision.

Remember, the client may be coping with many psychosocial issues when it comes to standing—this is not just about obtaining a new chair. It may allow your client to access a world once thought lost to them, a world most of us take for granted.

Rachael G. Finke, PT, and Kristeen Muldoon, MSPT, are therapists at Spaulding Framingham Outpatient Center in Framingham, Mass.

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