By Diane Holland, PT, CWS, and Tom Holland, PT, PhD
Many health care clinicians and researchers are aware of the medical complications associated with an inability to stand. Cardiovascular, pulmonary, musculo-skeletal, integumentary, gastrointestinal, and renal function have been shown to be adversely effected by prolonged periods of not being able to achieve and maintain a standing posture.1-4 For those who can not volitionally stand or require some degree of assistance, there should be options to provide assisted standing.
The medical costs for complications associated with being wheelchair and/or bed bound are extensive. In the spinal cord injury (SCI) population, pressure ulcer prevalence has been estimated to be between 17% and 33%.5,6 Surgical cost of pressure ulcer treatment is reported to exceed $70,000 per case and is further compounded by the need to extend the hospital length of stay.7
Many different patient populations can benefit from standing therapy. Individuals with paraplegia and quadriplegia can be given the option to use a standing frame or stander for extended periods to minimize muscle and bone changes that occur from disuse and a lack of weight-bearing. Stroke patients that have not progressed to the point of ambulating or have stopped ambulating due to the difficulty of the task can use a stander to prevent lower extremity contractures while maximizing functional capabilities and maintaining quality of life. Individuals with traumatic brain injury, multiple sclerosis, amyotrophic lateral sclerosis, muscular dystrophy, Parkinson’s disease, and cerebral palsy can all benefit from assisted standing when independent standing is not possible. A standing frame may assist individuals with amputations that require moderate to maximal assistance for standing as they begin training with a new prosthesis.
Rehabilitation professionals agree that assisted standing with standers provides needed weight-bearing forces to help keep bones strong for individuals with congenital neurological conditions such as cerebral palsy.8 Increased time spent in the upright position will also minimize problems associated with orthostatic hypotension. The cardiovascular system will have an easier time in responding to position changes when more time can be spent in a standing position. Breathing exercises that allow more diaphragmatic and rib cage excursion should help to improve pulmonary function. The ability to move air in and out of the lungs more effectively will help to prevent pulmonary infections commonly seen in individuals with decreased mobility.
A major benefit of assisted standing with standing frames is the ability to provide sustained range of motion (ROM). Animal studies have revealed how muscles, when fixed in a flexed position, resulted in increased atrophy and contracture.9 Individuals that do not stand are at an increased risk for developing tight hip and knee flexors as well as ankle plantar flexors. Assisted standing systems target a sustained stretch to promote hip and knee extension and ankle dorsiflexion.
Research studies have shown that combined use of standing frames and passive ROM (PROM) not only benefits patients by preventing contracture but also aids in reducing hypertonicity in individuals with spasticity. Use of a standing frame along with passive ROM reduced hypertonicity by 32% versus a 17% reduction with only passive ROM.10 Normalization of tone helps improve transfers, wheelchair positioning, and mobility, and reduces fatigue and pain. In addition, the tendency to develop contractures due to spasticity can be minimized by early and subsequent use of standers.
There are numerous studies of bone mineral density changes due to decreased mobility and weight-bearing.11-14 Many patient populations have been studied with a consistent finding of bone mineral density loss as a result of immobility and weightlessness. This loss contributes to subsequent osteoporosis and increased risk for bone fracture.15 Wheelchair- or bed-bound individuals demonstrate increased bone calcium loss and elevated blood calcium levels due to bone reabsorption.15,16 Bone calcium loss can be staggering as there is an increased risk for spontaneous fractures that further contribute to disability. As more reabsorbed calcium needs to be excreted by the kidneys, there is an increased risk for urinary tract infections (UTI). The high levels of calcium increase the risk for developing UTIs as calcium crystals create blockage or stagnation of urine flow within the urinary tract. Frequent UTIs for many patients with central nervous system lesions (ie, MS, CVA, and SCI) result in an abnormal increase in neuromuscular tone and decreased mobility. Urinary tract infections are a major and frequent medical complication for individuals with SCI due to hypercalciuria (increased urocalcium output).16 The frequent use of antibiotics for these patients leads to antibiotic resistance, which may make it difficult to treat subsequent upper respiratory tract and other types of infections linked to decreased mobility.
Assisted standing also assists with bowel function. Being in an upright position with the use of a stander decreases the risk of complications associated with constipation and promotes a more normal bowel regimen.17 Movement of intestinal contents is less restricted and is assisted by gravity when prolonged standing is achieved. Bowel impaction has serious implications for individuals with quadriplegia as autonomic dysreflexia (a dangerous rise in blood pressure) is triggered by such stimuli. Appetite and nutritional intake can be improved for those individuals adversely affected by poor bowel function due to a lack of mobility as assisted standing is integrated into their daily program.
Psychological benefits have also been reported with the use of assisted standing frames. For the pediatric population, a child is better able to see other children face to face and interact with their peers and adults when allowed to stand. Any modality such as a stander that helps to increase social interaction and independence may aid in improving a child’s self-esteem and prevent depression associated with a negative self-image.18
Many individuals that use standers previously believed that they would be completely wheelchair bound and that standing would not be possible. They report that they would like to see the world again from a standing position. Even if volitional standing and ambulation are not possible or a realistic goal, they feel that being upright should be an available option.
A proper assessment will help to identify patients that can benefit from a stander. Individuals that can do an assisted stand or sit pivot transfer but cannot ambulate functional distances because of lower extremity weakness, increased tone, or poor motor control and coordination would be good candidates for standing frame use. In addition, individuals that are at risk for lower extremity contractures and are unable to stand for prolonged periods would be indicated for a standing frame. Contractures make general mobility more difficult, and impact the ability to properly position an individual in a wheelchair or bed for prevention of pressure ulcers. A preventive approach with a stander should decrease long-term medical costs and, more important, maintain quality of life.
An assessment similar to the Braden Scale,19 which assigns points based on such factors as lack of sensation, poor motor function, incontinence, decreased bed mobility, cognitive deficits, and concurrent medical problems, can be used when deciding if a stander is indicated for prevention of pressure ulcers. Those individuals identified at high risk for pressure ulcers can be provided pressure-relieving devices and periodic use of an assisted standing system. The standing position offers one way to reduce prolonged pressure on such areas as the occiput, spinous processes, sacrum, ischial tuberosities, trochanters, heels, and malleoli.
There are contraindications and precautions for assisted standing systems. A stander should not be used for orthopedic conditions that restrict spinal and lower extremity weight-bearing. Unhealed fractures or recently sutured soft tissue may be traumatized if excessive weight-bearing forces are introduced too early. Patients with severe medical conditions in which they become more medically unstable while standing would also be contraindicated. It is important to monitor vital signs such as heart and respiratory rate as well as blood pressure and transcutaneous oxygen saturation levels for those individuals that are medically debilitated or need close monitoring during position changes. Patients with thrombophlebitis should use a standing frame only after resolution of their blood clot. Individuals with severe lower extremity venous stasis and dependent edema may need to reduce their standing times, use compression stockings, and elevate their lower extremities following standing frame use. If an individual has severe fixed lower extremity and spinal contractures, the use of a stander may not be possible. If a patient experiences increased pain or spasticity in the standing position, the use of a stander may need to be modified or not allowed at all. As with other treatment modalities, patients with cognitive deficits will need to be more closely monitored during standing frame use. If an individual is able to stand for more prolonged periods with less assistance, dependency on the stander should be reduced to maximize function.
Standing frames can be used in the home care setting as a way of continuing the benefits of inpatient rehabilitation. Many of the standing frame systems that are now available make it possible for family members and primary caregivers to operate these devices. While in the standing position, the patient can be encouraged to perform upper extremity and cervical ROM exercises. Deep breathing exercises can also be performed when in the standing frame. Aerobic exercises can be performed when the stander is interfaced with upper extremity ergometry.
A stander may be used in an extended care or assisted living environment for those individuals that may be at risk for contractures and other complications linked to decreased mobility. Maintaining an individual’s functional status and quality of life can reduce the exorbitant costs associated with the medical management and nursing care for individuals that lose their ability to stand and walk.
There are a variety of standing frames available on the market that are suited to patients’ individual needs.20 Adaptations are available, such as adjustable knee pad blocks if the patient has a pelvic obliquity or leg length discrepancy. Adjustable foot-plate angles are incorporated to accommodate heel cord tightness. Lateral trunk supports and headrests are available for those who require more support due to weakness or poor motor control. Some units are designed to be self-propelled by the patient as they are supported in the standing position. Independent movement in the home, school, and work environment is possible provided the individual has good upper extremity strength and coordination. For those who want to maintain cardiovascular fitness, a gliding option permits bilateral reciprocal upper and lower extremity movement.
The use of a standing frame system can be a valuable adjunct in the rehabilitation process to prepare patients for ambulation. For those individuals for whom ambulation and unassisted standing is not a realistic goal, a stander can help minimize the many complications associated with a loss in standing mobility.
Diane Holland, PT, CWS, is a physical therapist and certified wound specialist at Bellevue Medical Center, Manhattan, NY. Tom Holland, PT, PhD, is an assistant professor at the Hunter College Physical Therapy Program, Manhattan.
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