Stand Up and Function!

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August/September 2002

By Brenlee Mogul-Rotman, OTR, ATP, OT Reg (Ont), and Kathryn Fisher, ATS, OT Reg (Ont)

Wheelchair-dependent people lose out on all of the social and functional benefits of standing. As assistive technology specialists, we strive to ensure that our wheelchair-dependent clients are seated with optimal posture and functional ability. We also need to encourage them in gaining the benefits of standing. Standers can help people with disabilities gain the benefits of standing (see sidebar below).

THE BASICS

Although standing is medically and functionally desired, there are cautions that need to be considered, including malformation of weight-bearing joints; excessive contractures; medical complications (G-tubes, oxygen use, bone density, cardiac-related conditions, seizures); length of time as dependent sitter; transfer ability; and need for supervision/assistance, muscle tone, and client compliance.¹ Prior to beginning any standing evaluation or program with a client, a complete consultation with a physician is recommended. The standing evaluation should be supervised by the clinician and monitored to ensure safety and ability to continue with the evaluation process.

When assessing the pediatric client for standing, there are multiple considerations including: medical status, comfort and endurance, severity of disability, development of deformities, required postural support, reflex patterns, joint development, growth, and social/developmental/educational needs.^2,3

Early intervention and standing at the usual developmental milestone of approximately 9 months benefit the child both physically and socially.³ Weight bearing is essential to the development of a stable hip joint. Normal acetabular formation occurs through early and regular weight bearing, joint movement, and muscle development.² In standing, children are able to interact with their peers eye-to-eye. Exploration and control of the environment are better achieved through a combination of upright postures.^3,4

PEDIATRIC STANDING STRATEGIES

There are four types of standing technologies that are generally used with children. Supine standing can be considered for introduction to weight bearing where head control has not yet been achieved. Prone standing is used when head control is developing, for stimulation of trunk and lower extremity extensors, and as a functional position for play and upper extremity use. The upright stander supports the child in an erect posture with the goal of maximal weight bearing.¹ A mobile stander is a further development of upright standing where a child coordinates function with mobility to enhance independence.³

The traditional static standing frame presents limitations and challenges to clients:

Transfers—assistance often required to position client in device with the necessary supports;
Assistance to stand—clients often unable to independently move from sitting to standing and Back to sitting;
Size of equipment—standing frames are large in order to distribute clients’ weight and maintain stability;
Storage—large equipment is difficult to move and house;
Funding—difficult to obtain for multiple pieces of equipment; and
Function—limited opportunity for functional, purposeful activity while standing.

In recent years, standing technology has developed so there are more options beyond standing only in a static position. The newest technology now includes products that provide the opportunity to move from sitting to standing within the same piece of equipment; to exercise while standing; to complete daily, vocational, and avocational activities; and to have a range of positions between sitting and standing. Such products include dynamic standers, mobile standers, gliders (range of motion and exercisers), and standing manual/power wheelchairs.

The need for postural support in standing should be assessed and provided as appropriate. Areas of the body that may require external support in standing include the feet, knees, hips, pelvis, trunk, shoulders, and head.2 There are various accessories available with the newest standing technology to meet the unique needs of each individual. With dynamic systems, the transition from sitting to standing must ensure that the client’s posture and positioning needs are met and that pressure/shearing forces are limited. The clinical assessment and determination of needs will identify issues, cautions, client goals, and physical needs in order to assist with the choice of standing product that will meet the user’s needs. Ease of use of the equipment is essential and caregiving needs must be addressed.4 Once clinical considerations are determined, then functional implications and goals for the user must also be determined and met.

Wheelchair-dependent individuals benefit from standing both medically and functionally. Lifestyle, social, and self-esteem needs can be addressed through meaningful activity while standing, thus optimizing physical and psychosocial potential. Purposeful activity is a necessary factor in goal achievement, client compliance, and enhancement of quality of life. Therefore, it is essential to include purposeful, meaningful activity in the consideration of standing technology.

References

Chin M. Consider the alternatives. In: Perlich N, ed. Funding Guide to Standing Technology. Morton, Minn: Altimate Medical; 2000:21-23.
Alcock D, Antoniuk E, Eastman M. How do we stand. Presented at: International Seating Symposium; March 9, 1996; Vancouver, Canada.
Lollar J. Stand alone. In: Perlich N, ed. Funding Guide to Standing Technology. Morton, Minn: Altimate Medical; 2000:25-28.
Kimball R, Downs K. Beyond the wheelchair: standers, walkers and bikes. Presented at: Canadian Seating and Mobility Conference; September 1999; Toronto.

Brenlee Mogul-Rotman, OTR, ATP, OT Reg (Ont), owns a private practice in Toronto. Kathryn Fisher, ATS, OT Reg (Ont), is an assistive technology supplier in Toronto.

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August/September 2002