StandingMobilityAlternative positioningRehabTechnology

Standing 101 Educational Seminar

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Welcoming remarks & overview of seminar content

History of standing and weight bearing

Early literature identifying secondary complications associated with

immobilization syndrome.

Evolution of standing technology, device types and their current applications

• Long leg braces• Tilt table/supine standers• Standing boxes• Prone standers• Multi-position standers• Standing wheelchairs• Sit-to-stand standers

Program Agenda

Break

Current Clinical Practices• Indication and Contraindications for standing • Accepted Medical Benefits for standing• Current clinical studies and research

Video Case Studies

1720

1500 19701500 1980

History of

Standing

Taylor et al (3) The effect of bed rest

on the blood volumeof normal young men

Cristobal Mendez (1) Book of bodily exercise

Treatise on the physiologic responses to exercise and its therapeutic indications Exercise therapy History of exercise

1533

1940’S

19291500 1900 1950

Tied to prolonged immobilization

• Cuthbertson (2) • The influence of prolonged

muscular rest on metabolism

Dietrick et al (4) Effects of immobilization upon

various metabolic and physiologicfunctions of normal man

Widdowson (5) Effects of rest in bed on plasma

volume as indicated by hemoglobinand hematocrit

Miller, Johnson and Lamb (7) Effects of four weeks absolute bed rest

on circulatory functions in man

1960’s

19671965 1980

Space exploration resulted in a flurry of research with goal of measuring adaptation of human body to weightlessness

Graybiel and Clark (6) Symptoms resulting from prolonged immersion in water The problem of zero G asthenia

• Gemini (9)Summary Conference

1970

1975

1977

• Space medicine (8)in project mercury

• Biomedical results of Apollo (10)

• Biomedical (11)results of Skylab

1960

1960’s

1965

Simultaneously, rehabilitation researchers documented the pathophysiologic changes exhibited by patients with extensive paralysis

19701970’s

• Browse (12)• The physiology and

pathology of bed rest

1960

• Spencer (13)• Physiology concepts of

immobilization • Kottke (14)

• The effects of limitation of activity upon the human body

• Long and Bonilla (15)• Metabolic effects of

inactivity and injury

StandingDevices

• Different types & manufacturers• Made locally with variations within types

• KAFO- (Knee-Ankle Foot Orthosis)

• RGO- (Reciprocal Gait Orthosis) Louisiana State University

• HGO- (Hip Guidance Orthosis) Para-Walker, Adult• Often driven by desire to walk

• Impractical

• Expensive

• Therapy time intensive

• Usually cannot be utilized independently

• Poor compliance

• Minimal support on anterior and posterior surface of body• Earliest example of assisted standing devices

• Often homemade• Inexpensive

• Often requires two attendants• Does not include a lifting mechanism• Adult and pediatric sizes• Minimal positioning or alignment options• Usually cannot be used independently

• Full support along posterior surface of body• Two-three straps to secure body to support surface • Platform to secure feet• Horizontal to vertical transition in supine position• Developed for cardiovascular testing

• To evaluate how body regulates blood pressure in

response to simple stress• Orthostatic hypotension• Rarely seen outside hospital environment

• Adult sizes• Manual or power lift mechanism• Minimal positioning or alignment options• Cannot be used independently

• Posterior surface support from head, thoracic

area, pelvis, knees and feet• Stander angle accommodates from horizontal to

vertical in supine position• Often prescribed for lack of head control• May have a lift mechanism • Available in sizes from pediatric to adult• Usually will accommodate options for growth,

positioning and alignment• Usually cannot be used independently

• Support on anterior surface of the body• Contact at upper thoracic area, pelvis, knees and feet

• Used to promote head control• Gravity assist for full extension of hips• Usually accommodates 30º of prone positioning to upright• May have a lift mechanism• Available in sizes from pediatric to adult• Options for growth, positioning and alignment• Usually cannot be used independently

• Prone, Supine, and Upright• Primary supports can be interchangeable

• Between anterior and posterior surfaces of the body• For positioning in prone, supine, or upright position

• Usually accommodates 30º of supine positioning to upright,

and 30º of prone to upright• Available in sizes from pediatric to adult

• Traditionally used with pediatric clients• Options for growth, positioning and alignment • Usually cannot be used independently

• Power and/or manual wheelchair• Main support on posterior surfaces of body

• Anterior support at knees• Hip belt and chest belt

• Usually includes lift mechanism• Available in sizes from pediatric to adult, including baratric• Power wheelchair may be able to move in the standing

position• Standing mechanism transitions person from sitting to

standing approximately (80º of supine)• Integrated lift mechanism is independently operated• Heavy and expensive

• Anterior and posterior variable support• Minimal support

• Anterior (mid-thoracic, knees, feet)• Posterior (PSIS to popliteal)

• Maximum support• Anterior (head, shoulder, thoracic, knees, feet)• Posterior (head to popliteal, feet)

• Transitions person from sitting to standing upright• Stop at any point from sitting to standing• Supported during incremental weight bearing

• Usually includes a lift mechanism• Available in sizes from pediatric to adult, including bariatrics• Options for growth, positioning and alignment• Usually can be used independently

CurrentResearchStudies

Does prolonged standing improve bone mineral density in non-ambulatory children with spastic quadriplegia?

• Principal Investigator(s)• Brian Snyder, MD • Antion Dodek, MD

• Co-Investigator(s)• Danielle Katz, MD • Maria Fragala, PT• Laura Freeman, PT

• Site(s)• Franciscan Children’s Hospital, Boston, MA• Kennedy Day School, Boston, MA• Mass. Hospital School, Canton, MA

• Purpose• This study will test the hypothesis that non-ambulatory children

with spastic quadriplegia who participate in two hours of lower

extremity weight bearing a day, will have an increase in bone

density.

Does prolonged standing improve bone mineral density in non-ambulatory children with spastic quadriplegia?

• Pilot finished

• Pilot Conclusions: It is feasible to have non-ambulatory children

participate in a rigorous standing program. The weight bearing “dose”

affects BMD at the calcaneous but the benefits appear to be transient if

the intensive standing program is not sustained

• Significance: The intensive use of standing devices (10hrs a week)

may have a beneficial effect on BMD of weight bearing bones in

non-ambulatory children

• Full study underway

The effects of passive standing on health-related areas for individuals with spinal cord injuries.

• Principal Investigator• Ronald Davis, PhD

• Co-Investigator• Leonard Kaminsky, PhD

• Site• Ball State University, Muncie, IN

• Purpose• This study is to assess the effects of prolonged passive

standing on bone mineral density (BMD) and health-related

factors in individuals with spinal cord injury.• Pilot Finished

• Conclusion • Standing must be longer than 30 minutes per day to

have effect on BMD

Working on weight bearing and gait with functional electric stimulation.

• Investigator• Dr. Richard Sheilds

• NIH Grants• Site

• University of Iowa Hospitals & Clinics, Iowa City, IA• Purpose

• To assess the use of the EasyStand 6000 Glider

and its potential with patients in their grant study.

Keep Moving: Technologies to enhance mobility and function for the individual with spinal cord injury.

• Principal Investigator(s)• Samuel Landsberger, ScD • Robert Waters, MD

• Site• California State University, Los Angeles, CA

• Purpose• To enhance the beneficial effects of therapeutic exercise

programs developed for individuals with spinal cord injury by

improving the equipment to make it more clinically effective

and easy to use, while minimizing the risk of injury. Our

strategy is to evaluate existing devices during one-on-one

training sessions with spinal cord injury subjects.

Health Parameters in Standing and Non-Standing, Non-Ambulatory Adults with Cerebral Palsy.

• Principal Investigator(s)• Kevin Murphy, MD • Kevin Sheridan, MD

• Site• Gillette Children’s Specialty Healthcare (Lifetime Clinic)

• Purpose• To describe health parameters of a population of standing

and non-standing, non-ambulatory adults with cerebral palsy

with a focus on measures of bone mineral density.

Parameters include bone mineral content and density, and

changes in bone metabolic parameters such as anabolic and

catabolic function. Other physical health parameters including

bowel and bladder function, upper extremity strength and

subjects report of pain.

The effects of passive and dynamic standing in multiple sclerosis.

• Director• Christine Martin, PhD• Pat Provance, PT

• Site• University of Maryland Medical School, Baltimore, MD• Veteran's Administration Multiple Sclerosis Center of

Excellence, East, Baltimore, MD• Purpose

• Enhance functions for individuals with multiple sclerosis• Pilot Finished

The effects of passive and dynamic standing in multiple sclerosis.

• Conclusion • This small pilot study compared static and dynamic standing to

no standing on multiple measurements. Statistical significance

was not reached due to the small sample size, however,

important trends were observed.

• We hypothesized that subjects in Group B (dynamic standing)

would demonstrate the greatest improvement in outcome

measurements. However, results (thus far) indicate Group A

(static standing) had more consistent and positive outcomes.

The effects of passive and dynamic standing in multiple sclerosis.

• Conclusion

• Subjects in Group B with higher functional ability to baseline

indicate the greatest individual improvement mid-way through

the study.

• Observations (thus far) indicate that active upper and lower

extremity movements required of Group B are too vigorous for

subjects with greater functional impairment.

• Based upon the trends seen in the treatment phase of this

pilot, a larger trial is warranted. The trial is currently in the

follow-up phase to assess any carry-over benefit

of passive or dynamic standing.

PendingResearchStudies

Prototype pediatric active stander pilot study for clients with cerebral palsy.

• Principal Investigator• Thomas Polisoto, MD

• Site(s)• Children’s Hospital, Erie County Medical Center, Buffalo, NY• Elmwood Health Center, Buffalo, NY

• Purpose• Treatment of risk/development of osteoporosis in kids with

cerebral palsy using the prototype pediatric active stander with

and without supplemental vitamin D and calcium with controls.• Influence of the use of the prototype pediatric active stander on

hip/acetabular development in the same population.

Indications/Contraindications

• Individuals at risk for immobilization syndrome • Restricted neuromuscular activity due to paralysis• Individuals who stay in a given position

• i.e. sitting in a wheelchair for continuous

or prolonged periods of time • Impaired mobilization due to disease, illness, or disability

• Physician referral• Therapist evaluation and program set up• Therapeutic follow up

Clinical Indications

• Physician declined referral • Orthostatic intolerance syndrome

• Orthostatic hypotension• Postural tachycardia syndrome

• Impaired skeletal structure that will not tolerate weight bearing• Osteogenesis imperfecta, osteoporosis, or other

forms of brittle bone disease• Certain orthopedic disorders

• Hip and/or knee flexion contractures greater

than 20º and non reducible

Clinical Contraindications

AcceptedMedicalBenefits

of Standing

• Prevention of contractures and improvement of joint range of motion • Reduction of spasticity• Prevention or reversal of osteoporosis and resultant hypercalciuria• Improvement in renal function, drainage of the urinary tract, and

reduction in urinary calculi• Prevention of pressure ulcers• Improvement in circulation as it relates to orthostatic

hypotension and other benefits of good circulation• Improvement of bowel function

Passive standing has been demonstrated to prevent, reverse, or

improve many of the adverse affects of prolonged immobilization.

Musculoskeletal System

• Immobilization has dramatic effects on the musculoskeletal system.• It has been demonstrated that the immobilization of muscles and

lack of weight bearing on bones causes bone demineralization and

true osteoporosis.

The immobilized patient: Functional pathology and management,Steinberg, F.U. et al (16)

Musculoskeletal System

• Experiment demonstrated healthy men immobilized by complete

bed rest reversed increased calcium excretion by quiet standing

three hours per day.

Effects of prolonged bed rest on urinary calcium output. Issekutz et al (17)

Musculoskeletal System

• Investigators found that muscle stretch by weight load in standing

was able to reduce spasticity 26%-32% depending on the flexion of

the feet.

Evaluation of the effects of muscle stretch and weight load in patients

with spastic paraplegia. Odeen and Knutsson (18)

• After a period of weight load with calf muscle stretch, this spastic

restraint may be reduced by up to 70% and the effect may be sustained

for several hours.• The standing procedure is easily managed and may therefore be used

in a home program if the patient is supplied with supported standing.

Effects of Muscle Stretch. Odeen and E. Knutsson (18)

Musculoskeletal System

Loss of Strength

• Muscles at rest lose strength at a rate of about 10-15% per week, at 4 weeks the patient will have only 50 to 60% of their strength remaining.

The malignant effects of bed rest. Richardson, J.K. (19)

Loss of Skeletal Mass

• Bones need the stress of gravity and tendons to maintain their mass. Patients who have been immobilized for several weeks or more will not re-gain their pre-morbid bone density for several months and so are at an increased risk for fracture should they fall during that time.

Musculoskeletal System

• Since osteoporosis is a major risk factor, patients with cerebral

palsy should bear weight to prevent pathological fractures.• Any stiffness of major joints and extended periods of immobilization

should be avoided.

Pathological fractures in patients with cerebral palsy. Brunner, R.D et al (20)

Pulmonary

• The patient needs to be turned, sat (the lungs dangled), percussed and

generally mobilized; avoiding these treatments is as detrimental as

choosing the wrong antibiotic.

The malignant effects of bed rest. Richardson, J.K. (19)

Renal and Urinary Tract

• Hypercalciuria resulting from bone changes induced by

immobilization predisposes the patient to urinary tract calculi and

infection. This is especially true for spinal cord injured that also have

impaired bladder function and inhibited bladder emptying.

The physiology and pathology of bed rest. Browse, N.L. (21)

• Urine may stagnate in the kidneys since gravity cannot assist

in drainage. The result is stasis or stagnation of urine in

bladder with subsequent formation of calculi.

Renal and Urinary Tract

• Hypercalciuria associated with immobilization is thought to be due to

reduced axial weight bearing on the long bone of the skeletal

system causing loss of large amounts of bone calcium, which is

excreted in the urinary tract.

A long-term survey of the incidence of renal calculosisin paraplegia. Browse, N.L. (21)

Renal and Urinary Tract

• Suggests weight bearing within 18 months of injury would

significantly reduce incidence of urinary calculi.

The metabolism of calcium in patients with spinal cord injuries.Freeman, L.W. (22)

Renal and Urinary Tract

• Quiet standing for two or more hours per day appears to reverse the

changes in mineral metabolism induced by bed rest.• Evidence of this type supports the concept that it is the absence of

pressure forces on the skeleton which if primarily responsible for disuse

osteopenia.

Effects of prolonged bed rest on bone mineral. Donaldson, C.L. (23)

Renal and Urinary Tract

• Standing programs have been shown to have an effect on bone

development in humans and animals. Bone mineral density has

been demonstrated to increase with exercise programs that

provide a physiologic stimulus for bone modeling.

Considerations related to weight bearing programs in children with

developmental disabilities. Stuberg, W.A. (24)

Skin and Underlying Tissue

• The prevention and treatment of these ulcers require pressure relief

that may be accomplished by postural changes.• Passive standing provides pressure relief to the seated or supine

individual by shifting the pressure from the ischial tuberosities,

trochanters, and sacrum to the long bones of the legs.

Pressure sore prevention for the wheelchair bound spinal injury patient.Fergusion-Pell, M. et al (25)

Skin and Underlying Tissue

• The average number of hospitalization days for pressure ulcer

treatment was 150 days, with an average cost of $150,000 per

patient hospitalized.

Pressure ulcers in veterans with spinal cord injury; A retrospective study.Garber, S.L. (26)

Cardiovascular System

• After a period of immobilization, if an individual attempts to sit or stand,

there is a marked pooling of blood in the lower extremities causing a

decrease in the circulating blood volume. Blood pressure drops and the

brain is depleted of blood and oxygen, which may lead to fainting.

Effects of immobilization upon various metabolic and physiologic

functions of normal men. Deitrick, J.E. (27)

Cardiovascular System

• The problem of orthostatic hypotension caused by immobilization

can be improved by repeated standing.

Cardiovascular and hemodynamic response to tilting and to

standing in tetraplegic patients. Figonia, S. (28)

Digestive System

The digestive system is affected by prolonged immobilization. Valibona, C.

(29)

• There is a general decrease in gastrointestinal activity. The decrease in mobility leads to constipation. Prolonged constipation may lead to fecal impaction and serious intestinal dysfunction.

Conclusion

Many of the documented pathological changes that occur due to

immobilization may be prevented, reversed or improved by a regular

standing regimen.

Funding andDocumentationfor Standing

Achieving Effective Documentation

• Detail the client: Who is this person medically (brief specific history)?• Provide the client’s history of compliance.• Explain how the stander will help achieve functional goals/outcomes.• Describe trial use of the proposed standers.• List alternatives that were considered & rejected (include less/most

costly medical alternative).• If possible, present photos & videos to convey the information along with

documentation.• Be complete, but concise; reviewers do not have time to read a novel.• Include supporting material: clinical studies, papers, etc.• Re-submit and appeal when necessary.

Letter of Medical Necessity Outline

Personal Information

• Name• Date of birth• Diagnosis• Onset of disability• Height• Weight• Funding (primary/secondary)• Brief medical history (specific to the need of the device)

Current Function

• This section should draw a complete picture of the client with words.• Ambulation: Type and how much assist• Transfers: Type and how much assist• Activities of daily living: How independent or dependent• Living environment (brief description)• Mobility: Home and community (brief description)• School/Employment (brief description)• Transportation (i.e. own car, van, public transportation)

Physical/Medical Condition

• Concentrate on a medical overview. Give specific medical factors that

will be affected by standing technology and how they will change.• Facilitating symmetrical posture• Developing/improving head, neck, and upper body muscle control• Inhibiting abnormal muscle tone and reflexes• Preventing loss of range of motion (ROM)• Improving systemic functions (i.e. bladder, respiratory, circulatory,

and digestive)• Preventing loss of bone density• Developing standing tolerance and endurance• Aid in normal skeletal development• Aid in balance restoration through upright posture• Other

Current Program

• What is the client’s current therapy program at home, school, work &

their history of compliance?• What are client’s functional goals?• What other less costly alternatives were considered (ROM, splints,

other methods of weight bearing)?• What other medical interventions may be necessary if client cannot

receive a stander (surgeries, bracing, etc. approximate cost of other

interventions)?

Equipment Trail

• What equipment was considered and/or tried for how long

(least to most costly)?• What were the outcomes of each trial and why was each trail either

accepted or rejected?

Recommendations

• What equipment is being recommended and why?• What is the prescribed standing program (what setting, describe

protocol, minutes/hours/day, times/week)?• What are the expected outcomes?

CurrentTechnology

Standing Technology Providers

• Altimate Medical - Sit to Stand• Levo - Standing Wheelchair• Life Stand - Standing Wheelchair• Mulholland- Prone• Permobil - Standing Wheelchair• Prime Engineering - Sit to Stand• Sammons Preston - Prone, Multi-positioning, Supine • Snug Seat - Prone, Multi-positioning, Supine• Stand Aid of Iowa- Sit to Stand• DavisMade Inc. - Standing Wheelchair• Rifton - Prone, Multi-positioning, Supine• Theradapt - Supine, Prone• Vertran - Standing Wheelchair

www.easystand.com