10/28/12

STANDING IN SPINAL CORD INJURY:

Objec&ves:  
Examining the Evidence •  Iden&fy  at  least  three  health  outcomes  of  standing  
for  clients  with  SCI  based  on  research.  
•  Describe  at  least  three  func&onal  outcomes  of  
standing  that  provide  greater  independence  to  
clients  with  SCI.  
Amy Morgan, PT, ATP
•  List  at  least  three  benefits  to  integra&ng  a  standing  
National Clinical Education Manager feature  into  a  client s  wheelchair  base  as  opposed  to  
using  a  separate  standing  device.  

Op&ons  for  Standing   Wheelchair  Standers  

•  Improves  compliance  with  
standing  program  
•  Ambula&on/Ambulatory  Aids   •  Promotes  func&onal  
–  Quality  of  weight  bearing?   independence  
–  Ability  to  use  UE s  for  func&on   •  Greater  medical  benefits  of  
•  Separate  Standing  Devices   weight  bearing  
–  Sta&c  or  Dynamic   –  Higher  Frequency  
–  Dynamic  Loading  
•  Wheelchair  Standing  Devices  
–  Manual/Manual   •  Provides  natural  means  of  
pressure  relief  
–  Manual/Power   –  Reducing  risk  of  pressure  ulcers  
–  Power/Power   –  Helps  heal/treat  current  
pressure  ulcers  

Standing  –  There s  Nothing  Like  It!   Why  Stand?  

Examining  the  Evidence  
•  Why  NOT?  
•  Poten&al  Complica&ons  of  Immobility  
–  Decreased  Bone  Mineral  Density  (BMD)  
–  Risk  of  Pressure  Ulcers  
–  Development  of  Joint  Contractures  
–  Impaired  bowel  and  bladder  func&oning  
–  Impaired  respiratory  func&oning  
–  Gastro-­‐Intes&nal  problems  
•  Deitrick  J,  Whedon  G,  Shorr  E.  Effects  of  immobiliza&on  
upon  various  metabolic  and  physiologic  func&ons  of  
normal  men.  American  Journal  of  Medicine,  1948;  4:  3.  

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Why  Stand?    
RESNA  Posi&on  Paper  on   Reviewing  the  Evidence  
 Wheelchair  Standers    
•  Best  comprehensive  overall  summary  of   •  Bone  Mineral  Density  
–  Dynamic  Weight  Bearing  –  Shorter,  More  Frequent  
research  examining  wheelchair  standers.   •  GI/Respiratory/Circulatory  
•  Originally  approved  in  March,  2007.   –  Frequency  of  Standing    
•  Recently  published  in  peer-­‐reviewed  journal.   •  Bowel/Bladder  
–  Reducing  UTI/kidney  stones/cons&pa&on/bowel  accidents    
•  Benefits,  Indica&ons,  Contraindica&ons,  Case   •  Spas&city  
Studies  (CP,  MS,  SCI)   –  Immediate  and  significant  effect    
•  Contractures  
•  Arva  JA,  Paleg  G,  Lange  M,  Lieberman  J,  Schmeler  M,   –  Providing  prolonged  stretch    
Dicianno  B,  Babinec  M,  Rosen  L.    RESNA  Posi&on  on  the   •  Pressure  Management  
Applica&on  of  Wheelchair  Standing  Devices.  Assis&ve   –  Reduced  frequency  when  using  stander  –  Best  pressure  relief  
Technology.    2009  Fall,  21(3):  161-­‐168.   overall    

Bone  Density  -­‐  Dynamic  Load   Dosage  -­‐  Bone  Density  

  •  Right  forelimbs  of  adult  rats  loaded  360  cycles,  3  days/
•  Rubin  CT,  Sommerfeldt  DW,  Judex  S,  Qin  Y  .    Inhibi&on  of   week,  4  months  dura&on  (16  weeks)  
osteopenia  by  low  magnitude,  high  frequency  mechanical   –  Group  1  -­‐  360  cycles  at  one  &me  
s&muli.    DDT  .    2001  Aug;  6  (16):    848-­‐858.     –  Group  2  -­‐  90x4  cycles  (3  hours  between)  
•  Rubin  C,  Turner  AS,  Mallinckdrodt  C,  Jeorme  C,  McLeod  K,  Bain   •  Loaded  limbs  (Right)  -­‐  significantly  greater  bone  density  
S.  Mechanical  strain,  induced  non-­‐invasively  in  the  high   •  Group  2  -­‐  significantly  greater  bone  density  
frequency  domain,  is  anabolic  to  cancellous  bone  but  not  to  
cor&cal  bone.    Bone.  2002  Mar;  30  (3):    445-­‐  452.       •  Conclusion:  Shorter  dura&on  with  periods  of  rest  may  
be  beker  for  bone  density  
•  Rubin  C,  Turner  AS,  Muller  R,  Mikra  E,  McLeod  K,  Lin  W,  Qin  
YX.    Quan&ty  and  quality  of  trabecular  bone  in  the  femur  are  
enhanced  by  a  strongly  anabolic,  non-­‐invasive  mechanical   •  Robling  AG,  Hinant  FM,  Burr  DB,  Turner  CH.    Shorter,  more  
interven&on.  Journal  of  Bone  and  Mineral  Research.  2002;  17 frequent  mechanical  loading  sessions  enhance  bone  mass.  
(2):  349-­‐57.   Medicine  &  Science  in  Sports  &Exercise.  2001  May:  196-­‐202    

Spinal  Cord  Injury   Spinal  Cord  Injury  

•  Standing  Mobility  Devices  -­‐  follow  up  to  survey  
•  People  with  SCI  (n=99)  who  stood  30  min.  or  more  per  day.   •  Survey  Based  (32%  response  rate)  
•  Improvements  noted:  quality  of  life,  fewer  bed  sores,  fewer   •  87%  male  (ages  41-­‐50  y/o)  -­‐  77%  paraplegic  
bladder  infec&ons,  improved  bowel  regularity,  improved   •  41%  -­‐  1-­‐6  &mes  per  week  
ability  to  straighten  legs.   •  67%  -­‐  30  minutes  -­‐  1  hour  at  a  &me  
•  Compliance  with  regular  home  standing  (at  least  1x/week)  was   •  Improved  bladder  emptying,  Bowel  regularity,  UTI s,  
high  -­‐  74%.   Leg  Spas&city,  Number  of   bed  sores  
•  Benefits  were  seen  -­‐  even  if  standing  began  several  years  aper   •  79%  highly  recommended  use  of  standing  device  
injury.  
•  Dunn  RB,  Walter  JS,  Lucero  Y,  Weaver  F,  Langbein  E,  Fehr  L,  
•  Walter  JS,  Sola  PG,  Sacks  J,  Lucero  Y,  Langbein  E,  Weaver  F.  Indica&ons  for   Johnson  P,  Riedy  L.  Follow-­‐up  assessment  of  standing  
a  home  standing  program  for  individuals  with  spinal  cord  injury.  Journal   mobility  device  users.  Assis&ve  Technology,  1998;  10(2):  
of  Spinal  Cord  Medicine.  1999;  22(3):  152-­‐8     84-­‐93.    

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Spinal  Cord  Injury   Orthosta&c  Hypotension  -­‐  SCI  

•  Survey  to  determine  how  Orthosta&c  Hypotension  affects  use  
•  17  item  self-­‐report  survey  looking  at  pakerns  of  use  for   of  standing  devices.  
standing  devices.  
•  293  respondents  
•  Adults  (ages  18-­‐55)  with  SCI  (n=126)  
•  38%  suffered  with  Orthosta&c  Hypotension  (majority  complete  
•  38  people  (30%)  stand  an  average  of  40  min/session,  3-­‐4   injuries  T5  or  above.)  
&mes/week  as  a  method  to  improve  or  maintain  health.  
•  Perceived  benefits  include:  well-­‐being,  circula&on,  skin   •  52%  reported  using  standing  wheelchairs  or  frames  (20%  of  
integrity,  reflex  ac&vity,  bowel  and  bladder  func&on,  diges&on,   those  stated  Orthosta&c  Hypotension  limited  their  use)  
sleep,  pain,  and  fa&gue.   •  5.5%  reported  not  using  standing  devices  because  fear  of  
•  Most  common  reason  respondents  did  not  stand  (88  people)   Orthosta&c  Hypotension.  
was  the  cost  of  standing  devices.  
•  Chelvarajah  R,  Knight  SL,  Craggs  MD,  Middleton  FR.  Orthosta&c  
•  Eng  JJ,  Levins  SM,  Townson  AF,  Mah-­‐Jones  D,  Bremner  J,  Huston  G.   hypotension  following  spinal  cord  injury:  impact  of  the  use  of  
Use  of  prolonged  standing  for  individuals  with  spinal  cord  injuries.   standing  apparatus.  NeuroRehabilita&on.  2009;  24(3):237-­‐42.  
Physical  Therapy.  2001  Aug;  81(8):  1392-­‐9.  

Cons&pa&on  Management   Bladder  Management  

•  Single  case  study  -­‐  62  y/o  male  with  T12-­‐L1   •  Kaplan  PE,  Gandhavadi  B,  Richards  L,  
ASIA  B  paraplegia   Goldschmidt  J.  Calcium  balance  in  paraplegic  
pa&ents:  influence  of  injury  dura&on  and  
•  Injured  in  1965  -­‐  chronic  cons&pa&on   ambula&on.  Archives  of  Physical  Medicine  &  
•  Standing  table  5x/week  -­‐  1  hour  dura&on   Rehabilita&on.  1978  Oct;  59(10):  447-­‐50.  
•  Significant  increase  in  frequency  of  BM s   •  Kaplan  PE,  Roden  W,  Gilbert  E,  Richards  L,  
Goldschmidt  JW.  Reduc&on  of  hypercalciuria  
•  Significant  decrease  in  bowel  care  &me   in  tetraplegia  aper  weight  bearing  and  
strengthening  exercises.  Paraplegia.  1981;  
•  Hoenig  H,  Murphy  T,  Galbraith  J,  Zolkewitz  M.  Case   19:  289-­‐93.  
study  to  evaluate  a  standing  table  for  managing  
cons&pa&on.  SCI  Nursing.  2001  Summer;  18(2):  74-­‐7.    
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Spas&city  Management   Pressure  Relief  

•  Compared  &lt,  recline,  and  standing  -­‐  looking  at  seat  
•  Single  Case  -­‐  T12  SCI   and  backrest  pressure  
•  Tilt  table  used  5  non-­‐consecu&ve  days   •  6  Able-­‐Bodied  (AB)  and  10  Subjects  with  SCI  
•  Immediate  and  significant  effect  on  spas&city  las&ng  un&l   •  Maximum  Decreases  in  Load:  
the  following  morning   •  Seat  -­‐  Full  Standing  and  Full  Recline  (SCI);  Full  
•  Par&cularly  useful  to  improve  car  transfers   Standing  (AB)  
•  Indica&on  for  wheelchair  stander  allowing  management  of   •  Back  -­‐  Standing  (Both  Groups)  
spas&city  when  needed      
•  Sprigle  S,  Mauer  C,  Sorenblum  S.  Load  redistribu&on  in  
variable  posi&on  wheelchairs  in  people  with  spinal  cord  
•  Bohannon  RW.  Tilt  table  standing  for  reducing  spas&city  aper  spinal   injury.  Journal  of  Spinal  Cord  Medicine.  February  2010;33(1):
cord  injury.  Archives  of  Physical  Medicine  &  Rehabilita&on.  1993   58-­‐64.  
Oct;  74(10):  1121-­‐2.    

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Pressure  Ulcer  Management   Compliance  

•  Recommends  power  wheelchair  standing  for   •  Single  Case  -­‐  Man  with  T10  complete  paraplegia  
those  who  are  able  to  tolerate  weight  bearing   •  Standing  Wheelchair  monitored  x  2  years  
for  preven&on  and  treatment  of  pressure   •  Exceeded  recommended  minimum  dosage  (130.4%)  
ulcers.   •  Short  dura&on  (Mean  =  11.57  minutes)  
•  Average  angle  =  61  degrees  
•  Edlich  RF,  Winters  KL,  Woodard  CR,  Buschbacher  RM,  Long  WB,   •  Average  3.86  days/week  
Gebhart  JH,  Ma  EK.  Pressure  Ulcer  Preven&on.  J  Long  Term  Eff   •  Reported  improved  spas&city  and  bowel  mo&lity  
Med  Implants.  2004;  14(4):  285-­‐304.    

•  Shields  RK,  Dudley-­‐Javoroski  S.  Monitoring  standing  wheelchair  use  

aper  spinal  cord  injury:  a  case  report.  Disability  Rehabilita&on.  2005  
Feb  4;27(3):142-­‐6.    

PERCEPTIONS  OF  STANDING  

WHEELCHAIRS  
•  Funding  Challenges  
•  Posi&oning  Challenges  
–  Sisng  and  Standing  
•  Bone  Density  Requirements  
–  Safety  
•  Complexity  of  Equipment  
•  Range  of  Mo&on  Requirements  

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Benefits  of  Wheelchair  Standers   Func&onal  Benefits  

•  Gain  medical  benefits  of  weight  bearing  in  upright   •  Improves  ver&cal  range  of  reach  
posi&on   –  Kitchen  counters/cabinets,  medicine  cabinets,  
•  Perform  func&onal  ac&vi&es  in  standing  posi&on   refrigerator,  sinks,  drawers,  closets,  thermostat,  light  
•  More  natural  posi&on  (esp.  pressure  redistribu&on)   switches,  window  shades/blinds,  etc.)  
•  Reduce  amount  of  caregiver  assistance  required   •  Improves  produc&vity  at  work  or  school  
–  Open  paid  akendants  (by  insurance)  
•  Improves  psychological  well  being  
•  Improved  compliance  with  standing  program  
•  Improves  performance  of  MRADLs  
•  Provide  energy  conserva&on  
–  Less  transfers  required  
–  Toile&ng,  Feeding  (cooking),  Dressing  (access  to  
closets/drawers),  Grooming  (access  to  mirrors/sinks),  
•  Psycho-­‐social  benefits   Bathing  (access  to  supplies)  
•  Supports  clients  self-­‐chosen  desire  to  stand  
–  Improved  autonomy  

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Funding  Challenges   THANK  YOU!  

•  What  is  covered?    Non-­‐covered?  
–  Know  your  policy  
–  Government  regula&ons  
Questions??
•  What  do  you  do  when  mee&ng  resistance  for  
the  mobility  device  requested?  
–  Appeal  .  .  .  Don t  give  up!   Amy  Morgan,  PT,  ATP  
–  Involve  the  manufacturer  
1-­‐800-­‐736-­‐0925  x3606  
•  Private  Pay  op&ons  
–  Fund  raising   amy.morgan@permobil.com  
–  Philanthropy  organiza&ons  

References:  

•  Arva  JA,  Paleg  G,  Lange  M,  Lieberman  J,  Schmeler  M,  Dicianno  B,  Babinec  M,  Rosen  L.    
 
RESNA  Posi&on  on  the  Applica&on  of  Wheelchair  Standing  Devices.  Assis&ve  Technology.    
2009  Fall,  21(3):  161-­‐168.
•  Binder  H,  Hawks  L,  Graybill  G,  Gerber  NL,  Weintrob  JC.  Osteogenesis  Imperfecta:  
 
rehabilita&on  approach  with  infants  and  young  children.  Archives  of  Physical  Medicine  &  
Rehabilita&on.  1984  Sept;  65(9):  537-­‐41.
•  Bleck  EE.  Nonopera&ve  treatment  of  Osteogenesis  Imperfecta:  ortho&c  and  mobility  
management.  Clinical  Orthopaedics  &  Related  Research.  1981  Sept;  159:  111-­‐22.  
•  Bohannon  RW.  Tilt  table  standing  for  reducing  spas&city  aper  spinal  cord  injury.  Archives  of  
Physical  Medicine  &  Rehabilita&on.  1993  Oct;  74(10):  1121-­‐2.  
•  Bonnick  SL.  The  Osteoporosis  Handbook.  Dallas:  Taylor  Publishing  Company.  1994.  
•  Caulton  JM,  Ward  KA,  Alsop  CW,  Dunn  G,  Adams  JE,  Mughal  MZ.  A  randomized  controlled  
 
trial  of  standing  programme  on  bone  mineral  density  in  non-­‐ambulant  children  with  cerebral  
palsy.  Archives  of  Disease  in  Childhood.  2004;  89(2):  131-­‐5.
•  Chad  KE,  Bailey  DA,  McKay  HA,  Zello  GA,  Snyder  RE.    The  effect  of  a  weight-­‐bearing  ac&vity  
 
program  on  bone  mineral  content  and  es&mated  volumetric  density  in  children  with  spas&c  
cerebral  palsy.    Journal  of  Pediatrics.  1999;  135(1):  115-­‐7.
•  Chang  AT,  Boots  RJ,  Hodges  PW,  Thomas  PJ,  Paratz  JD.  Standing  with  the  assistance  of  a  &lt  
table  improves  minute  ven&la&on  in  chronic  cri&cally  ill  pa&ents.    Archives  of  Physical  
Medicine  and  Rehabilita&on.  2004;  85(12):  1972-­‐6.  

References:   References:  

• 
postmenopausal  women.  Annals  of  Internal  Medicine.  1988;  108:  824-­‐  8.  
Dalsky  G,  Stocke  K,  Ehsani  A,  et  al.  Weight-­‐bearing  exercise  training  and  lumbar  bone  mineral  content  in   • 
similarity  of  low-­‐magnitude  strains.  Journal  of  Biomechanics.  2000  Mar;  33(3):  317-­‐25.  
Frikon  SP,  McLeod  KJ,  Rubin  CT.  Quan&fying  the  strain  history  of  bone:  spa&al  uniformity  and  self-­‐

• 
of  normal  men.  American  Journal  of  Medicine,  1948;  4:  3.  
Deitrick  J,  Whedon  G,  Shorr  E.  Effects  of  immobiliza&on  upon  various  metabolic  and  physiologic  func&ons   • 
bone  modeling  problem.  The  Anatomical  Record.  1990;  226:  403-­‐13.  
Frost,  HM.  Skeletal  structural  adapta&ons  to  mechanical  usage  (SATMU)  -­‐  Redefining  Wolff's  Law:  The  

• 
1071.  
Donaldson  C,  Hulley  S,  Vogel  J,  et  al.  Effect  of  prolonged  bed  rest  on  bone  mineral.  Metabolism.  1970;  19:   • 
do  not  perform  standing.  Osteoporosis  Interna&onal.  1994  May;  4(3):  138-­‐43.  
Goemaere  S,  Van  Laere  M,  De  Neve  P,  Kaufman  JM.  Bone  mineral  status  in  paraplegic  pa&ents  who  do  or  

• 
osteoporosis?  Research  Quarterly  for  Exercise  and  Sport.  1994  Sept;  65(3):  197-­‐206.  
Drinkwater  BL.  1994  C.H.  McCloy  Research  Lecture:  Does  physical  ac&vity  play  a  role  in  preven&ng   •  Gudjonsdosr  B,  Mercer  VS.  Effects  of  a  dynamic  versus  a  sta&c  prone  stander  on  bone  mineral  density  
and  behavior  in  four  children  with  severe  cerebral  palsy.  Pediatric  Physical  Therapy.  2002;  14(1):  38-­‐46.  
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