On Their Own Two Feet

Today’s Technology Offers Multiple Ways for Consumers to Benefit from Standing -- So, What Works Best?

StandingSuch are the advances in complex rehab technology today that clinicians, providers and consumers have multiple choices when it comes to standing. That means being able to select from different types of equipment based on goals, environment and other factors.

The first thing that comes to mind when considering a standing regimen is the traditional standing frame. But other types of equipment, including wheelchairs with standing options and gait trainers, also give consumers the chance to stand on their own two feet.

So how do you determine which type of standing technology is best suited to a particular client?

Standing Frames & Standing Wheelchairs

Several different types of equipment move people into and/or support them in a standing position. But because of how the different types of equipment function and what their goals are, they sometimes can be considered complementary to each other rather than competitive against each other.

Take, for instance, standing frames and standing wheelchairs.

Says Mark Schmitt, sales & marketing director at Altimate Medical: “The basic division could be looked at as the standing wheelchairs would be more functional as far as work-related activities or activities around the house — ADLs.”

In addition to providing mobility, another major function of standing wheelchairs, Schmitt notes, is providing a change of position to redistribute the patient’s weight and relieve pressure.

Standing frames, meanwhile, “do a better job of standing you straight up and down, hips over center,” Schmitt says.

That’s because, he notes, standing frames don’t have to take stability issues into account the way a standing wheelchair does.

“If it’s a power one and you’re driving along,” Schmitt says of standing wheelchairs, “you want the center of balance to be a little further back so you don’t stand straight up and down.”

Some standing frames — including Altimate Medical’s — offer mobile options so the standers can be moved to different locations. Still, Schmitt says mobile standing frames are not meant to function in the same way as standing wheelchairs, which have indoor and outdoor mobility as a main priority.

“We get customers who say, ‘I want to do some things in my shop,’” Schmitt says as an example. “A lot of times, we say, ‘We may not be the perfect product for you.’ Even though we do have a mobile stand that does go around the house, we’re still focusing on how you stand straight up and down and get all the benefits that a standing frame can give you. Even though we have a mobile (option), it’s not really (as) functional as a standing wheelchair would be.”

A standing frame with a mobile option, he adds, “could be good in a classroom; it could be good in everyday living if you want something a lot less expensive, and you want a little bit of (mobile) function, but the benefits of standing are more of a priority.”

Standing & Gait Training

There’s also a relationship between standing equipment and gait training equipment.

Mary Boegel is the president of Prime Engineering, which offers both standers and gait trainers.

“Gait trainers can be used as standing devices because obviously, when you are up and moving in a gait device, you’re standing,” Boegel says. “Standing programs and gait programs are largely about weight bearing and encouraging weight bearing. But one requires you have some ability to hold yourself up with your own legs — that would be the gait device.

“A stander does not require that; a stander offers you full support, and continues to give you full support. The really easy way of looking at that is the knee support that you see on all standing devices and which are absent on gait devices. And the reason that you have the gait support is because that client does not have the ability to lock their knees in and hold themselves up without the assistance of that support pad.”

Standing frames, Boegel adds, can complement a gait training program.

“Frequently, standers are used as a preliminary therapy to putting the child or the person into a gait device,” she explains. “There are all sorts of reasons it might be used preliminarily, like for conditioning — getting that person used to being in that upright posture. And for stretching, for increasing the range of motion so that a kiddo can use a gait device more effectively.”

What a Standing Regimen Can Do

The current variety of standing equipment options is good news for therapists and their clients, because the act of standing offers such a wide range of benefits.

One potential benefit — improvement in bone density — can be controversial because some funding sources contend that the length of time a patient would need to stand in order to increase bone density is longer than what is typically achieved.

Asked if Altimate Medical discusses bone density as a potential benefit of standing, Schmitt says, “We definitely still talk about that.

It is kind of a lightning-rod issue for some people. But when we are talking about children especially, it’s hard to deny that standing helps with proper development. And with adults, it’s definitely not going to be a detriment to bone health. That’s a lightning rod for some people, but for us, it’s one of the benefits that we stand by.

“With pediatrics, kids are still growing, and standing them up promotes proper growth, bone development and muscle development. But even for adults, their muscles are connected to their bones, so they’re getting range of motion, and you still are considering orthopedics. If they have a contracture, all of a sudden you’re thinking about if the bone’s not mobile because of muscle contractures. Then you start to run into overlapping problems.”

Many other benefits of standing are well understood and supported in the medical community: reduced spasticity, improved respiratory functions, improvements in digestion and bowel functions, for instance.

There is also strong anecdotal evidence that standing can improve eating, drinking and swallowing abilities for some clients.

“There’s no doubt that you open up the diaphragm when you’re standing,” Schmitt says. “We’ve seen it in eating and swallowing and breathing — but also in talking. We’ve seen that when speech therapists have used standers; they change the way the kid is breathing, and the diaphragm opens up and allows a little better environment for that.”

But proving the correlation between standing and some of these physical benefits is still a challenge when payors want to see the types of expansive research studies they’re accustomed to receiving from the pharmaceutical industry, for instance.

“Physical therapists will tell you that is what happens,” Schmitt says of improvements in eating, swallowing and talking, “but there’s not a lot of evidence to back it up. (Payors) say, ‘Now, prove it.’ That’s where the fighting has to come in: ‘This kid can swallow because he’s standing. Do you want to go the feeding tube route? What do you want to do?’ We still fight the battles, because we have a lot of research. But a lot of funding sources still fight us on it.”

Finding the Right Standing Fit

While the client’s and seating & mobility team’s goals are obviously critical to choosing the appropriate standing device, Schmitt says there are a few other important factors to consider.

“You start with what the goals are that you want, and then you start to pick the stander,” he notes. “However, probably the biggest thing in ensuring that the standing device will be used is how easy it is to either put yourself into it by a self transfer, or what it takes for the caregiver to put the person in there.

“If you have a stander that will fit your goals, but it is too difficult to operate, they will not use it.”

That’s where trying different standing products is useful, Schmitt says, since every client’s transfer routine — and opinion of what is “convenient” and what is not — will differ.

“The way they can stand up, the way they can twist, turn — that could make it easier for them to use a certain product,” Schmitt says. “They might have a quirky way of transferring, and only one of the product choices works. You may find two or three that fit their goals, but only one that the caregiver or the individual likes, for whatever reason.”

Another big consideration: overall comfort within the standing system, which also varies from client to client. Some clients, Schmitt says, can feel comfortable in a variety of systems and circumstances. Others are more sensitive.

“Sometimes you’re dealing with people who aren’t very responsive, but you sure can tell when they’re uncomfortable,” he says. “There’s crying, there’s moaning.”

Some clients require a considerable amount of padding to be comfortable, or only feel comfortable moving into the standing position in a specific way — maybe they only feel safe going from sitting to standing, or strongly prefer starting from a lying position, then going into a standing position.

In any case, comfort also becomes an important issue as time in the standing device lengthens.

“Sometimes you want to stand them for long periods of time,” Schmitt says. “You’re trying to work out some better range of motion for them, and you want to spend not just a half hour standing, but a couple of hours standing. Nobody can stand that long; even able-bodied people can’t stand that long. You get very, very uncomfortable.”

If standing for long periods is one of the client’s and rehab team’s goals, Schmitt says a device that allows for quick transitions from standing into a resting position and back again might be the best answer. In that case, comfort may be defined as “getting in and out quickly.”

Like any complex seating & mobility device, finding the best fit between client and technology is partly a matter of personal taste.

“There are a lot of things to look at,” Schmitt says, “but it all comes down to what the goals are, how easy it is for them to use it, and then probably comfort.”

This article originally appeared in the June 2012 issue of Mobility Management.

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