ATP Series

Standing on Principle

Comparing & Contrasting the Functions of Standing Wheelchairs to Standing Frames

StandingAs human beings, we are meant to stand. Not exclusively. But there’s a reason stand-up desks are so popular in today’s offices, and why passengers enduring long flights bounce to their feet the moment the pilot turns off the seatbelt sign. Standing does help our bodies to function better in many ways, and thus, standing can make us feel better.

And that fact remains, even for people incapable of standing independently. Those consumers may still be able to stand by using a standing frame or a standing wheelchair. But beyond the obvious — a standing wheelchair drives around, while a standing frame does not — what are the differences in function between the two? Are their functional benefits different? Are their indications and contraindications different?

Similarities & Distinctions

As with every discussion of complex rehab technology (CRT), this one starts with a disclaimer. Comparing and contrasting standing frames and standing wheelchairs isn’t meant to proclaim which type of product is “better.” Every CRT client is a unique combination of not just diagnosis and prognosis, but goals, environments, abilities and challenges. So choosing between standing frame and standing wheelchair (or choosing a different standing technology; see sidebar) is up to the seating and mobility team, the client and the caregivers based on the overall picture.

Of course, standing wheelchairs and standing frames have a number of things in common. But perhaps surprisingly, they also differ from each other in a number of ways.

For instance, standing frames and standing wheelchairs have different “main” objectives.

Nancy Perlich, COTA, ATP is EasyStand’s reimbursement specialist.

“Standing frames tend to be more about the health benefits,” she said. “They do a more accurate job of mimicking true standing with the hips over the knees over the ankles, which provides proper range of motion for all three joints. Standing wheelchairs are more focused on the functionality of the person and can be used in a vocational setting.”

Ashley Detterbeck, DPT, ATP/SMS, is Permobil’s clinical education manager, central region.

“The standing power wheelchair allows for programmable options to achieve standing, making it more adaptable to the patient’s direct needs,” she said.

“Standing frames function to properly support and align the user for a weight-bearing program,” Perlich said, “and they differ from standing wheelchairs in that they provide more intimate components for detailed alignment and support throughout the sit-to-stand, prone or supine transition and the weight-bearing position.”

Reaping the Benefits

“The primary goals of the standing frame are to provide a safe and stable base to promote improvement in multiple areas of body function,” Detterbeck said. “Standing frames have been shown to improve such body functions as bone density, digestion, respiration, flexibility, as well as in some cases to reduce tone. While the functions and goals of the standing power wheelchair are the same as the standing frame, it differs in that in addition, it provides mobility. The standing power wheelchair allows for greater interaction with one’s environment when in the standing position, as the patient can continue with their daily functional activities.”

“Clinical goals will vary depending on the clients,” Perlich said, “but a standing frame enables a prolonged weight-bearing program. Range of motion (ROM) will probably be the initial goal for many users, as most standing frames provide full extension of the hips and knees, with the weight-bearing (hips over knees, over ankles) being a critical part of the equation. Other health benefits could include change of position or pressure relief, bone density maintenance in the long bones of the legs, improved circulation, and improved bowel and bladder function.”

Where standing frames and standing wheelchairs do show similarities is in the wide range of benefits from standing.

“The benefits of improved respiration, digestion and bone density accomplished during a standing regimen can be obtained using either a standing frame or standing power wheelchair,” Detterbeck said. “The advantage that standing power wheelchairs bring to the table is combining these amazing benefits with function. More often with standing frames, patients tend to have to stand idle in one location for a set period of time. With standing power wheelchairs, the addition of mobility allows the patient to not only perform their standing regimen, but in addition be able to move around and perform functional activities, participate in school or work functions, or social gatherings. Standing power wheelchairs allow for a socially more acceptable standing program that can be done anywhere and at any time.”

Knowing the Mechanics

While both standing frames and standing wheelchairs achieve upright positioning, they arrive at those positions in different ways.

Perlich explained, “Standing frames focus on getting the person to stand in a more natural position with the hips, knees and ankles being ranged. Sit-to-stand standers tend to focus on the pivot points at the knees and hips to make sure all are as closely aligned as possible when going from sitting to standing, which reduces shear during the sit-to-stand transition that occurs in both types of devices. Standing frames also are more adaptable to fitting users with issues such as leg-length discrepancies and contractures because of the support and positioning components available. Standing frames tend to have more components to accommodate the most difficult cases.”

“Standing frames typically are either set up for sit-to-stand or supine-to-stand with very little adjustment,” Detterbeck said. “The standing power wheelchair, on the other hand, can move the patient into the standing position through movements of their choice and tolerance. Often, this programming can be altered, as the patient’s needs may change, allowing them to utilize the equipment for a much longer period of time.”

Indications & Contraindications

Detterbeck and Perlich agreed that indications and contraindications for both types of CRT standing technology are very similar.

For standing, Perlich said the main indication for a standing frame is “need for a weight-bearing program. If the person is having issues with contractures or is having difficulty maintaining ROM, the standing frame is the product that will do it. Also, if the person is thinking of participating in a walking program, they may want to consider a standing frame over a standing wheelchair. They may also want to consider a standing frame with active movement, e.g., the [EasyStand] Glider.”

For standing wheelchairs, “The patient needs to have the desire to stand along with being medical stable for standing,” Detterbeck said. “Often, power standing wheelchairs are considered to promote more frequent standing for patients. The independence with the equipment to come to standing and reduced need for transfers in and out of the equipment make it more user friendly.”

“Standing frames tend to have more components to accommodate for standing the more complicated cases,” Perlich said. “A supine or multi-position standing frame should allow for more flexibility of position to accommodate the flexible deformities, where a standing wheelchair would need both standing and tilt or recline to accommodate postural deformities if it can support in standing also.”

“The contraindications for a standing regimen are the same with both a standing frame and a standing power wheelchair,” Detterbeck said. “You should always be aware of postural hypotension and skeletal deformities when beginning or proceeding with a standing regimen, regardless of the device. The standing power wheelchair allows for the patient to independently come to standing or partial standing for short periods of time, which may allow for better tolerance with a standing regimen in the beginning. Multiple loading and unloading into the standing position for short increments of time often assists in building the standing tolerance and mimics how we as ablebodied humans function during the day.”

The Funding Factor

In addition to sharing clinical benefits, indications and contraindications, standing frames and standing wheelchairs also have funding challenges in common.

“Securing funding for a standing power wheelchair can be a lengthy process that requires not only evaluation from a skilled PT/OT, but interaction from an experienced dealer and manufacturer’s rep,” Detterbeck said. “Standing trials, home trials, and sometimes driving trials are performed to ensure that the decision to place the patient in the system is the right one.

“Procurement of a standing frame is a lengthy process depending on third-party funding; however, the length of time to secure the standing frame is considerably shorter in comparison to a standing power wheelchair.”

“Justification is somewhat similar, yet dependent on payor,” Perlich said. “Most companies provide funding and justification assistance, whether that is funding guides, templates or a tool like Justify It from EasyStand or Permobil’s LMN generator.

“Standing frames tend to follow stricter medical justification, where standing wheelchairs tend to focus on mobility-related activities of daily living (MRADLs) or functional needs. From a funding and a cost-comparison perspective, a standing frame can be 1/10th the cost of a standing wheelchair and can be used regardless of the wheelchair. That presents the opportunity to provide an optimal wheelchair platform and optimal standing program.”

Choosing the Better Option

So, is a standing frame or a standing wheelchair the better choice?

“Both will help to a degree in achieving clinical goals,” Perlich said. “Standing frames tend to do a better job of standing the individuals to maximize the health benefits because of the support and alignment components and by maximizing the weight-bearing position.

“A lot is dependent on the client, their individual needs and what each device has to offer for those needs by priority, be they functional or medical. The problem with choosing function is that typically it’s at the cost of at least some of the health benefits — i.e., in exchange for the functional gains a standing wheelchair provides, one will typically sacrifice range of motion if a standing wheelchair is the exclusive provider of range of motion/weight-bearing stretch.”

Since there is something of a trade-off in choosing one device over the other, Perlich said the final decision should be made on a client-by-client basis.

“Most standing frames are static and don’t allow the same degree of functional activities that a wheelchair would,” she pointed out. “Yet the wheelchair does not provide the same amount support that the standing frames provide. It’s not necessarily which is better by design, but instead the decision is driven by individual needs, either medical or functional. Transfers into a standing frame or standing wheelchair are similar — a transfer must be completed for use of either device and should not be the deciding factor when choosing a product. The deciding factor should be whether the user is looking for health benefits or functional benefits. The product that does the best job is the right product to choose.”

This article originally appeared in the February 2018 issue of Mobility Management.

In Support of Upper-Extremity Positioning