ATP Series

Standing Connections

Standing Technology Continues to Evolve, But Future Funding Support Might Occur for a Surprising Reason



From our bones to our hearts, standing has the ability to make us healthier, stronger human beings. For wheelchair users, the benefits of standing are even more profound. An increasing amount of research in the past decade has shown that standing can help protect bone density, resist orthostatic stress, relieve pressure on the skin and combat other damaging effects of immobility.

Beyond medical benefits, standing does so much more. It allows wheelchair users to navigate environments that were built for able-bodied people: workplaces, schools, even homes. And it gives people with disabilities the chance to connect better with those who matter most: colleagues, friends, family.

Fortunately, continued innovation in assistive standing technologies makes it possible for wheelchair users to stand, enabling them to live healthier, more independent lives.

Evolving Technology

In the last two years, not many new standing technologies have made their way into the market. But there is still plenty happening in the world of standing. Some manufacturers are working to improve what’s already there, and with new product introductions to the U.S. market and new products upcoming in 2019, innovation in standing is alive and well.

Nancy Perlich, COTA, ATP, Funding and Product Specialist at Altimate Medical, said that while the manufacturer hasn’t released any new standing frames, it is adding “more components to better support the consumer who’s using the standing device. Whether it be a swingaway tray or a lateral or a ROHO knee or a ROHO insert, that sort of thing is where we are right now.”

In March 2017, Numotion began distributing the Tek RMD from Matia Robotics in the United States. The Tek RMD is a unique motorized standing movement device that is best described as a standing frame and wheelchair hybrid. It allows active users to engage in daily activities from an upright position while receiving all the medical benefits that standing has to offer.

“It’s really geared toward a segment of clients that really aren’t interested in power wheelchairs and standing frames,” said John Pryles, Numotion’s VP of Sales. “The Tek is geared more towards [paraplegics] who want to move around while they’re standing and actually be functional.”

In 2019, Motion Concepts is introducing a new standing system to its ranks — the ROVI A3. Unlike its predecessor, the ROVI X3, the A3 power base is wider for better stability and will have one of the lowest floor-to-seat heights, starting at 17.75". On the design change, Steffen Tiskus, PT, Training & Development Coordinator of Power Positioning at Motion Concepts, explained that in the X3 “the batteries are placed in a portrait configuration, so from whenever power wheelchairs were first introduced, the batteries would have been side by side in the battery box [which allows] for a narrower-width base. With that said, the A3, although narrower than most power bases, will be a little bit wider than the X3 for stability purposes.”

In addition to the wider base, the A3 will feature a new suspension, which Tiskus said is the biggest difference between the two devices. “It gives the end user the ability to go over smaller thresholds and allows them to access their environment, whether it be in the home or school or work.” The suspension system will also contribute added stability to the device. “Due to its unique forward locking suspension, it will provide greater stability in an active stand and drive position,” he added.

Funding Updates

Unfortunately, not much has changed in the way of funding in the last few years, as securing funding from payors continues to be a struggle for both clinicians and their clients. Despite the large body of research showing the many ways that standing can improve the lives of wheelchair users, Medicare remains unwilling to fund standing frames and wheelchairs.

“You can say the last 12 or 24 years probably and still get the same answer, honestly and unfortunately,” Pryles said on Medicare’s unchanging stance on funding standing devices. “I think they’re doing it because they don’t really understand the benefit. It’s not like funding somebody’s heart medication. If someone is getting blood pressure medication, they understand that. You understand the medical necessity around that.”

Clinicians know all too well the struggle of making payors understand the medical necessity of standing as they work closely with clients to write letters of medical necessity. In the past two years, many clinicians have seen pressure relief and weight shifting, medical justifications that have long been used for tilt and recline devices, making their ways into standing justifications, though the correlation between standing and pressure relief and weight shifting has been known for years.

“I’ve definitely seen, within the last year and a half, an uptick in clinicians asking me to ask questions about pressure relief and studies around that sort of thing,” Perlich said. “And it’s really interesting that the most current study I know of specific to standing devices was probably back in 2010, when [Stephen] Sprigle did his load redistribution looking at variable position wheelchairs for people with spinal cord injuries.”

In the study that Perlich referenced, “Load redistribution in variable position wheelchairs in people with spinal cord injury,” published in the Journal for Spinal Cord Medicine, Sprigle and co-authors Chris Maurer and Sharon Sonenblum concluded, “Standing and recline offered similar seat load reductions at their respective terminal positions. Standing also reduced loading on the backrest... the results of this study indicate that tilt, recline, and standing systems should be considered as a means of weight shifting for wheelchair users.”

Tiskus, another advocate for the benefits of standing, explains, “In a seated position, about 70 percent of the patient body weight is situated over their ischial tuberosities, those two butt bones that stick out. That’s a lot of pressure on small surface areas. Tilting allows them to redistribute those pressures over a larger surface area. Combining tilt and recline [is] even better.

“But ultimately, standing — the way our body was designed is to stand — really maximizes pressure redistribution, essentially offloading those key areas of concern, and focuses those pressures on the lower extremities, which are designed to accommodate a patient’s body weight. So it’s very effective in terms of pressure management and just makes sense from the anatomy of the human body.”

With pressure relief and weight shifting, a client’s risk for pressure wounds significantly decreases, saving the client from painful and costly medical experiences. Perlich cites a 2018 review of current management for pressure injuries published in Advanced Wound Care. Authors Tatiana V. Boyko, Michael T. Longaker and George P. Yang found that “In the United States, an estimated $11 billion is spent on pressure ulcers yearly, with $500 to $70,000 being spent on a single wound.”

Considering the cost of pressure wounds compared to the cost of standing frames and wheelchairs, Perlich said, “If you’re talking about wound treatment — that’s not even surgery — and you’re spending $70,000 and the average standing frame is somewhere between $3,000 to $7,000, which can totally offload the person, I don’t get it. I don’t get why [standing technology] wouldn’t be considered.

“Usually, if you look at payor policies, skin health is one of those benefits of standing. If there’s any issues with pressure ulcers, definitely, I think it needs be in the justifications of a letter of medical necessity.”

For clients, Medicaid programs are becoming more reliable payors for standing. “I think there’s been some more lobbying efforts at the state level for Medicaid programs to look at this as a possibility for the patients that they serve. We’re starting to see improvement. We’re starting to see standing becoming more acceptable,” Tiskus said.

Private payors have been less reliable, and while some have funded standing, many take their guidelines from Medicare. But whether it’s Medicaid or private insurance that a client is seeking funding from, Perlich advises industry professionals to write documentation that ties standing to the client’s needs.

For instance, Ashley Detterbeck, DPT, ATP, SMS, the Clinical Education Manager for Permobil’s Central Region, explains that in Minnesota “the state medical assistance program is really designated out of functional goals.” Detterbeck points out specific questions that professionals should try to answer in addressing the state’s assistance program’s policies: “What is the patient going to be able to do in a standing position that they cannot do in a seated position? Is it going to increase their independence? Are they going to be able to participate in their environment and reduce their need for caregivers or be able to increase their independence at home or live independently?

“[Those considerations] drive [funding] first and foremost.”

In addition to Medicaid and private insurance, Detterbeck has noticed an increase in patients turning to alternative funding from organizations such as ABLE National Resource Center, a collaborative managed by National Disability Institute. Through ABLE, people with disabilities and their families can open tax-advantaged savings accounts. “It’s a federal granted program that states choose to participate in,” Detterbeck explained. “It’s like a savings account that a parent can put money in if their child has a disability. Then that money can be used for medical expenses, equipment, housing, independent living.”

This type of alternative funding helps clients to spread financial responsibility across multiple sources. For example, Detterbeck said that a Medicare beneficiary could receive approval for a power chair and then privately fund through a foundation or through personal funds to upgrade to a Group 4 standing chair.

“Patients will often do what we call the ‘F3 to the F5 DS’ upgrade,” she said. “They make their insurance pay for a majority of it, and then that component of the standing upgrade is just line-itemed out, and the patient provides the funding, whether it’s alternative or private.”

Yet, no matter where or how clients seek out funding, the multiple psychosocial and clinical benefits of standing are not considered necessities to justify funding. “Unfortunately, justification is all [based] on the medical [outcomes],” said Pryles. “There are some things standing can do that tilt and recline cannot.”

Pryles pointed out that using tilt and recline can be disruptive, requiring users to take time to do a weight shift every 30 to 40 minutes. “Most of the people in our demographic are working. Most of them are raising kids. Most of them lead very full lives. If you allow somebody to do a weight shift while being functional, so they can stand and look around, or stand and cheer at a soccer game, or stand at a lab at school, I think people are much more compliant to doing that.”

Tiskus also emphasized the psychosocial aspect of standing, particularly its integral role in how humans communicate with each other. “It’s not just verbal,” he said. “It’s being able to look into somebody’s eyes, looking to see what type of facial expressions they have as we communicate, and giving that ability to somebody who’s typically in a seated position.”

People in the industry like Pryles and Tiskus, who spend time with wheelchair users, understand the therapeutic side of standing. Detterbeck, who spent 14 years in a clinic prior to joining Permobil, acknowledged how difficult it can be for clients, some for the first time in their lives, to be unable to access things or participate in activities and daily life in the way that they’re accustomed. But currently, research just isn’t being done to investigate the connection between mental health and mobility.

“We’ve tried to pull articles on clinical depression in relationship to wheelchair usage, and there’s nothing,” said Detterbeck. “Unfortunately, our funding sources are so medically-only driven that they don’t take into consideration the patient’s well-being and quality of life.”

Standing in the Mainstream

In 2012, a group of researchers from the United Kingdom published the first comprehensive study on the dangers of a sedentary lifestyle titled “Sedentary time in adults and the association with diabetes, cardiovascular disease and death: systematic review and meta-analysis.” In their meta-analysis of 18 studies with an overall 794,577 participants, they concluded that people who spent most of their day sitting or lying down had a 112-percent increased risk for diabetes, a 147-percent increase in cardiovascular events and a 49-percent increase in the risk of all-cause mortality.

Since then, we have a seen a flurry of inventions infiltrate our lives in the form of standing desks in the office and smart watches that ping us when it’s time to get up and move — all meant to disrupt our sedentary lifestyles and encourage us to stand more and sit less. But the mainstream popularity of standing has revolved around able-bodied people who can exercise some level of choice over their daily sit-to-stand ratio. Wheelchair users and people with disabilities who require assistive technologies to stand are often deprived of that choice, not because of their disability or a lack of innovation, but because payors continue to decline funding for standing wheelchairs and standing frames.

Perlich said that some payors are “still saying that [standing] is experimental and investigational, and there’s no proven efficacy, which we know is not true. There are plenty of studies that do have their merits. That’s a great frustration.”

As early as 2007, five years before the mainstream panic began about sitting, the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) published its position in support of standing, citing positive outcomes in enhancing independence, maintaining vital organ capacity, bone mineral density, circulation, and range of motion, reducing tone and spasticity and decreasing the occurrence of pressure injuries and skeletal deformities.

Ironically, it is likely that the success of the able-bodied market around standing has potential to change minds and influence the opinion of funding sources. Pryles thinks that the groundswell of popularity in standing will have positive effects on the CRT industry. “I think that the thing that’s helped our industry the most isn’t necessarily our own research, our own outcomes around standing, but it’s been through the furniture industry and all the stuff people are finding out around the dangers of sitting,” he said. “I think as the general consensus as a society moves forward and people recognize it as a benefit, so too ultimately will those payor sources follow.”

For seating and mobility clinicians who have been advocating for the necessity of standing long before smart watches could, it can be frustrating to see opinions on standing change only when able-bodied people have found they can benefit from standing as well. But the critical role of the clinician in ensuring their clients receive the technology they need remains.

“Keep on advocating for your clients, it’s important,” said Perlich. “It’s very necessary for their health. Don’t let a policy get in the way. There’s always an appeal that can be addressed, and there are alternative payors out there.”

This article originally appeared in the February 2019 issue of Mobility Management.

In Support of Upper-Extremity Positioning