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Standing 101 (Standing Therapy for the People with Disabilities)


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Standing 101 is for Physical Therapists, Occupational Therapists, and Assistive Technology Professionals. It covers the history of standing therapy for the disabled, including research studies on standing programs. It also discusses the different types of standing frames including: prone standers, supine standers, and sit to stand standers. It concludes with information on funding and documentation for standing equipment and writing a letter of medical necessity for standing.

Published in: Health & Medicine
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Standing 101 (Standing Therapy for the People with Disabilities)

  1. 1. Standing Mobility Alternative positioning Rehab Technology Standing 101 Educational Seminar
  2. 2. Program Agenda <ul><li>Register </li></ul><ul><li>Welcoming remarks & overview of </li></ul><ul><li>seminar content </li></ul><ul><li>History of standing and weight bearing </li></ul><ul><li>Early literature identifying secondary complications associated with immobilization syndrome. </li></ul><ul><li>Evolution of standing technology, device types and their current applications </li></ul><ul><ul><ul><li>• Long leg braces </li></ul></ul></ul><ul><ul><ul><li>• Tilt table/supine standers </li></ul></ul></ul><ul><ul><ul><li>• Standing boxes </li></ul></ul></ul><ul><ul><ul><li>• Prone standers </li></ul></ul></ul><ul><ul><ul><li>• Multi-position standers </li></ul></ul></ul><ul><ul><ul><li>• Standing wheelchairs </li></ul></ul></ul><ul><ul><ul><li>• Sit-to-stand standers </li></ul></ul></ul>Standing 101 Educational Seminar <ul><li>Break </li></ul><ul><li>Current Clinical Practices </li></ul><ul><ul><ul><li>• Indication and Contraindications for standing </li></ul></ul></ul><ul><ul><ul><li>• Accepted Medical Benefits for standing </li></ul></ul></ul><ul><ul><ul><li>• Current clinical studies and research </li></ul></ul></ul><ul><ul><li>Video Case Studies </li></ul></ul>
  3. 3. 1720 1500 1970 1500 1980 History of Standing
  4. 4. Tied to prolonged immobilization <ul><ul><li>Taylor et al (3) </li></ul></ul><ul><ul><ul><li>The effect of bed rest </li></ul></ul></ul><ul><ul><ul><li>on the blood volume </li></ul></ul></ul><ul><ul><ul><li>of normal young men </li></ul></ul></ul><ul><ul><li>Cristobal Mendez (1) </li></ul></ul><ul><ul><ul><li>Book of bodily exercise </li></ul></ul></ul><ul><ul><ul><ul><li>Treatise on the physiologic responses </li></ul></ul></ul></ul><ul><ul><ul><ul><li>to exercise and its therapeutic indications </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Exercise therapy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>History of exercise </li></ul></ul></ul></ul>Early Research of Standing 1533 1940’S 1929 1500 1900 1950 <ul><ul><li>Cuthbertson (2) </li></ul></ul><ul><ul><ul><li>The influence of prolonged </li></ul></ul></ul><ul><ul><ul><li>muscular rest on metabolism </li></ul></ul></ul><ul><ul><li>Dietrick et al (4) </li></ul></ul><ul><ul><ul><li>Effects of immobilization upon </li></ul></ul></ul><ul><ul><ul><li>various metabolic and physiologic </li></ul></ul></ul><ul><ul><ul><li>functions of normal man </li></ul></ul></ul><ul><ul><li>Widdowson (5) </li></ul></ul><ul><ul><ul><li>Effects of rest in bed on plasma </li></ul></ul></ul><ul><ul><ul><li>volume as indicated by hemoglobin </li></ul></ul></ul><ul><ul><ul><li>and hematocrit </li></ul></ul></ul>
  5. 5. Space exploration resulted in a flurry of research with goal of measuring adaptation of human body to weightlessness <ul><ul><li>Miller, Johnson and Lamb (7) </li></ul></ul><ul><ul><ul><li>Effects of four weeks absolute bed rest </li></ul></ul></ul><ul><ul><ul><li>on circulatory functions in man </li></ul></ul></ul>Early Research of Standing 1960’s 1967 1965 1980 <ul><ul><li>Graybiel and Clark (6) </li></ul></ul><ul><ul><ul><li>Symptoms resulting from prolonged immersion in water </li></ul></ul></ul><ul><ul><ul><li>The problem of zero G asthenia </li></ul></ul></ul><ul><ul><li>Gemini (9) </li></ul></ul><ul><ul><li>Summary </li></ul></ul><ul><ul><li>Conference </li></ul></ul>1970 1975 1977 <ul><ul><li>Space medicine (8) </li></ul></ul><ul><ul><li>in project mercury </li></ul></ul><ul><ul><li>Biomedical results of Apollo (10) </li></ul></ul><ul><ul><li>Biomedical (11) </li></ul></ul><ul><ul><li>results of Skylab </li></ul></ul>1960
  6. 6. Simultaneously, rehabilitation researchers documented the pathophysiologic changes exhibited by patients with extensive paralysis Early Research of Standing 1960’s 1965 1970 1970’s <ul><ul><li>Browse (12) </li></ul></ul><ul><ul><ul><li>The physiology and pathology of bed rest </li></ul></ul></ul>1960 <ul><ul><li>Spencer (13) </li></ul></ul><ul><ul><ul><li>Physiology concepts of immobilization </li></ul></ul></ul><ul><ul><li>Kottke (14) </li></ul></ul><ul><ul><ul><li>The effects of limitation of activity upon the human body </li></ul></ul></ul><ul><ul><li>Long and Bonilla (15) </li></ul></ul><ul><ul><ul><li>Metabolic effects of inactivity and injury </li></ul></ul></ul>
  7. 7. Standing Devices
  8. 8. Standing Devices <ul><ul><li>Different types & manufacturers </li></ul></ul><ul><ul><ul><li>Made locally with variations within types </li></ul></ul></ul><ul><ul><ul><ul><li>KAFO- (Knee-Ankle Foot Orthosis) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>RGO- (Reciprocal Gait Orthosis) Louisiana State University </li></ul></ul></ul></ul><ul><ul><ul><ul><li>HGO- (Hip Guidance Orthosis) Para-Walker, Adult </li></ul></ul></ul></ul><ul><ul><li>Often driven by desire to walk </li></ul></ul><ul><ul><ul><li>Impractical </li></ul></ul></ul><ul><ul><ul><li>Expensive </li></ul></ul></ul><ul><ul><ul><li>Therapy time intensive </li></ul></ul></ul><ul><ul><ul><li>Usually cannot be utilized independently </li></ul></ul></ul><ul><ul><ul><li>Poor compliance </li></ul></ul></ul>Long Leg Braces
  9. 9. Long Leg Braces
  10. 10. Standing Devices <ul><ul><li>Minimal support on anterior and posterior surface of body </li></ul></ul><ul><ul><li>Earliest example of assisted standing devices </li></ul></ul><ul><ul><ul><li>Often homemade </li></ul></ul></ul><ul><ul><ul><li>Inexpensive </li></ul></ul></ul><ul><ul><li>Often requires two attendants </li></ul></ul><ul><ul><li>Does not include a lifting mechanism </li></ul></ul><ul><ul><li>Adult and pediatric sizes </li></ul></ul><ul><ul><li>Minimal positioning or alignment options </li></ul></ul><ul><ul><li>Usually cannot be used independently </li></ul></ul>Standing Box
  11. 11. Standing Boxes
  12. 12. Standing Devices <ul><ul><li>Full support along posterior surface of body </li></ul></ul><ul><ul><li>Two-three straps to secure body to support surface </li></ul></ul><ul><ul><li>Platform to secure feet </li></ul></ul><ul><ul><li>Horizontal to vertical transition in supine position </li></ul></ul><ul><ul><li>Developed for cardiovascular testing </li></ul></ul><ul><ul><ul><li>To evaluate how body regulates blood pressure in response to simple stress </li></ul></ul></ul><ul><ul><ul><ul><li>Orthostatic hypotension </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Rarely seen outside hospital environment </li></ul></ul></ul></ul><ul><ul><li>Adult sizes </li></ul></ul><ul><ul><li>Manual or power lift mechanism </li></ul></ul><ul><ul><li>Minimal positioning or alignment options </li></ul></ul><ul><ul><li>Cannot be used independently </li></ul></ul>Tilt Table
  13. 13. Tilt Tables
  14. 14. Standing Devices <ul><ul><li>Posterior surface support from head, thoracic area, pelvis, knees and feet </li></ul></ul><ul><ul><li>Stander angle accommodates from horizontal to vertical in supine position </li></ul></ul><ul><ul><li>Often prescribed for lack of head control </li></ul></ul><ul><ul><li>May have a lift mechanism </li></ul></ul><ul><ul><li>Available in sizes from pediatric to adult </li></ul></ul><ul><ul><li>Usually will accommodate options for growth, positioning and alignment </li></ul></ul><ul><ul><li>Usually cannot be used independently </li></ul></ul>Supine Stander
  15. 15. Supine Standers
  16. 16. Standing Devices <ul><ul><li>Support on anterior surface of the body </li></ul></ul><ul><ul><ul><li>Contact at upper thoracic area, pelvis, knees and feet </li></ul></ul></ul><ul><ul><li>Used to promote head control </li></ul></ul><ul><ul><li>Gravity assist for full extension of hips </li></ul></ul><ul><ul><li>Usually accommodates 30º of prone positioning to upright </li></ul></ul><ul><ul><li>May have a lift mechanism </li></ul></ul><ul><ul><li>Available in sizes from pediatric to adult </li></ul></ul><ul><ul><li>Options for growth, positioning and alignment </li></ul></ul><ul><ul><li>Usually cannot be used independently </li></ul></ul>Prone Stander
  17. 17. Prone Standers
  18. 18. Standing Devices <ul><ul><li>Prone, Supine, and Upright </li></ul></ul><ul><ul><li>Primary supports can be interchangeable </li></ul></ul><ul><ul><ul><li>Between anterior and posterior surfaces of the body </li></ul></ul></ul><ul><ul><ul><li>For positioning in prone, supine, or upright position </li></ul></ul></ul><ul><ul><li>Usually accommodates 30º of supine positioning to upright, and 30º of prone to upright </li></ul></ul><ul><ul><li>Available in sizes from pediatric to adult </li></ul></ul><ul><ul><ul><li>Traditionally used with pediatric clients </li></ul></ul></ul><ul><ul><li>Options for growth, positioning and alignment </li></ul></ul><ul><ul><li>Usually cannot be used independently </li></ul></ul>Multi-Positioning Stander
  19. 19. Multi-Positioning Standers
  20. 20. Standing Devices <ul><ul><li>Power and/or manual wheelchair </li></ul></ul><ul><ul><li>Main support on posterior surfaces of body </li></ul></ul><ul><ul><ul><li>Anterior support at knees </li></ul></ul></ul><ul><ul><ul><li>Hip belt and chest belt </li></ul></ul></ul><ul><ul><li>Usually includes lift mechanism </li></ul></ul><ul><ul><li>Available in sizes from pediatric to adult, including baratric </li></ul></ul><ul><ul><li>Power wheelchair may be able to move in the standing position </li></ul></ul><ul><ul><li>Standing mechanism transitions person from sitting to standing approximately (80º of supine) </li></ul></ul><ul><ul><li>Integrated lift mechanism is independently operated </li></ul></ul><ul><ul><li>Heavy and expensive </li></ul></ul>Standing Wheelchairs
  21. 21. Standing Wheelchairs
  22. 22. Standing Devices <ul><ul><li>Anterior and posterior variable support </li></ul></ul><ul><ul><ul><li>Minimal support </li></ul></ul></ul><ul><ul><ul><ul><li>Anterior (mid-thoracic, knees, feet) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Posterior (PSIS to popliteal) </li></ul></ul></ul></ul><ul><ul><ul><li>Maximum support </li></ul></ul></ul><ul><ul><ul><ul><li>Anterior (head, shoulder, thoracic, knees, feet) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Posterior (head to popliteal, feet) </li></ul></ul></ul></ul><ul><ul><li>Transitions person from sitting to standing upright </li></ul></ul><ul><ul><ul><li>Stop at any point from sitting to standing </li></ul></ul></ul><ul><ul><ul><li>Supported during incremental weight bearing </li></ul></ul></ul><ul><ul><li>Usually includes a lift mechanism </li></ul></ul><ul><ul><li>Available in sizes from pediatric to adult, including bariatrics </li></ul></ul><ul><ul><li>Options for growth, positioning and alignment </li></ul></ul><ul><ul><li>Usually can be used independently </li></ul></ul>Sit-to-Stand Standers
  23. 23. Sit-to-Stand Standers
  24. 24. Current Research Studies
  25. 25. Does prolonged standing improve bone mineral density in non-ambulatory children with spastic quadriplegia? <ul><ul><li>Principal Investigator(s) </li></ul></ul><ul><ul><ul><li>Brian Snyder, MD • Antion Dodek, MD </li></ul></ul></ul><ul><ul><li>Co-Investigator(s) </li></ul></ul><ul><ul><ul><li>Danielle Katz, MD • Maria Fragala, PT </li></ul></ul></ul><ul><ul><ul><li>Laura Freeman, PT </li></ul></ul></ul><ul><ul><li>Site(s) </li></ul></ul><ul><ul><ul><li>Franciscan Children’s Hospital, Boston, MA </li></ul></ul></ul><ul><ul><ul><li>Kennedy Day School, Boston, MA </li></ul></ul></ul><ul><ul><ul><li>Mass. Hospital School, Canton, MA </li></ul></ul></ul><ul><ul><li>Purpose </li></ul></ul><ul><ul><ul><li>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. </li></ul></ul></ul>Current Research Studies
  26. 26. Does prolonged standing improve bone mineral density in non-ambulatory children with spastic quadriplegia? <ul><ul><li>Pilot finished </li></ul></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>Significance: The intensive use of standing devices (10hrs a week) may have a beneficial effect on BMD of weight bearing bones in </li></ul></ul><ul><ul><ul><li>non-ambulatory children </li></ul></ul></ul><ul><ul><li>Full study underway </li></ul></ul>Current Research Studies
  27. 27. The effects of passive standing on health-related areas for individuals with spinal cord injuries. <ul><ul><li>Principal Investigator </li></ul></ul><ul><ul><ul><li>Ronald Davis, PhD </li></ul></ul></ul><ul><ul><li>Co-Investigator </li></ul></ul><ul><ul><ul><li>Leonard Kaminsky, PhD </li></ul></ul></ul><ul><ul><li>Site </li></ul></ul><ul><ul><ul><li>Ball State University, Muncie, IN </li></ul></ul></ul><ul><ul><li>Purpose </li></ul></ul><ul><ul><ul><li>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. </li></ul></ul></ul><ul><ul><li>Pilot Finished </li></ul></ul><ul><ul><ul><li>Conclusion </li></ul></ul></ul><ul><ul><ul><ul><li>Standing must be longer than 30 minutes per day to have effect on BMD </li></ul></ul></ul></ul>Current Research Studies
  28. 28. Working on weight bearing and gait with functional electric stimulation. <ul><ul><li>Investigator </li></ul></ul><ul><ul><ul><li>Dr. Richard Sheilds </li></ul></ul></ul><ul><ul><li>NIH Grants </li></ul></ul><ul><ul><li>Site </li></ul></ul><ul><ul><ul><li>University of Iowa Hospitals & Clinics, Iowa City, IA </li></ul></ul></ul><ul><ul><li>Purpose </li></ul></ul><ul><ul><ul><li>To assess the use of the EasyStand 6000 Glider </li></ul></ul></ul><ul><ul><ul><li>and its potential with patients in their grant study. </li></ul></ul></ul>Current Research Studies
  29. 29. Keep Moving: Technologies to enhance mobility and function for the individual with spinal cord injury. <ul><ul><li>Principal Investigator(s) </li></ul></ul><ul><ul><ul><li>Samuel Landsberger, ScD • Robert Waters, MD </li></ul></ul></ul><ul><ul><li>Site </li></ul></ul><ul><ul><ul><li>California State University, Los Angeles, CA </li></ul></ul></ul><ul><ul><li>Purpose </li></ul></ul><ul><ul><ul><li>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. </li></ul></ul></ul>Current Research Studies
  30. 30. Health Parameters in Standing and Non-Standing, Non-Ambulatory Adults with Cerebral Palsy. <ul><ul><li>Principal Investigator(s) </li></ul></ul><ul><ul><ul><li>Kevin Murphy, MD • Kevin Sheridan, MD </li></ul></ul></ul><ul><ul><li>Site </li></ul></ul><ul><ul><ul><li>Gillette Children’s Specialty Healthcare (Lifetime Clinic) </li></ul></ul></ul><ul><ul><li>Purpose </li></ul></ul><ul><ul><ul><li>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. </li></ul></ul></ul>Current Research Studies
  31. 31. The effects of passive and dynamic standing in multiple sclerosis. <ul><ul><li>Director </li></ul></ul><ul><ul><ul><li>Christine Martin, PhD </li></ul></ul></ul><ul><ul><ul><li>Pat Provance, PT </li></ul></ul></ul><ul><ul><li>Site </li></ul></ul><ul><ul><ul><li>University of Maryland Medical School, Baltimore, MD </li></ul></ul></ul><ul><ul><ul><li>Veteran's Administration Multiple Sclerosis Center of Excellence, East, Baltimore, MD </li></ul></ul></ul><ul><ul><li>Purpose </li></ul></ul><ul><ul><ul><li>Enhance functions for individuals with multiple sclerosis </li></ul></ul></ul><ul><ul><li>Pilot Finished </li></ul></ul>Current Research Studies
  32. 32. The effects of passive and dynamic standing in multiple sclerosis. <ul><ul><li>Conclusion </li></ul></ul><ul><ul><ul><li>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. </li></ul></ul></ul><ul><ul><ul><li>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. </li></ul></ul></ul>Current Research Studies
  33. 33. The effects of passive and dynamic standing in multiple sclerosis. <ul><ul><li>Conclusion </li></ul></ul><ul><ul><ul><li>Subjects in Group B with higher functional ability to baseline indicate the greatest individual improvement mid-way through the study. </li></ul></ul></ul><ul><ul><ul><li>Observations (thus far) indicate that active upper and lower extremity movements required of Group B are too vigorous for subjects with greater functional impairment. </li></ul></ul></ul><ul><ul><ul><li>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 </li></ul></ul></ul><ul><ul><ul><li>of passive or dynamic standing. </li></ul></ul></ul>Current Research Studies
  34. 34. Pending Research Studies
  35. 35. Prototype pediatric active stander pilot study for clients with cerebral palsy. <ul><ul><li>Principal Investigator </li></ul></ul><ul><ul><ul><li>Thomas Polisoto, MD </li></ul></ul></ul><ul><ul><li>Site(s) </li></ul></ul><ul><ul><ul><li>Children’s Hospital, Erie County Medical Center, Buffalo, NY </li></ul></ul></ul><ul><ul><ul><li>Elmwood Health Center, Buffalo, NY </li></ul></ul></ul><ul><ul><li>Purpose </li></ul></ul><ul><ul><ul><li>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. </li></ul></ul></ul><ul><ul><ul><li>Influence of the use of the prototype pediatric active stander on hip/acetabular development in the same population. </li></ul></ul></ul>Pending Research Studies
  36. 36. Indications/ Contraindications
  37. 37. Clinical Indications <ul><ul><li>Individuals at risk for immobilization syndrome </li></ul></ul><ul><ul><ul><li>Restricted neuromuscular activity due to paralysis </li></ul></ul></ul><ul><ul><ul><li>Individuals who stay in a given position </li></ul></ul></ul><ul><ul><ul><ul><li>i.e. sitting in a wheelchair for continuous </li></ul></ul></ul></ul><ul><ul><ul><ul><li>or prolonged periods of time </li></ul></ul></ul></ul><ul><ul><ul><li>Impaired mobilization due to disease, illness, or disability </li></ul></ul></ul><ul><ul><li>Physician referral </li></ul></ul><ul><ul><li>Therapist evaluation and program set up </li></ul></ul><ul><ul><li>Therapeutic follow up </li></ul></ul>Indications/Contraindications
  38. 38. Clinical Contraindications <ul><ul><li>Physician declined referral </li></ul></ul><ul><ul><li>Orthostatic intolerance syndrome </li></ul></ul><ul><ul><ul><li>Orthostatic hypotension </li></ul></ul></ul><ul><ul><ul><li>Postural tachycardia syndrome </li></ul></ul></ul><ul><ul><li>Impaired skeletal structure that will not tolerate weight bearing </li></ul></ul><ul><ul><ul><li>Osteogenesis imperfecta, osteoporosis, or other </li></ul></ul></ul><ul><ul><ul><li>forms of brittle bone disease </li></ul></ul></ul><ul><ul><li>Certain orthopedic disorders </li></ul></ul><ul><ul><ul><li>Hip and/or knee flexion contractures greater </li></ul></ul></ul><ul><ul><ul><li>than 20º and non reducible </li></ul></ul></ul>Indications/Contraindications
  39. 39. Accepted Medical Benefits of Standing
  40. 40. <ul><ul><ul><li>Prevention of contractures and improvement of joint range of motion </li></ul></ul></ul><ul><ul><ul><li>Reduction of spasticity </li></ul></ul></ul><ul><ul><ul><li>Prevention or reversal of osteoporosis and resultant hypercalciuria </li></ul></ul></ul><ul><ul><ul><li>Improvement in renal function, drainage of the urinary tract, and reduction in urinary calculi </li></ul></ul></ul><ul><ul><ul><li>Prevention of pressure ulcers </li></ul></ul></ul><ul><ul><ul><li>Improvement in circulation as it relates to orthostatic </li></ul></ul></ul><ul><ul><ul><li>hypotension and other benefits of good circulation </li></ul></ul></ul><ul><ul><ul><li>Improvement of bowel function </li></ul></ul></ul>Passive standing has been demonstrated to prevent, reverse, or improve many of the adverse affects of prolonged immobilization. Accepted Medical Benefits of Standing
  41. 41. Musculoskeletal System <ul><ul><ul><li>Immobilization has dramatic effects on the musculoskeletal system. </li></ul></ul></ul><ul><ul><ul><li>It has been demonstrated that the immobilization of muscles and lack of weight bearing on bones causes bone demineralization and true osteoporosis. </li></ul></ul></ul><ul><ul><ul><li>The immobilized patient: Functional pathology and management, </li></ul></ul></ul><ul><ul><ul><li>Steinberg, F.U. et al (16) </li></ul></ul></ul>Accepted Medical Benefits of Standing
  42. 42. Musculoskeletal System <ul><ul><ul><li>Experiment demonstrated healthy men immobilized by complete bed rest reversed increased calcium excretion by quiet standing three hours per day. </li></ul></ul></ul><ul><ul><ul><li>Effects of prolonged bed rest on urinary calcium output. Issekutz et al (17) </li></ul></ul></ul>Accepted Medical Benefits of Standing
  43. 43. Musculoskeletal System <ul><ul><ul><li>Investigators found that muscle stretch by weight load in standing was able to reduce spasticity 26%-32% depending on the flexion of the feet. </li></ul></ul></ul><ul><ul><ul><li>Evaluation of the effects of muscle stretch and weight load in patients </li></ul></ul></ul><ul><ul><ul><li>with spastic paraplegia. Odeen and Knutsson (18) </li></ul></ul></ul>Accepted Medical Benefits of Standing <ul><ul><ul><li>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. </li></ul></ul></ul><ul><ul><ul><li>The standing procedure is easily managed and may therefore be used in a home program if the patient is supplied with supported standing. </li></ul></ul></ul><ul><ul><ul><li>Effects of Muscle Stretch. Odeen and E. Knutsson (18) </li></ul></ul></ul>
  44. 44. Musculoskeletal System <ul><ul><ul><li>Loss of Strength </li></ul></ul></ul><ul><ul><ul><ul><li>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. </li></ul></ul></ul></ul><ul><ul><ul><li>The malignant effects of bed rest. Richardson, J.K. (19) </li></ul></ul></ul>Accepted Medical Benefits of Standing <ul><ul><ul><li>Loss of Skeletal Mass </li></ul></ul></ul><ul><ul><ul><ul><li>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. </li></ul></ul></ul></ul>
  45. 45. Musculoskeletal System <ul><ul><ul><li>Since osteoporosis is a major risk factor, patients with cerebral palsy should bear weight to prevent pathological fractures. </li></ul></ul></ul><ul><ul><ul><li>Any stiffness of major joints and extended periods of immobilization should be avoided. </li></ul></ul></ul><ul><ul><ul><li>Pathological fractures in patients with cerebral palsy. Brunner, R.D et al (20) </li></ul></ul></ul>Accepted Medical Benefits of Standing
  46. 46. Pulmonary <ul><ul><ul><li>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. </li></ul></ul></ul>Accepted Medical Benefits of Standing <ul><ul><ul><li>The malignant effects of bed rest. Richardson, J.K. (19) </li></ul></ul></ul>
  47. 47. Renal and Urinary Tract <ul><ul><ul><li>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. </li></ul></ul></ul>Accepted Medical Benefits of Standing <ul><ul><li>The physiology and pathology of bed rest. Browse, N.L. (21) </li></ul></ul><ul><ul><ul><li>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. </li></ul></ul></ul>
  48. 48. Renal and Urinary Tract <ul><ul><ul><li>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. </li></ul></ul></ul><ul><ul><li>A long-term survey of the incidence of renal calculosisin paraplegia. </li></ul></ul><ul><ul><li>Browse, N.L. (21) </li></ul></ul>Accepted Medical Benefits of Standing
  49. 49. Renal and Urinary Tract <ul><ul><ul><li>Suggests weight bearing within 18 months of injury would significantly reduce incidence of urinary calculi. </li></ul></ul></ul><ul><ul><li>The metabolism of calcium in patients with spinal cord injuries. </li></ul></ul><ul><ul><li>Freeman, L.W. (22) </li></ul></ul>Accepted Medical Benefits of Standing
  50. 50. Renal and Urinary Tract <ul><ul><li>Quiet standing for two or more hours per day appears to reverse the changes in mineral metabolism induced by bed rest. </li></ul></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>Effects of prolonged bed rest on bone mineral. Donaldson, C.L. (23) </li></ul></ul>Accepted Medical Benefits of Standing
  51. 51. Renal and Urinary Tract <ul><ul><li>Standing programs have been shown to have an effect on bone development in humans and animals. Bone mineral density has </li></ul></ul><ul><ul><li>been demonstrated to increase with exercise programs that </li></ul></ul><ul><ul><li>provide a physiologic stimulus for bone modeling. </li></ul></ul><ul><ul><li>Considerations related to weight bearing programs in children with </li></ul></ul><ul><ul><li>developmental disabilities. Stuberg, W.A. (24) </li></ul></ul>Accepted Medical Benefits of Standing
  52. 52. Skin and Underlying Tissue <ul><ul><ul><li>The prevention and treatment of these ulcers require pressure relief that may be accomplished by postural changes. </li></ul></ul></ul><ul><ul><ul><li>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. </li></ul></ul></ul><ul><ul><li>Pressure sore prevention for the wheelchair bound spinal injury patient. </li></ul></ul><ul><ul><li>Fergusion-Pell, M. et al (25) </li></ul></ul>Accepted Medical Benefits of Standing
  53. 53. Skin and Underlying Tissue <ul><ul><ul><li>The average number of hospitalization days for pressure ulcer treatment was 150 days, with an average cost of $150,000 per patient hospitalized. </li></ul></ul></ul><ul><ul><li>Pressure ulcers in veterans with spinal cord injury; A retrospective study. </li></ul></ul><ul><ul><li>Garber, S.L. (26) </li></ul></ul>Accepted Medical Benefits of Standing
  54. 54. Cardiovascular System <ul><ul><li>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. </li></ul></ul>Accepted Medical Benefits of Standing <ul><ul><li>Effects of immobilization upon various metabolic and physiologic </li></ul></ul><ul><ul><li>functions of normal men. Deitrick, J.E. (27) </li></ul></ul>
  55. 55. Cardiovascular System <ul><ul><ul><li>The problem of orthostatic hypotension caused by immobilization can be improved by repeated standing. </li></ul></ul></ul><ul><ul><li>Cardiovascular and hemodynamic response to tilting and to </li></ul></ul><ul><ul><li>standing in tetraplegic patients. Figonia, S. (28) </li></ul></ul>Accepted Medical Benefits of Standing
  56. 56. Digestive System <ul><ul><li>The digestive system is affected by prolonged immobilization. Valibona, C. </li></ul></ul><ul><ul><li>(29) </li></ul></ul>Accepted Medical Benefits of Standing <ul><li>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. </li></ul>
  57. 57. Conclusion <ul><ul><ul><li>Many of the documented pathological changes that occur due to immobilization may be prevented, reversed or improved by a regular standing regimen. </li></ul></ul></ul>Accepted Medical Benefits of Standing
  58. 58. Case Histories
  59. 59. Funding and Documentation for Standing
  60. 60. Achieving Effective Documentation <ul><ul><ul><li>Detail the client: Who is this person medically (brief specific history)? </li></ul></ul></ul><ul><ul><ul><li>Provide the client’s history of compliance. </li></ul></ul></ul><ul><ul><ul><li>Explain how the stander will help achieve functional goals/outcomes. </li></ul></ul></ul><ul><ul><ul><li>Describe trial use of the proposed standers. </li></ul></ul></ul><ul><ul><ul><li>List alternatives that were considered & rejected (include less/most costly medical alternative). </li></ul></ul></ul><ul><ul><ul><li>If possible, present photos & videos to convey the information along with documentation. </li></ul></ul></ul><ul><ul><ul><li>Be complete, but concise; reviewers do not have time to read a novel. </li></ul></ul></ul><ul><ul><ul><li>Include supporting material: clinical studies, papers, etc. </li></ul></ul></ul><ul><ul><ul><li>Re-submit and appeal when necessary. </li></ul></ul></ul>Funding and Documentation
  61. 61. Letter of Medical Necessity Outline <ul><ul><li>Personal Information </li></ul></ul><ul><ul><ul><ul><ul><li>Name </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Date of birth </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Diagnosis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Onset of disability </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Height </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Weight </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Funding (primary/secondary) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Brief medical history (specific to the need of the device) </li></ul></ul></ul></ul></ul>Funding and Documentation
  62. 62. <ul><ul><li>Current Function </li></ul></ul><ul><ul><ul><ul><li>This section should draw a complete picture of the client with words. </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Ambulation: Type and how much assist </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Transfers: Type and how much assist </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Activities of daily living: How independent or dependent </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Living environment (brief description) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Mobility: Home and community (brief description) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>School/Employment (brief description) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Transportation (i.e. own car, van, public transportation) </li></ul></ul></ul></ul></ul>Funding and Documentation
  63. 63. <ul><ul><ul><li>Physical/Medical Condition </li></ul></ul></ul><ul><ul><ul><ul><li>Concentrate on a medical overview. Give specific medical factors that will be affected by standing technology and how they will change. </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Facilitating symmetrical posture </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Developing/improving head, neck, and upper body muscle control </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Inhibiting abnormal muscle tone and reflexes </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Preventing loss of range of motion (ROM) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Improving systemic functions (i.e. bladder, respiratory, circulatory, and digestive) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Preventing loss of bone density </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Developing standing tolerance and endurance </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Aid in normal skeletal development </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Aid in balance restoration through upright posture </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Other </li></ul></ul></ul></ul></ul>Funding and Documentation
  64. 64. <ul><ul><ul><li>Current Program </li></ul></ul></ul><ul><ul><ul><ul><li>What is the client’s current therapy program at home, school, work & their history of compliance? </li></ul></ul></ul></ul><ul><ul><ul><ul><li>What are client’s functional goals? </li></ul></ul></ul></ul><ul><ul><ul><ul><li>What other less costly alternatives were considered (ROM, splints, other methods of weight bearing)? </li></ul></ul></ul></ul><ul><ul><ul><ul><li>What other medical interventions may be necessary if client cannot receive a stander (surgeries, bracing, etc. approximate cost of other interventions)? </li></ul></ul></ul></ul>Funding and Documentation
  65. 65. <ul><ul><ul><li>Equipment Trail </li></ul></ul></ul><ul><ul><ul><ul><li>What equipment was considered and/or tried for how long </li></ul></ul></ul></ul><ul><ul><ul><ul><li>(least to most costly)? </li></ul></ul></ul></ul><ul><ul><ul><ul><li>What were the outcomes of each trial and why was each trail either accepted or rejected? </li></ul></ul></ul></ul>Funding and Documentation <ul><ul><li>Recommendations </li></ul></ul><ul><ul><ul><ul><li>What equipment is being recommended and why? </li></ul></ul></ul></ul><ul><ul><ul><ul><li>What is the prescribed standing program (what setting, describe protocol, minutes/hours/day, times/week)? </li></ul></ul></ul></ul><ul><ul><ul><ul><li>What are the expected outcomes? </li></ul></ul></ul></ul>
  66. 66. Current Technology
  67. 67. <ul><ul><ul><li>Standing Technology Providers </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Altimate Medical - Sit to Stand </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Levo - Standing Wheelchair </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Life Stand - Standing Wheelchair </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Mulholland- Prone </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Permobil - Standing Wheelchair </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Prime Engineering - Sit to Stand </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sammons Preston - Prone, Multi-positioning, Supine </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Snug Seat - Prone, Multi-positioning, Supine </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Stand Aid of Iowa- Sit to Stand </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>DavisMade Inc. - Standing Wheelchair </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Rifton - Prone, Multi-positioning, Supine </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Theradapt - Supine, Prone </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Vertran - Standing Wheelchair </li></ul></ul></ul></ul></ul>
  68. 68.